A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. BY FRANK HASTINGS HAMILTON, A.B., A.M., M.D., LT. COL.; MEDICAL INSPECTOR, U. S. A. J PROFESSOR OF MILITARY SURGERY AND HYGIENE, AND OF FRACTURES AND DISLOCATIONS IN BELLEVUE HOSPITAL MEDICAL COLLEGE ; ONE OF THE SURGEONS TO BELLEVUE HOSPITAL, NEW YORK : PROFESSOR OF MILITARY SURGERY, ETC., IN THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN; AUTHOR OF A TREATISE ON MILITARY SURGERY. SECOND EDITION, REVISED AND IMPROVED. ILLUSTRATED WITH TWO HUNDEED AND EIGHTY-FIVE WOOD-CUTS PHILADELPHIA: BLANCHARD AND LEA. 1863- Entered according to the Act of Congress, in the year 1860, by BLANCHARD AND LEA, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. TO THE CIVIL AND MILITARY SURGEONS OF THE UNITED STATES OF AMERICA, BY WHOSE KINDNESS HE HAS BEEN PLACED UNDER MANY OBLIGATIONS; AND IN TESTIMONY OF HIS PERSONAL ESTEEM, IS RESPECTFULLY DEDICATED BY T HE AUTHOR. PREFACE TO THE SECOND EDITION. By a careful revision I have sought to render this edition, as far as possible, a faithful record of the progress of that branch of surgical science of which it treats. With this view some portions have been amended, some paragraphs have been excluded, and considerable additions have been made. The short chapter on "Grunshot Fractures" seemed to be demanded at this moment, and especially as the work has been placed upon the United States Army Supply Table for Post and General Hospitals. Whether on the whole, by these new labors, the character of the volume has been improved, the reader must judge. FRANK H. HAMILTON, Gramercy Park, New York. May, 1863. PREFACE TO THE FIRST EDITION. The English language does not at this moment contain a single complete treatise on Fractures and Dislocations. The two small volumes of Desault, and the one of Boyer, issued near the close of the last century, and translated into English early in this, may perhaps properly enough have been regarded as complete treatises at the time of their publication, but they certainly cannot be so considered now. The several chapters on " Diseases and Injuries of the Bones," contained in the Legons Orales of Dupuytren, translated in 1846, and the Treatise on Fractures in the Vicinity of Joints, and on Certain Forms of Accidental and Congenital Dislocations, by Robert Smith, are invaluable monographs, but neither of them claims to be anything more than a collection of occasional and miscellaneous papers. The writings of Amesbury and of Lonsdale relate only to fractures. Even the justly celebrated quarto of Sir Astley Cooper is no more than what its title plainly declares it to be, A Treatise on Dislocations and on Fractures of the Joints; but since the announcement of the present volume, a translation of Malgaigne's great and crowning work on Fractures and Dislocations has been commenced by Dr. Packard, of Philadelphia, and the first volume has been placed in the hands of the American profession. Should the remaining volume be rendered into English, the gap in our literature will be measurably filled. Under these circumstances I might scarcely have thought it worth while to continue my labors, already so near their completion, had it not seemed to me that Malgaigne, whose researches have been truly marvellous, had failed in some measure to give a just representation of the observations and improvements which have been made from time to time by my own countrymen. The contributions of American surgeons to this department had to be sought chiefly in medical journals, many of which have long been discontinued, and most of which were inaccessible to the great French writer. Even to an American, the labor of exhumation from archives hitherto almost unexplored has not been small; and it is probable VIII PREFACE TO THE FIRST EDITION. that many valuable papers have been overlooked; indeed it is impossible that it should be otherwise. I am free to say, also, that I have been encouraged by a hope that my own personal experience, obtained during many years of public and private service, might be of some value to my contemporaries. Very little space has been devoted to what is now only historical, except so far as was necessary to correct certain time-consecrated errors, or to confirm and illustrate the practice of the present day; but, by a pretty full report of characteristic examples, selected from more than one thousand cases already published by myself, by copious references to the examples recorded by others, and by a careful exclusion of whatever has not been confirmed by experience or established by dissection, I have endeavored to make this treatise useful both to the student and practical man, and a reliable exponent of the present state of our art upon those subjects of which it treats. In order to render the description of the various forms of apparatus employed in the treatment of fractures more intelligible, and to avoid the necessity of lengthened explanations, a large number of illustrations have been introduced, more, perhaps, than might be thought necessary, especially as in several instances the apparel which is figured is not that which is recommended by the author. It is believed, however, that by a study of the principal forms of approved dressings, the reader will be better prepared for the exigencies of practice; and that by the simultaneous presentation of those which are not approved, he will be saved from a wasteful expenditure of his time in the contrivance of useless apparatus. It is not in the discovery and multiplication of mechanical expedients that the surgeon of this day declares his superiority, so much as in the skilful and judicious employment of those which are already invented. The author desires to acknowledge his indebtedness to very many of his professional brethren, throughout the United States, for the promptness with which they have responded from time to time to his inquiries, and for the generosity with which they have opened their pathological collections and placed valuable specimens at his disposal. He wishes also to express his special obligations to Dr. J. R. Lothrop, of this city, who has kindly aided him in revising most of the proof sheets as they have been issued from the press. FRANK II. HAMILTON. Buffalo, N. Y., December, 1859. CONTENTS. § 2. Fractures and Displacements of the Septum Narium . . .93 § 1. Ossa Nasi ........ 88 Fractures of the Nose ........ 88 CHAPTER VIII. § 3. Fissures ........ 83 § 2. Partial fracture of the Long Bones ..... 73 § 1. Bending of the Long Bones ...... 69 Bending, Partial Fractures, and Fissures op the Long Bones . . .69 CHAPTER VII. Delayed Union and Non-Union of Broken Bones . . . .60 CHAPTER VI. General Treatment of Fractures ...... 44 CHAPTER V. Repair of Broken Bones ........ 37 CHAPTER IV. General Semeiology and Diagnosis ...... 33 CHAPTER III. General Etiology of Fractures ....... 29 CHAPTER II. General Division op Fractures . . . . ... .27 CHAPTER I. FRACTURES. PART I. X CONTENTS CHAPTER IX. Fractobes op the Malar Bone ....... 96 CHAPTER X. Fractures of the Upper Maxillary Bones. ..... 99 CHAPTER XI. Fractures of the Zygomatic Arch . . . . . .104 CHAPTER XII. Fractures of the Lower Jaw ....... 107 CHAPTER XIII. Fractures of the Hyoid Bone ....... 129 CHAPTER XIY. Fracture of the Cartilages of the Larynx ..... 134 § 1. Thyroid Cartilage ....... 134 § 2. Thyroid and Cricoid Cartilages ..... 134 § 3. Cricoid Cartilage ....... 136 CHAPTER XY. Fractures of the Vertebrae ....... 138 § 1. Fractures of the Spinous Processes ..... 138 § 2. Fractures of the Transverse Process ..... 140 § 3. Fractures of the Vertebral Arches . . . . . 141 § 4. Fractures of the Bodies of the Vertebrae .... 146 1. Fractures of the Bodies of the Lumbar Vertebrae . . 148 2. Fractures of the Bodies of the Dorsal Vertebra? . . . 150 3. Fractures of the Bodies of the five lower Cervical Vertebra? . 151 §5. Fractures of the Axis ....... 155 § 6. Fractures of the Atlas ....... 158 § 7. Fractures of the first two Cervical Vertebrae (Atlas and Axis) at the same time ........ 158 CHAPTER XYI. Fractures of the Sternum . . . . . . .159 CHAPTER XVII. Fractures of the Ribs and their Cartilages ..... 164 § 1. Fractures of the Ribs . . . . . . .164 § 2. Fractures of the Cartilages of the Ribs . . . .169 CHAPTER XVIII. Fractures of the Clavicle . . . . . . .170 CONTENTS. XI CHAPTER XIX. Fractures of the Scapula . . . . . . .193 § 1. Fractures of the Body of the Scapula ..... 193 § 2. Fractures of the Neck of the Scapula .... 198 § 3. Fractures of the Acromion Process ..... 199 § 4. Fractures of the Coracoid Process ..... 202 CHAPTER XX. Fractures of the Humerus ....... 204 § 1. Fractures of the Head and Anatomical Neck .... 205 § 2. Fractures through the Tubercles ..... 210 § 3. Longitudinal Fractures of the Head and Neck; or splitting off of the Greater Tubercle ....... 210 § 4. Fractures through the Surgical Neck (including Separations at the Upper Epiphysis) ....... 212 § 5. Fractures of the Shaft below the Surgical Neck, and above the Base of the Condyles 224 § 6. Fractures at the Base of the Condyles (including Separations of the Lower Epiphysis) ....... 233 § 7. Fracture at the Base of the Condyles, complicated with Fracture between the Condyles, extending into the Joint . . . 241 § 8. Fractures of the Internal Epicondyle ..... 244 § 9. Fractures of the External Epicondyle .... 248 § 10. Fractures of the Internal Condyle ..... 249 § 11. Fractures of the External Condyle ..... 251 CHAPTER XXI. Fractures of the Radius ....... 255 CHAPTER XXII. Fractures of the Ulna ........ 282 § 1. Shaft of the Ulna . . . . . . .282 § 2. Coronoid Process of the Ulna ...... 287 § 3. Fractures of the Olecranon Process ..... 295 CHAPTER XXIII. Fractures of the Radius and Ulna ....... 303 CHAPTER XXIV. Fractures of the Carpal Bones ...... 312 CHAPTER XXV. Fractures of the Metacarpal Bones ...... 313 CHAPTER XXVI. Fractures of the Fingers . . . . . . .316 XII CONTENTS. CHAPTER XXVII. Fractures of the Pelvis, and Traumatic Separations of its Symphyses , 319 § 1. Pubes 319 § 2. Ischium ........ 322 § 3. Ilium ......... 324 § 4. Acetabulum ........ 327 § 5. Sacrum ........ 333 § 6. Coccyx . . . . . . .334 CHAPTER XXVIII. Fractures of the Femur ....... 335 § 1. Neck of the Femur ....... 335 (a.) Neck of the Femur within the Capsule . . . 33b' (6.) Neck of the Femur without the Capsule . . . 369 (c.) Fractures of the Neck partly within and partly without the Capsule . . . . . . . 376 § 2. Fracture through the Trochanter Major and Base of the Neck of the Femur ........ 377 § 3. Fracture of the Epiphysis of the Trochanter Major . . . 378 § 4. Fractures of the Shaft ©f the Femur ..... 379 § 5. Fractures of the Condyles ...... 423 (a.) Fractures of the External Condyle .... 423 (6.) Fractures of the Internal Condyle .... 424 (c.) Fractures between the Condyles and across the Base . . 426 CHAPTER XXIX. Fractures of the Patella ....... 428 CHAPTER XXX. Fractures of the Tibia ........ 439 CHAPTER XXXI. Fractures of the Fibula ....... 442 CHAPTER XXXII. Fractures of the Tibia and Fibula ...... 446 CHAPTER XXXIII. Fractures of the Tarsal Bones ...... 466 CHAPTER XXXIV. Fractures of the Metatarsal Bones ...... 471 CHAPTER XXXV. Fractures of the Phalanges of the Toes ..... 472 CONTENTS. XIII PART II. DISLOCATIONS. CHAPTER I. General Considerations ....... 475 § 1. General Division and Nomenclature ..... 475 § 2. General Predisposing Causes ...... 476 § 3. Direct or Exciting Causes ...... 477 § 4. General Symptoms . . . . . . .477 § 5. Pathology ........ 479 § 6. General Prognosis ....... 480 § 7. General Treatment ....... 480 CHAPTER II. Dislocations of the Lower Jaw ...... 483 § 1. Double or Bilateral Dislocations ..... 483 § 2. Single or Unilateral Dislocations ..... 487 § 3. Conditions of the Jaw simulating Luxations . . . 488 CHAPTER III. Dislocations of the Spine ....... 490 § 1. Dislocations of the Lumbar Vertebrae .... 491 § 2. Dislocations of the Dorsal Vertebrae . . . . . 492 § 3. Dislocations of the Six Lower Cervical Vertebrae . . . 495 § 4. Dislocations of the Atlas ...... 502 § 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dislocations ........ 503 CHAPTER IV. Dislocations of the Ribs ....... 504 § 1. Dislocations of the Ribs from the Vertebrae .... 504 § 2. Dislocations of the Ribs from the Sternum .... 505 § 3. Dislocations of one Cartilage upon another .... 506 CHAPTER V. Dislocations of the Clavicle . . . . . . .506 § 1. Dislocation forwards at the Sternal End .... 506 § 2. Dislocation of the Sternal End of the Clavicle Upwards . . 510 § 3. Dislocation of the Sternal End of the Clavicle Backwards . . 512 § 4. Dislocation of the Acromial End of the Clavicle Upwards . . 513 § 5. Dislocation of the Acromial End of the Clavicle Downwards . 518 § 6. Dislocation of the Acromial End of the Clavicle under the Coracoid Process ........ 519 XIV CONTENTS. CHAPTER VI. Dislocations of the Shoulder (Humerus at its Upper Extremity) . . 520 § 1. Dislocation of the Shoulder Downwards (Subglenoid) . . 521 Dislocation, with Fracture of the Humerus near its Upper End . 546 § 2. Dislocation of the Humerus Forwards (Subcoracoid and Subclavicular) 547 § 3. Dislocation of the Humerus Backwards (Subspinous) . . 552 § 4. Partial Dislocations of the Humerus . . . . .556 CHAPTER VII. Dislocations of the Head of the Radius . . . . .559 § 1. Dislocation of the Head of the Radius Forwards . . . 559 § 2. Dislocation of the Head of the Radius Backwards . . .564 § 3. Dislocation of the Head of the Radius Outwards . . . 566 CHAPTER VIII. Dislocations of the Upper End of the Ulna Backwards . . .567 CHAPTER IX. Dislocations of the Radius and Ulna (Forearm at the Elbow-Joint) . 568 § 1. Dislocations of the Radius and Ulna Backwards . . .568 § 2. Dislocation of the Radius and Ulna Outwards (to the Radial Side) 577 § 3. Dislocation of the Radius and Ulna Inwards (to the Ulnar Side) . 581 § 4. Dislocation of the Radius and Ulna Forwards . . . 583 CHAPTER X. Dislocations of the Wrist (Radio-Carpal Articulation) . . . 585 § 1. Dislocations of the Carpal Bones Backwards . . . 587 § 2. Dislocation of the Carpal Bones Forwards .... 590 CHAPTER XI. Dislocations of the Lower End of the Ulna (Inferior Radio-Ulnar Articulation) ......... 591 § 1. Dislocations of the Lower End of the Ulna Backwards . . 591 § 2. Dislocation of the Lower End of the Ulna Forwards . . 592 CHAPTER XII. Dislocations of the Carpal Bones (among themselves) . . . 593 CHAPTER XIII. Dislocation of the Metacarpal Bones (at the Carpo-Metacarpal Articulations) .......... 595 CHAPTER XIV. Dislocations of the First Phalanges of the Thumb and Fingers (at the Metacaepo-Phalangeal Articulations) . . . . .597 § 1. Dislocations of the First Phalanx of the Thumb Backwards . 597 § 2. Dislocations of the First Phalanx of the Thumb Forwards . . 604 § 3. Dislocations of the First Phalanx of the Fingers . . . 605 CONTENTS. XV CHAPTER XV. Dislocations of the Second and Third Phalanges of the Thumb and Fingers 606 CHAPTER XYI. Dislocations op the Thigh (Coxo-Femoral) ..... 609 § 1. Dislocations Upwards and Backwards on the Dorsum Ilii . . 611 § 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch 634 § 3. Dislocations Downwards and Forwards into the Foramen Thyroideum 639 § 4. Dislocations Upwards and Forwards upon the Pubes . . 643 § 5. Anomalous Dislocations, or Dislocations which do not properly belong to either of the four principal divisions before described . 647 1. Dislocations directly Upwards ..... 647 2. Dislocations Downwards and Backwards upon the Posterior Part of the Body of the Ischium, between its Tuberosity and its Spine ........ 649 3. Dislocations Downwards and Backwards into the Lesser or Lower Ischiatic Notch ....... 649 4. Dislocations directly Downwards .... 650 5. Dislocations Forwards into the Perineum . . . 651 § 6. Ancient Dislocations of the Femur ..... 652 § 7. Partial Dislocations of the Femur ..... 654 § 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur 656 CHAPTER XVII. Dislocations op the Patella ....... 659 § 1. Dislocations of the Patella Outwards .... 659 § 2. Dislocations of the Patella Inwards ..... 661 § 3. Dislocations of the Patella upon its Axis .... 662 § 4. Dislocations of the Patella Upwards ..... 664 CHAPTER XVIII. Dislocations of the Head of the Tibia . . . . . .665 § 1. Dislocations of the Head of the Tibia Backwards . . . 665 § 2. Dislocations of the Head of the Tibia Forwards . . ' . 667 § 3. Dislocations of the Head of the Tibia Outwards . . . 669 § 4. Dislocations of the Head of the Tibia Inwards . . . 670 § 5. Dislocations of the Head of the Tibia Backwards and Outwards . 671 § 6. Internal Derangement of the Knee-Joint .... 672 CHAPTER XIX. Dislocations of the Lower End of the Tibia . . . . .674 § 1. Dislocations of the Lower End of the Tibia Inwards . . 674 § 2. Dislocations of the Lower End of the Tibia Outwards . . 679 § 3. Dislocations of the Lower End of the Tibia Forwards . . 680 § 4. Dislocations of the Lower End of the Tibia Backwards . . 683 XVI CONTENTS. CHAPTER XX. Dislocations of the TJppek End of the Fibula ..... 684 §1. Dislocations of the Upper End of the Fibula Forwards . . 684 § 2. Dislocations of the Upper End of the Fibula Backwards . . 685 CHAPTER XXI. Dislocations of the Inferior Peroneo-Tibial Articulation . . . 686 CHAPTER XXII. Tarsal Luxations ........ 686 § 1. Dislocations of the Astragalus ..... 686 § 2. Astragalo-Calcaneo-Scaphoid Dislocations .... 693 § 3. Dislocations of the Calcaneum ..... 694 § 4. Middle Tarsal Dislocations ...... 695 § 5. Dislocations of the Os Cuboides ..... 695 § 6. Dislocations of the Os Scaphoides ..... 695 § 7. Dislocations of the Cuneiform Bones .... 696 CHAPTER XXIII. Dislocations of the Metatarsal Bones ..... 698 CHAPTER XXIV. Dislocations of the Phalanges of the Toes ..... 700 CHAPTER XXV. Compound Dislocations of the Long Bones ..... 701 CHAPTER XXVI. Congenital Dislocations . . . . . . .716 § 1. General Observations and History ..... 716 § 2. Etiology ........ 718 § 3. Congenital Dislocations of the Inferior Maxilla . . .719 § 4. Congenital Dislocations of the Spine .... 722 § 5. Congenital Dislocations of the Pelvic Bones .... 723 § 6. Congenital Dislocations of the Sternum .... 723 § 7. Congenital Dislocations of the Clavicle .... 724 § 8. Congenital Dislocations of the Shoulder (Upper End of the Humerus) 724 § 9. Congenital Dislocations of the Radius and Ulna Backwards . 728 § 10. Congenital Dislocations of the Head of the Radius . . 728 § 11. Congenital Dislocations of the Wrist .... 729 # 12. Congenital Dislocations of the Fingers .... 730 § 13. Congenital Dislocations of the Hip ..... 730 § 14. Congenital Dislocations of the Patella .... 736 § 15. Congenital Dislocations of the Knee .... 736 § 16. Congenital Dislocations of the Tarsal Bones . . . 738 § 17. Congenital-Dislocations of the Toes ..... 739 CHAPTER XXVII. Gunshot Fractures ........ 793 LIST OF ILLUSTRATIONS. 35. Complete oblique fracture, near the middle of the clavicle . . 172 B 34. Fracture of ribs, with lateral union . . . . .166 33. Parker's case of fracture of the odontoid process of the axis . . 157 32. Key's case of fracture of the first lumbar vertebra . . . 149 31. Oblique fracture of the body of a vertebra .... 147 30. Fracture of the vertebral arches ...... 141 29. Fracture of the spinous process ...... 138 28. The author's apparatus for a broken jaw . . . . . 127 27. Pasteboard compress for the chin . . . . . .126 26. Four-tailed bandage or sling for the lower jaw .... 126 25. Barton's bandage for a fractured jaw ..... 125 24. Gibson's bandage for a fractured jaw . . . . 125 23. Mutter's clamp for fractured jaw . . . . . . 122 22. Fracture of the lower jaw . . . . . . .107 21. Partial fracture after union is consummated .... 80 20. Partial fracture of the clavicle without spontaneous restoration . . 78 19. Partial fracture of the femur without restoration of the bone to its natural form ......... 78 18. Fergusson's case of permanent bending without fracture . . 72 17. Brainard's perforator for ununited fracture .... 68 16. Dieffenbach's drill for ununited fracture . . . . 67 15. Physick's first case, treated by seton—after 28 years ... 66 14. Clavicle, united by ligamentous bands ..... 62 13. Apparatus immobile, applied over a compound fracture . . . 56 12. Opening the apparatus with Seutin's pliers . . . . 56 11. Seutin's pliers ........ 54 10. Starch bandage applied for a broken thigh .... 53 9. Wood and leather splint ....... 50 8. Bandage of Scultetus ....... 46 7. Application of the many-tailed bandage ..... 46 6. Many-tailed bandage ....... 45 5. Application of the roller, by circular and reversed turns . . . 45 4. Fracture united with an oblique callus ..... 40 3. Union of fracture with the fragments widely separated ... 40 2. Impacted extra-capsular fracture of neck of femur ... 28 1. Longitudinal and oblique fracture ... 28 FIG. PAGE FRACTURES. LIST OF ILLUSTRATIONS. XVIII FIG. PAGE 36. Fracture of the clavicle outside of the trapezoid ligament . . 175 37. Complete oblique fracture of the clavicle at the outer end of the inner two-thirds . . . . . . . .176 38. Comminuted fracture of the clavicle united . . . .178 39. Velpeau's dressing for a fractured clavicle .... 182 40. Figure-of-8 bandage, for a broken olavicle . . . . 186 41. Keckerly's apparatus for a fractured clavicle .... 187 42. Bartlett's apparatus for a fractured clavicle .... 189 43. Fox's apparatus for a fractured clavicle. . . . '. .190 44. The author's apparatus for a fractured clavicle . . . .192 45. Fracture of angle of scapula ...... 194 46. Fractures of the body and acromion process of the scapula . . 195 47. Comminuted fracture of the glenoid cavity .... 198 48. Fracture of the neck of the scapula ..... 199 49. Fracture of the coracoid process ...... 203 50. Fracture at the anatomical neck of the humerus .... 206 51. 52. Pope's specimen of supposed fracture at the anatomical neck of the humerus, and reversion of the head—front and side views . . 209 53. Separation of upper epiphysis of humerus .... 213 54. Welch's shoulder splint ....... 224 55. Oblique fracture of the shaft of the humerus .... 225 56. Dressings applied for fracture of the humerus, with the sling looped under the wrist ........ 227 57. Lonsdale's apparatus for extension, in fractures of the humerus . . 227 58. Fracture of the humerus at the base of the condyles . . . 234 59. Fergusson's dressing for fracture of the humerus near the elbow . 238 60. Physick's elbow splints ....... 238 61. Kirkbride's elbow splint ....... 238 62. Rose's arm and forearm splint ...... 239 63. Welch's arm and forearm splint ...... 239 64. Bond's elbow splint ....... 239 65. The author's elbow splint ....... 240 66. Fracture at the base of the condyles of the humerus, and between the condyles. ........ 241 67. Fracture of internal epicondyle of the humerus .... 244 68. Fracture of the internal condyle of the humerus .... 249 69. Physick's splint for fractures of the condyles of the humerus . . 254 70. Mutter's specimen of fracture of the neck of the radius . . . 256 Fractures of head of radius . . . . . .258 72. Fracture of the shaft of the radius ..... 260 73. Colles' fracture —radius near its lower end .... 262 74. Bigelow's case of comminuted fracture of the lower end of the radius . 266 75. Nelaton's splint for fracture of the radius near its lower end . . 271 76. Bond's splint for fracture of the lower end of the radius . . . 271 77. Hay's splint for fracture of the lower end of the radius . . . 272 78. E. P. Smith's splint for fractures of the lower end of the radius—front view 272 79. Same as above—back view ...... 272 80. Shrady's splint for Colles' fracture ..... 272 81. The author's splint for fracture near the lower end of the radius . 276 82. The author's dressing for a fracture of the radius near its lower end— complete ........ 277 LIST OF ILLUSTRATIONS. XIX FIG. PAGE 83. Fracture of the shaft of the ulna . . . . . 283 84. Fracture of the coronoid process of the ulna . . . .287 85. Fracture of the olecranon process at its base .... 296 86. Olecranon process united by ligament . . . . . 298 87. Sir Astley Cooper's method of dressing a fracture of the olecranon process 300 88. The author's splint for a fracture of the olecranon process . . 301 89. The same applied . . . . . . .301 90. Fracture of the radius and ulna in the middle third . . . 303 91. Fracture of the radius and ulna in the lower third . . . 304 92. Radius and ulna united with displacement .... 304 93. Clark's case of comminuted fracture of the pelvis . . • 321 94. Fracture of the neck of the femur, within the capsule . . . 336 95. Impacted fracture of the neck of the femur, within the capsule . 339 96. Neck of unsound femur —case of Mr. S., reported by Mussey . . 347 97. The same—vertical section ...... 347 98. Sound femur of Mr. S. . . . . . . , 347 99. Neck of unsound femur; case of Mr. N., reported by Dr. Mussey . 349 100. Same as above—vertical section . . . . . . . 350 101. Sound femur of Mr. N. . . . .1. 4 Trans. Amer. Med. Assoc. Report on " Deformities after Fractures," vol. viii. p. 385, Case 17. 5 Malgaigne, op. cit., p. 377, from Ledran, Observ. Chirurg., torn. i. obs. viii. 110 FRACTURES OF THE LOWER JAW. and the ramus on the left. 1 In two of these examples the fragments were not displaced. The coronoid process is so well protected by muscles and by the surrounding bony projections, that it is very rarely broken. Houzelot mentions a case in which a fall from a height produced at the same time a fracture of both condyles, of both coronoid processes and of the symphysis. 2 With this single exception, I am not able to find a recorded example of a fracture of this process. At least nine cases have been reported of fracture of the condyles, in all of which the separation occurred through the neck, viz., three by Ribes, two by Desault, one by Bdrard, one by Houzelot, one by Bichat, one by Packard, of Philadelphia, and two by Watson, of 1ST. Y. The fracture always occurring through the neck and just below the insertion of the external pterygoid muscle. According to Malgaigne, the analysis of these cases, excepting those mentioned by Packard and Watson, shows two classes of examples: the one occasioned by falls or blows upon the chin, and producing a simple fracture of the neck of the condyle; the other, occasioned by injuries inflicted upon the side of the face, and producing a fracture of the neck on the side corresponding to that upon which the injuries are received, and at the same time a fracture of the body upon the opposite side. These two varieties seem to be about equally common. In the case mentioned by Houzelot, and already cited, there existed at the same time a fracture of both condyles, of both coronoid processes and at the symphysis. The man also whom Watson saw in the New York Hospital, had fallen from the yard-arm of a vessel, breaking his thigh and arm bones and both condyles of the lower jaw. "His face was somewhat deformed by the retraction of the chin; the mouth could not be opened so as to protrude the tongue to any great extent beyond the teeth, and the teeth of the upper and lower jaw could not be brought into contact. In attempting to move the jaw the patient experienced pain and crepitation just in front of the ears; the crepitation could easily be felt by placing the fingers over the fractured condyles. Nothing was done for the fractures of the jaw. In a few weeks the rubbing of the broken surfaces and attendant soreness ceased to trouble him; but the shape of the jaw and difficulty of opening the mouth, to any great extent, still remained unaltered." 3 Etiology. —The causes, in such cases as I have myself investigated, seem generally to have been direct blows, in most instances inflicted by a club, or by the kick of a horse; in one instance the blow was inflicted by the fist. I have also seen a fracture immediately in front of the right cuspid, in a lad eight years of age, produced by being pressed between two wagons, the pressure being made upon the two angles of the jaw. In ten of eleven cases mentioned by Stephen Smith, the causes were direct blows. Examples of fracture of the inferior 1 New York Journ. Med., Jan. 18f>7. Bellevue IIosp. Reports. 2 Malgaigne, op. cit., p. 400. 3 New York Journ. of Med., Oct. 1840. Hospital Reports. 111 FRACTURES OF THE LOWER JAW. maxilla from indirect blows have, however, been mentioned by other surgeons, the angles of the bone being pressed together by the passage of a wheel, and the fracture taking place usually towards the symphysis. We have already alluded to the observation of Malgaigne, that fractures of the condyles belong to two,classes: the one being occasioned by falls upon the chin, and the other by blows upon the side of the face: the former acting as a counter force and the latter as a direct. The coronoid process can only be broken by a direct blow. Symptoms. —Fractures of the body of the bone are characterized by the usual signs of fracture elsewhere, namely, displacement, mobility, crepitus, and pain. The displacement is generally present; but its direction and amount vary according to the situation and course of the fracture, and also according to the violence and direction of the force producing the fracture. In one instance the displacement did not exist, and indeed I think it ought to be regarded as an example of a partial fracture. A lad, aet. 9, was kicked by a horse on the 22d of June, 1858, the blow being received on the right side of the jaw. I saw him very soon after the accident, but could not detect any fracture, only the body of the jaw seemed to be bent in. On the third day, however, while endeavoring to straighten the jaw by violent pressure from within outwards I detected a feeble crepitus, which on more careful examination proved to be opposite the second incisor of the right side. I was also able to detect a slight motion at the same point. It was found impossible to rectify the bending, and no further efforts were employed. At this moment, after a lapse of nearly a year, the natural curve is partially but not completely restored. Ledran and other surgeons have also seen examples where neither the periosteum nor mucous membrane was torn. Generally, in fractures of the body, the anterior fragment is depressed; and Malgaigne affirms that where an overlapping occurs, the anterior fragment lies, generally, within the posterior; a fact which he explains by the direction which the line of fracture usually takes, namely, from without, inwards and backwards, as we have already mentioned. In one instance, reported by me to the Amer. Med. Assoc., where the jaw was broken at the symphysis and also on both sides through the body, the central fragments were found, after about four weeks, lifted two lines above the lateral fragments, and also slightly carried backwards. 1 I have twice also met with examples in which the posterior fragments were inclined to fall inwards toward the mouth, a circumstance which seemed to indicate that the course of the obliquity was in a direction opposite to that which Malgaigne has observed to be most frequent. In each of these examples the jaw was broken up»n both sides, by blows inflicted with a club, and the fractures were situated well back. 2 It is possible, however, that the position of the fragments was due rather to the direction and force of the impression than to the direction of the line of fracture. Trans. Amer. Med. Assoc., vol. viii. p. 380, 1855, Case 6. 2 Ibid., Cases 1 and 10. 112 FRACTURES OF THE LOWER JAW. As to the action of the muscles in the production of displacement, Boyer, S. Cooper, Erichsen, and Malgaigne, have observed that their action upon the anterior fragment is greater in proportion as the fracture is nearer the symphysis, and less in proportion as it approaches the angle. So that in the former case the attempt to close the mouth is sometimes attended with a depression of the anterior fragment, causing a separation of the fragments at their alveolar margins; while in the latter case, the attempt to close the mouth forcibly is occasionally attended with separation of the fragments along the line of the base. While I am not prepared to deny the accuracy of these observations, it is proper to notice that Liston finds the greatest displacement when the fracture is opposite the first molar, and I must confess that the fact, as stated by Boyer and others, does not seem to admit of a satisfactory explanation; since the number, and consequently the power of the muscles which act upon the anterior fragment from below, is greatest at a point considerably remote from the symphysis. These muscles, namely, the digastricus, the genio-hyo-glossus, and the mylo-hyoideus, with several other muscles which act less directly, all tend to depress the anterior fragment, and in some slight degree to carry it backwards, a direction which, indeed, it usually takes, and which it would probably always take if left alone to the action of the muscles. If the fracture has occurred through the angle, or at any point within the attachments of the masseter muscle, the action of those fibres of this muscle which remain connected with the anterior fragment will sufficiently explain the fact that it is not now so easily depressed below the level of the posterior fragment; while the separation of the fragments along the line of the base when an attempt is made to close the jaw forcibly, is probably due to the loosening and partial dislodgment of some of the molars, which, being pressed upwards, act as a pivot upon which the fragments are made to bend. Boyer affirms, also, that " the fractured portions are never deranged so as that one passes on the other, or in the direction of their length; for the action of none of the muscles of the lower jaw is parallel to the axis of that bone; besides, its extremities are retained in the glenoidal cavities of the temporal bones." But this theory is too exclusive, since the fragments may have become displaced in any direction independently of the muscular action. Moreover, the action of the muscles attached to the anterior fragment, although not parallel to the axis of the bone, does somewhat favor a displacement in this direction; and the action of the pterygoid muscles upon the posterior fragment still farther favors this form of displacement. An overlapping of the fragments in the direction of the axis is, no doubt, exceptional, and in such examples as I have seen, it was very trivial. It occurred in case "three" of my "Report," the fracture being near the mental foramen; in case "two," the fracture being just anterior to the last molar; and also in case "six," where the bone had been broken through the centre of the body on both sides and through the symphysis; but in neither case did the overlapping exceed two or three lines, and it was always easily overcome. 113 FRACTURES OF THE LOWER JAW. The mobility of the fragments is not so striking in these accidents as in fractures of the long bones, yet it is generally sufficiently marked and especially where the bone is broken upon both sides at the same time. If only one side is broken, both motion and crepitus will be most easily detected by lateral pressure upon the posterior fragment, which, being the smallest and the least supported by antagonizing muscles, will be found to be the most movable. If the fracture is upon both sides, mobility and crepitus will be most readily developed by seizing upon the anterior fragment and moving it gently up and down, while the finger rests upon the alveolus within the mouth. Sometimes a slight swelling or tenderness at some point of the dental arcade, or the loosening or complete dislodgment of a tooth, will indicate the point of fracture. Pain, especially when the fragments are moved, is here more constant than in most other fractures, owing, perhaps, in part to the superficial position of the bone which renders the soft parts lying over it more liable to injury from the causes of fracture; but also, in part, to the lesions which the inferior dental nerve may have suffered. It is, indeed, a matter of surprise that injury to this nerve does not oftener seriously complicate these accidents, coursing, as it does, through so large a portion of the angle and body of the bone. One might naturally suppose that its complete disruption would often occasion paralysis of those portions of the face to which it is finally distributed, and that its partial lesions and contusions would create, in many cases, the most acute and constant suffering. It is rare, however, that we have present an amount of pain which might not be attributed to a severe shock, or a slight strain upon its fibres. I have myself never seen any extraordinary suffering distinctly attributable to an injury of the dental nerve after fracture, nor any degree of facial paralysis. Rossi relates a case in which convulsions followed this accident, and in which, as a final remedy, he proposed to expose and bisect the nerve; and Flajani saw a patient whose jaw had been broken,, die in convulsions on the tenth day, the muscular contractions having commenced as early as the fourth day after the accident. The autopsy disclosed a rupture of the dental nerve, but no injury to the brain. These two examples are, as far as I know, all which our records supply, in which grave results have been attributed to lesions of this nerve; and even here some doubt must remain whether the symptoms were not quite as much due to the immediate injury done to the brain as to the nerve. Boyer explained the infrequency of severe injury to the dental nerve by the supposition that the " greater part of these fractures takes place between the symphysis and the foramen by which this nerve comes out." An opinion which may be correct, but needs confirmation. I have seen the body or angle broken at points posterior to the mental foramen, and where the nerve lies within its bony canal, twelve times, and in front of the mental foramen, eight times, and twelve times the point of fracture has not been noted with such accuracy as to enable 114 FRACTURES OF THE LOWER JAW. me to say whether it was in front of or behind the foramen; of these latter, ten are said to be near the foramen. I suspect that a better explanation may be found in the fact that the fragments seldom overlap, to any appreciable extent, and that even the displacement in the direction of the diameters of the bone is generally inconsiderable; or if it does exist, the fragments are easily and promptly replaced. If the displacement is sufficient to occasion a complete disruption of the nerve, some degree of temporary paralysis in the portions of the face supplied by it must be inevitable; and, perhaps, this occurs oftener than it has been noticed, since, during the confinement of the jaw by dressings, it is not likely to be observed, and after the lapse of a few weeks it will probably cease altogether. Boyer remarks that when it is torn, "the square and triangular muscles of the chin are paralyzed. The. skin of that part and the internal membrane of the under lip preserve their sensibility, which it appears they owe to some threads of the portio dura of the seventh pair; but the paralysis of these muscles does not prove of itself that the jaw is fractured." Boyer has, however, noticed this result but once, and then in a case where the bone was broken upon both sides and the soft parts greatly contused. The triangular and square muscles were paralyzed, in consequence of which there was a slight contortion of the mouth. A. Berard has also mentioned a case of vertical fracture occurring between the second and third molars, without displacement, which was accompanied with complete insensibility of the lip on the same side throughout the space comprised between the commissure and the median line, and between the free border of the lip and the chin. The paralysis disappeared after a few days. 1 To these signs now enumerated, we may add as occasional complications, rather than as diagnostic symptoms, salivation, swelling of the submaxillary and sublingual glands, abscesses, necrosis, &c. If the blow has been vertical upon the chin, and the direction of its force has been towards the articulations, the bony structure of the ear, and even the brain may have suffered serious lesions, which may be indicated by a deafness, or a roaring in the ears, by bleeding from the external meatus, and by fatal coma. Tessier saw a man who had received the kick of a horse exactly upon the centre of the chin, breaking the bone on both sides, and who, in consequence, bled freely from his ears; 4 and Alix relates the case of a young man who, falling from a height and striking upon his chin, had broken his jaw. Insensibility immediately followed; convulsions also ensued upon the fourth day and he died upon the sixth. 3 If the fracture is at the symphysis, it is generally vertical, and either fragment may be found slightly displaced upwards or downwards. In one of the examples seen by myself, the left fragment fell three lines below the right, and in another the right side had fallen about 1 Malgaigne. from Gazette des H 'pitanx, 10 Aout, 1*41. 2 Ibid., p. MS3 and 386 ; from Journ. de Med., 1789. torn, lxxix., p. 246. 3 Ibid., p. 386 ; from Alix, Ubservata Chir., fascia. 1, obs. 10. 115 FRACTURES OF THE LOWER JAW. one line. In a case mentioned by Syme there was scarcely any displacement 1 Liston remarks that it is usually slight. Erichsen and B. Cooper have observed the same. The signs which indicate a fracture through the angle have already been sufficiently considered when speaking of fractures of the body; from which it only differs in the less degree of displacement, and in the fact that the posterior fragments are a little more prone to fall inwards toward the mouth. I have noticed, also, that owing probably to the loosening and partial dislodgment of the last molar, it is sometimes difficult to close the mouth, the same as in the fractures a little farther forwards. In the only example of fracture of the ascending ramus which I have seen, the bone being broken also through its body, the fracture of the ramus was easily recognized by both crepitus and mobility. As to the signs which indicate a fracture of the coronoid process, I am only able to infer them from its anatomical relations. There must be some embarrassment in the motions of the jaw, occasioned by the detachment of a portion of the fibres of the temporal muscle; and it is probable that an examination by the finger within the mouth, would readily detect mobility and displacement. A fracture through the neck of the condyle is characterized by pain at the seat of fracture, especially recognized when an attempt is made to open or shut the mouth, by embarrassment in the motions of the jaw, by crepitus, which may usually be felt or heard by the patient himself, by mobility and displacement. The upper fragment, if disengaged from the lower, is drawn forwards, upwards, and inwards, by the action of the pterygoideus externus; and it is felt not to accompany the movements of the lower fragment. The lower fragment is at the same time drawn upwards, in consequence of which the lower part of the face is distorted: a circumstance first noticed by Ribes, and which supplies an important diagnostic mark between a fracture of one condyle and a dislocation. In dislocation, the chin is commonly thrown to one side, but it is to the side opposite that on which the dislocation has occurred, while in fracture the chin is drawn to the same side. Prognosis. —Physick, of Philadelphia, saw a case of non-union of the body of this bone, which had existed nine months. 2 Dupuytren mentions a case which had existed three years. 3 Horeau has recorded one example in a man who had received a gunshot wound through his face. 4 Stephen Smith, of New York, reports a case of fracture of both the body and ramus, in a man forty-five years old. The severity of the injury, with the, supervention of delirium tremens, prevented the application of dressings until the thirteenth day. On the twentieth day about a pint of blood was lost by hemorrhage from the seat of fracture. He remained in the hospital one hundred and thirty-seven 1 Amer. .lonrn. Med. Sci.. vol. xviii. p. 243. 2 Phila. Med. and Surg. Journ., vol. v. 3 herons Orales. 4 Malgaigne, from Journ. de Med., par Corvisart, etc., torn. x. pi 195. 116 FRACTURES OF THE LOWER JAW. days, and was finally discharged, the fragments not having yet united. 1 Malgaigne says that Boyer has seen several examples, but I know of no other cases which have been recorded. In no instance under my observation, has the bone refused finally to unite, although I have seen the union delayed six, seven, ten, and even eleven weeks or more. 2 In three of these cases the fractures were either compound or comminuted ; but in one case the fracture was simple, the delay in the union being due to a feeble condition of the system, and in part, perhaps, to neglect of proper treatment. The infrequency of non-union after this fracture, is a fact worthy of especial attention, because of the extreme difficulty, if not actual impossibility, in many cases, of preventing motion between the fragments, by any mode of dressing yet devised. Any one who has observed attentively, must have seen, not only that his dressings are more often found disturbed and loosened, than in the case of almost any other fracture, unless it be the clavicle, and thus the fragments have been through all the treatment subjected to frequent changes of position; but, also, that even while the dressings remain snugly in place, the patient seldom is able to perform the necessary acts of deglutition, or to speak, even, without inflicting some motion upon the fragments. Indeed, the rapidity as well as certainty with which this bone unites, has, I think, been observed by other surgeons, and I have myself noticed one instance, in an adult person, in which the bone was immovable at the seat of fracture, on the seventeenth day, and, perhaps, earlier. In other instances, the union has been speedily effected after the removal of all dressings. The amount of deformity resulting, also, from these fractures is usually very trifling, whatever treatment has been adopted. Ten of the twenty-nine examples seen by me, are recorded as resulting in some degree of imperfection, but one of these cases was complicated with other injuries, of which the patient died in a few days, and one was a case of delayed union. Only eight of the united fractures are imperfect, and in none of these is the imperfection such as to be noticed in a casual examination of the face. The deformity which is usually found, is a slight irregularity of the teeth, produced, in most cases, by a falling of the anterior fragment, but in one case by a slight elevation of the anterior fragment. But even this does not always interfere with mastication, and would often pass unnoticed by the patient himself. It is probable, too, that time, and the constant use of the lower jaw in mastication, will gradually effect a marked improvement in the ability to bring the opposing teeth into contact. I think I have observed this in several instances. Chelius remarks that in "double or oblique fractures it is very difficult to keep the broken ends in their proper place; deformity and displacement of the natural position of the teeth commonly remain." In the second example of fracture through the symphysis mentioned 1 Smith, New York Journ. of Med. and Surg., Jan. 1857. 2 My Report on Deformities after Frac, Cases 2, 14, 15, 18. 117 FRACTURES OF THE LOWER JAW. by me, the left fragment remained slightly elevated, and the patient could not close his teeth perfectly, yet he could close them sufficiently for the purposes of mastication. It is probable, however, that ordinarily no difficulty will be experienced in accomplishing a perfect cure, when the separation has taken place only at the symphysis. In fractures of the condyles, more care is requisite to retain the fragments in apposition, and sometimes it may be found to be impossible. Richerand mentions the case of a man, who, having been three months in the "Hopital de laCharite," for a double fracture of the lower jaw, one fracture being near the middle, and the other near the right condyle, left before the cure was complete. Seven or eight months after, he called upon Boyer, who extracted from a fistula in the meatus auditorius externus, a bony mass, which had evidently the form of the condyle.' Bichat mentions a similar case as having come under the observation of Desault ; 2 possibly it was the same which Boyer saw. Ribes says that a Parisian surgeon treated a double fracture of the jaw in a gentleman, one fracture being through the body, and the other through the neck of the condyle; and in spite of the most assiduous and skilful attention, the patient recovered with a lateral distortion of the jaw, occasioned by the displacement of the fragments. 3 Ribes himself had to treat an accident of a similar character, and notwithstanding all his care, the result was the same as in the other example just cited. 4 Fountain, of Iowa, was much more fortunate, having made a complete and perfect cure. 5 The proximity of this fracture to the articulating surface may occasion contraction of the ligaments about the joint; and a degree of embarrassment to the motions of the jaw has followed in the experience of Desault and others, even when the cure has been most complete ; but this has usually remained only for a short period. Sanson asserts that when the coronoid process is broken, the fracture never unites; but that mastication is performed very well, the masseter and pterygoid muscles then fulfilling the office of the temporal 6 Treatment. —The few attempts which I have made to restore a completely dislocated tooth to its socket, or to retain it in place when very much loosened, have generally resulted in its removal at some later day, and especially where the fracture has been near the angle and a molar has been disturbed. I believe it would be better practice always to remove the molars under these circumstances, unless they remain attached to the alveoli, and cannot be removed without bringing them away also; and this, whether the loosened teeth are situated in the line of fracture or not. It is seldom that they can be made again to occupy their sockets perfectly, and where the teeth are in the line of the fracture, the attempt to restore them to place will sometimes 1 Boyer, Lectures on Dis. of Bones, p. 53, Phila. ed., 1805. 2 Desault, Treatise on Fractures and Luxations, 1 hila. ed., 18(5, p. 3. 3 Malgaigne, op. cit., p. 402. 4 Ibid., p. 402. 5 Fountain, New York Jour. Med., Jan 1860. 6 S. Cooper's First Lines, Amer. ed., 1844, vol. ii. p. 311. 118 FRACTURES OF THE LOWER JAW. prevent the proper adjustment of the fragments. In cases, also, in which the teeth farther forwards are completely dislodged at the seat of fracture, it is scarcely worth while to replace them. As to those teeth whose loosened condition is due only to a splitting of the alveoli, the same rule will not always apply. Sometimes, after a careful readjustment, the fragments will reunite, and the teeth remain firm. If the bone is chipped off upon the outside, through or near the line of the sockets, the teeth may not be always much disturbed, and the loss of the fragments may be of less consequence, nor have I generally succeeded in saving them; yet if they remain adherent to the soft parts, it is proper to make the attempt. The expedients to which surgeons have resorted for the purpose of retaining in place the fragments, when the bone is broken through its body, may be arranged under the names of ligatures, splints, bandages, and slings. The ligature has been applied both to the teeth and to the bone itself. Thus, in an oblique fracture near the angle, where the fragments could not otherwise be prevented from falling inwards, Baudens passed a strong ligature, formed of thread, around the fragments and in immediate contact with them, tying the ligature over the teeth within the mouth. No accident followed, and on the twenty-third day, when he removed the ligature, the bone had united firmly and smoothly. 1 In the case of the fracture of the inferior maxilla, reported by Dr. Buck, to the New York Pathological Society, and already referred to, the bone " was broken between the two incisor teeth of the left side: the part of the bone on the left of the fracture was driven in, and interlocked behind the end of the right portion, so as to be separated by a finger's breadth. Finding it impossible otherwise to reduce the fracture, Dr. B. dissected off the under lip, so as to expose the fracture. He found that the right anterior portion of the fractured bone terminated in an angular projection as far as on a line below the left angle of the mouth. The lip was then divided to the chin, and the soft parts holding the fragments together incised. A chisel was then insinuated behind the projecting angle of the bone, while it was being excised by the metacarpal saw. When the bone was restored to its natural position, it was found so apt to become displaced, that holes were drilled at the lower angle of the fracture, and adjustment maintained by wiring them together, the wire passing out through the lower angle of the wound. Sutures and adhesive straps, with a bandage, were employed to maintain the adjustment of the parts. So far the patient has done well, being supported by liquid nourishment introduced through a tube, passed through the space left by one of the incisors, which, on account of its looseness, was removed." 2 In May, 1858, while trephining at the angle of the jaw for the purpose of cutting out a portion of the dental nerve in a patient suffering from 1 Malgaigne, op. cit., p. 398. 2 New York Journ. of Med., &c, March, 1847, p. 211. 119 FRACTURES OF THE LOWER JAW. neuralgia, I accidentally broke the jaw in two at the point at which the trephine was applied. I immediately bored a hole in the opposite extremities of the two fragments, and fastened them together with a silver wire, by which I was able to maintain complete apposition, and in three weeks the union was accomplished, the wire separating and falling out of itself. No splints were ever used. 1 With these exceptions, so far as I am aware, the ligature has been employed as a means of retention only by fastening it upon the teeth, either upon those which are situated on the opposite sides of the fracture, or upon others a little more remote, or upon the corresponding teeth of the upper jaw, or upon the teeth on the opposite sides of the same jaw. Ordinarily the ligature, composed of either fine gold, platinum, or silver wire, or of firm silk or linen threads—(Celsus advised the use of horsehair) —has been applied to the two teeth on the opposite sides of the fracture, or if these have been not sufficiently firm, to the next teeth. This practice, recommended first by Hippocrates, has received the occasional sanction of Ryff, Walner, Chelius, Lizars, Erichsen, Miller, B. Cooper, Skey, and others, but by Boyer, Gibson, and Malgaigne, it has been reprobated. Dr. S. G. Ellis, of Gowanda, N. Y., as we have already seen, has treated a fracture, occurring through the symphysis, in an adult, by placing the mainspring of a watch within the dental arcade, and securing it in place with silver wire. The mouth was kept closed by bandages carried under the chin. The fragments united with only a slight vertical displacement. 2 Dr. George Hayward, of Boston, surgeon to the Massachusetts General Hospital, says, " When the bone is not comminuted and there are teeth on each side of the fracture, the ends of the bone can be kept in exact apposition by passing a silver wire or strong thread around these teeth and tying it tightly. In several cases of fracture of the jaw, in which the bone was broken in one place only, I have in the course of the last few years, adopted this practice with entire success, and without the aid of any other means. It will be found very useful, also, as an auxiliary, in more severe cases, in which it may be required to use splints and bandages, or to insert a piece of cork between the jaws, as recommended by Delpech. It requires some mechanical dexterity to apply the thread neatly; but in large cities we can avail ourselves of the skill of dentists for this purpose." 3 I have myself in two or three instances used a linen thread with excellent results. Guillaume de Salicet advises to secure, with a silk thread, at the same moment the teeth belonging to the two fragments, and the corresponding teeth of the upper jaw ; 4 while the dentist Lemaire, being applied to by Dupuytren to secure in place the ununited fragments of a broken jaw, fastened the two left canine teeth to each other by a 1 Buffalo Med. Journ., vol. xiv. p. 148. 2 Trans. Amer. Med. Assoc. My report on " Defor.," &c, vol. viii. p. 383, Case 14. 3 Boston Med. and Surg. Journ., vol. xix. p. 133, 1838. 4 Malgaigne, op. cit., p. 392. 120 FRACTURES OF THE LOWER JAW. wire of platinum, as had been already suggested by Guillaume de Salicet; to these he added two other modes of ligature which were altogether original. One wire, made fast to the last molar upon one side, traversed the mouth and was secured to one of the bicuspids upon the opposite side; the other was stretched from the first inferior bicuspid on the right to the first superior bicuspid on the left. A cure was accomplished at the end of two months, but one of the wires had nearly bisected the tongue; and as it had gradually become imbedded, the flesh had closed over it until it rested like a seton through the middle of the tongue! 1 None of these various methods recommended themselves very satisfactorily to the practical surgeon; for besides that they are all of them, in a large majority of cases, wholly unnecessary, and in other cases, owing to the absence of the teeth, or to their loosened or decayed condition, or to the closeness with which they are set against each other, absolutely impossible, it must be seen, also, that they will generally prove feeble and inefficient. The wires act only upon the upper extremity of the line of fracture, leaving its lower portions liable to be disturbed by trivial causes; they tend gradually to loosen even the firm teeth which they embrace, and not unfrequentfy, after having been made fast with much labor, they soon become disarranged or break. They require, therefore, almost always the additional protection afforded by bandages. Alone they are usually insufficient, and if properly constructed bandages or slings are employed, they are not needed. Sometimes, moreover, they are actually mischievous, as when they loosen a sound tooth or press upon and inflame the gums. A. Bdrard passed a silver wire twice around the necks of two adjoining teeth on the opposite sides of a fracture. It retained the fragments perfectly in apposition during several days; but soon the gums swelled and became painful; the teeth loosened, and it was found necessary to remove the wire. Chassaignac sought to avoid these evils by placing the wire upon the middle of the crown, free from the gums, and by including four teeth instead of two. A waxed linen thread was made fast in this manner, in a case of simple fracture, on the seventh day. On the following morning the thread was found broken. He applied then a silk ligature in the same manner. On about the third day this also was disarranged; the ligatures were now discontinued until the eighteenth day, when he renewed the experiment with a piece of gold wire. Fourteen days after this the ligature remained firm, but the gums were red and bleeding. The patient not having again returned to Chassaignac, the result is not known. 2 As to the method suggested by Guillaume de Salicet, it presents no advantages to compensate for its inconveniences; while that actually practised by the dentist Lemaire, successful indeed, threatened to substitute a loss of the tongue for an ununited fracture of the jaw. Splints have been employed in various ways. First, simple interdental splints, laid along the crowns of the teeth and only sufficiently 1 Jour. Univer. des Sci. Med., torn. xix. p. 77. 2 Loud. Med and Phys. Journ., Nov. 1822, p. 401. 121 FRACTURES OF THE LOWER JAW. grooved to be easily retained in place; Second, clasps, which are applied over the crowns and sides of the teeth, operating chiefly by their lateral pressure; Third, splints applied to the outer and inferior margin of the jaw; Fourth, interdental splints or clasps, combined with outside splints. Interdental splints have been recommended by many surgeons from an early day, and they continue to be employed occasionally up to this moment. Boyer advises the use of cork splints placed one on each side between the upper and lower jaws, in a few exceptional cases. Miller recommends the same in all cases, the " two edges of cork sloping gently backwards, with their upper and under surfaces grooved for the reception of the upper and lower teeth." Fergusson also has usually adopted the same practice. Muys and Bertrandi employed ivory wedges. 1 On the other hand they are rejected entirely by Syme, Chelius, Skey, Erichsen, and Gibson. The objections which have been stated to their use are: that they are unsteady and become easily loosened and disarranged; that they occasionally press painfully upon the inside of the cheeks; that they accumulate about themselves an offensive sordes, and finally that they are unnecessary, since experience has proven, says Gibson, that " there is always sufficient space between the teeth to enable the patient to imbibe broth or any other thin fluid placed between the teeth." It is not strictly true, however, that in all cases there will be found sufficient space between the teeth, when the mouth is closed, for the imbibition of nutrient fluids. I have myself seen exceptions, and in such a case the patient, if the mouth were closed in the usual way, would have to be fed through a tube conveyed along the nostrils into the stomach, as suggested by both Samuel and Bransby Cooper in certain bad compound fractures, or through an opening made by the extraction of one of the front teeth; neither of which methods ought to be preferred to the interdental splints; but then the separation of the front teeth for the purpose of receiving food, is by no means the only object to be gained by their use, nor indeed the principal object. Their great purpose is to act as splints whenever the absence of teeth either in the upper or lower jaw renders the two corresponding arcades unequal and irregular and prevents our making use of the upper jaw as a kind of internal splint for the lower jaw. It is with a view to the accomplishment of this important end that they are often valuable, and ought sometimes to be considered as indispensable. I believe, also, that many of the inconveniences which have been found to attend the use of cork or wood, are obviated by the substitution of gutta percha in the manner which I have already recommended in my report to the American Medical Association, made in the year 1855. I have employed this method several times myself, and my suggestions have been followed by Stephen Smith, of 1 Lond. Med.-Chir. Rev., vol. xx. p. 470. 9 122 FRACTURES OF THE LOWER JAW. the Bellevue Hospital, New York, who, after having used the gutta percha in four cases, affirms that nothing can surpass it in efficiency. The mode of preparing gutta percha, and of adapting it between the teeth, is as follows: Dip a couple of pieces of the gum, of a proper size, into boiling water, and when they are sufficiently softened, mould them into wedge-shaped blocks, and, having wrapped each block with a piece of cotton cloth, carry them to their appropriate places between the back teeth; immediately press up each horizontal ramus of the jaw until the mouth is sufficiently closed, and the line of the inferior margin is straight; in this position retain the fragments a few minutes, until the gum has sufficiently hardened. Meantime, it will be practicable, generally, to introduce the fingers into the mouth, and to press the gutta percha laterally on each side towards the teeth, and thus to make its position more secure. When it is sufficiently hardened, remove the splints for the purpose of determining more precisely that they are properly shaped and fitted. The superiority of this splint is now at once perceived. If properly made, it is smooth upon its surface, and not, therefore, so liable to irritate the mouth as wood or cork, and it is so moulded to the teeth that it will never become displaced. The clasp, applied over the crowns and sides of the teeth is not intended to act as an interdental splint; but by its lateral pressure it is expected to hold the fragments in apposition upon nearly the same principle with the ligature. Mutter, of Philadelphia, employs for this purpose a plate of silver, folded snugly over the tops and sides of two or more teeth adjacent to the fracture: which apparatus he calls a " clamp." 1 Fig. 23. Nicole, of Nuremburg, employed for the same purpose a couple of steel plates fitted accurately along the anterior and posterior dental curvatures, secured in place Ilii HR a steel clasp, the clasp being furnished with a thumb- Wmp screw, in order the more effectually to accomplish the Mutter's clam i atera l preSSUTC for fractured jaw. Malgaigne has extended the idea of Nicole, by substituting for the two steel plates, a single plate composed of flexible and ductile iron, which is fitted accurately to all the irregularities of the posterior dental arch. From the two extremities of this plate, and from two other intermediate points, four small steel shafts arise perpendicularly, cross the crowns of the teeth at right angles, and then fall down again perpendicularly upon the anterior dental arcade. Each steel shaft being furnished with a thumb-screw, the iron plate can now be made to bear against the teeth so as to form a posterior dental splint. The teeth are also protected in front against the direct action of the thumb-screw by the interposition of a leaden plate. I am not aware that either of these modes has ever been practically tested; and I confess that I can see many disadvantages and inconveniences which would be likely to arise from their use. With the exception of Mutter's "clamp," they are all complex and must be Mutter's clamp for fractured jaw. the fracture: which apparatus he calls a " clamp." 1 Nicole, of Nuremburg, employed for the same purpose a couple of steel plates fitted accurately along the anterior and posterior dental curvatures, secured in place by a steel clasp, the clasp being furnished with a thumbscrew, in order the more effectually to accomplish the lateral pressure. Malgaigne has extended the idea of Nicole, by substituting for the two steel plates, a single plate composed g, „„„ „„ W H.,~V~ jS, ~ — J. of flexible and ductile iron, which is fitted accurately to all the irregularities of the posterior dental arch. From the two extremities of this plate, and from two other intermediate points, four small steel shafts arise perpendicularly, cross the crowns of the teeth at right angles, and then fall down again perpendicularly upon the anterior dental arcade. Each steel shaft being furnished with a thumb-screw, the iron plate can now be made to bear against the teeth so as to form a posterior dental splint. The teeth are also protected in front against the direct action of the thumb-screw by the interposition of a leaden plate. I am not aware that either of these modes has ever been practically tested; and I confess that I can see many disadvantages and inconveniences which would be likely to arise from their use. With the exception of Mutter's "clamp," they are all complex and must be 1 Trans. Am. Med. Assoc., vol. viii. p. 391. 123 FRACTURES OF THE LOWER JAW. liable to disarrangement; while thumb-screws in the mouth cannot but inflict serious injury by their pressure and friction against the mucous membrane. Gutta percha employed in the manner which I have recommended, is capable of giving no inconsiderable degree of lateral support to the teeth, and I snspect quite as much as the comfort or interest of the patient will permit, and without many of the inconveniences of the other modes, while it possesses the additional advantage of serving also, where this is needed, as an efficient interdental splint. External splints, applied along the base or outside of the jaw, were first recommended by Pare, who used for this purpose, leather; and they have been employed in some form, occasionally, by most surgeons. Generally they have been composed of flexible materials, such as wetted pasteboard, first recommended by Heister, felt, linen saturated with the whites of eggs, paste, dextrine or starch; plaster of Paris has also been used : and they have been retained in place by either bandages or the sling. I have myself used for this purpose, gutta percha, but I shall speak of it as one form of the sling dressing. Undoubtedly useful, and even necessary in some cases, especially where there exists a great tendency to a vertical displacement, they will be found, also, in many cases, to render no esssential service, and may properly enough be dispensed with. Whatever objections hold to the use of metallic clasps, must hold equally to the use of those forms of apparatus in which it is attempted to secure the fragments by means of a combination of these clasps with outside splints, and in which it is proposed to dispense with all bandages or slings, the mouth being permitted to open and close freely during the whole treatment. They are liable, moreover, to additional objections, which will be readily suggested by an explanation of their mode of construction. Chopart and Desault originated this idea as early as 1780, for fractures occurring upon both sides; in which cases they advised "bandages composed of crotchets of iron or of steel, placed over the teeth, upon the alveolar margin, covered with cork or with plates of lead, and fastened by thumb-screws to a plate of sheet iron, or to some other material under the jaw." The apparatus invented by Eutenick, a German surgeon, in 1799, and improved by Kluge, is thus described by Dr. Chester: " It consists, 1st, of small silver grooves, varying in size according as they are to be placed on the incisors or molars, and long enough to extend over the crowns of four teeth; 2d, of a small piece of board, adapted to the lower surface of the jaw, and in shape resembling a horseshoe, having at its two horns, two holes on each side ; 3d, of steel hooks of various sizes, each having at one extremity an arch for the reception of the lower lip, and another smaller for securing it over the silver channels on the teeth, and at the other end a screw to pass through the horseshoe splint, and to be secured to it by a nut and a horizontal branch at its lower surface; 4th, of a cap or silk nightcap to remain on the head; and 5th, of a compress corresponding in shape and size with the splint. The net or cap having been placed on the head and the two straps fastened to it on each side, one immediately in front of 124 FRACTURES OF THE LOWER JAW. the ear and the other about three inches farther back, which are to retain the splint in its position by passing through the two holes in each horn; a silver channel is placed on the four teeth nearest to the fracture, on this the small arch of the hook is placed, and the screw end having been passed through a hole in the splint, is screwed firmly to it by the nut, after a compress has been placed between the splint and the integuments below the jaw. " If there is a double fracture, two channels and two hooks must of course be used." 1 Bush invented a similar apparatus in 1822, 2 and Houzelot in 1826; since which the apparatus has been variously modified by Jousset, Lonsdale, Malgaigne, and perhaps others. Lonsdale says he has employed his instrument in numerous cases and with complete success. 3 Eutenick succeeded with his apparatus in a case where the displacement persisted in spite of all other means. 4 Jousset was also successful in two cases. 5 Wales, Asst. Surg. TJ. S. Navy, succeeded with an instrument of his own invention. 6 But others have not been equally fortunate; or if they have succeeded in holding the fragments in apposition, and in securing a bony union, other serious accidents have followed. In the first case mentioned by Houzelot, the instrument was kept on thirteen days, after which an attack of epilepsy deranged everything, and the patient was transferred to Bicetre. The second patient complained immediately of an intense pain under the chin and a profuse salivation followed. These symptoms were subdued by the sixth day, but, for some reason, the apparatus was finally removed on the tenth day. The fragments hereafter showed no tendency to derangement. Seven days after its removal, an abscess, which had formed under the chin, was opened. In the third case the apparatus was left in place thirty days, and an abscess formed also under the chin. Neucourt applied it in a double fracture where the central fragment was much displaced. The apposition was well preserved, but he was obliged to remove it on the seventeenth day on account of a phlegmon which was forming under the chin. The patient to whom Bush applied his apparatus, would wear it but a few days. Malgaigne had the same experience with Bush's apparatus. In addition to the pain and inflammation, followed by submaxillary abscesses, which have been such frequent results of its use, Malgaigne has noticed that it is exceedingly inclined to slide forwards and become displaced. In short, notwithstanding the unqualified testimony of Lonsdale in favor of this method of treatment, especially in fractures at the symphysis, and in fractures through any portion of the shaft anterior to the masseter muscle, it is, in my judgment, sufficiently plain that it is applicable to only a very limited number of cases, and I am not certain but that it would be better to reject it altogether; and I should 1 London Med.-Chir. Rev., vol. xx. p. 471, from Monthly Archives of the Medical Sciences, 1834. 2 Malgaigne, op. cit., p. 395. 3 Lonsdale : Practical Treatise on Fractures ; London, 1838, p. 234. 4 Malgaigne, op. cit., p. 396. 5 Ibid., p. 396. 6 Wales, Am. Journ. Med. Sci., Oct. 1860. 125 FRACTURES OF THE LOWER JAW. scarcely have thought it worth while to notice these modes of treatment at all were it not for the respectability of the gentlemen who have given them their countenance, and perhaps to show how fruitful and exhaustless in resources is the genius of our profession. The treatment of fractures of the inferior maxilla by a single-headed bandage or roller, numbers among its distinguished advocates the names of Gibson and Barton; indeed, I think the practice is at the present time peculiar to a few American surgeons. Gibson gives the following directions for applying his roller: " A cotton or linen compress, of moderate thickness, reaching from the angle of the jaw nearly to the chin, is placed beneath and held by an assistant, while the surgeon takes a roller, four or five yards long, an inch and a-half wide, and passes it by several successive turns under the jaw, up along the sides of the face and over the head; now changing the course of the bandage, he causes it to pass off at a right angle from the perpendicular cast, and to encircle the temple, occiput and forehead, horizontally, by several turns; finally, to render the whole more secure, several additional horizontal turns are made around the back of the neck, under the ear, along the base of the jaw, under the point of the chin. To prevent the roller from slipping or changing its position, a short Fig. 24. Gibson's bandage for a fractured jaw. piece may be secured by a pin to the horizontal turn that encircles the forehead, and passed backwards along the centre of the head as far as the neck, where it must be tacked to the lower horizontal turn —taking care to fix one or more pins at every point at which the roller has crossed." Barton employs, also, a compress, and a roller five yards long; the application of which is thus described by Sargent: Place the initial ex- tremity of the roller upon the occiput, just below its protuberance, and conduct the cylinder obliquely over the centre of the left parietal bone to the top of the head; thence descend across the right temple and the zygomatic arch, and pass beneath the chin to the left side of the face; mount over the left zygoma and temple to the summit of the cranium, and regain the starting point at the occiput by traversing obliquely the right parietal bone; next wind around the base of the lower jaw on the left side to the chin, and thence return to the occiput along the right side of the maxilla; repeat the same course, step by step, until the roller is spent, and then confine its terminal end. Fig. 25. Barton's bandage for a fractured jaw. 126 FRACTURES OF THE LOWER JAW. These bandages possess the advantages of being easily obtained, of simplicity and facility of application, and in general, we may add, of complete adaptation to the ends proposed. The only objections to their use which I have ever noticed, are occasional disarrangements, and the tendency, as in all other continuous rollers, to draw the fragments to one side or the other, according as the successive turns of the bandage are carried to the right or left. There is one other objection, having reference to the occasional inadequacy of this dressing to prevent an overlapping of the fragments, to which objection also the sling, as usually constructed, is equally obnoxious, and of which I shall speak presently. Finally, it is to the sling, in some of its various forms, that surgeons have generally given the preference. The sling is known, also, by Fig. 26. Four-tailed bandage or sling, for the lower jaw. the name of the four-headed or the four-tailed roller or bandage. B. Bell, Boyer, Skey, S. Cooper, B. Cooper, Syme, Fergusson, Mayor, Lizars, and Chelius, employ the sling usually; and the favorite mode is to use for this purpose a piece of muslin cloth about one yard long and four inches wide, torn down from its two extremities to within about three or four inches of the centre. Others have used leather, gutta percha, adhesive straps, gum-elastic, etc. Where the muslin is used, it is quite customary to lay against the skin a piece of pasteboard, wetted, and moulded to the chin, or simply a soft compress; and some choose to open the centre of the bandage sufficiently to receive the chin. The mid- dle of this bandage being laid upon the chin, the two ends corresponding to the upper margin of the roller are now carried across the front Fig. 27. Pasteboard compress. of the chin, behind the nape of the neck, and made fast; while the two lower heads are brought directly upwards from under the sides of the chin, along the sides of the face, in front of the ears, and made fast upon the top of the head. The dressing is completed by a short counter-band extending across the top of the head from one bandage to the other; or the several bands may be made fast to a nightcap, in which case the counter-band will be unnecessary. It only remains for me to describe my own method of dressing these fractures with the sling. Having frequently noticed the tendency of the sling, as ordinarily constructed, and of Gibson's roller, to carry the anterior fragment backwards, especially in double fractures where the body of the bone 127 FRACTURES OF THE LOWER JAW. is broken upon both sides, I devised, some years since, an apparatus intended to obviate this objection, and which I have used now several times with complete success. It is composed of a firm leather strap, called maxillary, which, passing perpendicularly upwards from under the chin, is made to buckle upon the top of the head, at a point near the situation of the anterior fontanelle. This strap is supported by two counterstraps, called, respectively, occipital and frontal, made of strong linen webbing. One of these, the occipital, is attached to the posterior margin of the maxillary strap about half an inch above the ear, and being carried around behind and under the occiput, it is finally buckled to the maxillary strap upon the opposite side, and at a point exactly corresponding to its origin. The frontal stay simply antagonizes the occipital; and having its origin and termination at the anterior margins of the maxillary strap, it is buckled horizontally across the forehead, and just above the eyebrows. The maxillary strap is narrow under Fig. 28. The author's apparatus. the chin to avoid pressure upon the front of the neck, but immediately becomes wider so as to cover the sides of the inferior maxilla and face, after which it gradually diminishes to accommodate the buckle upon the top of the head. The anterior margin of this band, at the point corresponding to the symphysis menti, and for about two inches on each side, is supplied with thread holes, for the purpose of attaching a piece of linen which, when the apparatus is in place, shall cross in front of the chin, and prevent the maxillary strap from sliding backwards against the front of the neck. The advantage of this dressing over any which I have yet seen, consists in its capability to lift the anterior fragment almost vertically, and at the same time it is in no danger of falling forwards and downwards upon the forehead. If, as in the case of most other dressings, the occipital stay had its attachment opposite to the chin, its effect would be to draw the central fragment backwards. By using a firm piece of leather, as a maxillary band, and attaching the occipital stay above the ears, this difficulty is completely obviated. Having removed such teeth as are much loosened at the point of fracture, and replaced those which are loosened at other points, unless it be far back in the mouth, and adjusted the fragments accurately, the lower jaw is to be closed completely upon the upper, and the apparatus snugly applied. It is not necessary in most cases to buckle the straps with great firmness, since experience has shown that a sufficient degree of immobility is obtained when the apparatus is only moderately tight. In this matter I am sustained also by the opinion of Mr. Fergusson. 128 FRACTURES OF THE LOWER JAW. If the integuments are bruised and tender, a compress made of two or more thicknesses of patent lint should be placed underneath the chin, between it and the leather. If the inability to introduce nourishment between the teeth when the mouth is closed, or the irregularity of the dental arcade renders the use of interdental splints necessary, gutta percha, as I have already explained, ought to be preferred to any other material. The patient must be forbidden to talk, or laugh, and when he lies down his head should rest upon its back, for whatever mode of dressing is employed, and however carefully it is applied, it will be found that a slight motion and displacement will occur whenever the weight of the head rests upon the side of the face. Occasionally, indeed, as often as every two or three days, the apparatus may be loosened or removed, only taking care generally not to disturb the interdental splints, when they are used, and to support the jaw with the hand, during its removal; and, at the same time, the face may be sponged off with warm water and castile soap. It should not be left off entirely, however, in less than three or four weeks, even where the fracture is most simple, nor ought the patient to be allowed to eat meat in less than four or five weeks. To cleanse the mouth and prevent offensive accumulations, it should be washed several times a day with a solution of tincture of myrrh, prepared by adding one drachm to about four ounces of water. The same apparatus, and without any essential modification, is applicable to fractures of the symphysis and of the angle of the inferior maxilla, as well as to fractures of the body of the bone. Instead of the leather, I have in a few instances, especially of compound fractures, where it became necessary to allow the pus to discharge externally, used a sling or a splint composed of gutta percha, suspended by bands carried over the top of the head. The piece from which this splint is made should be two or three lines in thickness, covered with cloth, and padded under the chin. It will be found convenient to cover it with cloth before immersing it in the hot water. The water should be nearly at a boiling temperature, so that the splint may become perfectly pliable; and it should be laid upon the face and allowed to mould itself while the patient lies upon his back. Having thus fitted it accurately to the face, it may be removed and openings made at points corresponding with the wounds upon the skin, before it is reapplied. In fractures of either condyle, unaccompanied with displacement, the simple leather or muslin sling will sometimes accomplish a perfect and speedy cure, as the two cases reported by Desault will sufficiently demonstrate. But if the fragments have become separated, the replacement is difficult, and the retention uncertain. Bibes was the first to suggest and to practice a very ingenious method of reduction in these cases. Having seen two examples which had resulted in deformity under the usual treatment, which consisted in simply pressing forwards the angle of the jaw, it occurred to him that while the upper or condyloidean fragment was not acted upon at the same moment by pressure from the opposite direction, a reduction FRACTURES OF THE HYOID BONE. 129 must be impossible. The case of a cannonier whose jaw was broken through the neck of the condyle on the right side, and through its body on the left, afforded him an opportunity to determine the practicability of a method of which he had as yet only conceived the idea. Malgaigne thus describes his procedure: " With the left hand seize the anterior portion of the jaw, for the purpose of drawing it horizontally forwards, while you carry the index finger of the right hand to the lateral and superior part of the pharynx. You will meet at first the projection formed by the styloid process, but moving your finger forwards you will find soon the posterior border of the ramus of the jaw; and following this border from below upwards, you will arrive at the inner side of the condyle, which you will push outwards in such a manner as to engage it upon the other fragment. This manoeuvre cannot be made without causing nausea, as the finger always does when carried into the posterior part of the pharynx; but this is a slight inconvenience. The reduction obtained, bear the jaw upwards and backwards in order to press and fix the condyle between it and the glenoid cavity, then fasten it in place with the sling." The fragments were thus easily brought into apposition in the case reported by Ribes, and the patient was cured without any deformity. In addition to these means, the angle of the jaw ought to be pressed permanently forwards by means of a compress placed between it and the mastoid process, and held in place by a suitable bandage; or we may adopt the method which proved so successful with Fountain, namely, wire the front teeth of the lower jaw to the front teeth of the upper in such a manner as to draw the chin forwards and thus maintain apposition. If the coronoid process be alone broken, it is sufficient to close the mouth with any form of sling or bandage which may be most convenient. CHAPTER XIII. FRACTURES OF THE HYOID BONE. M. Orfila has reported the case of a man, aged sixty-two years, who had been hanged, and whose os hyoides was broken through its body on its right side. 1 M. Cazauvieilh has also seen a fracture of this bone in two persons who had been hanged: in one of which the fracture was probably in the body of the bone, and in the other through one of its cornua. 2 Lalesque published in the Journal Hebdomadaire, for March, 1833, a case which occurred in a marine, sixty-seven years old, "who, in a 1 Traite de Med. legale, troisieme ed., torn. ii. p. 423. 2 Cazauvieilh, du Suicide, etc., p. 221. 130 FRACTURES OF THE HYOID BONE. quarrel, liad his throat violently clenched by the hand of a vigorous adversary. At the moment there was very acute pain, and the sensation of a solid body breaking. The pain was aggravated by every effort to speak, to swallow, or to move the tongue, and when this organ was pushed backwards, deglutition was impossible. The patient could not articulate distinctly; and he was unable to open his mouth without exciting a great deal of pain. He placed his hand upon the anterior and superior part of his neck to point out the seat of the injury. This part was slightly swollen, and presented on each side small ecchymoses, one above, more decided, immediately under the left angle of the lower jaw. ''The large cornua of the os hyoides was very distinctly to the right side," and it could be felt on the left deeply seated by pressing with the fingers; in following it in front toward the body of the bone, a very sensible inequality near the point of junction of these two parts could be perceived. By putting the finger within the mouth, the same projections and cavities inverted could be felt, and even the points of the bone which had pierced the mucous membrane, &c, were evident. Having bled the patient, and placed a plug between his teeth to keep the mouth open,, the broken branch was brought by the finger back to the surface of the body of the bone, and easily reduced. The position of the head inclined a little back; rest, absolute silence, diet and some saturnine fomentations, composed the aftertreatment. To avoid a new dislocation, by the efforts of swallowing, the oesophagus tube of Desault was introduced, to conduct the drinks and liquid aliments into the stomach ; this sound was allowed to remain until the twenty-fifth day; at this time the patient could swallow without pain, and began to take a little more solid nourishment, and at the end of two months the cure was complete. By placing a finger within his mouth, a slight nodosity could be felt in the place where, in the recent fracture, the splintered points were perceptible. 1 Dieffenbaeh has also recorded a fracture of the great right horn, produced in the same manner, by grasping the throat between the thumb and fingers, which occurred in a girl only nineteen years old. Very slight pressure upon the side of the bone was sufficient to move the fragment inwards, and to produce a crepitus, but it immediately resumed its place when the pressure was removed. There being, therefore, no displacement, the cure was effected in a short time without resort to any remedies except tisans and antiphlogistics. She was not even forbidden to speak. 2 Auberge saw a similar case, in a person fifty-five years old, occasioned by grasping the throat. The fracture was in the great horn of the right side, and the displacement was so complete that crepitus could not be felt, and the mucous membrane of the pharynx was penetrated by the broken bone. 3 The following example is reported by Dr. "Wood, of Cincinnati, Ohio, as having come under his observation in the year 1855:— 1 Amer. Journ. Med. Sci., vol. xiii. p. 250. 2 Medic. Vereinszeitung fur Preussen, 1833, No. 3; Gazette Med., 1834, p. 187. » Revue Med., July, 1835. 131 FRACTURES OF THE HYOID BONE. " Through the kindness of our friend Dr. P. G. Fore, of this city, we were invited to examine a case of fracture of the os hyoides, that had occurred about one week before we saw it, in one of his patients. The patient was a female, about thirty years of age, who had fallen down the cellar steps, striking the prominent parts of the larynx and hyoid bone against a projecting brick, severely injuring the larynx as well as fracturing the bone. " The fracture was on the left side, and near the junction of the great horn with the body of the bone. Crepitation was distinctly felt on pressing the bone between the thumb and finger; or when the patient would swallow; though, at this time, the severe symptoms that followed the accident, and continued for several days, had somewhat subsided. "Immediately after the accident, there was profuse bleeding from the fauces, and she experienced great difficulty and pain in the act of swallowing, and,the power of speech was almost entirely lost. On attempting to depress or protrude the tongue, she felt distressing symptoms of suffocation. Considerable inflammation and swelling of the throat and larynx ensued, and continued in some degree up to the time of our visit. "To-day (about four weeks since the accident) Dr. F. informs us that the patient has so far recovered as to be able to converse, though the voice is somewhat impaired. She is yet unable to swallow solid food, and is wholly sustained by fluids." 1 Marcinkovsky saw a woman in whom both the lower jaw and the left horn of the os hyoides were broken by a fall from her carriage against a wall. She died in about twenty-four hours from suffocation. 3 Dr. Grander reports the following:— " A laborer, aet. 63, fell from a wagon on his face, and discharged a large quantity of blood by the mouth. He found he could not swallow, and when seen twelve hours afterward, complained of severe pain in the neck and nape, with inability to turn his head, though no injury of the vertebrae could be detected. His voice was hoarse and difficult. On attempting to drink, the fluid was rejected with violent coughing, the patient declaring he felt it as if entering the air-passages. An examination of the fauces led to no explanation of this condition. The epiglottis did not, however, appear to completely close the larynx, or to be in its exact position. The tongue was movable in all directions, and pressing it down with a spatula caused no inconvenience. The hyoid seemed to possess its continuity. No crepitation or abnormal movability could be perceived, and no pain at the root of the tongue occurred on attempting to swallow. After repeated examinations, the case was concluded to be one in which the functions of the nervus vagus had undergone great disturbance, or the muscles of the larynx had become torn or paralyzed. Medicine and food were administered by means of an elastic tube. The patient had a good appetite and slept well; the pain of the neck was lost, and its motion recovered; ' Western Lancet; also N. Y. Journ. Med., vol. xv. p. 152. 2 Medic. Vereinszeitung, fur Preussen, 1833, No. 15 ; Gazette Medicale, 1833, p. 354. 132 FRACTURES OF THE HYOID BONE. a hectic cough, from which he had long suffered, alone remaining. After continuing, however, to go on thus well for six days, the cough increased; the appetite failed; strength was lost; the voice was scarcely audible ; and in five more days the patient died exhausted. At the autopsy a fracture of the os hyoides was found. One of the large cornua was broken, and had become firmly imbedded between the epiglottis and rima glottidis, inducing the raised position of the epiglottis, loss of voice, and difficulty in swallowing. The fracture was probably produced by muscular action, a cause first assigned in a case occurring to Ollivier dAngers." 1 I think it more probable, however, that this fracture was the result of a direct blow, than of muscular action. In the case referred to, however, as having been reported by Ollivier, there can be no doubt that the fracture was due to muscular action alone. A woman, fifty-six years old, made a misstep and fell backwards, and at the same moment that her head was thrown violently back, she felt distinctly a sensation as if a solid body had broken in the upper part of her neck, and upon its left side. An examination showed that she had fractured the great left horn of the os hyoides. Inflammation and suppuration followed, and finally, after about three months, the posterior fragment made its way out in a condition of necrosis, and the fistula promptly healed, but there remained for many years a sense of uneasiness about these parts when she swallowed, sometimes amounting to pain. 2 Etiology. —Of the ten cases which I have found upon record, three were produced by hanging; three by grasping the throat between the thumb and fingers; three by direct blows, or by falls upon the front of the neck; and one by muscular action alone. The observation of Mr. South that fracture of the bone " is almost invariably found" 3 in persons executed by hanging, is probably incorrect, since although a large proportion of these subjects are submitted to dissection both in this arid other countries, yet I know of but these three examples which have been published. Pathology, Symptomatology, and Diagnosis. —The body of the bone seems to have been broken in all of those cases which resulted from hanging: while in all of the other examples the fracture has occurred in one of the great horns, or at the junction of the horns with the body. Generally the displacement inwards of one of the fragments has been so complete that crepitus could not be detected. It was present, however, in the examples mentioned by Dieffenbaeh and Wood. In two instances the mucous membrane has been penetrated, and in one the fragment was projected between the epiglottis and rima glottidis. The accident has been characterized by a sudden sensation as if a bone had broken; in a few instances, by profuse bleeding from the fauces; by difficulty in opening the mouth; by impossibility of deglutition, and by loss of voice in others; with great pain in moving the 1 Schmidt's Jahrbuch, vol. lxviii.; also Amer. Journ. Med. Sci., vol. xlix. p. 253, Jan. 1852. 2 Malg., op. cit., p. 405. 3 Note to Chelius' Surgery, Amer. ed., vol. i. p. 581. 133 FRACTURES OF THE HYOID BONE. tongue, the pain being especially at its root; in one instance the tongue was perceptibly drawn to one side. There is also usually more or less swelling and soreness about the neck, with ecchymosis; and at a later period, cough, expectoration, hoarseness, &c. The circumstances which, however, indicate certainly the nature of the accident, are preternatural mobility of the fragments, with or without crepitus, and the angular, inward projection, which may in most cases be distinctly felt in a careful examination of the pharynx. In the case related by Griiner, the only symptoms were a loss of voice, difficulty of deglutition, and a sensation when the attempt was made to swallow, as if the fluids passed into the windpipe; with also an imperfect closure of the epiglottis upon the rima glottidis. No preternatural mobility or irregularity in the fragments could be detected, nor was there crepitus, and it was concluded that the bone was not broken, yet the autopsy showed that the fragment was imbedded deeply between the epiglottis and the rima glottidis. Prognosis. —It is only in view of its complications that this accident can be regarded as serious; where the severity of the injury has been such as to fracture the lower jaw at the same time, as in the case related by Marcinkovsky, or such as to bury the fragment deep in the tissues about the rima glottidis as in the case mentioned by Griiner, a favorable termination could scarcely have been expected ; and these are the only cases yet published in which the death was in any way connected with the fracture. One-half of the whole number have died, but of these, three have died by hanging, and the remaining two from the causes named. Of the three in which the accident resulted from a direct blow, only the patient of Dr. Fore, of Cincinnati, has survived; while of the three whose fractures resulted from lateral pressure upon the cornua, all recovered; so, also, did the patient in whom the fracture was produced by muscular action. Treatment. —No doubt when the fragments are displaced an attempt ought to be made to replace them by introducing one finger into the mouth, while with the opposite hand the fragments are supported from without. Lalesque found this a matter of some difficulty, but Auberge experienced no difficulty at all. I suspect, however, that the amount of difficulty will very much depend upon the degree of displacement, and the consequent lacerations of the soft tissues about the bone. But however this may be, it must be altogether another thing to be able to keep in exact apposition the broken ends of a bone whose diameter is so inconsiderable and upon which it is quite impossible to apply any apparatus or dressings to retain the fragments in place. Lalesque threw the head of his patient slightly back, with the view of making " permanent extension" upon the fragments through the action of the muscles and ligaments attached to the bone, and he recommends this position as that which is best calculated to preserve the coaptation. Malgaigne, on the contrary, without having himself seen any example of this fracture, believes that the position of flexion of the neck, with entire relaxation of the muscles, would be most suitable. In all cases it will be proper to enjoin silence, and to adopt suitable measures to combat inflammation: such as general or topical bleeding, 134 FRACTURE OF THE CARTILAGES OF THE LARYNX. fomentations, moistening the mouth with cool water, or permitting small pieces of ice to rest in the mouth until dissolved, without in general allowing the fluid to be swallowed; but in some examples, no doubt the patient may be permitted to swallow. CHAPTER XIV. FRACTURE OF THE CARTILAGES OFTHE LARYNX. § 1. Thyroid Cartilage. The examples of fracture of the larynx which may be found upon record, are also very few. M. Ladoz examined the larynx of a man who had been assassinated, and upon whose neck he found a handkerchief bound so tightly as to leave, after its removal, a deep furrow; but the neck showed also distinct marks produced by the fingers and thumb. There was a fracture of the thyroid cartilage which extended obliquely downwards and outwards through its right wing. The whole of the larynx was very much ossified, although the subject was only thirty-seven years old. 1 In 1823, M. Ollivier communicated to the Academy of Medicine a case in which, this cartilage being broken, the patient died of suffocation 2 M. Marjolin says, "Two women at the hospital being engaged in a quarrel, one of them seized her antagonist by the throat, and griped her so strongly that she broke the thyroid cartilage from its upper to its lower margin. You will imagine that it was not very difficult to determine the existence of a fracture, and that no retentive apparatus was demanded. Silence, regimen, a small bleeding, and the cure was accomplished." 3 These are the only cases of fracture of the cartilages of the larynx of which we have any precise account, in which the thyroid cartilage was alone involved. § 2. Thyroid and Cricoid Cartilages. Plenck saw a fracture of both the thyroid and cricoid cartilages produced by falling upon the rim of a pail. 4 Morgagni also says that he had seen fractures of the larynx; and Remer mentions a fracture of the larynx found in a person who had been hanged ; 5 but in neither 1 Gazette Medicale, 1838, p. 698. 2 Archives Generates de Medecine, tome ii. p. 307. 3 Marjolin, Cours de Patholog. Chir., p. 396. 4 Malg., op. cit., p. 409. 5 Morgagni, de Sedibus, etc., Epist. 19, num. 13,14 et 16 ; Remer, Annales d'hygiene, tome iv. p. 171; from Malg. 135 THYROID AND CRICOID CARTILAGES. case is it said in which cartilage the fracture occurred, or whether it had not occurred in both. I am able, however, to furnish from my own observation another example of fracture of both cartilages:— John Calkins, of Collins, Erie Co., N. Y., set. 41, is supposed to have been kicked by a young horse on the 10th of Nov. 1856. He was alone in the stables when the accident occurred, and being stunned by the blow, he could not himself give any account of the manner in which the injury was received. When found he was sitting upright, but unable to articulate except in a whisper. Drs. Barber and Davis, of Colden, saw him about two hours after. His countenance was anxious; his pulse feeble; extremities cold; and he was breathing with great difficulty. A small quantity of blood was issuing from his fauces. His upper lip was cut and a few of. his teeth dislocated; the wound appearing as if inflicted by one of the corks of the horse's shoes. There was no other wound; but over the left wing of the thyroid cartilage there was a slight discoloration, pressure upon which produced intense pain and suffocation, and disclosed the fact that the thyroid prominence was depressed very much and broken. Cold lotions were directed to be applied, and as the thirst was excessive, but deglutition impossible, he was permitted to hold pieces of ice in his mouth. This plan, with but slight modifications, such as the substitution of warm fomentations to the neck for the cold lotions, was continued until the following evening, when, at the request of the attending physician, Dr. Barber, I was called to see him. The symptoms remained nearly the same as at first. He was unable to speak audibly, or perform the act of deglutition; his breathing was difficult and at times threatened suffocation. The lateness of the hour, with other circumstances, determined me to defer surgical interference until morning. At daybreak of the 12th I made the operation of laryngotomy, and introduced a large double canula into the crico-thyroidean space. This operation was rendered difficult by the great amount of swelling about the neck, due both to emphysema, and bloody with serous infiltrations. The breathing immediately became easy, and gradually the appearance of asphyxia disappeared from his face; but after about six or seven hours, he began perceptibly to fail in strength, and died at 3 o'clock P. M., of the following day, apparently from exhaustion rather than from suffocation: having survived the accident about seventy-two hours, and the operation about thirty-four hours. The autopsy disclosed a comminuted fracture of the thyroid cartilage, with a simple fracture of the cricoid. The thyroid was broken almost perpendicularly through the centre; the line of fracture being irregular, and inclining slightly to the left side. The left inferior horn was broken off about three lines from its articulation with the cricoid cartilage. The right ala was broken also in a line nearly vertical, but irregular, at a point about six lines from its posterior margin. The pomum Adami was depressed to the level of the cricoid cartilage, and the left ala, being completely detached, was thrown inwards and upwards several lines. Underneath the perichondrium, especially upon the inner side, there was pretty extensive bloody infiltration. Ossifi- 136 FRACTURE OF THE CARTILAGES OF THE LARYNX. cation of the cartilages had commenced at several points, but it had made but little progress. The central fracture of the thyroid was through cartilage alone. The fracture of the right ala was through cartilage until it reached a bony belt comprising the two inferior lines of its course. The left lower horn was ossified, and the fracture was through this bony structure. The fracture through the cricoid cartilage commenced close upon the margin of a bony plate, but in its whole course it traversed only cartilage. It was on the left side. There was also an incomplete fracture on the right ala of the thyroid cartilage, commencing in the line of the principal fracture and extending obliquely downwards about three lines, until it was arrested by the bony plate which constituted the lower margin of this wing. A ragged, lacerated wound in the back of the larynx, above the cricoid cartilages, communicated directly with the oesophagus. § 3. Cricoid Cartilage. Both Valsalva and Cazauvieilh have each met with a single example of this fracture, without fracture of the thyroid cartilage; and Weiss has found the cricoid cartilage broken into numerous fragments, and at the same time separated from the trachea. 1 General Etiology of Fractures of the Laryngeal Cartilages.—As a predisposing cause, advanced age, with its usual concomitant, partial or complete ossification of the cartilages, has been thought to occupy a prominent place. The number of recorded cases is, however, too small to establish its actual value. In the case reported by Plenck, the cartilages were already very much ossified, although the subject was only thirty-seven years old. Morgagni observed that in his experience it had occurred always in advanced life. In my own case, however, the cartilages were only slightly ossified, the patient being forty-one years old ; nor did the lines of the several fractures indicate a preference for the bony plates; but it seems to me that they rather avoided them, and in the case of the incomplete fracture, the bone appeared to have arrested the fracture. In fact, a few experiments have satisfied me that the adult laryngeal cartilages are quite as brittle as bone, and, consequently, that ossification in no way increases their liability to fracture. The immediate causes have been direct blows, as falling upon the edge of a pail, a kick from a horse, or pressure, as in hanging, or in grasping the larynx strongly between the thumb and fingers. General Symptomatology, etc. —The signs of this accident are such as usually attend any severe injury of this organ, whether accompanied with a fracture or not, such as pain, swelling, difficult deglutition, embarrassed respiration, a loss of voice, cough, and perhaps bloody expectoration, with emphysema, &c. But none of these can be regarded as diagnostic; although, when taken in connection with the history of the accident, especially if a 1 Malg., op. cit., p. 408. 137 CRICOID CARTILAGE. very severe and direct blow "has been received, or more certainly still when symptoms so grave and complicated have followed an attempt at strangulation by grasping the throat, they may be regarded as probable or presumptive evidences. A positive diagnosis must depend upon the presence of a sensible displacement, or motion of the fragments, with crepitus. In the case related by Plenck, death followed almost immediately, with convulsions, and without any outcry; indicating, probably, some severe lesion of the spinal marrow; while in M. Ollivier's patient suffocation ensued, at first intermittent, and finally permanent. In my own case, suffocation was throughout a prominent symptom, with only such slight intervals of amelioration as might have been occasioned by the extrication of the blood or mucus from the larynx. General Prognosis.—The prognosis ought to depend rather upon the complications and upon the gravity of the symptoms, than upon the simple decision of the question of fracture. A fracture produced by grasping the wings of the thyroid cartilage, and without any great contusion or laceration of the soft parts,* might reasonably be expected to terminate favorably under judicious management; but when, on the contrary, the fracture is the result of great violence inflicted directly upon the front of the cartilages, producing severe contusion and laceration, and is by great swelling, very difficult respiration, complete aphonia, impossibility of deglutition, &c, the prognosis cannot but be unfavorable—and indeed the woman spoken of by Marjolin, whose larynx was broken by grasping the neck, is the only one, so far as we know, whose recovery has been mentioned. General Treatment.—In examples of simple, uncomplicated fracture, "silence, regimen and a small bleeding," may suffice; but in other cases, it may become necessary to introduce a tube into the stomach to supply the patient with food and drinks, since deglutition may be impossible. If, also, suffocation is imminent, there may remain no alternative but a resort to tracheotomy, or to laryngotomy. I am not aware that this has ever been practised except by myself, yet its propriety, under certain conditions, is sufficiently manifest. As to a " reduction " of the fragments, by manipulation, I believe it will be found generally, if not always, impracticable. Whatever displacement exists must be mostly inwards, and we can have no means of forcing them again outwards. Nor if once replaced, do I see any reason to suppose that they would not become immediately displaced. Chelius has suggested the propriety, in such cases, of cutting open the coverings of the larynx freely in the mesian line, and after stanching the bleeding, proceeding at once to divide the larynx itself in its whole length and then. replacing the broken cartilages. 1 The procedure has an aspect of severity, but I can well conceive of circumstances which would justify its adoption; not, however, so much for the purpose of replacing the cartilages, as for the purpose of arresting a fatal internal hemorrhage, and of giving a free admission of air to the 1 System of Surgery, Philadelphia ed., vol. i. p. 581, 1847. 10 138 FRACTURES OF THE VERTEBRA. lungs. If this operation were to be practised, the wound ought to be left open for a sufficient length of time to allow of the subsidence of the inflammation, and then permitted to close with such precautions as experience teaches are usually necessary after the windpipe has been opened. Active antiphlogistic measures, combined with fomentations to the neck, so far as these latter are found to be agreeable and practicable, are important measures, and not to be overlooked in the general plan of treatment. My own patient, also, found small pieces of ice, permitted slowly to dissolve in the mouth, very grateful; but he preferred very much as an external application, the warm fomentations to the cold lotions. CHAPTER XV. FRACTURES OF THE VERTEBRAE. It will be convenient to divide fractures of the vertebrae into fractures of the spinous processes, transverse processes, vertebral arches and bodies. § 1. Fractures op the Spinous Processes. Fractures of the spinous apophyses, independent of a fracture of the arches, may occur at any point of the vertebral column; and they may Fig. 29. Fracture of the spinous process. be occasioned by a blow received upon either side of the spinal column; or by a force directed from above or from below. Symptoms and Pathology. —These accidents may be recognized by the lively pain at the point of fracture, produced especially when the patient bends forwards, which position renders the skin and muscles tense and drives the fragments into the flesh; by the swelling, tenderness and discoloration; but chiefly by the lateral displacement of the broken process, and the mobility. Duverney met with a fracture of two of the processes in the same person, and which could only be recognized by the mobility, since, as the autopsy proved, there was no displacement. Nor would it be surprising if the displacement was absent in a majority of these accidents, inasmuch as the attachment of the ligaments from above and below with the strong and short muscles upon either side, must prevent a deviation in any direction until these tissues were 139 FRACTURES OF THE SPINOUS PROCESSES. more or less torn. Sir Astley mentions a case in which, however, such lacerations did occur, and the lateral deformity was quite conspicuous. A boy had been endeavoring to support a heavy weight upon his shoulders, when he fell, bent double. Immediately he had the appearance of one suffering under a distortion of the spine of long standing. Three or four of the processes were broken off and the correspondingmuscles were detached so as to allow the processes to fall off to the opposite side. There was no paralysis, and he was soon discharged with the free use of his limbs, but the deformity remained. 1 If the fragment is thrown directly downwards, as it possibly may be, especially in the cervical or lumbar region, yet not without a rupture of the supra-spinous ligaments, or of the ligamentum nuchas, then the displacement will be more difficult to detect, and it may require some more care not to confound it with a fracture of the vertebral arch or of the plates from which the spinous processes arise. The process not being felt in its natural position, nor upon either side, it may seem to have been forced directly forwards, when in fact it is only thrown downwards towards its fellow. The danger of error in the diagnosis will be increased when to these conditions are added paralysis of those portions of the body which are below the seat of the fracture, and which, in this case, may be the result of an extravasation of blood or of simply a concussion of the spinal marrow. Nor do I think it would be possible now to determine positively whether it was simply a fracture of a spinous process, of the arch, or of the body itself of the vertebra. In case, however, the paralysis results from concussion, the fact will in most cases soon become apparent by a return of sensation and of the power of motion. Prognosis. —Hippocrates affirmed that here, as in fractures of other spongy bones, the union took place speedily. It is quite probable that this venerable father of surgery has stated the fact correctly, and yet in the only example known to me where the condition of this process, as proved by dissection, has been carefully stated, the fragment had not united by bone at all. This is the case related by Sir Astley as having been examined by Mr. Key. A subject was brought into the dissecting room in which one of the processes had been broken, and, on dissection, a complete articulation was found between the broken surfaces, which surfaces had become covered with a thin layer of cartilage. The false articulation was surrounded with synovial membrane and capsular ligaments, and contained a fluid like synovia. 4 Ordinarily the displacement continues, whatever treatment may be adopted; but Malgaigne says he has seen one instance in which the twelfth dorsal spine being broken and displaced laterally, resumed its place spontaneously after a few days. Aurran mention a similar example. 3 Treatment. —If in any case it should be found possible to act upon the fragment, an attempt might be made to press it into place, and to retain it there by means of a compress and bandage; but even this 1 Sir Astley Cooper, op. cit., p. 459. 2 A. Cooper, op. cit., p. 459. 3 Malgaigne, op. cit., p. 412. 140 FRACTURES OF THE VERTEBRA. would not be admissible so long as any doubt remained whether it was not a fracture of the vertebral arch, since if it were, any attempt to restore the bone to place by pressure would be likely to drive it more deeply upon the spinal marrow. Yet what need is there of surgical interference of any kind ? If the apophysis remains displaced it cannot result in any serious, perhaps we may say in any appreciable deformity. The surgeon has therefore only to lay the patient quietly in bed and in such a position as he finds most comfortable, enjoining upon him perfect rest, and employing such other means as may be proper to combat inflammation. § 2. Fractures op the Transverse Process. A fracture of a transverse process can scarcely occur except as a consequence of a gunshot wound. Dupuytren relates a case of this kind in which the ball had penetrated the transverse process of the second cervical vertebra. The man bled very little at the time, and his symptoms progressed favorably for ten days; after which secondary hemorrhage occurred, of which he ultimately died. The autopsy showed that the vertebral artery had been injured, and that the inflammation of its coats being followed by a slough, caused his death. 1 I have also elsewhere reported the case of Charles Harkner, of this city, who was shot with a pistol on the 21st of Jan., 1851. I did not see him until the following day. The ball had entered the chin, a little to the left side and below the inferior maxilla, but its place of lodgment could not be discovered. He lay with his face constantly turned to the right. The left side of his neck was swollen and crepitant; the left arm and leg were paralyzed; he slept most of the time, but could be easily aroused, and when aroused he seemed to be conscious, but was unable to speak. By signs he indicated to us that he was suffering no pain. He gradually sank, without hemorrhage, and died in thirtysix hours from the time of the receipt of the injury. The autopsy, made four hours after death, enabled us to trace the wound from the chin, through the left ala of the thyroid cartilage, and also through the roots of the transverse process of the fourth cervical vertebra; immediately behind which, lying imbedded in the muscles, was the bullet. The cavity of the tunica arachnoides contained considerable serous effusion. The emphysema in the neck was occasioned, no doubt, by the wound of the larynx, the ball having opened freely into its cavity. This circumstance also explained the aphonia; but the immediate cause of his death seems to have been arachnoid effusion as a result of meningeal inflammation. The symptoms arising from this accident can only refer to the complications, since a mere fracture of the process is not likely to present any peculiar signs which could be recognized. Concussion or bloody effusion may take place so as to occasion more or less paralysis, or, at a later period, inflammation and its consequent effusions may give rise to the same phenomenon. 1 Dupuytren, Diseases, &c, of Bones, Syd. ed., p. 360. 141 FRACTURES OF THE VERTEBRAL ARCHES. In itself considered, and independent of these complications, it is sufficiently trivial, but inasmuch as it has not been known to occur except from gunshot wounds, nor is it likely to occur except from penetrating wounds of some kind, the accident must always be regarded as exceedingly grave, if not actually fatal. As to the treatment, nothing but strict rest and antiphlogistic remedies can prove of any service. § 3. Fractures of the "Vertebral Arches. The vertebral arches, upon which both the spinous and transverse processes have their principal support, may be broken at any point of their circumference, by a blow received upon the spinous process; but generally it is the lamellar portion, or the " vertebral plate," which gives way rather than the neck or pedicle of the arch; and in all of the cases recorded the plates have been broken upon both sides. On the first of May, 1851, during a violent storm of wind and rain, a balustrade fell from the top of a high building, striking a man named John Larkin, who was about forty years of age, upon the back of his head and neck. He fell to the ground instantly, and did not again move his feet or legs, although he never lost his consciousness until he Fig. 30. Fracture of the vertebral arch. died. I found the bladder paralyzed also, and his left arm, but his right arm he could move pretty well. He conversed freely up to the last moment, and said that he was suffering a good deal of pain, which was always greatly aggravated by moving. His death took place thirty-six hours after the receipt of the injury. Dr. Hugh B. Yandeventer, who was the attending surgeon, made a dissection on the following day in my presence, which disclosed the fact that the plates of the sixth cervical vertebra were broken upon each side, and that the spinous process with a small portion of the arch attached was forced in upon the spinal marrow. There was no blood effused, or serum at this point, but about one ounce of serum was found in the cavity of the tunica arachnoides at the base of the brain. The bodies of the vertebrae were not broken. It was our opinion, therefore, that the immediate cause of his death was the direct pressure of the spinous process. In the case related by Prout, of Alabama, the man having died within forty-eight hours after the receipt of the injury, the arch of the fifth cervical vertebra was found to be broken in three places, and the spinous process was driven in upon the spinal marrow. There was a slight effusion of blood between the sheath of the spinal marrow and the bone, and a considerable effusion between the sheath and the cord. 142 FRACTURES OF THE VERTEBRAE. There was no material lesion of the cord or of its membranes, and the body of the bone was neither broken nor dislocated. 1 It is probable, also, that in the following example the arch was broken, but that the force of the blow having been somewhat oblique, the process was but little if at all thrown in upon the spinal marrow. R. L., of this county, aged about forty years, was thrown from a loaded wagon in February of 1851, striking, as he thinks, upon the back of his neck. He was stunned by the injury, and remained insensible several hours; on the return of consciousness, he found that his lower extremities and bladder were paralyzed. During four weeks his bladder had to be emptied by a catheter. Nine months after the injury was received he consulted me, and I found the spinous process of the last cervical vertebra pushed over to the left side. His head was strongly bent forwards, and he was unable to straighten it. He could walk a few steps, but not without great fatigue; and he suffered almost constant pain in his lower extremities, accompanied with excessive restlessness and watchfulness, for which he was obliged to take morphine in large quantities. * In the case related by Alban G. Smith, of Kentucky, to which I shall refer again presently, the deviation was lateral, and so also in Ollivier's case, mentioned by Malgaigne. Symptoms. —We can imagine a case of fracture of the vertebral arch, with a lateral displacement only, in which the symptoms might not differ essentially from a simple fracture of the spinous process; and it is quite possible that some of' the cases which have been supposed to be examples of this latter accident, and in which a speedy recovery has taken place, were really examples of fracture of the arches; yet it must be admitted that such a fortunate result is only possible, since the arches can hardly be broken without communicating a severe concussion to the marrow, nor without lacerations, inflammation, and effusions, which will be most certain to produce compression and paralysis, and probably death. If, however, it is possible for us to confound a fracture of the process with a fracture of the arches, it is still more possible for us to confound a fracture of the arches with a fracture of the bodies of the vertebrae. If, as is usually the fact, the process, in case of a fracture of the arch, is less prominent than natural, and that portion of the body receiving its nervous supply from below this point is paralyzed, we may have reasons to believe that the arch is broken and the process driven in upon the spine; but dissections have shown that in many of these cases, or in most of them, indeed, the bodies of more or less of the vertebrae are broken also, and in still other cases the bodies were alone broken. If, as in the case mentioned by Ollivier, we can feel the plates move separately, the diagnosis might be made out, so far at least as to determine that the plates were broken; but we should be still unable to say that the bodies of the vertebrae were not broken also. 1 Prout, Amer. Journ. Med. Sci., Nov. 1837, vol. xxi. p. 276, from Western Journ. of Med. and Phys. Sci. FRACTURES OF THE VERTEBRAL ARCHES. 143 Something perhaps may be inferred from the direction and manner of the blow which has produced the fracture. Thus a fall upon the top of the head would most often produce a comminution of the bodies by crushing them together, while a blow upon the back could scarcely break one of the vertebrae without breaking the corresponding arch also. We might thus be led to infer, in the first instance, that the arches were not broken; and, in the second instance, if we could convince ourselves that the arches were not broken, we might rest pretty well assured that the bodies were not. In the case related by Prout, there was no external mark of injury over the point of fracture, but a distinct crepitus was perceptible on pressure. Treatment. —If the fragments are not displaced, nothing but rest and a cooling regimen are indicated; but if they are forced in upon the marrow, an important question is presented, and which has received from different surgeons different solutions. Shall an effort be made to reduce the fragments? and if so, by what means shall the indication be attempted ? It will be remembered that in nearly all of these cases we must remain in doubt, even after the most careful examination, as to the actual condition of the fracture. It may be that what we suppose to be a fracture of the arch is only a fracture of the apophysis, or that on the other hand it is a fracture of the body of the bone itself, and if we are expert enough to make out clearly a fracture of the arch, it is not possible for us to say that the body is not broken also, indeed it is quite probable that it is broken. With a diagnosis so uncertain, can we ever find a justification for surgical interference ? Mr. Cline and Mr. Cooper thought that we might. According to them, the case presents in no other direction a point of hope or encouragement. Death is inevitable, sooner or later, if the fragment is not lifted, and we can scarcely make the matter any worse by interference. If it proves to be a fracture of the apophysis, as happened to be the case in a patient upon whom Sir Astley operated, 1 our interference was unnecessary, but it has done no harm. If the body of the bone is broken, the operation affords no resource, but the patient is probably beyond suffering damage at our hands. If the diagnosis is correctly made out and the arch only is broken, and if, as was the fact in the case of Larkin already mentioned, there is no bloody effusion, or laceration of the membranes or of the marrow, and if the concussion was not sufficient to determine much inflammation of the cord, then it would seem possible that an operation might save the patient. Paulus first suggested that the compressing fragments ought to be removed by excision; and in 1762 Louis removed from a man who had received a gunshot wound in his back, after the lapse of five days, several loose pieces of bone belonging to the arch of the vertebra, and the patient recovered, but not without a partial paralysis of his lower extremities. Of course nothing could be more rational or simple than this procedure, adopted by Louis, in any case of Chelius's Surgery, Amer. ed., note by South, vol. i. p. 592. 144 FRACTURES OF THE VERTEBRAE. an open wound, where the fragments could be easily reached; but the younger Cline was the first, in the year 1814, to put into practice the more ancient suggestion of Paulus iEgineta, namely, to attempt the removal of the fragments in a case of simple fracture. He made an incision upon the depressed bone as the patient was lying upon his face, raised the muscles covering the spinal arch, applied a small trephine to the arch, and cut it through on each side, so as to remove the spinous process, and the arch of the bone which pressed upon the spinal marrow. This patient died on the 4th day after the receipt of the injury and the 3d after the operation. Mr. Oldknow repeated this operation in 1819 in a case of fracture of the arch of the sixth vertebra. The patient died on the 7th day. In 1822, Mr. Tyrrell operated at St. Thomas Hospital on a man who had just been admitted with a fracture through the arches of the ninth and tenth vertebrae. The operation was accomplished with considerable difficulty, and resulted in only a partial return of sensibility. He died on the twelfth day. 1 In 1827, Tyrrell operated a second time, and death resulted on the fifth day. On the 30th of August, 1824, Dr. J. Rhea Barton, of Philadelphia, operated upon a man who had been received into the Pennsylvania Hospital twelve days before, with a fracture of the arch of the seventh dorsal vertebra, and the lower part of whose body was at the time completely paralyzed. On removing the spinous process, it was discovered that the seventh and eighth dorsal vertebrae were dislocated upon each other. No immediate relief was afforded by the operation, but sensibility began to return in the lower extremities after about forty-eight hours. On the third day he was attacked with a violent chill, and death took place twelve hours after. The dissection showed about half a gallon of blood in the posterior mediastinum, and bloody effusions existed along the whole length of the spinal canal. 2 Dr. Potter, of New York, who operated three months after the receipt of the injury, lost his patient on the eighteenth day. 3 The patient whom Laugier trephined at the base of the spinous process of the ninth dorsal vertebra, died on the fourth day. Chelius says that the operation has been repeated unsuccessfully by Wickham, Attenburrow, and Holscher. 4 February 5th, 1834, Dr. David L. Rogers, of New York, operated upon a man who had fallen two days before, breaking the arch of the first lumbar vertebra, and forcing the spinous process upon the cord. In the first steps of the operation several fragments of bone were removed which had been broken from the spinous process, and only those portions of the arch remained which were attached to the oblique processes. An effort was made to separate these processes by the knife, but this was found to be impossible; and an attempt to use Hey's saw caused great pain accompanied with convulsive actions of the muscles of the back. Having finally made the bone fast by the aid of a double hook and elevator, the saw was again applied success- 1 Sir A. Cooper, op. cit., pp. 478—80. 2 Barton, Godman's ed. of Sir A. Cooper on Disloc, &c, p. 421. 3 Potter, Malgaigne, translated, note by Packard, p. 344. * Chelius's Surgery, Amer. ed., vol. i. p. 590. 145 FRACTURES OF THE VERTEBRAL ARCHES. fully on one side. The opposite side was also at length removed at the articulations of the oblique processes by the cautious use of the knife and by tractions. About two inches of the spinal cord was now exposed, covered with coagulated blood. The cord itself did not seem to be injured. In about fifteen minutes after the operation, this patient expressed himself as being much relieved; sensibility returned to his lower extremities; respiration became easy, and with the assistance of an anodyne he slept for several hours. Subsequently he became worse, and on the eighth day he died; when the autopsy revealed a fracture of the body of the vertebra from which the spinous process and arch had been removed, but no displacement of the fragments. 1 These are all of the cases of which we have any very accurate information in which this operation has been made, and they have all terminated fatally in a very few days. The case reported by Alban G. Smith, of Kentucky, is not related in such a manner as to enable us to make use of it safely, nor is it stated how long the patient survived the operation; Gibson says it gave no permanent relief. The example mentioned by an English writer is equally unreliable, inasmuch as it is given only upon rumor, and but a "few months" had elapsed since the operation was performed. It was said to have been made in the year 1838, by a surgeon of the name of Edwards, in South Wales; and it was affirmed that the compression was relieved and that the patient "did well." 8 So unique a case would certainly have found before this an ample confirmation. Experience, then, seems to have sufficiently shown that we have no right to expect anything from this surgical expedient; and notwithstanding the strong hope expressed by Sir Astley, that Mr. Cline's operation might hereafter prove a valuable resource, and contrary to the conclusions which we in common with many other surgeons had drawn from the anatomical relations of these parts, we are compelled reluctantly to declare that the expedient is no longer worthy of a trial. To the same conclusion also many of the most distinguished surgeons have arrived; among whom we may mention, as especially entitled to confidence, Brodie, Liston, Malgaigne, and Gibson. What more can be said of the attempt to raise the depressed bone by seizing the spinous process with the fingers, or with a pair of strong hooked forceps passed through the skin, or finally, if this cannot be done, by laying bare both sides of the process and seizing upon it with a pair of firm tenacula ? This is the alternative presented to Malgaigne, and which he ventures to recommend as deserving a trial. In the absence, however, of any testimony in its favor, beyond the mere rational argument adduced by this distinguished writer, we must waive any farther consideration of the subject; only expressing our well-established conviction that it will be found, after a fair trial, as useless and as inexpedient as the more severe operation of Cline. Jeffries Wyman, of Boston, in a private communication, informs me that he has met with six examples of fracture of the vertebral arch 1 Rogers, Amer. Journ. Med. Sci., May, 1835, vol. xvi. p. 93. 2 Edwards, British and Foreign Med. Rev., 1838, p. 162. 146 FRACTURES OF THE VERTEBRAE. occurring in the fifth lumbar vertebra, between the lower articulating and the transverse processes. All of them old, ununited fractures. He has also met with the same fracture once in the third lumbar vertebra. The frequency of this peculiar form of fracture in this region Dr. Wyman ascribes to the fact that the upper and lower articulating processes are widely separated from each other, and connected only by a narrow neck, in which respect they contrast very strongly with the dorsal vertebrae. The observation is interesting, and, I think, has not before been made. As to the therapeutical treatment of the various symptoms belonging to these accidents, and in relation to the prognosis, the remarks which we shall make will be found equally applicable to fractures of the bodies of the vertebrae, and we shall reserve the consideration of these topics for the following section. § 4. Fractures op the Bodies of the Vertebrae. The same causes which produce fractures of the arches produce also fractures of the bodies of the vertebrae, that is, blows received directly upon the extremities of the spinous processes; but in these cases the arches are generally broken at the same time. In other cases the bodies of the vertebrae are broken by falls upon the top of the head, by which the vertebrae are not only driven forcibly together, but often doubled forwards upon each other; or the patient may have alighted upon his feet o v upon his sacrum. Reveillon has reported a case of fracture of the fifth cervical vertebra from muscular action, which occurred in diving. The man was taken out of the water unconscious, and died in a few hours, having declared before death that his head did not strike the bottom, although he had jumped from a height of seven or eight feet, and the water was only three feet deep. 1 The statement of the sufferer under such circumstances could not really possess much value, and we think we see good reasons to suppose that he was mistaken. South also relates a case of fracture of the fourth and fifth cervical vertebrae occasioned by diving, in which it was supposed that the fracture was caused by the concussion of the head upon the water.* Malgaigne says the spine bends at three principal points; comprised, the first between the third and seventh cervical vertebrae, the second between the eleventh dorsal and second lumbar, the third between the fourth lumbar and the sacrum; and that a majority of the fractures of the vertebrae occur at these points of flexion. He makes an argument from this also that these fractures " are generally the result of counterstrokes as the effect of forcible flexion of the column either forwards or backwards." Malgaigne observes moreover that dislocations follow the same rule. The direction of the line of fracture varies greatly in the different examples which we have seen; some are crushed, and more or less 1 Reveillon, Chelius's Surg., note by South, vol. i. p 584. 2 South, ibid., p. 583. FRACTURES OF THE BODIES OF THE VERTEBRAE. 147 comminuted. In some cases a narrow piece is chipped from the margin, others are broken transversely, and others obliquely. In oblique fractures the line of the fracture is generally from behind forwards and from above downwards. Malgaigne thinks that a crushing or comminution can only occur from a forcible flexion forwards; but I have seen at least one example in which this was not the fact; the patient having fallen so as to strike with the back of his neck upon an iron bar. This was the case of the sailor, to which I shall again refer more particularly. The upper fragment is almost always that which suffers displacement ; sometimes being simply driven downwards and thus made to penetrate more or less the lower fragment; at other times, as in cer- tain transverse fractures, it is only displaced forwards, and in still other examples, where the fracture is oblique, the upper fragment is displaced both downwards and forwards. In the first and last of these examples the spine becomes bent forwards at the point of fracture, producing an angle of which the most salient point posteriorly is represented by the extremity of the spinous process belonging to the broken vertebra; in the second example the spinous process of the broken vertebra is depressed, and the process of the vertebra next below is relatively prominent. In a pretty large proportion of cases also the fracture of the body of the vertebra is complicated, as we have already stated, with a fracture of the arches, in some instances with a fracture of the oblique processes and with a dislocation. Fig. 31. Oblique fracture of the body of a vertebra. Symptoms. —Severe pain at the seat of fracture, felt especially when the part is touched or the body is moved, tenderness, swelling, ecchymosis, occasionally crepitus, a slight angular distortion of the spine, or simply a trifling irregularity in the position of the processes, and paralysis of all the parts whose nerves take their origin below the fracture, are the usual signs of this accident. The paralysis may be due to the mere pressure of the displaced fragments, but it is much more often due to a severe and irreparable lesion of the cord itself. I have in one instance seen the cord almost completely separated at the point of fracture although the displacement of the fragments was inconsiderable. Accompanying the paralysis of the bladder, there has been generally observed an alkaline state of the urine, and subacute inflammation of the coats of the bladder. Priapism is present in a certain proportion of cases. Those who die immediately seem to be asphyxiated; while those who die later seem to wear out from general irritation, this condition being frequently accompanied with an obstinate diarrhoea and vomiting. A few become comatose before death. 148 FRACTURES OF THE VERTEBRA. It will be seen, moreover, that a certain proportion finally recover; but scarcely ever are all the functions of the limbs and of the body completely restored. "We shall render this part of our description of these accident more intelligible if we regard them as they occur in the various portions of the spinal column, since the symptoms, prognosis, and treatment, have reference mainly to the point at which the fracture has occurred. 1. Fractures of the Bodies of the Lumbar Vertebrae. The nerves which emerge from the intervertebral foramina below the fourth and fifth lumbar vertebrae, join with the sacral nerves to form a plexus, which supplies the sphincter and levator ani, the perineal muscles, the detrusor and accelerator urinae, the urethra, glans penis, and a great proportion of the lower extremities. A fracture, therefore, of the third, fourth, or fifth lumbar vertebra, produces more or less complete paralysis of the lower extremities, paralysis of the bladder, indicated by retention of the urine, and paralysis of the rectum, the latter being accompanied sometimes by involuntary discharges from the bowels and at other times by constipation. These patients generally die after a few months or years from a general nervous irritation with consequent exhaustion of the system. The following case, related by Sir Benjamin Brodie, illustrates, probably, a more favorable termination. A boy was admitted into St. George's Hospital, in Sept. 1827, with a fracture and considerable displacement of the third and fourth lumbar vertebrae, the displacement being sufficient to cause a manifest alteration in the figure of his spine. His lower limbs were paralytic. An attempt was made to restore the displaced vertebrae, but it was attended with only partial success. At the end of a month he had slight involuntary motions of the lower extremities, and at the same time he began to recover the power of using them voluntarily. Three or four months after the receipt of the injury he left the hospital, and the history of his case was interrupted at this date. 1 In case the fracture is at a point higher up, in the first or second lumbar or last dorsal vertebra, the whole of the lumbar nerves are cut off, producing a more complete paralysis of the lower extremities, accompanied with the same paralysis of the bladder and rectum. Death also ensues at a somewhat earlier period and from the same causes. A few years since a Mrs. Squires, of Bochester, N. Y., was shot in her back, the ball lodging in the body of one of the lumbar vertebrae, from which it was found impossible to extract it. Her lower extremities were completely paralyzed, and also the sphincters of her bladder and rectum; a pin thrust into the body at any point below the middle of the abdomen was not felt. She survived the accident several months, and died at last covered with bed-sores and exhausted with pain and watchfulness. On the 11th of Oct., 1851, Alfred McCarty, aet. 47, residing at Fort Brodie, Sir Ast. Cooper on Disloc, op. cit., p. 471. 149 FRACTURES OF THE BODIES OF THE VERTEBRAE. Erie, C. W., was struck upon the back with a falling timber weighing half a ton or more, fracturing four ribs upon the left side, and probably the lower dorsal vertebrae. The right leg was also badly broken at the same time. He was taken up insensible, but soon recovered his consciousness, when it was ascertained that the lower half of his body was paralyzed. I saw him a few days after the accident in consultation with Dr. Cronyn, a very intelligent surgeon residing at Fort Erie. We agreed that the treatment ought to be sustaining and expectant mainly. Constantly during the first three or four months, and occasionally for some time longer, the urine had to be drawn off* with a catheter. A large bed-sore soon formed upon his sacrum. There was, however, in the main, a steady improvement, so that in April, six months after the accident, he was able to sit with his back supported; the bed-sore had healed; sensation had in a great measure returned to his lower extremities, but motion only slightly; he had gained flesh and strength. He now only rarely required the use of the catheter, but as soon as the desire to urinate was experienced he was compelled to discharge it, having lost the power of retention. It was the same with his fecal discharges. The urine was alkaline. About this time he began to experience a stiffness in one of his hands, inability to close the fingers upon the palm, and slight uneasiness in the neck. Gradually both arms became completely paralyzed, vomiting and purging supervened, and after repeated attacks in the last month of his life of laryngotracheal constriction, on the 20th of Sept., 1852, he sank into a state of complete paralysis and insensibility, and died. A patient in Guy's Hospital, under Mr. Key, with a fracture of the first lumbar vertebra, lived one year and two days. On examination after death it was ascertained that bony union had occurred between the fragments, and that the spinal marrow was completely separated at the point of fracture. 1 Mr. Harrold relates a case of fracture of the first and second lumbar vertebras, in which the patient survived the accident one year lacking nine days; death having resulted finally from a sore on the tuberosity of the ischium and disease of the bone. After death it was ascertained that the fracture had united by ossific matter, and that the spinal marrow was almost completely cut in two, the divided extremities being enlarged and nearly an inch from each other. 3 Dr. Thompson, of Goshen, N. Y., has seen a partial recovery after a fracture of the third or fourth vertebra of the loins. The patient fell Fig. 32. Key's case of fracture of the first lumbar vertebra. from the roof of a house, striking first upon his feet and then upon his buttocks. This occurred in Oct. 1853. The usual signs of a fracture 1 Key, A. Cooper on Disloc, &c, op. cit., p. 467. 2 Harrold, A. Cooper, op. cit., p. 464. 150 FRACTURES OF THE VERTEBRA. were present, such as paralysis, &c. A bed-sore formed above the top of the sacrum, and a piece of bone exfoliated which seemed to belong to the last lumbar vertebra. He was confined to his bed seven months. After eighteen months he began to use crutches. At the end of about three years all impovement ceased; at which time he could not quite stand alone, yet with the aid of apparatus he was able to get about the country and peddle books, prints, &c. This was also his condition one year later. 1 2. Fractures of ihe Bodies of the Dorsal Vertebrse. In these examples, the same organs are paralyzed as in the fractures lower down, in addition to which there is generally considerable disturbance of the functions of respiration, irregular action of the heart, indigestion accompanied with a tympanitic state of the bowels. Dupuytren, who reports several examples of fractures of the dorsal vertebrae, has not taken the pains to record the length of time they survived the accident except in two instances, both of which were fractures of the eleventh vertebra. One died of suffocation on the tenth day, and the other on the thirty-second. In Sir Astley Cooper's cases, mention is made of a fracture of the twelfth dorsal vertebra, which the patient survived fifty-two days, one of the tenth dorsal, which terminated fatally in six days, and another of the ninth dorsal, which did not result in death until after nine weeks. In 1853 Dr. Parkman presented to the Boston Society for Medical Improvement a specimen of fracture of the fifth dorsal vertebra, the bodies of the third and fourth being also displaced forwards, in which position they had become firmly ossified. The spinal cord had been completely separated, yet the patient survived the accident two months. 2 Dupuytren has related also two examples of fractures, one of the tenth and the other of the last dorsal vertebra, from which the patients completely recovered after from two to four months' confinement. 3 A similar case is related by Lente, of New York. Barney McGuire, having fallen a distance of twelve or fifteen feet upon his back, was found with nearly complete paralysis of his lower extremities, and of his bladder. Swelling existed over the lower dorsal vertebrae, and this point was very tender. Subsequently, when the swelling subsided, the prominence of the spinous processes of the tenth and eleventh dorsal vertebrae put the question of a fracture beyond doubt. Gradually under the use of cups, strychnia, mineral acids, laxatives, buchu, and electricity, his symptoms improved. In six months he was able to walk about the streets, and four years after the accident he was employed in a foundry under regular wages, being able to stand fifteen or twenty minutes at a time, and to walk half a mile without resting. At this time there remained no tenderness in the spine, but the projection of the process was the same as at first. 4 1 Thompson, Amer. Journ. Med. Sci., Oct. 1857. Lente's paper. 2 Parkman, New York Journ. Med., March, 1853, p. 286. 3 Dupuytren, op. cit., pp. 356-7. 4 Lente, Amer. Journ. Med. Sci., Oct. 1857, p. 361. FRACTURES OF THE BODIES OF THE VERTEBRAE. 151 3. Fractures of the Bodies of the five lower Cervical Vertebrse. We shall now have added to the symptoms already enumerated, paralysis of the upper extremities, greater embarrassment of the respiration, and more complete loss of sensation and volition in the lower part of the body. In general also the eyes and face look congested, owing to the imperfect arterialization of the blood, and death is more speedy and inevitable. In nine recorded examples of fractures of the rive lower cervical vertebrae, one died within twenty-four hours, four in about forty-eight hours, one in eleven days, one lived fifteen weeks and six days, one about four months, and one, reported by Hilton, survived fourteen years. 1 The most common period of death seems therefore to be about forty-eight hours after the receipt of the injury. The example of the patient who survived the accident fifteen weeks and six days, is recorded by Mr. Greenwood, of England. A woman, Mary Vincent, aet. 47, was injured by a blow on the back of her neck, but she was not seen by Mr. Greenwood until after eleven days, at which time she was breathing with difficulty, occasioned by paralysis of the intercostal muscles, respiration being carried on by the diaphragm and abdominal muscles alone. This was the extent of the paralysis. There seemed to be a depression opposite the fourth and fifth cervical vertebras, and pressure at this point occasioned universal paralysis, as did also the action of coughing and sneezing. About three weeks after the accident, she attempted for the first time to move, in order to have her clothes changed, when she was immediately seized with paralysis in the right arm and hand. After this she lost her appetite, had frequent attacks of purging, and thus she gradually wore out. 2 The patient who survived about four months, was admitted into Hotel Dieu, under the care of Dupuytren, in 1825, on account of a fracture of the fourth cervical vertebra, caused by a fall on the back of his neck, and suffering under paralysis of the bladder and extremities. After two months and a half of entire rest, he was convalescent and quitted the hospital, with only slight weakness in his left leg, and with his head a little bowed forwards. In returning from a long walk he fell paralyzed, and remained in the open air all night. From this time he continued to fail, and died thirty-four days after the second fall. On examination after death, the body of the vertebra was found to be broken, and also the processes of the fifth, allowing the fourth to slip forwards and compress the cord. A true callus existed in front of these bones, which looked as if recently broken. The cord itself exhibited an annular constriction, which Dupuytren conceived to be the seat of the original lesion narrowed by cicatrization. 3 The following example furnishes a fair illustration of the usual phenomena which accompany fractures of third or fourth cervical vertebra. 1 Hilton, Lond. Lancet, Oct. 27, 1860. 2 Greenwood, Sir A. Cooper on Disloc, p. 472. 3 Dupuytren, op. cit., p. 358. 152 FRACTURES OF THE VE RTEBRJ5. On the 25th of July, 1857, a sailor fell backwards from the wharf, striking with the nape of his neck upon a bar of iron. I saw him on the following day in consultation with his attending physician, Dr. Edwards. He was lying upon his back breathing rapidly. His lower extremities were completely paralyzed; legs and feet swollen and purple; right arm completely paralyzed, and his left partially; from a point below the line of the second rib, there was no sensation whatever; his bowels had not moved, although he had already taken active cathartics; the urine had been drawn with a catheter; the pulse was slower than natural, and irregular. He was constantly vomiting. In reply to questions, he said that he felt well, articulating distinctly and with a good voice. His eyes and face were somewhat congested, but with this exception his countenance did not betray the least physical disturbance. He lived in this condition about forty hours, only breathing shorter and shorter, and his consciousness remaining to the last moment. In proceeding to examine the spine a few hours after death, and before any incision was made, we were unable, upon the most minute examination, to detect any irregularity of the processes of the cervical vertebras, or any crepitus, but on dissecting the neck we found that the arches of the third and fourth vertebrae were broken, and the spinous processes slightly depressed upon the cord. The bodies of the corresponding vertebrae were comminuted and the vertebrae above were driven down upon them, carrying the processes in the same direction. The theca and the spinal marrow were almost completely severed upon a level with the fourth vertebra. A man residing in Erie Co., N. Y., was thrown backwards suddenly from the back end of a wagon, alighting upon the top of his head. Dr. Mixer having requested me to see this patient with him, I found the symptoms almost an exact counterpart of those which belonged to the case which I have just described, except that a crepitus and a mobility of the fragments could 'be distinctly felt in the upper and back part of his neck. His death occurred in very much the same manner after about forty-eight hours. No autopsy was allowed. We noticed in this case, also, that whenever he was turned over upon his face respiration almost entirely ceased, but it was immediately restored by laying him again on his back. Dupuytren, Sir Astley Cooper, South, and other surgeons, have related cases simulating fracture, but which proved to be strains of the ligaments uniting the cervical vertebrae, accompanied with more or less injury to the spinal marrow. In one instance, I have met with what has seemed to be a strain of the ligaments and muscles of the neck, but which presented no symptoms of serious injury to the spinal marrow. John Neuman, of Canada West, aet. 25, fell head foremost from a height of fourteen feet, striking upon the top of his head. He was taken up insensible, and remained in this condition six hours. When consciousness returned, his head was very much drawn backwards, and it was impossible to move it from this position. There was no lack of sensibility or of the power of motion in his limbs, and all the FRACTURES OF THE BODIES OF THE VERTEBRAE. 153 functions of his body were in their natural state; but he has suffered with occasional severe pains in his arms ever since. The accident happened on the twenty-fourth of November, 1857, and he called upon me eight months after. His head was then forcibly bent forwards instead of backwards, into which position it had gradually changed. In the morning he generally was able to erect his head completely, but after a few hours it was constantly drawn forwards, as when I saw him. There was no tenderness or irregularity over the cervical vertebrae, and he was so well as to be regularly employed as a day laborer. Sir Astley Cooper has collected four examples of what he terms "concussion of the spinal marrow," all of which recovered after periods ranging from a few weeks to many months; but in only one case is it stated that the recovery was complete. 1 Boyer also enumerates three cases of concussion which came under his own observation, all of which terminated fatally in a short time. In the first example mentioned by Boyer, the autopsy disclosed neither lesion nor effusion of any kind; in the second case, it does not appear that any autopsy was made. The third is related as follows: " A builder fell from a height of fourteen feet, and remained for some time senseless; and, on recovering from that situation, found that he had lost the use of his inferior extremities. He had at the same time a retention of urine, an involuntary discharge of the feces, and some disorder in the function of respiration. Death followed on the twelfth day after the accident. The body was opened, and the vertebral canal was found to contain a sanguineous serum, the quantity of which was sufficient to fill a little more than its lower half." 2 Treatment. —In a few instances, I have noticed among the recorded examples of fractures of the bodies of the vertebrae, that surgeons have made some slight attempt to reduce the fracture, or rather to rectify the spinal distortion, generally by the application of moderate extension to the limbs, and by laying the patient horizontally upon a hard mattress. But I have not been able to discover that in any case the patients have derived benefit from the attempt, although it has been said occasionally by the gentlemen making the report, that the deformity was slightly diminished. Nor am I aware that in any instance the patient has suffered any damage from the attempt; at least the reporter has in no case thought it necessary to make this observation. I am confident, however, that such manipulation can never serve any useful purpose; and I very much fear that it has been frequently a source of mischief. Although in cases so generally fatal, it might be very difficult to estimate with much accuracy the amount of injury done. If by any possibility the fragments could be replaced, I know of no means by which they could be kept in place; and in truth we are much more likely to increase the penetration of the spinal cord and the general disturbance, than to diminish it by extension or pressure. Moreover, it inflicts upon the unfortunate sufferer great pain, and for this reason, unless it can be shown to have 1 A. Cooper, op. cit., p. 454. 2 Boyer, Lecture on Diseases of the Bones, Amer. ed., 1805, p. 55. 11 154 FRACTURES OF THE VERTEBRJE. heretofore accomplished some good purpose, it ought to be discouraged. When treating of fractures of the arches of the vertebrae, I took occasion to call attention to Mr. Cline's operation, occasionally recommended and practised in such cases. I was not ignorant, however, that Mr. Cline and several other of the advocates of this operation had recommended it especially for fractures of the bodies of the vertebrae when accompanied with displacement. Even Malgaigne has preferred to consider the merits of this operation in its relations to these latter fractures; but while I am prepared to admit the propriety of an argument as to the value of Cline's operation considered in reference to fractures of the arches, I cannot admit its propriety in reference to fractures of the bodies of the vertebrae. The proposition appears to me too absurd to be entertained for a moment. The treatment, then, ought to be, in a great measure, expectant. The patient should be laid in such a position as he finds most comfortable, and, as far as possible, the spine should be kept at rest, since the most trivial disturbance of the fragments, and even that which may cause no pain to the patient, is liable to increase the injury to the spine, and prevent the formation of a bony callus. Especially ought the surgeon to be careful, while making the examination, not to turn the patient upon his face, in which position the spine loses its support and a fatal pressure may be produced. The urine should be drawn very soon after the accident, and at least twice daily, for the next few weeks. Indeed, it is a better rule to draw the urine as often as its accumulation becomes a source of inconvenience, or whenever the bladder fills, which will in some cases be as often as every four or six hours. It is especially necessary to attend to these urgent demands of the patient during the first few weeks, when the paralysis is most complete generally, and the mucous surface of the bladder, already irritated and inflamed by the excessively alkaline urine, suffers additional injury from any degree of painful distension of its walls. It is unnecessary to say that the frequent introduction of the catheter may itself prove a source of irritation unless it is managed carefully and skilfully. This duty ought never to be intrusted to an inexperienced operator. I do not see what advantage the surgeon can expect to derive from the administration of drastic purgatives, such as full doses of jalap, castor oil, or spirits of turpentine, at any period. If in the first instance the bowels are so completely paralyzed as that they seem to demand such violent measures to arouse them to action, we may be quite certain that the spinal cord is suffering from a pressure, or from some lesion which these agents have no power to remedy. The bowels may possibly be made to act, but it would be difficult to show how this is to relieve the suffering cord. So far from affording relief, these measures add directly to the nervous irritation and prostration, provoke vomiting and general restlessness. It is not desirable, we think, to obtain a movement of the bowels during the first few days by any means, however gentle. The effort to defecate, and the consequent motion, will probably do much more harm than the evacuation can do FRACTURES OF THE AXIS. 155 good; and especially for the same reason ought we to avoid putting into the stomach anything which will occasion nausea and vomiting. After the lapse of a few days, if reasonable hopes begin to be entertained of a recovery, it will become important to establish regular evacuations of the bowels, either by a judicious management of the diet, by gentle laxatives, or by enemata. At a still later period, when the inflammatory stage is past, and the nerves remain inactive or paralyzed, nothing could be more rational than the employment of strychnia in doses varying from the one-twelfth to the one-eighth of a grain three times daily. Nor do I think that any single remedy has more often proved useful in my own practice, or in the practice of other surgeons with whom I am acquainted. In order, however, to derive benefit from this or from any other remedy, it must be continued for a long time; perhaps for a year or more. Electricity, setons, issues, and blisters are no doubt also sometimes useful. Care must be taken that setons, &c., do not produce bed-sores. Passive motion and frictions, good fresh air and nourishing diet, become at last essential to recovery. During the whole course of the treatment great attention should be paid to the prevention of bed-sores, by supporting all of those parts of the body upon which the pressure is considerable. For this purpose we may employ circular cushions, air-cushions and water-cushions or water-beds; but with the utmost diligence they cannot generally be wholly prevented. When the sores have formed they should be treated, if sloughing, with yeast poultices, or the resin ointment. I find also the resin ointment an excellent dressing for the sores after the sloughs have separated. In case the surface is only slightly abraded, simple cerate forms the best application. § 5. Fractures of the Axis. The phrenic nerve is derived chiefly from the third and fourth cervical nerves. If, therefore, the second cervical vertebra is broken and considerably depressed upon the spinal cord, respiration ceases immediately, and the patient dies at once, or survives only a few minutes. In such examples of fracture of this bone as have not been attended with these results, the displacement and consequent compression have been inconsiderable, or there has been no displacement at all. Mr. Else, of St. Thomas's Hospital, says that a woman in the venereal ward, and who was then under a mercurial course, while sitting in bed, eating her dinner, was seen to fall suddenly forwards; and the patients, hastening to her, found that she was dead. Upon examination of her body, it was discovered that the processus dentatus of the axis was broken off, and that the head in falling forwards had driven the process backwards upon the spinal marrow so as to cause her death. 1 Sir Astley also relates the case of a man who was shot by a pistol through the neck, breaking and driving in upon the spinal marrow 1 Else, A. Cooper'on Disloc, &c, op. cit.. p. 4G2. 156 FRACTURES OF THE VERTEBRAE. both the " lamina and the transverse process" of the axis. He died on the fourth day. 1 Malgaigne has collected three cases of fracture of the odontoid apophysis, all of which were accompanied with a displacement of the atlas. The first, reported by Richet, died on the seventeenth day; the second, reported by Palletta, died after one month and six days; and the third, by Costes, lived four months and two weeks. In no case upon record has the patient survived this accident so long as in the case reported by Bigelow, and published by Parker, of New York. Says Dr. Parker:— " The patient, Mr. G. B. Spencer, was a man forty years of age, a milkman by occupation, of medium height, nervo-sanguine temperament, of active business habits, and capable of great endurance. His life was one of constant excitement, and he was addicted to the free use of liquors. He suffered, however, from no other form of disease than occasional attacks of rheumatism, for which he was accustomed to take remedies of his own prescribing, which were generally mercurials followed by liberal doses of iodide of potassium, 'to work it all out of the system.' "On the 12th of August, 1852, while driving a 'fast horse' at the top of his speed on the plank road near Bush wick, L. I., he was thrown violently from his carriage by the wheel striking against the toll-gate. He alighted upon his head and face about fifteen feet from the carriage. Upon rising to his feet he declared himself uninjured, but soon after complained of feeling faint; after drinking a glass of brandy he felt better, got into his carriage with a friend, and drove home to Rivington Street in this city, a distance of more than two miles. There was so little apparent danger in his case that no physician was called that night. Early on the morning of the following day, Dr. B. was called to visit him. He found his patient reclining in his chair, in a restless state, and learned that he had suffered considerable pain in the back part of his head and neck during the night. He was entirely incapacitated to rotate the head, which led to the suspicion of some injury to the articulations of the upper cervical vertebrae; but so great a degree of swelling existed about the neck as to prevent efficient examination. There was no paralysis of any portion of the body, his pulse was about 90, and his general system but little disturbed. Warm fomentations were applied to the neck, and a mild cathartic administered. On the following day there was no particular change in his symptoms, but as there existed considerable nervous irritability, tinct. hyoscyami was prescribed as an anodyne, and fomentations of hops applied locally. On the third day, leeches were applied to the neck, and after this the swelling so much subsided, that on the fifth day an irregularity was discovered to exist in the region of the axis and atlas, which had many of the features of a partial luxation of these vertebrae. " At this time he began to walk about the room, having previously remained quiet on account of the pain he suffered on moving. He persisted in helping himself, and almost constantly supported his head 1 A. Cooper on Disloc, etc., op. cit., p. 476. 157 FRACTURES OF THE AXIS. with one hand applied to the occiput. He often remarked, if he conld be relieved of the pain in his head and neck he should feel well. He began to relish his food, and the swelling nearly disappeared at the end of a week, leaving a protuberance just below the base of the occiput, to the left of the central line of the spinal column, with a corresponding indentation. Notwithstanding strict orders to remain quietly at home, on the ninth day after the accident he rode out, and in a day or two after returned as actively as ever to his former occupation of distributing milk throughout the city to his old customers. During the following four months no material change took place in his symptoms, although he constantly complained of pain in his head. For this period he did not omit a single day his round of duties as a milkman, which occupied him constantly and actively from five o'clock in the morning to nearly noon. On the first of November, Prof. "Watts examined him, and inclined to the opinion that there was a luxation of the upper cervical vertebrae. " About the first of January, 1853, the pains, from which he had been a constant sufferer, became more severe, and he was heard to complain that he could not live in his present condition; he remarked, also, that he had heard a snapping in his neck. After going his daily round on the eleventh of January, he complained of feeling cold, and afterwards of numbness in his limbs. In the evening he had a chill and complained of a pain in his bowels. He passed a restless night, and arose on the following morning about six o'clock; he was obliged to have assistance in dressing himself, and experienced a numbness of his left, and afterwards of his right side. He attempted to walk, but could not without help, and it was observed that he dragged his feet. He sat down in a chair and almost instantly expired, at eight o'clock A. M., on the 12th of January, precisely five months from the receipt of the injury. " The autopsy was made thirty hours after death by Dr. C. E. Isaacs, in presence of several medical gentlemen. Muscular development uncommonly fine. An unusual prominence discovered in the region of the axis and atlas. On making an incision from the occiput along the spines of the cervical vertebrae, the parts were found to be very vascular. These vertebrae were removed en masse, and a careful examination instituted. The transverse, the odontoid (ligamenta moderatoria), as also all the ligaments of this region, excepting the occipito-axoideum, were in a state of perfect integrity; this latter was partially destroyed. A considerable amount of coagulated blood was found effused between the fractured surfaces, some of it apparently recent, but much of it was thought to have occurred at the time of the accident, and afterwards to have prevented the union of the bones. The spinal Fig. 33. Fracture of the odontoid process of the axis. Parker's case. A. Broken surface. B. Odontoid process. cord exhibited no appearances of any lesion. The odontoid process 158 FRACTURES OF THE VERTEBRAE. was found in the position well represented in the accompanying illustration, completely fractured off, and its lower extremity inclining backwards towards the cord. Death finally took place, doubtless, from the displacement of the process during some unfortunate movement of the head, by which pressure was made upon the cord. The destruction of the occipito-axoid ligament, which would otherwise have protected the contents of the spinal cavity, must have favored this result." 1 § 6. Fractures op the Atlas. I have been able to find only one example of a fracture of the atlas alone, and this is the case related by Sir Astley Cooper as having come under the observation of Mr. Cline. A boy, about three years old, injured his neck in a severe fall; in consequence of which he was obliged to walk carefully upright, as persons do when carrying a weight on the head; and when he wished to examine any object beneath him, he supported his chin upon his hand, and gradually lowered his head, to enable him to direct his eyes downwards. In the same manner, also, he supported his head from behind in looking upwards. Whenever he was suddenly shaken or jarred, the shock caused great pain, and he was obliged to support his chin with his hands, or to rest his elbows upon a table, and thus support his head. The boy lived in this condition about one year, and after death Mr. Cline made a dissection and ascertained that the atlas was broken in such a manner that the odontoid process of the axis had lost its support and was constantly liable to fall back upon the spinal marrow.* § 7. Fractures of the First two Cervical Vertebrae (Atlas and Axis) at the same time. A woman, aet. 68, fell down a flight of steps, striking upon her forehead, and died immediately. Upon making a dissection, it was found that the atlas was broken upon both sides near the transverse processes, and the odontoid process of the axis was broken at its base. These fractures were accompanied with a rupture of the atloido-odontoid ligaments, and a dislocation of the atlas backwards. 3 South says there is a specimen in the museum of St. Thomas's Hospital, showing this double fracture. The man had received his injury only a few hours before admission to the hospital, and died on the fifth day. On examination the atlas was found to be broken in two places, and the odontoid process of the axis at its root. The fifth vertebra was also broken through its body. With neither fracture was there sufficient displacement to produce pressure, but a small quantity of extravasated blood lay in the substance of the spinal marrow, and its tissue was at one point broken down and disorganized." 1 Bigelow, New York Journ. Med., March, 1853, p. 164. 2 Cline, Sir Astley Cooper, op. cit., p. 459. 3 Malgaigne, op. cit., torn. ii. p. 333. 4 Chelius's Surgery, note by South, vol. i. p. 588. 159 FRACTURES OF THE STERNUM. Mr. Phillips relates that a man fell from a hay-rick, striking upon the occiput; after which, although momentarily stunned, he walked half a mile to the parish surgeon, and in two days more he returned to his occupation. About four weeks after the accident he was seen by Mr. Phillips, who discovered a small tumor over the second cervical vertebra, pressure upon which caused a slight pain. He complained also that his neck was stiff, and that he was unable to rotate it. No other disturbance of the functions of the body could be discovered. After a time the tonsils became swollen and the patient experienced some difficulty in deglutition, and upon examining the throat, a slight projection or fulness was discovered at the back of the larynx, opposite the second cervical vertebra. Subsequently he became affected with general anasarca and pleuritic effusions, of which he finally died. Up to the last week of his life he was able to Avalk about his bed-room, and his condition presented no other evidence than has been mentioned, that he was suffering from an injury of the spine. He died forty-seven weeks after the receipt of the injury. The autopsy disclosed a fracture with displacement of the atlas and a fracture of the odontoid process of the axis. The two vertebrae were united to each other firmly by complete bony callus. 1 CHAPTER XVI. FRACTURES OF THE STERNUM. Fractures of the sternum are of rare occurrence, owing, probably, to the elasticity of the ribs and their cartilages, upon which it mainly rests, and also, in part, to the softness of its structure. In advanced life, the ossification and fusion of all of its several portions becoming more complete, and the cartilages of the ribs also becoming more or less ossified, its fracture is relatively more frequent. Causes. —They are generally the result of direct blows inflicted upon the part, such as the passage of a loaded vehicle across the chest, the fall of a tree or of some heavy timber upon the body; the fracture implying always that great force has been applied. Indirect blows, and voluntary muscular action alone have been known also occasionally to produce this fracture. David, in his Memoire sur les Contrecoups, published as a prize essay by the Academy of Medicine, mentions the case of a mason, who, in falling from a great height, struck upon his back against a crossbar which intercepted his fall, in consequence of which the abdominal and sterno-cleido-mastoidean muscles were so stretched that the sternum broke asunder between its upper and middle portions. 2 Sabatier 1 Phillips, Med.-Chir. Trans., vol. xx. 1837, p. 384. 2 Boyer on Bones, p. 57. 160 FRACTURES OF THE STERNUM. reports another case of fracture at the same point, produced in a similar manner; 1 and Roland has described a third example in a woman sixty-three years old, who, falling from a height backwards and striking upon her back, broke the sternum near its centre. 2 Cruveilhier saw a man who, having fallen from a height of twenty feet upon his nates, was found to have a fracture of the sternum. 3 Cussan saw the same result in a person who fell from a third story, striking first upon his feet and then pitching over upon his back. 4 Maunoury and Thore have reported an analogous case, where a man fell from a height of twelve or fifteen mitres, first striking upon his feet and then falling over upon his back and head. 3 Mr. Johnson, late editor of the London Med.-Chir. Rev., reports a case of this kind, also, as having been received into St. George's Hospital, in London; the man, a healthy laborer, from the country, had fallen from the top of a hay cart, striking only upon his head. He walked with his head much bent forwards, and was incapable of either flexing, extending, or rotating it any further. The fracture was transverse, and about three inches below the top of the sternum, opposite the centre of the third rib, the lower fragment projecting in front of the upper. The fragments were easily replaced by simply throwing the head back, and they fell into place with an audible snap, but they immediately resumed their unnatural position when the head was flexed. They finally united, but with a slight projection and overlapping. 0 Gross has reported one more example. 7 Malgaigne expresses a doubt whether all these can be considered as the results of muscular action, since in a certain number of the examples cited, the head seems to have been thrown forwards by the concussion, and in others, also, there is no evidence that the muscles attached to the sternum were put upon the stretch. The only remaining explanation is that in such cases the sternum has been broken by the violent shock, or contrecoup. Seat and Direction of Fracture. —The sternum is separated most frequently either in the long central portion, or at the junction of this with the upper portion, where the bone is weakest. In fact a separation at this latter point may be regarded frequently as a diastasis or dislocation rather than as a fracture, since the two portions do not become firmly united by bone until late in life. The very late ossification and fusion of the xiphoid cartilage with the central piece, also, will explain the infrequency of its fracture. Boyer believed that the xiphoid cartilage was not susceptible of being permanently displaced backwards, except in aged persons after it had become ossified, " for," he says, " though violently struck and driven backwards by a blow on what is vulgarly termed the pit of the stomach, yet it restores itself by its own elasticity." 8 1 Malgaigne, from Sabatier, Mem. sur la Fract. du Sternum. 2 Ibid., from Bull, de Therap., torn. vi. p. 288. 3 Ibid., from Bull, de la Sou. Anat., Juin, 1826. 4 Ibid., from Archiv. de Med., Jan v., 1827. 6 Ibid., from Gaz. Med., 1842, p. 361. ¦ London Med.-Chir. Rev., vol. xvii. new series, p. 536, 1832. 7 Gross, System of Surg., vol. ii. p. 167. • Boyer on Diseases of Bones, p. 59. 161 FRACTURES OF THE STERNUM. The following case, however, which has come under my own observation, is conclusive as to the possibility of this accident:— A man, twenty-eight years old, fell forwards, striking the lower end of his sternum upon the top of a candlestick, breaking in the xiphoid cartilage. During two years following the accident he had frequent attacks of vomiting, which were excessively violent and distressing. The paroxysms occurring every five or six days. Both Dr. Green, of Albany, and Dr. White, of Cherry Yalley, upon whom he called for relief, recommended excision of the cartilage, but the patient would not submit to the operation. Twelve years after the accident, in the year 1848, while he was an inmate of the Buffalo Hospital of the Sisters of Charity, I examined his chest and found the xiphoid cartilage bent at right angles with the sternum, pointing directly towards the spine. He now suffered no inconvenience from it, except that it hurt him occasionally when he coughed. 1 , The upper portion of the sternum is rarely broken, unless at the same time the central portion is broken also. The direction of these fractures is generally transverse, or nearly so; occasionally a slight obliquity is found in the direction of the thickness of the bone. In three or four examples upon record the direction of the fracture was longitudinal. It is not so unfrequent, however, to rind the bone comminuted. Compound fractures are exceedingly rare. When the fracture is transverse, the lower fragment is almost always displaced forwards, and sometimes it slightly overlaps the upper fragment. In one instance mentioned by Sabatier, where the separation had taken place at the point of junction between the first and second piece, the lower fragment was displaced backwards, and was also carried upwards under the upper fragment to the extent of twenty-eight millimetres. Diagnosis. —In a few cases the patients have felt the bone break at the moment of the accident. When displacement exists it may generally be easily recognized, and the lower fragment will often be seen to move forwards and backwards at each inspiration and expiration. Crepitus may also be detected in some of these examples, but it is less often present where no displacement exists. To determine the existence of crepitus the hand should be placed over the supposed seat of fracture, while the patient is directed to make forced inspirations and expirations, or the ear may be applied directly to the chest. Emphysema has, also, occasionally been noticed, indicating usually that the lungs have been penetrated by the broken fragments. The frequent occurrence of congenital malformations of the sternum should warn us to exercise great care in our examinations lest we mistake these natural irregularities for fractures. Bransby Cooper mentions a remarkable instance of malformation of the xiphoid cartilage which he at first suspected to be a fracture. It was so much curved backwards that, as Mr. Cooper thinks, its pressure upon the 1 Buffalo Med. Journ., vol. xii. p. 282, Cases of Fractures of the Sternum. 162 FRACTURES OF THE STERNUM. stomach produced a constant disposition to vomit whenever he had taken a full meal, or had taken a draught of water. 1 Prognosis. —In simple fracture of this bone, uncomplicated with lesions of the subjacent viscera, and especially where the fracture is the result of muscular action or of a counter stroke, no serious consequences are to be apprehended. The bone unites promptly even where it is found impossible to bring its broken edges into apposition. Indeed, generally, where the fragments have been once completely displaced, although it is not difficult to replace them momentarily, a re-displacement soon occurs, and they are found finally to have united by overlapping; but no evil consequences usually result from this malposition. In nearly all of the cases reported in which palpitations, difficult breathing, &c, have been charged to the persistence of the displacement, the injuries were of such a character as to furnish for these unfortunate results other and much more adequate explanations. In one instance only, already mentioned, serious inconveniences followed from a displacement of the cartilage backwards. In other cases, however, where the fracture is the result of a direct blow, constituting a large majority of the whole number, the prognosis is often very grave: a conclusion to which one would naturally arrive from the fact already stated, that the fracture of the sternum thus produced, in itself implies the application of great force. An abscess occurring in the anterior mediastinum, and caries or necrosis of the bone, are among the most common results of a blow delivered directly upon the sternum; complications which generally end sooner or later in death. Blood may be also extensively effused into the anterior mediastinum. "Where emphysema is present we may anticipate inflammation of the pleura and of the lungs. In several instances, where death has occurred speedily after the injury, the heart has been found penetrated and torn by the fragments. Sanson and Dupuytren have each reported one example of this kind. Duverney has mentioned two, and Samuel Cooper says there is a specimen in the museum of the University College, exhibiting a laceration of the right ventricle of the heart by a portion of fractured sternum. Watson mentions a case in which the pericardium was torn, but the heart was only contused. 8 Treatment. —When the fragments are not displaced, the only indications of treatment are to immobilize the chest, and to allay the inflammation, pain, &c, consequent upon the injury to the viscera of the chest. The first of these indications is accomplished, at least in some degree, by inclosing the body, from the armpits down to the margin of the floating ribs, with a broad cotton or flannel band. A single band, neatly and snugly secured, and made fast with pins, is preferable to, because it is more easily applied than the roller which surgeons have generally employed; it is also much less liable to become disarranged. It should be pinned while the patient is making a full 1 B. Cooper, Princ. and Prac. of Surg., p. 359. 1 New York Journ. Med., vol. iii. p. 351. 163 FRACTURES OF THE STERNUM. expiration. To prevent its sliding down, two strips of bandage should be attached to its upper margin, and crossed over the shoulders in the form of suspenders. Generally the patients prefer the half sitting posture, with the head and shoulders thrown a little backwards; and this is the position which will be most likely to maintain the fragments in place, and also to secure immobility to the external thoracic muscles, while it leaves the diaphragm and the abdominal muscles free to act. The second indication may demand the use of the lancet; but more often it will be found necessary to allay the pain and disposition to cough by the use of opium. If, however, the fragments are displaced, it is proper first to attempt their reduction; which, as we have already intimated, is generally more easy of accomplishment than is the maintenance of them in place until a cure is effected. The upper fragment may be thrown forwards, and made to resume its position sometimes by a single full inspiration; but then it usually falls back during expiration; or it may be reduced by straightening the spine forcibly and at the same time drawing the shoulders back. Verduc and Petit proposed, in those cases in which it was found impossible to reduce the fragments by these simple means, to cut down and lift the depressed bone. Nelaton suggests the use of a blunt crotchet introduced through a narrow incision; and Malgaigne has thought of another plan, which is, to penetrate the skin with a punch, and directing it to the broken margin, to push the fragment into its place, but which he does not himself regard as a suggestion of much value, since the bone is too soft to afford the necessary resistance; and, moreover, this, in common with all of the other similar methods, is liable, in some degree, to the objection that it may increase the tendency to caries and suppuration, already imminent. If reduced, the fragments will probably immediately again become displaced; and more than all, it still remains to be proven conclusively, that the mere riding of the fragments is in itself ever a cause of subsequent suffering or even of inconvenience. When an abscess has formed in the anterior mediastinum, surgeons have occasionally recommended the use of the trephine. Gibson has twice operated in this manner at the Philadelphia Hospital, but in each case the caries continued to extend, and the patient died; an experience which has inclined him latterly to discountenance the operation. 1 There are other considerations mentioned by Lonsdale, which ought to decide us never to use the trephine in these cases. " For the symptoms denoting the presence of the abscess, when completely confined to the under surface of the bone, will be very uncertain; and when the matter collects in large quantities, it will show itself at the margin of the sternum, between the ribs ; when it can be let out by making a puncture with the point of a lancet, without the necessity of removing a portion of the bone." 2 Ashhurst, referring to the same point, 1 Gibson, Institutes and Practice of Surgery, vol. i. p. 269. 2 Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242. 164 FRACTURES OF THE RIBS AND THEIR CARTILAGES. remarks: "The fact that the mediastinal space can be cut into without injury to the pleura is shown by many cases, among others by one which came under my own observation." 1 "We have already said that a separation of the first from the second piece of the sternum, occurring before ossific union had taken place, might with some propriety be regarded as a diastasis, or as a dislocation even. Maisonneuve, Vidal (de Cassis), Malgaigne, and other French surgeons speak of it as a dislocation, and Vidal has collected five examples, in all of which the lower bone occupied a position in front of the upper. Malgaigne enumerates ten examples. The points of difference between the dislocation and the true fracture are too small, however, to demand of us especial attention. CHAPTER XVII. FRACTURES OF THE RIBS AND THEIR CARTILAGES. § 1. Fractures op the Ribs. Fractures of the ribs, observed more often than fractures of the sternum, are rare as compared with fractures of other long bones. In my records only twenty-one patients are reported as having had broken ribs; but as in several of the cases two or more ribs were broken at the same time, the total number of fractures is about forty-six. If, however, I had always accepted the diagnosis made by other surgeons, the number would have been much greater, since I have been repeatedly assured that the ribs were broken where, upon the most rigid examination, no evidence, beyond the existence of a severe pain and of difficult respiration, has been presented to me. Etiology. —The force requisite to break the ribs is scarcely less than what is requisite to break the sternum; and in childhood and infancy it is sometimes almost impossible to break them, so that children and even adults are often crushed and killed outright, where, although the pressure has been directly upon the thorax, the ribs have resumed their positions, and have been found not to be broken. I have met with several examples of this kind. In old age, the cartilages ossify and the ribs themselves suffer a gradual atrophy, which renders them much more liable to break. The most common causes are direct blows, of very great force, in consequence of which sometimes the fragments are not only broken, but more or less forced inwards; occasionally they are the result of counter-strokes, and then the fragments, if they deviate at all from their natural position, are salient outwards; a species of fracture which I 1 Ashhurst, Am. Jouru. Med. Soi., Jan. and Oct. 1862. 165 FRACTURES OF THE RIBS. Malgaigne has collected eight examples of fractures of the ribs produced by muscular action, by the beating of the heart, &c, all of which occurred upon the left side. It is believed, however, that in all of these cases the ribs had previously become atrophied, and perhaps undergone other changes in their structure, rendering them liable to fracture from the action of trivial causes. Pathology, Seat, &c. —The fourth, fifth, sixth, and seventh ribs are most liable to be broken; the upper ribs, and especially the first rib, being so well protected in various ways as to greatly diminish their liability, while the loose and floating condition of the last two ribs gives them an almost complete exemption. In my own cases I have found the first, second, and third ribs each broken twice; the fourth four times; the fifth and sixth, eleven times; the seventh, seven times; the eighth, ninth, and tenth, twice each. Twenty-one were broken through their anterior thirds, generally at or near the junction of the cartilages with the ribs; seven through their middle thirds; and eleven through their posterior thirds. Malgaigne has noticed, also, contrary to the general opinion of surgeons, that the ribs are most often broken in their anterior thirds, whether the cause has been a direct or a counter blow. The direction of the fracture is generally transverse or slightly oblique ; sometimes it is quite oblique. It is often compound; and in a few instances I have found it comminuted or multiple. Where the fracture is compound, it is rendered so generally by the fragments having penetrated the lungs, and noi by a tegumentary wound. In only eleven of the twenty-one cases seen by me, has the fracture been uncomplicated with fractures or dislocations of other bones. Displacement cannot occur in the direction of the axis of the bone unless several ribs are broken at the same time. The fragments are therefore either not at all displaced, or they fall inwards toward the cavity of the chest, or outwards, or very slightly downwards, in the direction of the intercostal spaces. Sometimes the rib moves a little upon its own axis. Prognosis. —Death occurs sooner or later in a pretty large proportion of the cases in which the ribs have been broken; yet not often as a direct consequence of the fracture, but only as a result of the injury inflicted upon the viscera of the chest, or of other injuries received at the same moment. The violent compression of the heart and lungs has frequently produced death, and sometimes, as I have more than once seen, almost immediately; or the patients have succumbed at a later period to acute pneumonitis. Lonsdale saw a case in which the body of a man having been traversed by the wheel of a wagon, eight ribs were broken, and death having followed almost immediately, the autopsy disclosed a rent in the left auricle of the heart, produced by one of the broken ribs. 1 — South says there is such a specimen in St. Thomas's Hospital. 2 Dupuytren reports a similar case. The same surgeon has also seen several deaths produced by the emphysema, independent of the frac- 1 Lonsdale on Fractures, p. 258. 2 Chelius's Surgery, by South, vol. i. p. 599. 166 FRACTURES OF THE RIBS AND THEIR CARTILAGES. ture, two of which are particularly described in his Clinical Lectures. 1 Amesbury has seen a case of death from rupture of the intercostal artery, where there was no injury of the lungs. 2 In several instances observed by me, patients have suffered from pains in the side, occasionally from cough, &c, after the lapse of two or more years, and I suspect it is no uncommon thing for these injuries to entail some such permanent disability, but which is a consequence rather of the injury to the viscera of the chest than of any condition of the broken ribs themselves. In general, simple fractures of the ribs unite in from twenty-five to thirty days. Malgaigne has seen one case of non-union; Huguier met with another upon the cadaver, in which a complete false joint existed, furnished with a capsule and lined with synovial membrane; 3 Eve, of Nashville, Tenn., saw a case of non-union occasioned, probably, by a caries or necrosis of the bone, since it was accompanied with a discharge of matter, and in which a removal of the ends of the fragments resulted promptly in a cure of the sinus ; 4 and Samuel Cooper says there is a specimen in the Museum of the University College, of a fracture of six ribs, where the fragments are only connected by a fibrous or ligamentous tissue. 4 The union generally occurs with only a slight degree of displacement. After the union is completed, even where there is no displacement, a certain amount of ensheathing callus may generally be felt at the point of fracture. Of five cases which I have carefully examined after recovery, in only one instance was I unable to detect any irregularity at this point. I have in my cabinet nine specimens of fractured ribs, in four of which the ensheathing callus is completely formed, but the fragments are in perfect apposition: in one, apposition is preserved, but Fig. 34. Fractured ribs joiued to each other by osseous matter. (From Dr. Gross's cabinet.) there is no ensheathing callus; and the remaining four, all occurring in the same person, are united with displacement, but without a proper ensheathing callus. In some specimens I have observed sharp spicule, in others broader sheets, of bone extending along the course of the intercostal muscles from one rib to the other, forming a species of anchylosis between their adjacent margins. Symptomatology. —Acute pain, referred especially to the point of fracture, sometimes producing great embarrassment in the respiration, 1 Dupuytren, op. cit., p. 79. 2 Amesbury on Fractures, vol. ii. 612. 3 Malgaigne, op. cit., p. 435. 4 Eve, N. Y. Journ. Med., vol. xv. p. 136. 5 S. Cooper's Surg., vol. ii. p. 321. 167 FRACTURES OF THE RIBS. and crepitus, are the most common indications of a fracture. The pain and embarrassed respiration are, however, far from being diagnostic, since they are often present in an equal degree when the walls of the chest have only been severely contused. The crepitus, also, is often difficult to detect, owing to the thickness of the muscular coverings, or to the amount of fat upon the body, or to the fracture having occurred perhaps directly underneath the mammas in the female. In three instances, where the presence of emphysema rendered the existence of a fracture quite certain, I have been unable immediately after the accident to discover crepitus. The crepitus may be discovered sometimes by pressing gently upon the seat of fracture, or by applying the ear or the stethoscope over this point while the patient attempts a full inspiration, or coughs; or we may press upon the front of the chest with one hand, while the fingers of the other hand rest upon the fracture. Occasionally the patient has felt the bone break, and very often he feels or hears the crepitus after it is broken, and will himself indicate very clearly the point of fracture. At the same time that we detect crepitus we are able also to discover motion in the fragments, but I have once or twice discovered preternatural mobility without crepitus. Emphysema, which is almost certainly indicative of a fracture, is present in a pretty large proportion of cases. It has been observed by me in eleven out of twenty-one cases; generally it did not extend over more than two or three square feet of surface; but in one instance it finally extended over nearly the whole body. It is remarkable, however, that in only four of these eleven cases did the patients expectorate blood, and then in a very small quantity, and not until the second or third day. Desault observes that emphysema rarely succeeds to fractures of the ribs; an observation which, as will be seen, my experience does not at all confirm. Treatment. —In simple fractures, where there is no displacement, or where the displacement is only moderate, the chest may be inclosed with a broad belt or band, as we have already directed in case of fracture of the sternum: provided always that it is not found to increase instead of diminishing the patient's sufferings. Some patients cannot tolerate this confinement at all, while with a majority, although it is at first uncomfortable and oppressive, after an hour or two it affords them great relief from the distressing pain, and they will not consent to have it removed even for a moment. In nearly all cases of comminuted, or multiple fracture, it is inadmissible, on account of its tendency to force the pieces inwards. Hannay, of England, has suggested the use of adhesive straps as a substitute for the cotton or flannel band; the several successive pieces being imbricated upon each other, until the whole chest is covered. 1 The same objection holds to this mode of dressing as to a similar mode of dressing a broken clavicle, which has been recently recommended. 1 American Journ. Med. Sci., vol. xxxix. p. 198. From Lond. Med. Oaz.,Nov. 1845. 168 FRACTURES OF THE RIBS AND THEIR CARTILAGES. It will certainly become loosened after a few hours, by the slight but uninterrupted play of the ribs. The forearm ought also to be brought across the chest at a right angle with the arm, and secured in this position with a moderately tight bandage or sling, so as to prevent any motion in the pectoral muscles. As to position, the patient generally prefers to sit up, or he chooses a position only partly reclining upon his back; but there is no positive rule to be observed in this matter, except that such a position shall be chosen as shall prove most comfortable to the patient. If the fragments are salient outwards, the fracture having been produced by a counter-stroke, they may be reduced by pressing gently upon them from without. If, on the contrary, the fragments are salient inwards, they will be found, in a great majority of cases, to have resumed their positions spontaneously or through the natural actions of respiration; but if they have not, it will be exceedingly difficult to restore them. Possibly it may be accomplished by pressing forcibly upon the front of the chest, or upon the anterior extremity of the broken rib; yet if the fragments are comminuted, and the ends are much driven in, this method will avail little or nothing. In such cases several surgeons have recommended that we should cut down to the bone and elevate the fragments, but Rossi alone claims to have actually put the suggestion into practice. No doubt, if the necessity was urgent, this method might be successfully adopted; or, instead of cutting down to the broken rib, we might even seize the fragment with a hook, as suggested by Malgaigne, or, what in some cases might be even more convenient, with a pair of forceps constructed with long teeth, obliquely set upon a firm shaft. Yet the exigency which will demand a resort to any of these measures will be exceedingly rare. In no case do I attach any value or importance to the advice given by Petit, that we shall place a compress upon the front of the chest, underneath the bandage, in order to reduce the fragments, or to retain them in place after reduction. Lisfranc, who advocated this method, claimed that its advantage consisted in the increased length which was thus given to the antero-posterior diameter of the chest, and the consequent accumulation of pressure from the encircling band, in this direction. 1 The mechanical law is no doubt correctly stated, but its value in practice is too inconsiderable to deserve consideration. The emphysema generally demands no especial attention, since it is usually too limited to occasion inconvenience, and when more extensive it generally disappears spontaneously after a few days, or a few weeks at most. The advice given by some surgeons, that we ought in these cases to cut down to the pleural cavity so as to allow the air to escape freely through the incision, seems thus far to have rested its reputation upon a more than doubtful theory rather than upon any testimony of experience. Abernethy alone, so far as I know, has actually made the experiment, and his patient died. Ranking'! Abstract, vol. ii. p. 204, from Gaz. des Hopitaux, July 8, 1845. FRACTURES OF THE CARTILAGES OF THE RIBS. 169 Dupuytren, in the two cases already alluded to, bled the patients and applied resolvent liquids, with rollers; he also made incisions with the lancet at various points of the body, more or less remote from the seat of fracture, a practice, however, in which he confesses he has no confidence whatever. These patients both died. Dr. Stedman, of the Massachusetts General Hospital, has reported the case of a man aged sixty-nine, of intemperate habits, who, in addition to a fracture of one of his ribs, had also a dislocation of the outer end of the clavicle. The emphysema commenced immediately and reached its acme on the twenty-second day. At this time it had extended over his whole body; his eyes were closed and he breathed with great difficulty; but on the forty-fifth day, the emphysema had entirely disappeared, and he was dismissed cured. The treatment consisted chiefly in the free internal use of stimulants, and in the application of bandages; but the bandages soon became disarranged, and after a few days they were entirely laid aside. 1 In the case of my own patient, where the emphysema was almost equally extensive, the patient recovered after a few weeks, under the use of a simple diet, and without any special medication whatever. § 2. Fractures of the Cartilages of the Ribs. Boyer was incorrect when he said that the cartilages of the ribs could not be broken until they were ossified. They are often broken when there is no ossification, at the same time that the ribs themselves are broken. Sometimes they are broken alone. Not unfrequently, also, the separation takes place at the precise point of junction between the two. Pyper relates a case in which the sternum was broken in a man aged twenty-five years, and also the cartilages of the sixth, seventh, and eighth ribs of the right side, as was proven by the autopsy, yet the cartilages were not ossified. The vena cava ascendens was also ruptured by the force of the compression. 2 Etiology. —The causes are the same as those which produce fractures of the ribs, yet it is generally understood that it will require greater force, and that consequently the injury done to the viscera of the thorax will be more complicated and intense. In the reports of the Massachusetts General Hospital, an account is given of the case of a man aged thirty, who was crushed by the fall of a heavy weight upon his body, and who died after about sixty hours. An examination after death revealed a fracture of the cartilages of the third and fourth ribs, with a laceration of the intercostal muscles to such an extent that a hernia of the lungs had occurred at this point. This hernia had been discovered and recognized by Dr. Warren, soon after the accident occurred; the protrusion being at that time as large as the clenched fist and regularly rising and falling with each movement of respiration. It was accompanied, also, with a moderate emphysema. 1 Boston Med. and Surg. Journ., vol. lii. p. 316. 2 Banking's Abstract, vol. i. p. 147, from the Lancet, Oct. 1844. 12 170 FRACTURES OF THE CLAVICLE. Pathology. —The fracture is clean and vertical, or transverse; never irregular or oblique. The direction of the displacement varies as in fractures of the ribs, but the anterior or sternal fragment is generally found in front of the posterior or spinal. Union takes place in these fractures, not through the medium of cartilage, but of bone. Sometimes the new bone being deposited only between the ends of the fragments, in the form of a thin plate, and at other times it is formed around the fragments as well as between them. The latter of these two processes has been most frequently observed. The ensheathing callus appears to be supplied by the perichondrium, while the experiments of Dr. Redfern render it probable that the intermediate callus may result from a conversation or transformation of the adjacent cartilaginous surfaces. Paget remarks, also, that the ossification extends to the parts of the cartilage immediately adjacent to the fracture. I have seen one example, in the person of Hiram Leech, ast. 38, which, after the expiration of more than one year, had not united. The fracture had occurred in the united cartilages of the tenth and eleventh ribs. The posterior fragment overlapped the anterior, and they played freely upon each other at each act of inspiration and expiration. I do not know that any observations have been made upon the repair of these cartilages in very early life, and it is possible that the process may differ from this which has been described as it has been observed in the adult. Treatment. —The treatment need not differ from that already recommended for fractured ribs. CHAPTER XVIII. FRACTURES OF THE CLAVICLE. For the sake of convenience, I shall divide fractures of the clavicle into those occurring through the inner, middle, and outer thirds. By the " outer third" is meant all that portion of the clavicle included between its scapular extremity and the internal margin of the conoid ligament. The remaining portion is intended to be divided equally into two separate thirds. The peculiarities of these several portions, in respect to anatomical relations, liability to fracture, results, etc., will explain the propriety of the divisions. Causes. —The clavicle is broken, in a large majority of cases, by a counter stroke, such as a fall, or a blow upon the extremity of the shoulder. Occasionally it is broken by a direct stroke, as when a blow aimed at the head is received upon the shoulder; it is broken sometimes by 171 FRACTURES OF THE CLAVICLE. the recoil of an overloaded gun, especially when the person lies upon the ground with the but of the gun resting against the clavicle. Gibson has seen a case in which it was broken in a child at birth, by an ignorant midwife pulling at the arm, 1 and Dr. Atkinson has reported an example of intra-uterine fracture of the clavicle.* I have once seen the clavicle broken by muscular action alone. A large, well-built and healthy man, aged thirty-seven, standing upon the ground, attempted to secure the braces of his carriage top with his right arm, when he felt a sudden snap, as if something about his shoulder had given way. He did not, however, suspect the nature of the injury, and did not consult any surgeon until eight days after, at which time I found the right clavicle broken near its centre, but rather nearer the sternal than scapular extremity. The fragments were but slightly, if at all displaced, but motion and crepitus at the point of fracture were distinct. The usual node-like swelling was also present, indicating the existence of a considerable amount of ensheathing callus. He had been unable to raise the arm to a right angle with the body since it was broken, but he had suffered no other inconvenience from it. A similar case is reported in the number for January, 1843, of the American Journal of Medical Sciences, copied from the Bevista Medica. The subject of this case was a colonel of cavalry, about sixty years of age. In mounting his horse, he experienced a sensation as if something had broken, followed by acute pain in his left shoulder, and, on examination, it was found that the clavicle was fractured in the middle. The health of this gentleman had been impaired, it is further stated, by repeated attacks of syphilis. Malgaigne has recorded three other examples of fracture of this bone from muscular action; and Parker saw a case which was produced by striking at a dog with a whip; the bone had been previously somewhat diseased, yet it united favorably. 3 Of these six cases, five occurred on the right side, and always near the middle of the bone, if we except one case reported by Malgaigne, in which the point of fracture is not mentioned. In neither case did the fragments become displaced, only as they were found, in some of the examples, inclined slightly forwards. Pathology. —It has already been observed, in speaking of partial fractures, that this bone suffers an incomplete fracture more often than any other, and that in such cases, the lesion occurs generally in the middle third, or rather to the sternal side of the centre, and in a direction nearly or quite transverse. They are not usually accompanied with much displacement, but if a displacement exists, it is a slight forward inclination of the fragments. Fractures which are complete occur mostly after the bones have become firm and unyielding. They are also generally oblique, seldom comminuted, still more rarely compound. The point of the clavicle 1 Gibson, Principles of Surg., sixth ed., vol. i. p. 272. 2 Atkinson, Bost. Med. and Surg. Journ., July 26, 1860. 3 Parker, N. Y. Journ. Med., July, 1852. 172 FRACTURES OF THE CLAVICLE. at which a complete fracture usually occurs, is at or near the outer end of the middle third, and a little to the sternal side of the coraco-clavicular ligaments, near where the trapezius and deltoid cease their attachments. It might be more exact to say, that the fracture extends from this point downwards and inwards, toward the sternum, embracing one inch or less of its entire length. In some cases the obliquity is greater, and the amount of bone involved is much more considerable. Why the bone should break more frequently at this point, especially in the adult and in the male, it is not difficult to understand. It is smaller here than elsewhere, and less supported by muscular and ligamentous attachments. At this point, also, the axis of the bone begins pretty abruptly to curve forwards, and more abruptly in the adult and male, than in the child and female. When, therefore, the clavicle is broken, as it usually is, by a counter-stroke, the force of the blow, conveyed from the shoulder through the outer portion of the bone, is suddenly arrested, and expends itself upon the point where the direction of the axis is changed. In a record of ninety-four fractures, including partial and comminuted, the latter of which have always been broken twice, seventy-one have occurred through the middle third, and, with the exception of the partial fractures, the fracture has in nearly all of the cases taken place near the outer end of this third. Three have occurred through the inner third, two of which were within one inch of the sternum; and twelve through the outer third. A more practical analysis can be based, however, upon the point of fracture with reference to its cause; and I have never seen a complete Fig. 35. Complete oblique fracture, near the middle of the clavicle. fracture of this bone produced clearly by a counter-stroke, which was not near the outer end of the middle third. When the fracture is at this point, or in any portion of the middle third, the direction of the displacement is almost uniformly the same. The sternal fragment is slightly lifted by the action of the clavicular portion of the sterno-cleido mastoid muscle, notwithstanding the resistance of the rhomboid ligament, and the subclavian muscle. On the other hand, the acromial fragment is dragged downwards by the weight of the arm, aided by the conjoined action of a portion of the pectoralis major and the latissimus dorsi, feebly resisted by the trapezius and other muscles from above; by the action of the same muscles, aided by the pectoralis minor, and perhaps by some portion of the subclavius, it is drawn toward the body, diminishing thereby the axillary space; while by the preponderating strength of the pectoralis major and minor, the acromial end of the fragment, with the 173 FRACTURES OF THE CLAVICLE. shoulder, is drawn forwards; the sternal end of the same fragment being rather displaced backwards, and at the same time resting at a point somewhat elevated above its acromial end. Desault has recorded one example of an overlapping by the elevation of the acromial fragment over the sternal j 1 and Bichat remarks, that Hippocrates speaks of the phenomenon as a thing which was familiar to him. Syme has mentioned a case of this kind which he had seen. 2 Gue'retin, Malgaigne, 3 and Stephen Smith, have each reported an example. 4 In Stephen Smith's case, the fracture occurred in a man thirty-eight years old. The bone was broken through the outer third, and transversely. He was treated at the Bellevue Hospital, but the overlapping, to the extent of one inch, remained after the cure was completed. In nearly all the cases of oblique fractures occurring through the middle third, there follows immediately an overlapping, varying from one-quarter of an inch to an inch, and sometimes, though very rarely, exceeding this. There is a specimen in the Dupuytren Museum, in which the shortening equals one-third of its entire length. Transverse fractures, wherever they may occur, are not so constantly found displaced, at least in the direction of the axis of the bone, as the following examples will illustrate:— An old lady, aged eighty years, fell down a flight of stairs, breaking the right clavicle transversely, about one inch from the sternum. I saw her, with Dr. Trowbridge, on the day following the accident. Motion and crepitus were distinct, but there was scarcely any displacement. No dressings were applied, but she was directed to keep quiet in bed, and upon her back. In the usual time the fragments had united, without deformity. A man, about forty years old, fell backwards from a wagon, breaking the collar bone near the middle. The fragments were movable, but not displaced. He was treated successfully and without any resulting deformity, by simple confinement in the recumbent posture during a few days, and after this by suspending the arm in a sling, while he was permitted to walk about. A young man, aged twenty-six, fell while wrestling, and broke the clavicle at the outer end of the middle third. There was some displacement at first, but the fragments being reduced, were found to support themselves. A cross, secured with straps, was applied to the back, and on the twenty-eighth day the union was complete, and without deformity. A child, aged three years, fell about six feet, striking upon his shoulder. He was sent to me on the same day, by Dr. G. Burwell. I found the left clavicle broken off completely, about one inch from its scapular end. Crepitus and motion were distinct, but the fragments were not displaced. The arm was placed in a sling, and on the seventh day both motion and crepitus had ceased. The cure was accomplished without any degree of displacement. 1 Desault on Frac.,op. cit., p. 16. 2 Atner. Journ. Med. Sci., vol. xvii. p. 251. » Malgaigne, p. 461. 4 N. Y. Journ. of Med., May, 1857. 174 FRACTURES OF THE CLAVICLE. The example of a fracture from muscular action, already mentioned as having been seen by me, was also probably transverse, and union has occurred without treatment and without displacement. Stephen Smith, of New York, has met with two examples of transverse fractures without displacement, in a hospital record of eleven cases. Bichat says Desault has frequently observed the same, it having been seen three times at Hotel Dieu, in the course of the year 1787. 1 Desault thinks, also, that sometimes the fracture, taking place obliquely upwards and inwards, the usual form of displacement is prevented, and apposition is preserved. If the fracture is near the sternum, and within the fibres of the costo-clavicular ligaments, as in the case of the old lady just cited, the displacement is inconsiderable. I have seen one other similar case in an adult also. Lonsdale mentions a case in a child, three years old, which came under his observation in Middlesex hospital, 2 which he regarded as a separation of the epiphysis; this bone, however, has no epiphysis, properly speaking, being formed entire from a single point of ossification. Malgaigne mentions two other examples, in one of which the fracture was so near the sternum that it was difficult to say whether it was not a partial dislocation. The displacement was only trivial. 3 But the only two specimens contained in the Dupuytren Museum offer a considerable displacement, and in both the external fragment is thrown downwards and forwards. With regard to the amount of displacement usually attendant upon fractures near the outer end of the bone, surgical writers have generally united in declaring that it was in a majority of cases very inconsiderable, while some have even affirmed that there would be found no displacement whatever; neither of which opinions, according to the recent observations of Robert Smith, of Dublin, is strictly correct. He has examined eight specimens of fracture of the outer extremity of the clavicle, contained in the museum of the Richmond Hospital School of Medicine; three of which were broken between the conoid and trapezoid ligaments, and are united with very little displacement, while the remaining five, broken beyond the trapezoid ligament present a very marked deformity. The following is a summary of the conclusions to which he has arrived:—¦ " When the clavicle is broken between the two fasciculi of the coraco-clavicular ligament, there is seldom any displacement of either fragment, and always much less than in fracture of any other portion of the bone. When displacement does occur, it is usually limited to a slight alteration in the direction of the bone, by which the natural convexity of this portion of the clavicle is increased. " The explanation of which facts is found in the attachments of the ligaments from below to the two fragments; and, in the action of the trapezius from above, by which they are antagonized. " But the case is very different when the bone is broken external to 1 Desault on Fractures, op. cit., p. 15. 2 Lonsdale on Fractures, p. 206. 3 Malgaigue, op. cit., p. 491. 175 FRACTURES OF THE CLAVICLE. the trapezoid ligament. Here the coraco-clavicular ligaments can have no direct influence upon the outer fragment, which is displaced now partly by muscular action, and partly by the weight of the arm, the sternal end of the outer fragment being drawn upwards by the clavicular portion of the trapezius, while, by the action of the muscles passing from the chest, the entire outer fragment is drawn forwards and inwards, so as to bring sometimes its broken surface into contact with the anterior surface of the inner fragment, and placing it nearly at right angles with this fragment, in which position it is gene- Fig. 36. Fracture outside of trapezoid ligament. Uuited. rally united. The displacement in this direction, rather than any degree of overlapping, explains also the shortening which existed in all of these cases, varying in the different specimens from half an inch to one inch, and averaging about three-quarters of an inch." Such are the views of Mr. Smith, and I see no reason to call in question their correctness. In my own experience, a fracture occurring in a child three years old, within one inch of the acromial end, probably between the ligaments, was never displaced at all; a second, occurring somewhere in the outer third, presented, after many years, no displacement. Two recent cases were displaced each one-quarter of an inch, and one old case, half an inch; these three latter cases occurred in adults, and always within an inch of the acromial end of the bone. In one of these last examples, the inner fragment was rather behind than above the outer fragment. But it would be unsafe to draw conclusions from an experience which is confined entirely to living examples, and in which no dissections have been made, to verify the exact point of fracture, or the precise amount and character of the displacement. So far as they go, however, they seem to me to confirm the general correctness of the observations made by Robert Smith. It has happened to me only six times to meet with a comminuted fracture of the clavicle, all of which fractures occurred through some portion of the middle third of the bone; the intercepted fragments being from one inch to one inch and a half in length, and lying obliquely, or, as in one case observed by me, at nearly a right angle with the main fragments. I have never seen a compound fracture of this bone, except as the result of a gunshot injury, although, in many cases, the sharp point of an oblique fracture has seemed just ready to penetrate the skin. One case is reported as having been presented at St. Bartholomew's Hospital. It occurred in a boy fourteen years old, and was produced by his having been drawn into some machinery while it was in motion. 1 Two similar cases are reported from the New York Hospital, as having been observed during the last ten years. The whole number of examples of fracture of the clavicle during this period was 191. 2 Lente also mentions a case, seen by himself, occasioned by the fall • London Med. Gaz., vol. ii. p. 382. 2 New York Med. Times, March 16,1861. 176 FRACTURES OF THE CLAVICLE. of a derrick upon the shoulder. The patient, twenty-four years old, was admitted into the New York Hospital in August, 1848. The left clavicle was broken at about its middle, and a large wound in the integuments communicated with the fracture. The fragments united firmly in about six weeks, after several pieces of bone had been discharged from the wound. 1 A double fracture, or a simultaneous fracture, occurring in both clavicles, seldom occurs. I have recorded two cases (four fractures, three of which are incomplete), both occurring in young boys. 2 Malgaigne says it has only happened to him to see it once in 2,358 cases, at the Hotel Dieu, and he can recollect only five other examples. And of 158 cases of broken clavicles reported from the New York Hospital, it is stated to have occurred in only four. These gentlemen, however, only report hospital cases, and they have reference, doubtless, to complete fractures; while double fractures, according to my experience, occur more often in children than in adults, and are of the character of partial fractures, without usually much displacement; which facts, if sustained by subsequent observations, would sufficiently Fig. 37. Complete Fracture.—Oblique ; at outer end of the inner two-thirds. (From nature.) explain their infrequency in hospital, and their relative frequency in private experience. Symptoms. —In all cases of complete fracture with displacement, no difficulty will be experienced in deciding upon the nature of the injury. The patient is found generally leaning toward the injured side, while the opposite hand sustains the elbow of the same side, to prevent its dragging downwards. The shoulder falls downwards, forwards, and inwards; while, at the same time, the line of the bone is interrupted by the sharp and projecting point of the sternal fragment. If the fracture is the result of a direct blow, a swelling and dis- coloration may be seen at the seat of fracture, but if it is the result of a counter-stroke, we must look to the top or point of the shoulder for the signs of a contusion. The patient also experiences pain when an attempt is made to raise the arm at a right angle with the body, and especially in attempting to carry the arm across the body, by which the ends of the broken clavicle are driven into the flesh. In two cases (cases 19 and 50 of my report on Deformities) of oblique fracture, accompanied with displacement, occurring in the middle third of the bone, I have particu- 1 Lente, N. Y. Journ. of Med., July, 1850. 2 Rep. on Def. after Frac, Cases 5,6,10. 177 FRACTURES OF THE CLAVICLE. larly noticed that the patients could easily lift the hands to the head, and in one of these cases the patient, a boy, fourteen years old, raised his arm perpendicularly over his head. Such exceptions are not very uncommon. Crepitus can be detected sometimes by simply pressing down the sternal fragment, but it is almost always present when we draw the shoulders forcibly back, so as to bring the broken fragments into more perfect contact. If there is no displacement, still crepitus may generally be discovered by grasping the bone between the thumb and fingers, and moving it gently up and down, or by slight pressure upon the point of fracture. When the fracture occurs close to the acromial extremity, external to the coraco-clavicular ligaments, although according to Robert Smith, there is usually considerable derangement, yet it is not accompanied with a corresponding amount of external deformity, and its diagnosis will require, therefore, more care and attention on the part of the surgeon. Prognosis in this fracture deserves especial attention. In no other bone, except' the femur, does a shortening so uniformly result. Of sixty-one complete fractures only fifteen united without shortening; and of twenty simple, oblique, complete fractures, which occurred at or near the outer end of the middle third, only one united without shortening (Case 46 of my Report), and in this case the patient was but fifteen years old, and the fragments were never much displaced; nor can I say that the treatment, a board across the back after the manner of Keckerly, had anything to do with the result. Five cases of complete transverse fracture, occurring at the same point, united without shortening. The shortening varies from one-quarter of an inch to one inch, or more, and the fragments are almost always, especially when the fracture is through the middle third, found lying in the position in which we have described them to be at the first—the outer end of the inner fragment being above, and often a little in front of the outer: sometimes, especially in lean persons, and when the fracture is very oblique, presenting a sharp and unseemly projection. The greatest amount of shortening is generally found in those fractures which occur through the middle third; in fractures near the sternal end there is usually very little permanent displacement; the same is true when the fracture is at the acromial end, and between the coraco-clavicular ligaments, as the observations of Robert Smith, already quoted, have sufficiently established; but if the fracture is beyond these ligaments, the final displacement and deformity may be very great. The presence of a small amount of ensheathing callus soon after the cure is completed, sometimes increases the deformity. It is rarely seen to encircle the bone completely, but, if present, it appears to be most abundant in the direction of the salient points of the fracture, that is, above and below; so that, unless the examination is made with care, the projecting points of callus which remain, sometimes after many years, may be easily mistaken for an intercepted fragment turned 178 FRACTURES OF THE CLAVICLE. at right angles to the axis of the bone. In the case of partial fracture, reported by Dr. Green, a similar circumstance was observed, which his natural shrewdness soon enabled him to explain. 1 Robert Smith has observed also, that in cases of fracture external to the conoid ligament, osseous matter is freely formed upon the under surface of each fragment, but there is seldom any deposited upon the upper surface of either. These osseous growths, occupying the situation of the coraco-clavicular ligaments, frequently prolong themselves as far as the coracoid process, and in some cases to the notch of the scapula. Still less frequently these osteophytes become fused with the coracoid process, and a true anchylosis exists. In comminuted fractures the intercepted fragments generally fall off from the line of the other fragments, and cannot easily be restored. The clavicle being a spongy and vascular bone, usually unites with great rapidity, generally within twenty days. In the fourth example Fig. 38. Comminuted Fracture.—United. (From nature.) of transverse fracture already mentioned as having been seen by me, the union seemed to be tolerably firm in seven days. Wallace reports one case from the Pennsylvania Hospital, which was cured in eight days, and another in nine days. 2 Yelpeau says the clavicle will unite in from fifteen to twentyfive days; Benjamin Bell, in fourteen; Stephen Smith has seen it firm in fifteen days. Whatever may be the degree of displacement, or the condition of the system, it is very seldom that it refuses to unite altogether, or that the union is ligamentous: and in the few cases found upon record of a ligamentous union, the functions of the arm. do not seem to have suffered any serious ultimate injury, as the following example, and the only one which has come under my observation, will illustrate:— Edmund Nugent, a stout Irish laborer, now twenty-five years old, was received into the Buffalo Hospital of the Sisters of Charity, in March, 1854. He states that several years before, he fell from a horse and broke his left clavicle, at the outer end of the middle third. This was near Cork, in Ireland, and without consulting any surgeon or " handy man," he continued at work, holding the tail of the plough, nor from that day forward did he employ a surgeon, or dress his arm, or cease from his work. The clavicle presents now the same deformity which nearly all other similar fractures present after what is usually termed successful treat- 1 Transac. of Amer. Med. Assoc. for 1855, Case 13 of Frac. of Clavicle. 1 Am. Journ. Med. Sci., vol. xvi. p. 115. 179 FRACTURES OF THE CLAVICLE. ment, except that it is not united by bone. The outer end of the inner fragment rides upon the inner end of the outer fragment half an inch. The ligament uniting the two extremities is so long and firm that it can be distinctly felt, and the fragments may be moved upon each other with great freedom. In order that we might determine the amount of injury which he had suffered from the ligamentous union, we directed him to lift weights placed on a table before him, while he was seated upon a chair. We ascertained from this experiment that with his left arm he could lift as much, within three ounces, as he could with his right, and he was not himself conscious of any difference. The muscles of the left arm seemed as well developed as those of the right. Chelius also refers to two cases mentioned by Gurdy and Velpeau, in which, although an artificial joint remained, the use of the limb was but little impaired. 1 Fergusson " once had occasion to remove various portions of this bone, which had become necrosed in consequence of neglected treatment. The patient, about twenty-years of age, had the right collar bone broken by the fall of a tree; not knowing the nature of the injury, he worked as a reaper for several hours after; violent inflammation, suppuration, and necrosis followed; but after the dead pieces were removed he made a rapid and excellent recovery." 2 In a case of compound and comminuted gunshot fracture reported by Ayres, of New York, the recovery was remarkable. The man was sixty-two years old, and in excellent health when the injury was received. The clavicle was so extensively comminuted that before the wound closed over one-third of the bone had escaped, and yet at the end of one year from the time of the accident the shoulder was perfectly symmetrical with its fellow, without drooping or falling forwards. Dr. Ayres thinks that all of the clavicle which was lost has been reproduced. A partial paralysis, with atrophy of the muscles of the arm, accompanied, also, with more or less rigidity and contraction of the muscles, both of the arm and forearm, is, according to my observation, a more frequent result of these fractures. Mr. Barle has recorded a case of comminuted fracture of the clavicle, in which the nerves converging to form the axillary plexus were so much injured that paralysis of the arm ensued; and it was noticed as an interesting fact, that the patient could not afterwards put her hand into even moderately warm water without the effects of a scald being produced, characterized by vesications, redness, etc. 3 Desault saw a case at Hotel Dieu, in which, athough the clavicle was not broken, the force of the blow upon the clavicle was sufficient to produce a severe concussion of the brachial plexus, and paralysis of the arm. A timber had fallen from a building, striking upon the external part of the left clavicle. A considerable wound, followed by 1 Chelius, Amer. ed., vol. i. p. 603. 2 Fergusson, System of Practical Surgery. Amer. ed., p. 215. * S. Cooper's First Lines, fourth Amer. ed., vol. ii. p. 323. 180 FRACTURES OF THE CLAVICLE. swelling, pointed out the place on which the blow had been received. No apparatus was applied, and on the third day a numbness and partial loss of the power of motion occurred in the arm of the affected side. Soon afterward an insensibility came on, and by the seventh day the paralysis of the arm was complete. It was not until after a tedious treatment that the limb recovered in part its original strength.' In Case 23 of my report to the American Medical Association, which was followed by paralysis of the opposite arm, and spinal curvature, these results were probably due to some injury of the back received at the time of the accident; but one cannot avoid a suspicion that the apparatus, Brasdor's jacket, contributed somewhat to the unfortunate result. No axillary pad was employed, but the straps over each shoulder were buckled so tight that he was compelled to incline his head constantly to the right side. He was unable to lie down, and could only recline in a half sitting posture. This treatment was continued four weeks; and two months after its removal the paralysis and spinal distortion commenced. In Case 38, also, of the same report, a comminuted fracture, paralysis with contraction of the muscles extending to the wrist and fingers, existed, but whether it was due to the severity of the original injury or to the treatment, could not be satisfactorily ascertained. Gibson relates a remarkable instance of this kind. A young man was struck on the clavicle by the falling limb of a tree, breaking it into numerous pieces, and bruising the parts so severely as to give rise to violent inflammation. " The fragments had been driven behind and beneath the level of the first rib, and so compressed the plexus of nerves as to wedge them into each other, and by the subsequent inflammation to blend them inseparably together. Complete paralysis and atrophy of the whole arm ensued, and the patient's object in visiting Philadelphia was to submit to an operation, in hopes of elevating the clavicle to its natural height, and taking off pressure from the nerves." Dr. Gibson, however, did not believe that the prospect of success was sufficient to warrant the operation, and the young man was sent home. 2 It will not do to deny, therefore, the possibility of a paralysis as resulting from a concussion of the axillary nerves, produced by a blow upon the clavicle, nor of a paralysis resulting from a direct injury inflicted by the points of the fragments upon this plexus in certain very badly comminuted fractures; but it is certain that these conditions will not satisfactorily explain all of the other examples in which paralysis has followed simple fractures. In some cases it is no doubt due rather to the injudicious mode of using an axillary pad, by means of which the arm is converted into a powerful lever, and thus the brachial nerves are made to suffer from compression along the inner side of the arm itself. In short, it must be confessed that it is sometimes due to the treatment alone, and not to the original injury. Parker, of New York, in a note to the edition of S. Cooper's Sur- 1 Desault on Frac. and Disloc, Amer. ed., 14, 1805. * Gibson, op. cit., vi. p. 271. FRACTURES OF THE CLAVICLE. 181 gery, just quoted, declares that he has seen one patient who had lost the use of his arm from the pressure upon the nerves by the wedgeshaped pad, over which the limb was confined, in order to pry the shoulder outwards. Stephen Smith mentions a case of partial paralysis from the same cause. 1 A similar case has come under my own observation. A lady, aged fifty-one years, was thrown from her carriage, breaking the right clavicle obliquely at the outer end of the middle third. During the first three weeks the arm was dressed with Fox's apparatus, which was at no time particularly painful. She was then placed under the care of another surgeon, who, finding the fragments overlapped, applied very firmly a figure-of-8 bandage, with an axillary pad, securing the arm snugly to the side of the body; hoping by these means to restore the fragments to their place. The pain which followed was excessive, and notwithstanding the free use of anodynes, it became so insupportable that at the end of fourteen hours the dressings were removed by another surgeon, and Fox's apparatus again substituted. These were also applied much more tightly than at first, and during the four weeks longer that they remained on, repeated attempts were made to reduce the fragments. Forty-eight days after the accident, she consulted me. The clavicle was then united, and overlapped half an inch. The whole arm was swollen, painful, and very tender, with total inability to move it. I removed all the dressings, and, during the time she remained under my care, in a private room at the hospital, there was a gradual improvement in the condition of her arm, in respect to swelling and tenderness, but the paralysis did not much abate. Erichsen thinks he has seen one case of comminuted fracture, produced by a direct blow, in which the subclavian artery was ruptured; great extravasation of blood resulted, and the arm was threatened with gangrene. The patient having recovered, however, the diagnosis could not be determined by actual dissection. 2 Since among surgeons some difference of opinion seems to exist as to the practicability of overcoming the displacement in certain fractures of the clavicle, it is proper that I should defend the accuracy of my own observations by a reference to the observations of others. In nine of eleven cases reported by Stephen Smith, one of the surgeons at Bellevue Hospital, New York, more or less deformity remained after the cure was completed. In the two remaining cases the actual results are unknown. 3 " Great difficulty has been experienced in treating this fracture." 4 "The indications of treatment are plain, but, unfortunately, not very easily fulfilled." 3 " Fractures of the clavicle will often cause greater trouble than those which are considered of a more serious character, and the utmost pains 1 New York Journ. of Medicine, May, 1857. 2 Erichsen, Surgery, Amer. ed., p. 205. 3 New York Journ. Med., May, 1857, p. 382. 4 Syme's Principles of Surgery, p. 266, Philadelphia ed., 1832. 5 Miller's Practice of Surgery, 3d Amer. ed. from 2d Edinburgh, p. 309 182 FRACTURES OF THE CLAVICLE. will not, on all occasions, suffice to prevent a slight prominence of the inner fragment." 1 "Setting of this fracture is easy, yet only in very rare cases is the cure possible without any deformity." 2 " It is considered, also, that the close union of the fracture of the collar bone depends less on the apparatus than on the position and Fig. 39. Velpeau's dextrine bandage ; no axillary pad. direction of the fracture; (therefore, in spite of the most careful application of this apparatus, some deformity often remains.") 3 The following statements of M. Yelpeau are found in a letter addressed to the editor of the Boston Medical and Surgical Journal, by J. Willis Fisher, dated Paris, Sept. 16th, 1846. Mr. Fisher remarks that the report is drawn in part from his own notes, and partly from "the report published in the Gazette des Hdpitaux." It is the annual summary of M. Yelpeau's practice at for the year ending Sept. 1846. "The fractures of the clavicle, less numerous than ordinarily, have been only four. They have proved these three often repeated propositions: First, that contrary to the general opinion, the patients can carry the hand to the head when they have a fractured clavicle. Secondly, that the consolidation of the bones demands only from fifteen to twenty-five days, and not six weeks or two months. Thirdly, that with all the bandage imaginable, we cannot prevent fracture of the two internal and oblique thirds from leaving a deformity." 4 "Fracture of the clavicle is almost always followed by deformity, whatever may be the perfection of the apparatus and the care of the surgeon."* 1 Practical Surgery. By Wm. Fergusson. 4th Amer. ed., from 3d London, p. 215. 2 System of Surgery. By J. M. Chelius, of Heidelburg, with notes by South. First Amer. ed., vol. i. p. 603. 3 Chelius, op. cit., vol. i. p. 605. 4 Bost. Med. and Surg. Journ., vol. xxxv. p. 212. This is evidently a misprint. Instead of " fracture of the two internal and oblique thirds," the writer means to say an oblique fracture at the junction of the two internal with the outer thirds. 4 Vidal (de Cassis), Paris ed., vol. ii. p. 105. 183 FRACTURES OF THE CLAVICLE. " Hippocrates has observed that some degree of deformity almost always accompanies the reunion of a fractured clavicle; all writers since his time have made the same remark; experience has confirmed the truth of it." 1 " As to the reduction of this fracture, it must be owned the same is often easier replaced than retained in its place after it is reduced; for its office being principally to keep the head of the scapula, or shoulder, to which, at one end, it is articulate, from approaching too near, or falling in upon the sternum, or breast bone, it happens that, on every motion of the arm, unless great care be taken, the clavicle therewith rising and sinking, the fractured parts are apt to be distorted thereby. Besides, even in the common respiration, the costas and sternum aforesaid, where the other end of this bone is adnected, together with the motion of the diaphragm, rising and falling, especially if the same be extraordinary, as in coughing and sneezing, are able to undo your work, not to mention the situation thereof, less capable of being so well secured by bandage as many others. All which, duly considered, it is no wonder that upon many of these accidents, although great care has been taken, these bones are sometimes found to ride, and a protuberance is left behind, to the great regret particularly of the female sex, whose necks lie more exposed, and where no small grace or comeliness is usually placed." 2 " Restituitur facile tractis humeris a ministro posterius, dum simul suo genu locato ad spinam dorsi, dorsum sustentet minister, nam tunc chirurgus folis digitis claviculam fractam reponere potest. Difficilius autem in reposita sede retinetur, sed loca cava supra et infra claviculam spleniis implenda." 3 " The reduction of a broken clavicle is not very hard to be effected, especially when the fracture is transverse: nor is it unusual for the humerus, with the fragment of the clavicle, to be so far distorted as not to be easily replaced with the fingers; but the difficulty is much greater to keep the bone in its place when the fracture is once reduced, especially if the bone was broken obliquely." 4 Amesbury, after having exposed the inefficacy of all previous modes of dressing, and especially of the figure-of-8 bandage, Desault's, Boyer's, and an apparatus recommended by Sir Astley Cooper, proceeds to describe his own apparatus and to affirm its excellence. It is, however, not much unlike a multitude of others, and is liable, I have no doubt, to the same objections. 3 M. Mayor, of Lausanne, thinks that up to this day no successful mode of treatment has been devised. " Here everything appears as yet so little determined that each day sees some new propositions and different procedures," etc. He believes, however, that in his simple handkerchief bandage, with straps across each shoulder, the indica- 1 Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav. Bichat, and translated by Charles Caldwell, M. D. Philadelphia, 1805, p. 9. 2 The Art of Surgery, by Daniel Turner, vol. ii. p. 256. London ed., 1742. 3 Johannis de Gorter; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742. 4 Heister's Surgery, vol. i. p. 134. London ed., 1768. 6 Treatment of Fractures, by Joseph Amesbury, vol. ii. p. 527. London ed., 1831. 184 FRACTURES OF THE CLAVICLE. tions are most fully accomplished and the most successful results are obtained. If, however, it were to be treated without apparatus, the horizontal position, lying upon the back, would, in the end, make the most perfect unions.' Says M. Malgaigne: "The prognosis, considering the trivial character of this fracture, is sufficiently difficult. For, little as may be the displacement, the surgeon ought not to promise a reunion without deformity; and certain successful results, proclaimed from time to time, betray, on the part of those who relate them, the most extravagant exaggerations."* M. Nelaton having spoken of the various plans which have been suggested to retain this bone in place, and of their inefficiency, comes at last to speak of the handkerchief bandage of M. Mayor, and remarks :— " This apparel is very simple; but neither will it remedy the overlapping." Of all the apparels which we have passed in review, there is, then, not one which fills completely the three indications usually present in the fracture of a clavicle. None of them oppose the displacement; they have no effect, with whatever care they may be applied, but to maintain immobility in the limb. We think, then, that it is useless to fatigue the patient with an apparatus annoying, and, perhaps, even painful; a simple sling, secured upon the sound shoulder, will be sufficiently severe. Nevertheless, as this does not assure so complete immobility as the bandage of M. Mayor, it is to this that we think the preference ought to be given in all cases of fractures of the clavicle, whether accompanied with displacement or not, whether they occupy the middle or the external part of the clavicle. If the fracture presents no displacement, we shall obtain a cure which will leave nothing to be desired. If there is a tendency to displacement, the consolidation will be effected with a deformity more or less marked; but since this deformity is inevitable, at least with adults, whatever may be the apparel which we employ, it is evident that the apparatus which causes the least constraint ought to have the preference. We may remark, farther, that this union with deformity in nowise impairs the free exercise of all the movements of the member." 3 " The venerable gentleman who stands at the head of American surgery, and whose manipulations with the roller approach very nearly to the limits of perfection, informed us, in 1824, that he had never seen a case of fractured clavicle cured by any apparatus, without obvious deformity. 4 I need not say that the " venerable gentleman" to whom Dr. Coates refers in this passage, was the late Dr. Physick, of Philadelphia. 1 Nonveau Systeme de Deligation Chirurgicale, par Mathias Mayor, de Lausanne, p. 384, etc. : (also Atlas, plate 3, fig. 23.) Paris edit., 1838. * Traite des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p. 473, Paris ed., 1847. Elemens de Pathologie Chirurgicale, par A. Nelaton, tome premier, p. 720, Paris ed., 1844. 4 Reynal Coates, Amer. Med. Journ.. vol. xviii. p. 62, old series. It is probable that Dr. Physick here referred to complete and oblique fractures of the middle third, or that Dr. Coates has forgotten the precise language employed on this occasion. FRACTURES OF THE CLAVICLE. 185 Treatment. —If evidence were needed beyond that which has been furnished, of the difficulty of bringing to a successful issue the treatment of this fracture, it might be supplied, one would think, by a reference merely to the immense number of contrivances which have been at one time and another recommended. A catalogue of the names only of the men who have, upon this single point, exercised their ingenuity, would be formidable, nor would it present any mean array of talent and of practical skill. All these surgeons, however, have admitted the same indications of treatment, viz., that in order to a complete restoration of the outer fragment, which alone is supposed to be much displaced, we are to carry the shoulder upwards, outwards, and backwards. But as to the means by which these indications can be most easily, if at all, accomplished, the widest differences of opinion have prevailed; and, in the debate, it may be seen that, while on the one hand, no invention has wanted for both advocates and admirers, on the other hand, no, method has escaped its equivalent of censure. Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and others, directed the patients to lie upon their backs, with little or no apparatus, but generally with the spinal column so supported and lifted with pillows, as that the shoulders would by their own weight fall backwards. S. Cooper and Dorsey also recommend that the patients should be confined in this position during most of the treatment ; and from the account given by Dr. Lente, it may be inferred that a similar plan is generally adopted in the New York City Hospital. " But this result (deformity) rarely happens when the patient has strictly followed the directions of the surgeon, as to position especially, for it is by position more than by any other remedial means, that a good result is to be effected. ***** The persevering continuance of the supine position in bed, with the head low, and, if necessary, a pad between the shoulders. This is the treatment uniformly adopted by Dr. Buck, in the hospital, and the results of his treatment are certainly such as to recommend it highly." Nearly the same method we find recommended by Alfred Post, in 1840, then one of the surgeons of that hospital; the arm being merely kept in a sling and bound to the side, with the patient lying upon his back. Dr. Post mentions a case treated in this manner, which terminated with very little deformity ;* and I have myself treated two cases by this plan with more than average success. Jan. 2, 1856—Mary Ann S., Eet. 24, fell down a flight of stairs, breaking the right collar bone obliquely near its middle. She was unwilling to submit to bandages, and I directed her simply to lie upon her back in bed. On the fourteenth day the fragments had united; and at the end of the third week I dismissed her with an overlapping of the fragments of less than half an inch, and with scarcely any perceptible deformity. Alexander Mooney, a?t. 33, was admitted to the Buffalo Hospital, December 3, 1856, with an oblique fracture of the left clavicle, at the 1 N. Y. Journ. of Med., vol. ii. p. 266. 13 186 FRACTURES OF THE CLAVICLE. outer end of the middle third. On measurement we found the fragments overlapped nearly half an inch. In presence of a class of medical students I applied Bartlett's apparatus, a very ingenious and convenient form of the sling dressing, and the same which is now in use at the Mass. General Hospital, in Boston. On the following day the apparatus was found to be loose, and it was carefully retightened. On the third and fourth day, also, it was found necessary to readjust it more or less, and the fragments of the broken clavicle continued to overlap. On the fifth day Bartlett's apparatus was removed, and the patient laid upon his back in bed, with his arm simply tied to the side of his body by a few turns of a roller. On the tenth day all motion had ceased between the fragments; but he was kept in bed three weeks. Jan. 10, 1857, he was discharged from the hospital, with an overlapping of only about one-quarter of an inch, and with scarcely any perceptible deformity. Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County, Fig. 40. Figure-of-8. N. Y., have also employed this method su ccessfully; 1 while Malgaigne declares it to be the most reliable means of obtaining an exact union. Albucasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, Brunninghausen, Parker, 2 and very many others, especially among the English, have preferred in order to carry the shoulders back, a figure-of-8, while Desault, Colles, South, and Samuel Cooper, have represented this bandage as useless, annoying, and mischievous. Heister, Chelius, Miller, Brefheld, Keckerly, 3 Coleman, 4 Hunton, 6 prefer, for this purpose, some form of backsplint, extending from acromion to acromion, against which the shoulders may be properly secured. Parker says that splints of this kind, with a figure-of-8 bandage, are " better than all the apparatus ever invented." While Mr. South gives his testimony in relation to all dressings of this sort, as follows: "I do not like any of the apparatus in which the shoulders are drawn back by bandages, as these invariably annoy the patient, often cause excoriation, and are never kept long in place, the person continually wriggling them off to relieve himself of the pressure." 1 Bost. Med. and Surg. Journ , vol. lvi. p. 46°. * Parker, Samuel Cooper's First Lines, Amer. ed., vol. ii. p. 325. 3 Keckerly, Amer. Journ. Med. Sci., vol. xv. p. 115; also, my Report on Deformities after Fractures, in Trans, of Amer. Med. Assoc., vol. viii. p. 440. 4 Coleman, New York Journ. Med., second series, vol. iii. p. 274, from New Jersey Med. Rep. 1 Hunton, ibid. ; also, New Jersey Med. Rep., vol. v. p. 146. 187 FRACTURES OF THE CLAVICLE. Fox, 1 Brown, 2 Desault, and others bring the elbow a little forwards, and then lift the shoulder upwards and backwards. Wattman and Fig. 41. E. C. Keckerly's Apparatus.—"The upper figure exhibits a front View, and the lower a back view of the splint, a, a. Are two bandages with buckles attached to one end of each, bb, bh. Are four mortised holes for the passage of the two bandages, a, a. c. A portion of the splint padded, to prevent its bruising the patient, d, d. Two loops of leather, tacked on the back of the splint, for the passage of the bandages, where the mortised holes are too far apart for the breadth of the patient from shoulder to shoulder. "Mode of Application. —The end of the splint corresponding to the uuiujured side is to be pressed close to the hack of the shoulder, and retained so by drawing the bandage tight, and retaining it by means of the buckle. Previous to lixing the bandage, it should be passed through two loops on a small pad, which is to be placed in the axilla. This pad is used for the purpose of preventing the cutting of the bandage. After passing the other bandage through two loops, on a large, cuneiform pad, which is placed in the axilla of the injured side, it is drawn sufficiently tight and secured by the buckle. The last thing to be done is to place a handkerchief, doubled into a triangular form, in such a manner over the arm, the front and back parts of the thorax, as that it shall draw and confine the ai m of the injured side close to the body, give it support, and prevent its falling down." Lonsdale carry the elbow still further forwards, so as to lay the hand across the opposite shoulder, while Guillou carries the hand and forearm behind the patient, and then proceeds to lift the shoulder to its place. Thus Desault, Fox, and Wattman accomplish the indication to carry the shoulder back, by lifting the humerus while the elbow is in front of the body, and Guillou accomplishes the same indication by lifting the humerus when the elbow is a little behind the body. Chelius also says: " The elbow, as far as possible, is to be laid backwards on the body." Sargent, who believes that with Fox's apparatus "the occurrence of deformity is the exception," and not the rule, and prefers it to all others, has treated three cases by Guillou's method, and is perfectly satisfied with its operation. Hollingsworth, of Philadelphia, has also treated one case successfully by Guillou's method, and adds his testimony in its favor. But how shall we explain these equal results from opposite modes of treatment? Is the indication to carry the shoulders back, which Fox sought to accomplish by pressing the elbow upwards and backwards, as easily attained by pressing the elbow upwards and forwards? Or are we not compelled to infer that there has been some mistake as 1 Fox, Liston's Practical Surgery, Amer. ed., p. 47. 2 Brown, Sargent's Minor Surgery, p. 132. 188 FRACTURES of the clavicle. to the precise amount of good accomplished by the apparatus in either case ? Moreover, Coates, 1 Keal, and others, instruct us that the only safe and proper position for the humerus is in a line with the side of the body, and that it must neither be carried forwards nor backwards. Paulus Boyer, Desault, Pecceti, Liston, Fergusson, Samuel Cooper, Erichsen, Miller, Skey, Levis, Dorsey, 2 Gibson, 3 Fox, H. H. Smith, 4 Norris, 4 Sargent, Eastman, 6 recommended an axillary pad, while Richerand, Velpeau, Dupuytren, Benjamin Bell, Syme, deny its utility, or affirm its danger. Dr. Parker has seen one patient in whom paralysis of the arm resulted from the pressure upon the brachial nerves, in the attempt " to pry the shoulder out;" and I have myself recorded another. Cabot, of Boston, Massachusetts, has recommended a mould of gutta percha laid over the front and top of the chest. 7 Desault's plan, which took its origin, as Yelpeau thinks, in the spica of Glaucius, under various modifications, is recommended by Delpech, Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson, Liston, Cutler, Physick, Dorsey, Coates, and Gibson; while by Yelpeau, Syme, Colles, Chelius, Samuel Cooper, and Parker, it is regarded as inefficient and troublesome. Says Mr. Cooper: "In this country, many surgeons prefer Desault's bandages; but I do not regard them as meeting the indications, and consider them worse than useless." The dextrine bandages, or apparatus immobile, of Blandin, Yelpeau, and others, constitute only another form of the bandage dressing of Desault. In this connection it ought to be noticed that Yelpeau does not regard the employment of this apparatus, or of any other demanding great restraint, as imperative. In his great work on anatomy, referring to the fact that when the bone is broken and overlapped, the patient is still able, in many cases, to move the arm freely, he remarks : " Do not these cases give support to the opinion of those who admit that fractures of the clavicle do not actually require any other apparatus than the simple supporting bandage?" "It is necessary to observe," he adds, " that by thus acting we do not prevent an overlapping, 8 etc. The sling, in some of its forms, is employed by Richerand, Huberthal, Colles, Miller, Fox, Stephen Smith, 9 H. H. Smith, Bartlett, 10 Levis, 11 1 Coates, Amer. Journ. Med. Sci., vol. xviii. p. 62. 2 Dorsey, Elements of Surgery, vol. i. p. 133. 3 Gibson, Institutes and Practice of Surgery, vol. i. p. 271. 4 H. H. Smith, Practice of Surgery, p. 354. 5 Norris, Liston's Practical Surg., Amer. ed., p. 46. 6 Eastman, Apparatus for Fractured Clavicle, by Paul Eastman, of Aurora, 111. ; Boston Med. and Surg. Journ., vol. xxiii. p 179. 7 Cabot, Bost. Med. and Surg. Journ., vol. lii. p. 232. 8 Velpeau, Anatomy, Amer. ed., vol. i. p. 242. 9 Stephen Smith, New York Journ. Med., vol ii. 3d series, p. 384 (May, 1857). 10 Bartlett, My " Report on Defor.," etc., Appendix ; also Bost. Med. and Surg. Journ., vol. Ii. p. 404. " Levis, H. H. Smith's Practice of Surg., p. 365. Am. Journ. Med. Sci., April, 1860, p. 428. 189 FRACTURES OF THE CLAVICLE. Dugas, 1 Benjamin Bell, Bransby Cooper, Earle, Chapman, Keal, and by a large majority of the English surgeons; while Dr. Gibson de- clares the sling bandage employed so much by the English, " the most inefficient, contemptible, and injurious of all contrivances for such purposes." No apparatus, perhaps, has been so generally employed, among American surgeons, as that form of the sling introduced by Dr. George Fox into the Pennsylvania Hospital in 1828. Sargent says of it: " Fractures of the clavicles, treated by this apparatus, are daily dismissed from the Pennsylvania Hospital, and by surgeons in private practice, cured without perceptible deformity." Norris, in a note to Listorfs Practical Surgery, affirms that " the chief indications in the treatment of fracture of the clavicle are perfectly fulfilled by the use of this apparatus." Smith, in his Minor Surgery, declares that Fox's apparatus accomplishes "perfect cures" in very many cases, and that it is " a very rare thing for a simple case to go out of the house (Pennsylvania Hospital) with any other deformity save that which time cures, viz., the deposi- Fig. 42. E. Bartlett's Apparatus.—"For an. axillary pad, roll a strip of woollen flannel, four or five inches wide,around the axillary strap, to the size required. The apparatus may be used for either side by changing the attachment of the sling." (Bartlett.) tion of the provisional callus." He has also repeated substantially the same opinion in his larger work entitled Practice of Surgery. Such testimony in favor of any dressing demands respectful attention; and I shall not be regarded as detracting from the respect due to these authorities, when I express my belief that it is in deference to the distinguished reputation of the surgeons who have during the last thirty years had charge of the services in that hospital, and who have been so loud in its praise, that the use of this apparatus has, with us, become so general. I believe, also, that, in some measure, this general preference is due fairly to the intrinsic excellence of the dressing. But I must be permitted to express a doubt whether it has made deformities of the clavicle " the exception, instead of the rule," with us. I have used this dressing oftener than any other form, and yet my success has by no means been so flattering as has been the success of these gentlemen. I have seen others employ it, also, and with pretty much the same results. Nor ought it to be forgotten that, in Great Britain, by far the greater majority of surgeons employ an apparatus essentially the same. I have seen it in many of the hospitals, and Mr. Bickersteth, one of the surgeons of the Liverpool Infirmary, informed 1 Dugas, Report on Surgery. 190 FRACTURES OF THE CLAVICLE. me, in 1844, that it had been in use with them as long as thirty years. All that has justly been said against the English mode of dressing by Fig. 43. George Fox's Apparatus "consists of a firmly stuffed pad of a wedge shape, and about half as long as the humerus, having a baud attached to each extremity of its upper or thickest margin; a sling to suspend the elbow and forearm, made of strong muslin, with a cord attached to the humeral extremity, and another to each end of the carpal portion ; and a ring made of inusliu stuffed with cotton to encircle the sound shoulder, and serve as means of acting upou and receiving the sling." (Sargent.) slings, is equally true of this; and whatever has been affirmed of the danger of using an axillary pad applies as much to this as" to any other mode of using the same. I believe, however, that in the Pennsylvania Hospital, the axillary pad employed is not so large, and especially, not so thick, as that recommended by Desault, and in this respect it is plainly an improvement; but then, in the same proportion that it is made less thick, it is less powerful to accomplish the indication in question; and if it merely fills the axillary space, then it is no longer a fulcrum upon which the -arm is to operate as a lever. Regarding, then, the importance of this question to the interests of surgery, and observing the wide differences of opinion which are entertained here and elsewhere as to the real value of this dressing, is it asking too much of these gentlemen that they will present us some more precise statistical testimony ? It will be observed that its advocates claim for it what is not to-day, at least, claimed for any other apparatus, viz: that, under its use in the Pennsylvania Hospital, and in the hands of private practitioners, so far as they have seen, deformities have become the "excep- tion." It is affirmed to answer "perfectly" all the indications. By which it must be intended to say, that, in addition to both of the other indications, that also, which has always heretofore been found so difficult, if not impossible, the carrying out of the shoulder, is in a majority of cases perfectly accomplished—the clavicles are not shortened. If it is intended, however, to say that a shortening is not generally prevented, but only that no unseemly projection of the fractured ends will be found to result, I reply, that then it does not answer all the indications; and I beg, further, to suggest that the avoidance of an upward projection seems to me, to depend much more upon that part of any apparatus which lifts the shoulder, and which belongs to a multitude of other forms of dressing as well as to that in question, than upon that which forces the shoulder out, and it may be accomplished, in a majority of cases, as well without an axillary pad, with a mere sling, as with it. But, in fact, my experience has convinced me that the absence or presence of such a projection, after union, is FRACTURES OF THE CLAVICLE. 191 due much to the circumstances of the fracture, as to whether it is more or less oblique; and still more especially, to the degree of roundness, or emaciation of the patient, rather than to any form, or part, or condition of the apparatus. It will be found more distinct in oblique fractures than in transverse, and much more marked in thin persons than in plump, or fat persons, and more so in muscular than in nonmuscular. In short, I affirm that such a projection has occurred as often under my observation, when this dressing has been used, as it has when other forms have been employed. Finally, while I deprecate incautious assumptions in regard to the capabilities of any form of dressing for broken collar bones, a disposition to which is manifested by more than one advocate of special plans, I am ready to bear my humble testimony in favor of that one of whose claims I have taken the liberty to speak so freely, and which is usually known in this country by the name of Fox's apparatus, consisting essentially of a sling, axillary pad, and bandages to secure the arm to the chest, and to which the stuffed collar is a convenient accessory, but admits of various modifications, answering the same ends. Among the considerable variety of dressings which I have used, this, either with or without such slight modifications as I shall presently suggest, has seemed to me most simple in its construction, the most comfortable to the patient, the least liable to derangement (if I except Velpeau's dextrine bandage), and as capable as any other of answering the several indications proposed. No apparatus is better able to answer the first indication, namely, " to carry the shoulder up," and thus to bring the fragments into line. If, as not unfrequently happens, the outer end of the inner fragment is also carried a little upwards and forwards, it may be, in some measure, replaced by inclining the head to the injured side, or by a carefully adjusted compress and bandage. But it is not probable that any patient will consent to remain a long time in a position so unnatural and constrained; nor is it very easy, as the experiment will show, to maintain a steady pressure upon this portion of the broken clavicle. The second indication, " to carry the shoulder back," is certainly much more difficult of accomplishment than the first; and it does not seem to me to be fully met by the sling dressing; but until some mode is devised less objectionable than any I have yet employed, or than any, the mechanism of which I have seen described, I see no alternative but to trust to that action of the muscles attached to the scapula, by which, as Desault first explained, when the shoulder is lifted perpendicularly, it is also in some degree carried backwards, and that, too, it has occurred to me frequently to observe, just as much as when the upward pressure is made with the elbow placed in front of the body. It is my belief, however, from the evidences now before us, that the third indication, "to carry the shoulder out," still remains unaccomplished ; that it cannot be claimed for this, or for any other apparatus yet invented, that, in a certain class of cases which I have sufficiently indicated, constituting a vast majority of the whole number, it is able 192 FRACTURES OF THE CLAVICLE. to prevent a riding of the fragments. Nor, seeing the difficulties in the way, and the amount of talent which has been already devoted to their removal, have I much confidence that this end, so desirable, and so diligently sought, will ever be attained. Yet it is presumptuous, perhaps, to say what the skill and ingenuity of a profession whose labors never cease, may not hereafter accomplish. Having already expressed my preference for the sling, I have only to add what I consider necessary modifications in the form of this dressing recommended by Dr. Fox. Dr. Coates, in the excellent paper already referred to, 1 calls attention to the danger of making too much pressure upon the brachial artery and nerves, when the axillary pad is used, and the arm is, at the same time, carried forwards upon the body. In bringing the elbow forwards so as to lay the forearm across the body, the humerus is made to rotate inwards, and the brachial artery and nerves are brought into more direct apposition with the pad. The same objection must hold, Fig. 44. The Author's Apparatus. only in a greater degree, to M. Guillou's method of carrying the forearm across the back. The humerus ought then to be permitted to hang perpendicularly beside the body, and thus the nerves and bloodvessels will be removed in a great measure, yet not entirely, from pressure. The pad (to be employed only as a part of the retentive means, and not as a fulcrum) should be no thicker than is necessary to fill completely the axillary space when the elbow is made to press snugly against the side of the body. In consequence of having placed the elbow farther back than is recommended by Dr. Fox, it will be necessary, also, to vary in some way, the suspensory tapes; those coming from the humeral portion of the arm-tray must pass in equal numbers, and in opposite directions—before and behind the body—toward the stuffed collar; and each set of front and back tapes, attached to the humeral portion of the tray, must be in pairs, for the convenience of tying. I find it necessary also to secure the arm to the body by two or three turns of a roller, applied always lightly and with great care, so that its pressure shall be in no degree painful or uncomfortable. In cases of partial fracture accompanied with a persistent bend in the line of the axis of the bone, it is proper to make some attempt by moderate pressure directly upon the salient fragments, to restore them to place; but I confess that I have never yet succeeded in accomplishing anything in this way. Nor is it a matter of much consequence, I 1 Am. Journ. Med. Sci., vol. xviii. p. 62. 193 FRACTURES of the body of the scapula. imagine, since, as I have already explained when speaking of partial fractures in general, the line of the axis of the bone will eventually, at least in a majority of cases, be completely restored. The only treatment which seems then to be indicated, and the only treatment which I have of late adopted in these cases, is to place the hand and forearm of the child in a sling, or I direct the mother to make fast the sleeve to the front of the dress in such a way that the child cannot use the arm until the union is consummated. Even this precaution I have several times omitted with no injury to the patient. For a more full consideration of partial fractures of the clavicle, I beg to refer the reader to the chapter on " Partial Fractures," &c. CHAPTER XIX. FRACTURES OF THE SCAPULA. Fractures of the scapula may be divided into those which occur through the body, the neck, the acromion, and coracoid processes. § 1. Fractures or the Body of the Scapula. Under this title I propose to consider not only fractures of the " body" properly speaking, but also fractures of the angles and of the spine. Causes. —It is usually broken by the fall of some heavy body directly upon the bone, or by some severe crushing accident, by the kick of a horse, by a fall upon the back—in short, by direct causes alone, and by such causes as operate with great violence. Malgaigne says that a Doctor Heylen has recently published a case of this fracture which he believes to have been the result of muscular action, occurring in a man forty-nine years old. The case, however, is not stated so clearly as to relieve us entirely of a doubt as to the nature and cause of the accident. I have myself had occasion to treat but two cases, one of which was produced by a fall upon the back, and the second, by the fall of a heavy weight upon the back. Dr. Neill called my attention to a fracture involving the spine of the scapula then under treatment in the Pennsylvania Hospital, in the year 1855. I have met with but one more example, except as the result of a gunshot wound. There are two cabinet specimens of fracture of the body of the scapula below the spine in the Pennsylvania Medical College, and two involving the spine. Dr. Mutter has in his collection a fracture of the posterior angle (Fig. 45), and Dr. March has a specimen of fracture of the body. I believe that Dr. Charles Gibson, of Richmond, has also one or two specimens of this fracture. I know of no other museum specimens in 194 FRACTURES OF THE SCAPULA. this country except my own of partial fracture, described in the chapter on Partial Fractures. Ravaton, after a practice of fifty years, declared that he had never Fig. 45. Fracture of the posterior angle of scapula, with fissure. Mutter's collection, specimen C. No. 1S7. seen a fracture of the scapula, except as it had been produced by fire-arms. Among 2358 fractures reported from Hotel Dieu during a period of twelve years, only four examples of fracture of the scapula are recorded; and at Middlesex Hospital, Lonsdale has noticed among 1901 fractures, only eight of the body of the scapula. The infrequency of this fracture i$ no doubt due in a great measure to the elasticity of the ribs, to the mobility of the scapula, and to the softness of the muscular cushion upon which it reposes. Symptoms. —Since this bone is seldom broken except by great force directly applied, the usual signs of fracture are likely to be concealed by the speedy occurrence of swelling. It is for this reason that it becomes necessary generally that the examination should be made with great care before we can safely determine upon the diagnosis. I have more than once had occasion to correct the diagnosis of other practitioners, who believed they had discovered a fracture of the scapula. When the line of the fracture has traversed the spine, and any considerable displacement has occurred, one ought to recognize the fracture easily by merely carrying the finger along the crest. In the example to which Dr. Neill called my attention in the Pennsylvania Hospital, although there was scarcely any displacement, the point of fracture could be distinctly felt; and Dr. Husted, of New York, brought to my notice a similar case in Sept. 1860. It is only when the swelling over the seat of fracture is very great that any difficulty in the diagnosis need to exist, or perhaps in the case of a patient who is very fat. If the fracture has occurred through the body, below or above the spine, or through either of the angles, the displacement may not be so easily recognized. The surgeon ought then to trace carefully with his finger the outlines of the scapula, and this he will be able to do more satisfactorily if he places the scapula in such positions as elevate its 195 FRACTURES OF THE BODY OF THE SCAPULA. margins and render them more prominent. In examining the posterior angle, the hand of the injured limb may be placed upon the opposite shoulder, the forearm being carried across the front of the chest; but in searching for a fracture below the spine, the forearm ought to be laid across the back. Crepitus, which is not always present, owing to the fact that the fragments overlap completely, or because they have been widely separated by the action of the muscles, may generally be detected by placing the palm of the hand upon some portion of the scapula, so as to steady the fragment upon which it rests, while the arm is moved backwards and forwards, and in various other directions, until their broken surfaces are brought into contact. Some degree of embarrassment in the motions of the shoulder and arm must always result from this fracture; sometimes this embarrassment is very great, but it ought not to be considered ever as diagnostic of a fracture, since it may be produced equally by a severe contusion; and even when it is accompanied with a fracture, it is due rather to the contusion than to the fracture. Pathology, seat, direction, &c. —Of incomplete fractures of the scapula, I have already mentioned that I have seen one example. Malgaigne thinks that he has seen one case of incomplete fracture, which occurred in a man who was injured by the fall of a heavy block of stone, upon his back; but as the patient recovered, his diagnosis must remain doubtful. I know of no other recorded examples. Complete fractures occur most often below the spine, and they are generally oblique or transverse, sometimes nearly longitudinal. Fractures involving the spine are noticed occasionally, but I am not aware that any one has ever seen a specimen of a fracture of the spine alone, although many surgeons have spoken of them. I have mentioned one example of a fracture of the posterior angle as being in the cabinet of Dr. Mutter, of Philadelphia. Malgaigne seems to doubt its existence, but speaks of it as a fracture which surgeons have "imagined." Occasionally the bone is broken into more than two fragments. As a result of the fracture there is usually more or less displacement; generally, if the fracture is below the spine and transverse, and especially if its direction is oblique from before backwards and downwards, the inferior fragment is displaced forwards, or forwards and upwards, by the action of the serratus major anticus, or of the teres major, while the superior frag- Fig. 46. Fractures of the body, and acromion process of the scapula. ment is inclined to fall backwards, and sometimes it is carried upwards and backwards, following the action of the rhomboideus major. In cases of comminuted fracture, and occasionally in simple frac- 196 FRACTURES OF THE SCAPULA. tures, the direction of the displacement is reversed, or altogether changed, so that the lower fragment instead of being in front is behind the upper fragment, and instead of overlapping, the two fragments are more or less drawn asunder. These are deviations which are not easily explained, but which depend, perhaps, rather upon the direction of the blow than upon the action of the muscles. In a few cases there is no displacement in any direction, although the crepitus with mobility sufficiently demonstrates the existence of a fracture. Prognosis. —If displacement actually has taken place, it will be found very difficult, as we shall see when we come to consider the treatment, to hold the fragments in apposition, until a cure is completed: so that they are pretty certain to unite with a degree of overlapping, or other irregularity. Lonsdale, Lizars, Chelius, Nelaton, Gibson, Malgaigne, and others have spoken of the difficulty or impossibility generally of keeping these fragments in place. Nelaton and Malgaigne, indeed, confess that they have never succeeded; Gibson declares that it is scarcely possible; while Chelius affirms, that if the fracture is near the angle the cure is always effected with some deformity. But then it is not probable that the patient will ever suffer any serious inconvenience from this irregular union of the fragments, since the perfection of its function depends less upon any given form or size than in the case of almost any other large bone ; and if, as has been observed by Lonsdale, the free use of the arm is not recovered for some time, or if, as has been noticed by B. Bell, a permanent stiffness results, these should be regarded as due to the injury which those muscles have suffered which envelop the scapula, or to some injury of the ligaments and muscles which surround the shoulder joint. In Dr. Husted's case, already noticed by me, there existed, thirty-five days after the accident, when he was presented to me, both partial paralysis of the arm and considerable anchylosis at the shoulder-joint. In some few examples upon record, the bone has been so comminuted, and the soft parts adjacent so much injured that suppuration and necrosis have ensued. Treatment. —In the treatment of this fracture, the first object with all surgeons has been to restore the fragments to place, and this they have chiefly sought to accomplish by position; after which, they have endeavored to immobilize the fragments by bandages, &c. In seeking to accomplish the first indication, they have placed the shoulder and arm in a great variety of postures. Nearly all seem to have regarded it as of some importance that the shoulder should be elevated, so as to relax the muscles attached to the upper and back part of the scapula, and thus permit the upper fragment to fall downwards and forwards. If we confine our remarks first to fractures through the body, and do not include fractures of the inferior angle, this indication is the only one which Nelaton and Mayor have sought to accomplish, and for this purpose they employ a simple sling, while Amesbury, Liston, Lonsdale, S. Cooper, South, Skey, Miller, Pirrie, have added to the 197 FRACTURES OF THE BODY OF THE SCAPULA. sling a bandage or roller, which is made to inclose snugly the body and arm. Erichsen uses the body bandage alone, as in fractures of the ribs, while B. Cooper, Lizars, and Tavernier employ a bandage which incloses not only the body, but also the arm; neither of these last-mentioned surgeons recommends a sling, or any other means to elevate the arm. Johannes de Gorter advises that a sling shall be used, but that the elbow shall be lifted away from the side of the body, so as to relax the deltoid. Chelius and Desault recommend the same position, but with the addition of an axillary pad, whose apex shall be directed upwards, secured in place with appropriate bandages. Pierre d'Argelata used also an axillary pad, but instead of a wedge he recommended a simple roll; and instead of lifting the elbow away from the body, he directed that the elbow should be secured against the side, making use of the axillary roll as a fulcrum. Petit and Heister advised that the elbow and forearm should be carried forwards upon the front of the chest, and secured in this position. In the treatment of no other fracture perhaps have surgeons differed more widely as to the indications than in this, since, as we have seen, some recommend the elbow to be carried from the body, and some that it shall be made to approach the body; one directs that the elbow shall fall perpendicularly beside the chest, a second prefers that it shall be carried a little back, and a third that it shall be brought well forwards. In one thing alone have they nearly all agreed, namely, that the elbow shall be lifted; and generally also it has been recommended that the arm, forearm, and body shall be confined by sufficient bandages to insure quietude. It might be proper to conclude, therefore, that the sling and bandage constitute all of the apparatus which is necessary or useful; and that it is relatively unimportant whether the elbow is near or remote from the body, or whether it is in front of, or behind, or beside the chest. Such, indeed, is the conclusion to which we have ourselves arrived; yet if, in relation to the position of the elbow, a choice were to be expressed, we would give the preference to that in which the arm is laid vertically beside the body, or, perhaps, with the elbow a little inclined backwards, so as to relax as completely as possible the teres major. It is quite probable, however, that no single position will be found of universal application; and perhaps it would be more safe to advise the surgeon in any given case first to reduce the fragments as completely as possible by manipulation, and then to place the arm in such a position as, upon careful experiment in this particular instance, he shall find enables him to best retain them in place. If, however, the fracture is such as to have separated the inferior angle from the body, it will be well to follow the advice of Boyer and of others, and to place a compress in front of the inferior angle to resist the greater tendency to displacement in this direction. This compress will more effectually accomplish this indication if the roller 198 FRACTURES OF THE SCAPULA. with which it is secured to the body, and with which we seek to immobilize the scapula and chest, is turned from before backwards, or in a direction of antagonism to the action of the muscles which produce the displacement. Desault, with Chelius and Bransby Cooper, has recommended also, in the case of a fracture through the angle, that the forearm should be acutely flexed upon the arm, and that the hand should be placed in front of the chest, upon the sound shoulder, a position which is always irksome, and sometimes insupportable, and which does not offer in any case sufficient advantages to render it worthy of a trial. § 2. Fractures op the Neck op the Scapula If by the " neck" of the scapula, surgeons mean that slightly constricted portion of this bone which is situated at the base of the glenoid cavity, and it is to this portion, we believe, that anatomists have generally applied the term " neck," then its fracture is certainly very rare. Indeed, the existence of this fracture, uncomplicated with a Fig. 47. Comminuted fracture of the glenoid cavity. comminuted fracture of the glenoid cavity, is denied by Sir Astley Cooper, South, Erichsen, and others. Mr. South says there is no such specimen in any of the museums in London; and I have not been able to find one in any of the American cabinets. Dr. Mott has said to me that he had never seen a specimen, and that in the natural condition of the bone he regards its occurrence as impossible. Such, I confess, also, is my own conviction. If, however, it is intended, in speaking of fractures of the neck of the scapula, to refer, as Sir Astley Cooper has done, only to fractures extending through the semilunar notch, behind the root of the coracoid process, then its existence is certain ; yet the fracture is not common. Duverney has reported one example, the existence of which he established by a dissection. The coracoid process was broken at the same time, but the fracture through what was called the neck, was distinct from this: and Sir Astley has recorded three examples in which the diagnosis was very clearly made out, yet not actually proven by an autopsy. Symptoms. —Sir Astley justly remarks that "the degree of deformity produced by this accident depends upon the extent of laceration of a ligament which passes from the under part of the spine of the scapula to the glenoid cavity. If this be torn" (and to this we ought to add the ligaments passing from the coracoid process to the clavicle and acromion process) " the glenoid cavity and the head of the os humeri fall deeply into the axilla, but the displacement is much less if this remains whole." The usual signs are, a depression under the acromion process, the 199 FRACTURES OF THE ACROMION PROCESS. same as in dislocation of the head of the humerus downwards, but not so deep; the head of the humerus felt, perhaps, in the axilla; crepitus, and the immediate recurrence of the displacement whenever, after the reduction has been fairly accomplished, the arm is left unsupported. The crepitus is best discovered by resting one hand upon the top of the shoulder in such a manner as that a finger shall touch the point of the process, while the arm is rotated and moved up and down by the opposite hand. It may also be easily ascertained that the coracoid process moves with the humerus instead of the scapula. Occasionally, the accident is accompanied with paralysis of the arm, from pressure upon the axillary nerves, and a rupture of the axillary artery is also mentioned by Dugas. 1 Treatment. —The indications of treatment are three, namely, to carry the Fig. 48. Fracture of the neck of the scapula; according to Sir Astley Cooper. head of the humerus, with the glenoid cavity, &c, up, to carry it out, and to confine the body of the scapula. The first is accomplished by a sling, the second, by a pad in the axilla, and the third by a broad roller carried repeatedly around the arm and chest and across the shoulder. § 3. Fractures of the Acromion Process. Examples of fracture of the acromion process have been reported by Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, Malgaigne, West, 8 Brainard, 3 Stephen Smith, 4 and others. I have myself seen three examples. 3 In the case seen by Cooper it entered the articulation of the clavicle and produced at the same moment a dislocation. Malgaigne says it occurs generally farther up, and posterior to the attachments of the clavicle, " near the junction of the diaphysis with the epipyhsis," and that the fracture is in most cases transverse and vertical; but Nelaton saw a case in which the fracture was oblique. In the case reported by C. West, of Hagerstown, Md., the fracture was through the base of the process. In two of the examples seen by me the fracture was in front of the clavicle; and in the third, occasioned by the fall of a barrel of flour upon the shoulder, the fracture occurred at the acromio-clavicular articulation, and was accompanied with an upward dislocation of the outer end of the clavicle. 1 Remarks on Frae. of Scapula, by L. A. Dugas, Georgia. Am. Journ. Med. Sci., Jan. 1858. 2 West, Penin. Journ. of Med., vol. v. p. 254. 3 Brainard, Bost. Med. and Surg. Journ., vol. xxxi. p. 501 * 4 S. Smith. Hamilton, Report on Deform., op. cit. 200 FRACTURES OF THE SCAPULA. There is some reason to believe, I think, that a true fracture of the acromion process is much more rare than surgeons have supposed, and that in a considerable number of the cases reported there was merely a separation of the epiphysis; the bony union having never been completed. If such fractures or separations occurred only in children, very little doubt might remain as to the general character of the accident: but the specimens which I have found in the museums, and the cases reported in the books, have been mostly from adults. It is more difficult, therefore, to suppose these to be examples of separations of epiphysis, but I am inclined to think that in a majority of instances such has been the fact. It is very probable, also, that in the case of many of the specimens found in the museums, called fractures, the histories of which are unknown, they were united originally by cartilage, and that in the process of boiling, or of maceration, the disjunction has been completed. The narrow crest of elevated bone which frequently surrounds the process at the point of separation, and which Malgaigne may have mistaken for callus, is found upon very many examples of undoubted epiphyseal separations which I have examined; and this circumstance, no doubt, has tended to strengthen the suspicion that these were cases of fracture. This opinion is confirmed by the remark of Mr. Fergusson, that a fracture of this process is an accident " of rare occurrence." " I have dissected," he adds, " a number of examples of apparent fracture of the end of this process; but in such instances it is doubtful if the movable portion had ever been fixed to the rest of the bone." But the most complete explanation is furnished by that distinguished pathologist Dr. J. B. S. Jackson, of Boston, who observes that this process ossifies in two pieces, instead of one, as has usually been stated by anatomists; so that we may find an example of a short epiphysis or of a long one, a difference which many of the cabinet specimens present, although the usual length is about three-quarters of an inch. These two extreme points of ossification first coalesce, and then unite with the body. Dr. Jackson says, moreover, that there are four specimens in the museum of the Massachusetts Medical College, and in the museum of the Boston Society for Medical Improvement, which might easily be mistaken for fractures, but which only illustrate to how late a period the bony union is sometimes delayed. In one specimen the patient could not have been less than forty years of age; " the acromial process of each scapula was fully formed, but having no bony union whatever with the bone itself. The union was ligamentous, but strong and close." 1 To the same class belong several specimens in my own. collection; specimens 163 and 997 in Dr. March's collection; 707 in the Albany College Collection; two specimens in the Mutter, and one in the Jefferson Medical College museums. I wish to mention, also, that in the case of my own specimens of epiphyseal separation, as well as most of the specimens which I have examined, the ends of the fragments were closed with a compact bony tissue. 1 The author's Report on Deform., &c, op. cit. 201 FRACTURES OF THE ACROMION PROCESS. No doubt, however, a fracture of this process does occasionally take place. In addition to my own, I have already mentioned several other examples, some of which have been confirmed by dissection; and in the case mentioned by Stephen Smith, an autopsy, made three weeks after the accident, showed a fracture without displacement, the periosteum covering its upper surface not being torn; the fragment could be turned back as upon a hinge. Prognosis. —The process generally unites with a slight downward displacement. This occurred in at least two of the examples seen by me; but in such cases the motions of the arm are not in consequence much, if at all, embarrassed; unless, indeed, it is so much depressed as to interfere with the upward movements of the arm; a result which Heister erroneously supposed was inevitable. Sir Astley Cooper says that a true bony union is rare in these fractures, and that there generally results a false joint, the fragments uniting by N a fibrous tissue; but sometimes the surfaces instead of uniting either by bone or ligament, become polished, and even eburnated. Malgaigne has noticed, also, in a specimen contained in the Dupuytren museum, a hypertrophy of the lower fragment, this portion having a diameter nearly twice as great as that of the portion from which it was detached. Symptoms. —Where no displacement exists, the diagnosis must always be difficult, if not impossible. In such a case we could only be instructed by the manner in which the injury had been received, by the contusion, and by the presence of mobility or crepitus. In examples attended with displacement, if no swelling is present, the finger carried along the spine of the scapula to its extremity, will easily detect the fracture by the abrupt termination of the process, or by the presence of a fissure, or a depression; but as to the other symptoms, they must depend very much upon the point at which the fracture has taken place. If in front of the acromio-clavicular articulation, the position of the arm in its relations to the body will not be changed; but if the fracture is through the articulation, and a dislocation of the clavicle results, or if it is behind the acromio-clavicular articulation, the arm, having in either case lost the support of the clavicle, will assume the same position that it does in a fracture of the clavicle; that is, the shoulder will fall downwards, inwards, and forwards. Treatment. —If the fracture has taken place in front of the acromioclavicular articulation, no doubt the most rational plan of treatment is that recommended by Delpech; that is, placing the patient in bed, upon his back, and carrying the arm out from the body nearly to a right angle; since by this method the fragment is not only lifted, but the deltoid muscle is relaxed, and, consequently, the fragment is no longer forcibly drawn away from the spine of the scapula. If, therefore, the patient will submit to this treatment for a sufficient length of time, the union must be accomplished with the least possible amount of displacement. In case he will not consent to such confinement, I am confident no other plan which has been recommended merits a 14 202 FRACTURES OF THE SCAPULA. trial, unless it be simply to place the arm in a sling until the union is accomplished. If, however, the fracture has taken place at, or behind the junction of the clavicle with the process, the indications of treatment must be in all respects the same as in a fracture of the clavicle. § 4. Fractures op the Coracoid Process. I am surprised that Mr. Lizars should have never seen a case or heard of a well authenticated example of a fracture of the coracoid process. " The coracoid process," he remarks, " is said to be broken off, but this I question very much; it must be along with the glenoid cavity, or there must be a fracture of the neck of the scapula." Dr. Neill, of Philadelphia, has in his cabinet a specimen of separation of this process at about one inch from its extremity. The line of separation is somewhat irregular; there is no callus, but it is united to the upper portion by a dried tissue, half an inch in length, and continuous with the periosteum. This has been regarded as an example of fracture; but although the scapula is large and evidently belongs to an adult, the fact that the acromion process is not yet united by bone, renders it probable that this, also, is an epiphyseal separation. Prof. Charles Gibson, of Eichmond, Ya., informs me also that he has in his cabinet a dried specimen, from an adult, which has been broken obliquely near the end, but which is now united by a ligamentous or fibrous tissue of one line and a half in length. The fragment is displaced a little forwards, as well as downwards. Reuben D. Mussey, of Cincinnati, is in possession of a very remarkable and conclusive example of this fracture. The humerus is dislocated forwards, the head and neck being firmly united to the neck and venter of the scapula, while at the same time the coracoid process is broken and displaced. Dr. Jackson, of Boston, says that specimen No. 453 in the museum of the Massachusetts Medical College, seems clearly to have been a fracture involving the base of the coracoid process, and which, having taken place somewhere within a year of the death of the person, had become united by bone, and that just before death the process had broken off, and so completely, as to involve a portion of the glenoid cavity. 1 Bransby Cooper relates a case of fracture through the base, which after eight weeks, when the patient died, was found to be united by a ligament. The acromion process was broken at the same time, and had united in the same manner. The head of the humerus was also broken and partly united. 2 One example is said to have occurred in the practice of Dr. Arnott, at the Middlesex Hospital, London, in consequence of which the patient died, when a dissection disclosed the true nature of the accident. 3 Mr. South has also reported a case resembling somewhat Mussey's, but much more complicated. The 1 The author's Report on Deformities, op. cit. 2 B. Cooper, edition of Sir Astley on Frac. and Disloc, Amer. ed., p. 380. 3 Arnott, Fergusson's Surg., p. 213. 203 FRACTURES OF THE CORACOID PROCESS. humerus was partially dislocated forwards, the clavicle, acromion process, and the olecranon were broken as well as the coracoid process. Neither the fracture of the clavicle nor of the coracoid process was made out until after the patient died, which was on the fourth day; the fact of the existence of these fractures being then ascertained by dissection. 1 Erichsen says there is in the museum of the University College, a preparation showing a fracture at the base of this process, the line of fracture extending across the glenoid cavity. 2 Duverney, Boyer, and Malgaigne, have also reported four additional examples confirmed by dissections. 3 The existence of this form of fracture, established by at least nine or ten dissections, can no longer be denied; yet it is usually accompanied with serious complications, such as must in most cases prove fatal. In the only case, however, in which I have had reason to believe that I had to deal with a fracture of this kind, the symptoms and termination were less grave, although it was complicated with an upward dislocation of the outer end of the clavicle. A gentleman residing in the country was struck by a board which fell edgewise upon his shoulder. The fracture of the coracoid process does not seem to have been recognized by his surgeon. An apparatus was applied to retain the clavicle in its place, but after three months, when he called upon me, it still remained displaced as at first. During all of this time the apparatus had been steadily kept on. On laying off the dressings I discovered that the coracoid process was detached, obeying constantly the movements of the head of the humerus, but being not at all subject to the movements of the scapula. Some months later I examined the arm again, and found the parts in the same condition as before, but the functions of the arm were not impaired. It has been generally stated that when this process is broken off) it will be carried downwards by the united action of the pectoralis minor, the short head of the biceps, and the coraco-brachialis muscles; but this will depend upon whether the coracoclavicular ligaments are ruptured also; a circumstance which is not very likely to occur, at least to any great extent; and in fact not one of the well-attested examples of this fracture has ever been accompanied Fig. 49. Fractures of the coracoid process with any considerable displacement in this direction. Treatment. —In a case of simple fracture of the process unattended with any other lesions, it is sufficient to place the arm in a sling with the elbow advanced as much as possible upon the front of the chest; 1 South, Lond. Med.-Chir. Rev., 1840, vol. xxxii., new ser., p. 41. 2 Erichsen, Surgery, p. 207. 3 Malgaigne, op. cit., p. 512. 204 FRACTURES OF THE HUMERUS. as by this position we relax somewhat all of the three muscles having attachments to this process. If we were to add anything to this simple procedure it would be merely to confine the scapula by a few turns of a roller. It is not probable, however, that by either, or both of these measures we should accomplish enough to justify their continuance if they were found to be painful, or even exceedingly irksome. In the graver forms of the accident, where other bones about the shoulder are broken or dislocated, which, as we have seen, constitute the larger proportion of the whole number, the treatment must generally have little or no regard to this particular injury. CHAPTER XX. FRACTURES OF THE HUMERUS. It is not sufficient to consider fractures of this bone as occurring through the shaft and its two extremities, as some systematic writers have done; since upon this simple arrangement it is impossible to base a natural division of their causes, symptoms, prognosis, and treatment. We shall find it necessary to consider, 1. Fractures of the head and anatomical neck. (Intra-capsular; nonimpacted and impacted.) 2. Fractures through the tubercles. (Extra-capsular; non-impacted and impacted.) 3. Longitudinal fractures of the head and neck, or splitting off of the greater tubercle. 4. Fractures of the surgical neck. (Including separations at the upper epiphysis.) 5. Fractures through the body of the shaft, or, of the shaft below the surgical neck and above the base of the condyles. 6. Fractures at the base of the condyles. (Including separations at the lower epiphysis.) 7. Fractures at the base, complicated with fractures between the condyles, extending into the joint. 8. Fractures or separations of the internal epicondyle. 9. Fractures or separations of the external epicondyle. 10. Fractures of the internal condyle. 11. Fractures of the external condyle. Of 104 fractures of the humerus examined by me, 20 occurred through the upper third, 16 through the middle third, and 68 through the lower third. Or, if we reject fractures of the head and neck, and fractures of the condyles, and confine our analysis to the shaft, 13 belong to the upper third, 16 to the middle third, and 31 to the lower third. An observation which is in contrast with the statement made 205 FRACTURES OF THE HEAD AND ANATOMICAL NECK. by Amesbury, and which has been repeated by Lizars, B. Cooper, Fergusson, Gibson, and others, that this bone is most often broken in its middle third. Of the fractures belonging to the upper third, one was a separation at the junction of the epiphysis with the shaft, one was probably a fracture at or near the anatomical neck, with impaction and splitting of the tubercles, one was a fracture of the greater tubercle alone, and eleven were fractures of the surgical neck. Of the fractures belonging to the lower third, 15 were through the internal condyle and epicondyle, 18 through the external condyle, 15 were at the base of the condyles, and 6 through the condyles and across the base at the same time. The remainder, 14, being through the shaft, but above the base. Unfortunately, surgical writers have not been agreed in the use and application of the terms "head," "neck," "anatomical neck," and "surgical neck" of the humerus; and, as a consequence, their meaning is often obscure, and their teachings are sometimes contradictory and absurd. 1 It is necessary, therefore, that we should define them more precisely. The head of the humerus is that smooth, elliptical surface, covered by cartilage and synovial membrane, which articulates with, and is received into the glenoid cavity of the scapula. The anatomical neck is the narrow line immediately encircling the head, and which receives the insertion of the capsular ligament. The surgical neck is that portion which commences at the lower margin of the tubercles, or at the point of junction between the epiphysis and the diaphysis, and which terminates at the insertion of the pectoralis major and latissimus dorsi. The neck is all of that portion included between the head and the insertion of the pectoralis major and latissimus dorsi, comprising not only the anatomical and surgical necks, but also the tubercles, which occupy the triangular space between these two. § I. Fractures op the Head and Anatomical Neck. (Intra- Capsular; Non-impacted, and Impacted.) Causes. —The causes which have been found competent to produce fractures of the head and anatomical neck are, the penetration of balls or of other missiles directly into the joint, producing thus a compound, and generally comminuted fracture of the head; or falls or direct blows upon the shoulder without penetration. Pathology, Results, &c. —"When the fracture results from the direct penetration of some foreign body into the joint, it is not only a compound fracture, but the head of the bone is almost necessarily broken into fragments. These accidents are generally fatal; not so much from the peculiar nature of the injury, as from the severity of the blow requisite for their production, and from the complications which usu- 1 Boston Med. and Surg. Journ., June 24, 1858, p. 410. 206 FRACTURES OF THE HUMERUS. ally attend them. If the patients recover, sooner or later the fragments have generally to be removed. Fractures of the anatomical neck, produced by falls upon the shoulder without penetration, are, however, usually neither compound nor comminuted, but they often follow, with a remarkable degree of accuracy, the line of the insertion of the capsular ligament, being Fig. 50. Fracture of the anatO' mical ueck. always, according to Robert Smith, within the inferior or outer margin of this insertion. He calls them, therefore, intra-capsular. It is probable, howeve —since, as we shall presently see, bony union is not denied to this fracture—that the line of separation is not always, or generally, perhaps, completely within the insertion of the ligament, but that it is in some degree extra-articular, if not extra-capsular. If it is entirely intra-articular, no doubt union of the fragments can never take place, and generally suppuration will ensue, demanding, at a period not very remote, an operation for their removal, the same as in compound fractures. Dr. Daniel Brainard, of Chicago, informs me that he has twice had occasion to open the shoulder-joint for the removal of the head of the bone, rendered necessary by the suppuration resulting from severe injuries. In the first case, Dr. Brainard removed the fragment about one year after the accident. It was " loose, necrosed, and partly absorbed or macerated." In the second case the operation was made about three months after the receipt of the injury. Both have recovered, with pretty useful arms. Gibson, however, thinks that the fragment occasionally remains, being gradually absorbed and changed in figure. He says that his museum contains three or four well-marked cases of this kind, in all of which the head has lost its spherical form, and is very much diminished, and rough and flattened next to the scapula. 1 Other cabinets contain similar specimens. The displacements to which the upper fragment, or the head of the bone, is subject, are remarkable, and some of them do not seem to be satisfactorily explained. Frequently, indeed, its position is not sensibly disturbed, but at other times it is found impacted, or driven into the cancellous structure of the inferior fragment, in consequence of which one or both of the tubercles are frequently broken off. Robert Smith relates the following case as having afforded him his first opportunity of ascertaining, by post-mortem examination, the exact nature of this form of displacement:— " A female, ast. 47, was admitted into the Richmond Hospital under the care of the late Dr. McDowell, for an injury to the humerus, the result of a fall upon the shoulder. Five years afterwards, the woman was again admitted, under the care of Mr. Adams, with an extra-cap- 1 Gibson, Elements of Surgery, vol. i. p. 279. FRACTURES OF THE HEAD AND ANATOMICAL NECK. 207 sular fracture of the neck of the femur, one month after the occurrence of which she died, in consequence of an attack of diarrhoea. "The shoulder was of course carefully examined; the arm was slightly shortened, the contour of the shoulder was not as full or round as that of its fellow, and the acromion process was more prominent than natural. Upon opening the capsular ligament, the head of the humerus was found to have been driven into the cancellated tissue of the shaft, between the tuberosities, so deeply as to be below the level of the summit of the greater tubercle; this process had been split off and displaced outward; it formed an obtuse angle with the outer surface of the shaft of the bone." 1 The description is accompanied with two excellent drawings of the specimen, showing the distance to which the superior fragment had penetrated the inferior, and showing also complete union by bone. I believe, also, that in the following example there was a fracture at or near the anatomical neck, with impaction, and splitting of the tubercles:— January 12,1858, a young man, aged about sixteen years, fell from a height in a gymnasium, severely injuring his left shoulder. I saw him, with Dr. Boarclman, soon after the accident, and found him complaining very much of the shoulder, which was some swollen and tender. He could not tell us how he fell, nor could we discover any contusions by which to determine the point where the blow was received. All motions of the shoulder-joint were painful; and there was a remarkable fulness in front of the joint, feeling like the head of the bone, yet not such as is usually present in a forward luxation. To determine this more positively, however, the limb was manipulated as for the reduction of a dislocation. Once during the manipulation a feeble but distinct crepitus was detected; yet the position of the bone remained unchanged. The head was found to be in the socket, but the precise nature of the injury was not made out. Fifteen days later, when the swelling had completely subsided, a careful examination was again made by Dr. Boardman and myself, when we arrived at the conclusion that it was a fracture through the bicipital groove, and that the lesser tubercle was carried forward half an inch or more from its fellow, while the head with the greater tubercle, occupied their natural positions opposite the socket. The fragment projecting in front presented a sharp point, and could not be confounded with any swelling of the soft parts. There was a distinct space between the tubercles, into which the finger could be laid. No depression existed under the acromion process behind, but on measurement the head of this humerus was found to be half an inch wider in its antero-posterior diameter than the opposite. That this fracture was accompanied with impaction was rendered certain by the repeated and careful measurements of the length of the humerus, which constantly showed a shortening of half an inch. Under these circumstances union generally takes place; but it is usually accompanied with the formation of an irregular mass of osteo- 1 South, Fractures in Vicinity of Joints, pp. 191-3. 208 FRACTURES OF THE HUMERUS. phytes, which encircle the head like a coronet; presenting in this respect again a remarkable resemblance to extra-capsular fractures of the neck of the femur. This ensheathing callus, as it may be called, is an outgrowth from the inferior fragment, and it sometimes incloses the upper fragment as the case of a watch incloses the crystal, only in a manner much more irregular, thus retaining it steadily in its place, although very little direct union has occurred. The cancellous tissue, nevertheless, is occasionally found united completely by a new and intermediate bony tissue, and at other times by a fibrous tissue, or by both fibrous and bony tissue. In some cases a perfect false joint has been formed between the opposing surfaces, while in a few unfortunate examples the head not only refuses to unite, but by its presence, as we have already remarked, produces inflammation and suppuration, resulting in its final extrusion from the joint. The cases reported to me by Dr. Brainard, and already described, illustrate this latter class. At other times the upper fragment turns upon its own axis, and is found more or less tilted or completely rotated in the socket; so that its cartilaginous or articulating surface rests upon the broken surface of the lower fragment, and its own broken surface presents toward the glenoid cavity. Robert Smith has described a specimen of this kind, which he removed from the body of a woman, aged forty, who many years previous to her death fell down a flight of stairs, and struck her shoulder with great violence against the edge of one of the steps. Whether she applied to a surgeon or not at the time of the accident, Mr. Smith was not able to ascertain. After death the shoulder looked somewhat as if there was a dislocation of the humerus into the axilla, there being a marked depression under the acromion process, but the shaft of the humerus was drawn upwards and inwards toward the coracoid process. When the capsular ligament was opened, the head of the bone was found to have been broken from the shaft through the line of the anatomical neck, and to have completely turned upon itself; and the cartilaginous surface was actually driven one inch into the cancellated structure of the shaft, so as to split off the lesser tubercle with a portion of the greater. Only one-half of the upper fragment was thus impacted, the other half projecting beyond the margin of the lower fragment. Between the cartilaginous surface and the shaft no union had occurred; but there was complete bony union between the upper and lower fragment, beyond the limits of the cartilage. The upper surface of the superior fragment rested in part against the inner half of the glenoid cavity and upon its inner margin, and in part it rested against the neck of the scapula in the direction of the coracoid process. 1 Nelaton saw a similar specimen in the possession of M. Dubled, the revolution of the upper fragment being complete; but there was no later displacement, and the union had been accomplished in a manner 1 R. Smith, op. cit., pp. 193-6. FRACTURES OF THE HEAD AND ANATOMICAL NECK. 209 similar to that which is seen after intra-capsular, impacted fractures, without reversion. 1 I have also been permitted to examine a specimen belonging to Dr. Charles A. Pope, of St. Louis, Mo., which seems to have been broken not only through, the line of the anatomical neck, but also through the surgical neck. Both fragments are united by bone, the lower fragment being carried in the direction of the coracoid process, while the upper fragment appears to be reversed, so that its articular surface is directed toward the shaft, and its broken surface articulates with the glenoid cavity. The history of this specimen is unknown. It is possible, we think, that these extraordinary changes of position were not the direct result of the accident which broke the bone, but that they had been taking place gradually and through a long period. It is certainly quite as probable that the constant motions of the arm should accomplish these displacements, as that they should be produced by a direct blow; indeed, the former supposition appears to us much the most probable. There is another supposition which, in my opinion, is capable of explaining most of the phenomena usually present in these cases, and which, if admitted, renders the supposition of a fracture unnecessary. It is, that these are all of them examples of Fig. 51. Fig. 52. Dr. Pope's Specimen. Front view. Side view. softening of the neck of the bone, as a result of chronic inflammation, ulceration, &c.; and that the changed position of the head is due to pressure alone, being acted upon by the muscles which surround the joint, and which act all the more vigorously because they partake also of the inflammation which has invaded the bone. This view of these specimens, which had already more than once suggested itself to me, was very strongly confirmed by its having occupied the mind also of Dr. Neill, of Philadelphia, and who at his own instance stated to me that he believed this was their true explanation. We were, at the time, examining Dr. Pope's specimen, already alluded to, and on comparing it with a specimen of dislocation and partial absorption of the head of the humerus, contained in Dr. Neill's Museum, the points of 1 Nelaton, Elements de Pathol. Chirur., torn. prem. p. 730. 210 FRACTURES OF THE HUMERUS. resemblance were so numerous and striking that we felt compelled to doubt whether Dr. Pope's specimen, together with those seen by Smith and Nelaton, did not belong to the same class with this of Neill's. In a case of fracture of the "cervix humeri within the capsular ligament," examined by Sir Astley Cooper, there was also a complete forward luxation of the head; but ligamentous union had occurred between the fragments. 1 Many similar cases have been reported by other surgeons. § 2. Fractures through the Tubercles. (Extra-capsular; Non-impacted and Impacted. Under this division we intend to speak of all fractures traversing the upper end of the humerus, and involving the tubercles, or of all those which occur between the anatomical neck on the one hand, and the epiphyseal junction, or surgical neck, on the other hand, and which may be more or less oblique as well as transverse. Fractures of the greater or lesser tubercles are of course excepted, since they are more properly longitudinal fractures, and do not completely traverse the diameter of the bone. Nor do we intend to include those fractures which occur at the epiphyseal junction, since, being below the principal insertion of those muscles which are attached to the tubercles, they present very peculiar and distinctive features which will demand for them a separate classification. Causes, Pathology, and Results. —Fractures through the tubercles, like fractures through the anatomical neck, are the results generally of direct blows received upon the shoulder. They are not usually accompanied with much lateral displacement at the point of fracture; a circumstance which finds a partial explanation in the fact that the line of fracture is through the insertions of the muscles converging upon the tubercles and not entirely above or below them, so that they continue to act nearly equally upon both fragments; but it is also sometimes due in a measure to impaction: the head being forced downwards toward the axilla, and upon the shaft until it is made to ride upon its inner or axillary wall like a cap; the compact bony tissue of the shaft penetrating the reticular structure of the head. These fractures generally unite by bone; yet more or less impairment of the motions of the limb results from the inflammation which occurs in and about the joint, or from the irregular deposits of callus in the vicinity of the fracture. § 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of the Greater Tubercle. Causes, Pathology, Symptoms, and Results. —Mr. Guthrie seems to have been the first to call attention to this peculiar injury of the shoulder. In a lecture delivered in November, 1833, he described four cases which had come under his observation, and which he re- 1 A. Cooper on Dislocations, &c, p. 372. 211 LONGITUDINAL FRACTURES OF THE HEAD AND NECK. garded as examples of separation of the small tuberosity, accompanied with more or less of the head, the fracture extending along a portion of the bicipital groove. 1 Robert Smith, however, believes that it was the greater and not the lesser tuberosity which was thus detached in the cases mentioned by Mr. Guthrie, since the external signs were so nearly like those which were present in a woman seen by himself, and in whom an autopsy enabled him to verify his diagnosis. The following is the case as related by Mr. Smith:— " In July, 1844,1 was requested to examine the body of Julia Darby, set. 80, who had died of chronic pulmonary disease. Upon entering the room, the appearances of the left shoulder-joint at once attracted my attention, and struck me as being different from those which attend the more common injuries of this articulation. " The shoulder had lost, to a certain extent, its natural rounded form; the acromion process, although unusually prominent, did not project as much as in cases of dislocation of the head of the humerus. The breadth of the articulation was greatly increased, and upon pressing beneath the acromion, an osseous tumor could be distinctly felt, occupying the greater part of the glenoid cavity; it formed a prominence which was perceptible through the soft parts; it moved along with the shaft of the humerus, but was manifestly not the head of the bone. " A second and larger tumor, presenting the rounded form of the head of the humerus, lay beneath the base of, and internal to, the coracoid process, and between the two the finger could be sunk into a deep sulcus, placed immediately below the coracoid process. The elbow could be brought into contact with the side, and there was no appreciable alteration in the length of the arm. " Upon removing the soft parts, the head of the bone presented itself, lying partly beneath and partly internal to the coracoid process. The greater tuberosity, together with a very small portion of the outer part of the head of the bone, had been completely separated from the shaft of the humerus. This portion of the bone occupied the glenoid cavity, the head of the humerus having been drawn inwards so as to project upon the inner side of the coracoid process; it was still, however, contained within the capsular ligament. " The fracture traversed the upper part of the bicipital groove, which, in consequence of the displacement which the head of the bone had suffered, was situated exactly below the summit of the coracoid process. A new and shallow socket had been formed upon the costal surface of the neck of the scapula, below the root of the coracoid process, and the inner edge of the glenoid cavity corresponded to the posterior part of the sulcus, which separated the head of the bone from the detached tuberosity. The latter was united to the shaft only by ligament. " The capsule had not been injured, but was thickened and enlarged, and bone had been deposited in its tissue. The injury had 1 Robert Smith, p. 181, from Lond. Med. and Phys. Journal. 212 FRACTURES OF THE HUMERUS. evidently occurred many years before the death of the patient, but the history connected with it could not be precisely ascertained." 1 Mr. Smith relates one other case, in the living subject, which he saw, in connection with Mr. Adams, at the Richmond Hospital, and he adds that " numerous" other living examples have fallen under his observation. Sir Astley Cooper has also published the particulars of a case of fracture of the greater tubercle, which was communicated to him by Mr. Herbert Mayo. 2 The following I believe also to have been an example of this rare accident:— John Hill, set. 78, fell upon the side-walk, striking upon his right shoulder. The physician to whom he was sent thought the humerus was dislocated, and directed him to the Buffalo Hospital of the Sisters of Charity, but he did not apply for admission until eight days after, Oct. 14, 1857, when Dr. Boardman and myself examined the limb carefully. Although we placed him under the influence of chloroform, the diagnosis was not satisfactorily made out. We inclined, however, to the opinion that it was a fracture of the greater tubercle. The anteroposterior diameter of the upper end of the bone was greatly increased; there was occasional distinct crepitus, but the limb was not shortened. Subsequently, the examinations were repeated many times, and the depression between the fragments becoming more palpable, the diagnosis was at length confirmed. No treatment was adopted, except confinement in bed, and stimulating embrocations. Two months after the accident he still remained an inmate of the hospital, his shoulder being quite stiff", and the projection continuing in front. Mr. Robert Smith thinks that when the displacement is considerable the fragments generally unite by ligament rather than by bone. § 4. Fractures through the Surgical Neck. (Including Separations at the Upper Epiphysis.) I have already defined the " Surgical Neck" as all of that narrow portion commencing at the epiphysis and terminating at the insertion of the pectoralis major and latissimus dorsi. It seems proper, therefore, that we should include under this division, both fractures and separations occurring at the epiphysis, especially since, owing to their anatomical relations, they are subject to the same displacements as fractures occurring half an inch or one inch lower down. The capsular muscles, with the exception of the teres minor, having no more influence over the lower fragment when a separation occurs at the epiphysis, than when a separation occurs at any other point of the surgical neck. ' Robert Smith, op. cit., p. 178. » A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. Cooper. American edition, p. 384. 213 FRACTURES THROUGH THE SURGICAL NECK. The following is an account of the only case of separation at the epiphysis which I have ever recognized:— Mike Bovin, sot. 13 months, fell sideways from his cradle in November, 1855. He was taken to an empiric, who called it a sprain, and applied liniments. Three weeks after the accident he was brought to me, and I found the arm hanging beside the body, with little or no power, on the part of the child, to move it. There was a slight depression below the acromion process, and considerable tenderness about the joint; but the shoulder was not swollen, nor had it been at any time. The line of the axis of the bone, as it hung by the side, was directed a little in front of the socket. On moving the elbow backwards and forwards, the upper end of the shaft moved in the opposite directions with great freedom, and could be distinctly felt under the skin and muscles. This motion was accompanied with a slight sound, or sensation, a sensation not like the grating of broken bone, but much lesss rough. There was no shortening of the limb. When the elbow was carried a little forwards upon the chest the fragments seemed to be restored to complete coaptation; and of this I judged by the restoration of the line of the axis of the shaft to the centre of the socket, and by the complete disappearance of the depression under the point of the acromion process. I applied suitable dressings to retain the arm in this position; but five months after the injury was received Fig. 53. Separation of upper epiphysis. the fragments had not united, and the child was still unable to lift the arm, although the forearm and hand retained their usual strength and freedom of motion. The same crepitus could occasionally be felt in the shoulder, and the same preternatural mobility. The shoulder was at this time neither swollen nor tender. Robert Smith and Sir Astley Cooper both speak of it as a frequent accident in early life, but the recorded cases are very few. The case mentioned by Mr. Smith has been given very much at length, and, as a characteristic example, deserves to be repeated:— " During the early part of last year, a boy, eight years of age, was admitted to the Richmond Hospital, under the care of Dr. McDowell. About a week previous to his admission he had fallen upon the shoulder, and at once lost the power of using his arm. " It was at first sight evident that there did not exist any luxation of the head of the humerus, and it was equally obvious that the case was not an example of any of the ordinary fractures to which the neck of the bone is liable. There was no diminution of the natural rotundity of the shoulder, nor any unusual prominence of the acromion process; the head of the bone could be distinctly felt in the glenoid cavity, and it remained motionless when the arm was rotated; there was very little separation of the elbow from the side, but it was directed slightly backwards. 214 FRACTURES OF THE HUMERUS. " About three-quarters of an inch below the coracoid process there existed a remarkable and abrupt projection, manifestly formed by the upper extremity of the shaft of the humerus, every motion imparted to which it followed. Its superior surface, which could be distinctly felt, was slightly convex, and its margin had nothing of the sharpness which the edge of a recently broken bone presents in ordinary fractures. " When this projecting portion of the bone was pushed outwards, so as to bring it in contact with the under surface of the head of the humerus (previously fixed as far as it was possible to do so), a crepitus was produced by rotating the shaft of the bone. It did not, however, resemble the ordinary crepitus of fracture, but it would be extremely difficult, by any description, to convey a clear idea of what the difference consisted in. " From a careful consideration of the symptoms and appearances above mentioned (taking into account also the age of the patient), the diagnosis was formed, that the injury consisted in a separation of the superior epiphysis of the humerus from the shaft of the bone. Various mechanical contrivances were employed in this case, but all proved ineffectual in maintaining the fragments in their proper relative position." 1 Sir Astley Cooper has also briefly described one example. " Its age was ten years. The symptoms of the injury were, inability of moving the elbow from the side, or of supporting the arm, unless by the aid of the other hand, without great pain. The tension which succeeded filled up the hollow which was at first produced by the fall of the deltoid muscle. When the head of the bone was fixed, the fractured extremity of the humerus could be tilted under the deltoid muscle, so as to be felt, and even shown,, by raising the arm at the elbow. Crepitus could be perceived, not by rotating the arm, but by raising the bone and pushing it outward. The cause of the fracture was a fall upon the shoulder into a saw-pit of the depth of eight feet." 2 It will be necessary, in order to a full understanding of the various aspects of this fracture—a fracture of the surgical neck —to relate several illustrative examples. Case 1. Simple fracture ; never displaced. Union without deformity. — Alexander Balentine, set. 62; admitted to the Buffalo Hospital of the Sisters of Charity, December 19, 1851. He had fallen upon the sidewalk, striking upon his right arm. Dr. Johnson, of Buffalo, had reduced the fracture and applied appropriate dressings. No union of the fragments had yet occurred; but as the surfaces were in apposition, it was only after considerable manipulation, and not until we bent the forearm upon the arm, and rotated the humerus by means of the forearm, that the crepitus became distinct, and gave unequivocal evidence of the existence of a fracture, and of its situation. The treatment, after admission, consisted in the application of one gutta percha splint, accurately moulded, and extending from above the shoulder to below the elbow, and encircling one-half the circumference of the arm; the splint being secured with the usual bandages, &c. The result is a perfect limb. 1 Robert Smith, op. cit., p. 201. 2 A. Cooper, op. cit., p. 382. 215 FRACTURES THROUGH THE SURGICAL NECK. Case 2. Simple fracture. Union with displacement and deformity. — White, of Buffalo, set. 12, fell fourteen feet, striking on the front and outside of the left shoulder. Dr. P., of Erie County, saw the lad within three hours (July 19,1853). He was brought to me on the fourth day after the accident. The upper part of the arm was then very much swollen. I found the arm dressed as for a fracture of the middle or lower tbfrd of the humerus. It was shortened one inch. The elbow was inclined backwards, and there was a remarkable projection in front of the joint, feeling like the head of the bone. The hand and arm were powerless. I suspected a dislocation of the head of the humerus forwards ; and, having administered chloroform, I attempted its reduction with my heel in the axilla. While making extension, I felt a sudden sensation like the slipping of the bone into its socket, but on examination I found the projection continued as before. I then repeated the effort, with precisely the same result. I now applied an arm sling, and directed leeches and cold evaporating lotions. On the 25th, five days after the accident, it was examined by Drs. Mixer, McGregor, Joseph Smith, with myself. We still believed it was a dislocation, and having administered chloroform, we again attempted its reduction. The same slipping sensation was produced as before, and the deformity was repeatedly made to disappear; but, on suspending the extension, it as often reappeared. The character of the accident was now made apparent, and we proceeded at once to apply the splint and bandages suitable for a fracture of the surgical neck of the humerus, namely, a gutta percha splint, extending, on the outside, from the top of the shoulder to below the elbow, with an arm and body roller secured with flour paste. On the 31st, twelve days after the accident, Dr. Wilcox, Marine Surgeon at Buffalo, saw the arm with me. The fragments were displaced the same as when I first saw it, and the same as when no apparatus was applied. We examined it again carefully, and attempted to make the fragments remain in place, but we were unable to do so, except while holding them and making extension. August 9 (twenty-first day). I removed all the dressings. Motion between the fragments had ceased, but the projection and shortening remained as before; now, also, the irregular projections of the fractured bones were more distinctly felt. The dressings were never reapplied. Three months later no change had occurred. He could carry the elbow forwards freely, as well as backwards, the motions of the shoulder-joint being unimpaired. Case 3. Simple fracture, with displacement; resulting in deformity and non-union. —L. B. of Lockport, ast. 43, was thrown from his horse in February, 1854, striking upon his right elbow. Dr. Maxwell, an experienced surgeon of Lockport, examined and dressed the fracture. Dr. Fassett was present and assisted at a subsequent dressing. Three surgeons who examined the arm before Dr. M., called it a dislocation. Twelve weeks after the accident, Mr. B. called upon me. The right arm was shortened one inch; the elbow hung off slightly from the 216 FRACTURES OF THE HUMERUS. body; the upper end of the lower fragment was distinctly felt in front of the shoulder-joint under the clavicle, feeling very much like the head of the bone. The fragments were not united, but they could be seized easily, and made to move separately and freely. He stated to me that he was subject to rheumatism, and especially in the shoulder and arm of the side injured. He wished to know whether it could not be " re-set." v Two years after, I found the bone still ununited. He was, however, able to write with that hand, having first lifted his arm with the other hand and laid it upon the table. Case 4. Simple fracture, probably impacted; resulting in deformity. — Wm, A., of Buffalo, set. 15, fell backwards, June 4, 1855, striking on his back and left shoulder. Dr. L. saw it immediately, and, regarding it as a dislocation, attempted its reduction. He subsequently repeated the attempt. I saw the patient with Dr. L. on the tenth day. The arm was shortened one inch and a half. The fragments were displaced forwards, projecting in front of and a little below the joint. As in Case 3, it might easily be mistaken for the head of the bone; but the difficulty of diagnosis had been very much lessened by the subsidence of the swelling. There was no motion between the fragments; nor could the deformity, by any manipulation or extension, be made to disappear. It was probably impacted. March 23, 1856, nearly ten months after the accident, I found the fragments remaining as when I first examined the limb, and the arm shortened one inch and a half. The elbow hung a very little back from the line of the body. The upper end of the lower fragment was lifted to within one inch of the head of the humerus; the upper fragment having its head in the socket, with its lower end downwards and forwards. The arm was, however, in every respect as useful as before it was broken. It was equally strong, and he could raise his arm as high, and move it in every direction as freely, as he could the other. Causes. —Epiphyseal separations belong almost exclusively to children, but true fractures at the surgical neck occur most often in adult life; with the exception of one girl and two lads, aged, respectively, eleven, twelve, and fifteen years, all of the examples of this latter accident seen by me occurred in adults, and of twenty-three cases in which I find the ages recorded, the average age is forty-three years; yet Sir A. Cooper declares these fractures to be most common in infancy, while Malgaigne has never seen a case in a person under fiftythree years. Both epiphyseal separations and fractures at this point are occasioned, in most cases, by direct blows or falls upon the shoulder. Of twenty-two examples in which I find the cause recorded, fifteen were from direct blows, six from indirect blows, and one from muscular action, as in throwing a ball. Of the six resulting from indirect blows, one was from a fall upon the hand, seen by Desault, and five were from falls upon the elbow, of which two were seen by Desault, and three by myself. Pathology. —I have found the fragments sensibly displaced in eight cases out of ten; a proportion much greater than has been observed 217 FRACTURES THROUGH THE SURGICAL NECK. by Malgaigne, who has only seen a displacement twice in more than twenty cases. It is certain, however, that complete or sensible displacement is less common in this fracture than in most other fractures, the broken ends being retained in place, probably, by the long tendon of the biceps. As to the direction of the displacement, I have seen the upper end of the lower fragment drawn forwards and upwards toward the coracoid process three times, in one of which examples the upper fragment plainly followed in the same direction. Sir Astley Cooper declares that with infants this direction is constant, and in museum specimens I have seen but one exception. In the specimen of fracture of the surgical neck, with also displacement of the head, belonging to Dr. Pope, this direction of the fragments is plainly seen, as also in a specimen belonging to Dr. Neill, of the Pennsylvania Medical College, where the lower fragment almost reaches the coracoid process, and in a specimen contained in one of the cabinets of the University of Pennsylvania, where the upper end of the lower fragment has become united by bone to the coracoid process. The only exception which I have met with is in the possession of Dr. Neill. In this example the two ends are tilted toward the axilla. In the recorded examples, also, I find the displacement forwards mentioned four times, and the displacement toward the axilla but once. I am compelled, therefore, to doubt the accuracy of Malgaigne's observations, who thinks he has seen the lower fragment most often drawn toward the axilla, as well as the observations of those who think that the upper fragment is generally displaced outwards; yet, no doubt, they do sometimes assume this position. Desault has seen them both thrown backwards; while Dupuytren, Paletta, and others have seen them pushed outwards; and I have in my cabinet the copy of a specimen in which both fragments are drawn outwards, but the lower fragment is to the inner side of the upper. "When the fracture occurs at or near the epiphysis, it is sometimes accompanied with impaction, of the same character as we have already described when speaking of fractures through the tubercles. Robert Smith has given, in his treatise, an engraving intended to illustrate the relative position of the fragments in extra-capsular impacted fractures, and the line of separation very nearly corresponds to the line of junction of the epiphysis with the shaft. But in a majority of cases no impaction occurs. Dr. Charles A. Pope, of St. Louis, Mo., has two specimens of this kind, in which no union has taken place, nor is there any evidence that impaction had ever occurred. In one case the line of fracture commences at the junction of the head with the shaft, and extends thence irregularly across to a point half an inch below the greater tuberosity. In the second specimen the fracture commences at the same point and terminates three-quarters of an inch below the greater tuberosity. In relation to these bones, Dr. Pope remarks: These are not cases of detachment of the epiphyses, as the bones are evidently those of adults, and there is, at their lower extremities above the condyles, no trace of an epiphyseal line." 15 218 FRACTURES OF THE HUMERUS. Results. —Five of the examples of fracture of the surgical neck seen by me resulted in perfect limbs, and three are more or less deformed, but it has already been noticed that of the whole number only eight were ever displaced, and of these, only three are completely restored. In one of these no bony union has taken place after the lapse of two years or more. It is satisfactory, however, to know that, with the exception of this last (Case 3), all of the patients have recovered the free and complete use of their arms. Symptoms, or Differential Diagnosis of Accidents about the Shoulderjoint.—No place could be more appropriate than this to call attention to the difficulty of diagnosis in the case of accidents about the shoulder-joint, a difficulty which surgeons have constantly recognized, and which has sometimes rendered diagnosis impossible. In presenting an epitome of the prominent diagnostic signs, I would refer the reader who seeks further information to my report to the American Medical Association, where the subject is treated more elaborately than is consistent with the design of the present volume. Let us first study the ordinary signs of a dislocation at the shoulderjoint, regarding this as the type with which the other accidents are to be compared. a. Signs of a Dislocation. (Cause, generally a fall upon the elbow or hand.) 1. Preternatural immobility. 2. Absence of crepitus. 3. "When the bone is brought to its place it will remain without the employment of force. These three are common signs, which apply to any other joint as well as the shoulder. 4. Inability to place the hand upon the opposite shoulder, or to have it placed there by an assistant, while at the same time the elbow touches the breast. This is a sign common to all of the dislocations of the shoulder. 1 The following are special signs, or such as belong only to particular dislocations of the shoulder. 5. Depression under the acromion process; always greatest underneath the outer extremity, but more or less in front or behind, according as the dislocation may be into the axilla, forwards or backwards. 6. Round, smooth head of the bone felt in its new situation, and very plainly removed from its socket; moving with the shaft. Absence of the head of the bone from the socket. 7. Elbow carried outwards, and in certain cases forwards or backwards, and not easily pressed to the side of the body. 8. Arm shortened in the dislocation forwards, and slightly lengthened when in the axilla. b. Signs of a Fracture ojKhe Neck of the Scapula. (Cause, generally a direct blow.) 1 Report on a New Principle of Diagnosis in Dislocations of the Shoulder-joint, by L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer. Med. Assoc., vol. x. p. 175. 219 DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 1. Preternatural mobility. . 2. Crepitus, generally detected by placing the finger on the coracoid process and the opposite hand upon the back of the scapula, while the head of the humerus is pushed outwards and rotated. 3. "When reduced it will not remain in place. 4. The hand may generally, but with difficulty, be placed upon the opposite shoulder. 5. Depression under the acromion process, but not so marked as in dislocation. 6. Head of the bone may be felt in the axilla, but less distinctly than in dislocation. Never much forwards or backwards. Head of the bone moves with the shaft. Head of the bone not to be felt under the acromion process, although it has not left its socket. 7. Elbow carried a little outwards, but not so much as in dislocation. Easily brought against the side of the body. 8. Arm lengthened. 9. The coracoid process carried a little toward the sternum, and downwards. 10. Pressing upon the coracoid process it is found to be movable, and it is also observed that it obeys the motions of the arm. c. Signs of Fracture of the Anatomical Neck of the Humerus. Intracapsular. (Cause, a direct blow; generally opening to the joint, but not always.) 1. Mobility not increased, nor diminished. 2. Crepitus, generally discovered by pressing up the head of the bone into its socket and rotating; or, when the tubercles are also broken, by grasping the tubercles and rotating the arm. 3. Fragments not generally displaced. 4. The hand can be placed easily upon the opposite shoulder. 5. Yery slight, if any, depression under the acromion process. 6. Head of the bone generally in its socket, but not felt so distinctly as before the fracture. 7. Elbow falls easily against the side of the body, or is easily placed there. 8. Arm not lengthened, nor appreciably shortened, unless the head be driven so much into the body as to separate the tubercles. 9. In this latter case there are present also the signs of fracture of the tubercles. d. Signs of Fracture of the Humerus through the Tubercles. Extracapsular. (Cause, direct blows.) 1. Generally, there is neither marked mobility nor immobility, except what immobility may be due to a contusiom of the muscles. 2. Crepitus, discovered, but not so easily as in intra-capsular fractures, by rotating the arm while the tubercles are grasped firmly. 3. If displacement exists, the fragments are not always easily kept in place when once reduced. 4. The hand can be placed upon the opposite shoulder. 5. No depression under the acromion process. 6. Head of the bone in its socket, and moving with the shaft, when, as is usually the case, it is impacted. 220 FRACTURES OF THE HUMERUS. 7. Elbow hangs against the side of the body. 8. Arm shortened when impacted, but not very appreciably. The signs which characterize this accident are more obscure than in either of the other shoulder accidents. They are mostly negative, and will not generally be determined positively except in the autopsy. e. Signs of a Longitudinal Fracture of the Head and Neck, or splitting off of the Greater Tubercle. (Cause, direct blow upon the front of the shoulder.) 1. Mobility of the limb natural. 2. Crepitus; elicited especially by grasping the tubercles and rotating the arm, or by carrying it up and back and then rotating. 3. When reduced, the fragments will not remain in place. 4. The hand can be placed upon the opposite shoulder. 5. Some depression under the acromion process. 6. A smooth bony projection directly underneath the coracoid process, or close upon its inner or outer side, moving with the shaft. The head of the bone cannot be felt in the socket, yet the space under the acromion is not entirely unoccupied. 7. Generally, but not always, the elbow hangs against the side. Sometimes it inclines a little backwards. It can always be easily brought to the side. 8. Arm generally neither lengthened nor shortened. 9. A remarkable increase in the antero-posterior diameter of the upper end of the bone. 10. A deep vertical sulcus between the tubercles, corresponding with the upper part of the bicipital groove. f. Signs of a Fracture through the Surgical Neck. (Cause, direct blows.) 1. Preternatural mobility often, but not constantly present. 2. Crepitus, produced easily when there is no impaction, or when the displacement is not complete, but with difficulty when impaction exists or the displacement is complete. 3. When once the fragments have been displaced, it is exceedingly difficult ever afterward to maintain them in place. 4. If the fragments remain in place, the hand can be easily placed upon the opposite shoulder. When completely overlapped it is difficult. 5. A slight depression below the acromion, not immediately underneath its extremity, but an inch or more below. 6. Head of the bone in the socket, and moving with the shaft when impacted, but not moving with the shaft when not impacted. The upper end of the lower fragment being often felt distinctly pressing upwards toward the coracoid process; its broken extremity being easily distinguished by its irregularity from the head of the bone. 7. Elbow hanging against the side when the fragments are not displaced, but away from the side when displacement exists. 8. Length of arm unchanged unless the fragments are impacted or overlapped; or both fragments are much tilted inwards. If the fragments are completely displaced, the arm is shortened. g. Signs of a Separation at the Epiphysis. (Cause, direct blows.) DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 221 1. Preternatural mobility. 2. Feeble crepitus; less rough than the crepitus produced when broken bones are rubbed against each other. 3. Fragments replaced are not easily maintained in place. 4. Same as in preceding variety of fracture. 5. The depression is not immediately under the acromion, yet higher than in most fractures of the surgical neck, perhaps three-quarters of an inch below the acromion process. 6. Head of the bone in its socket, and not moving with the shaft. Upper end of lower fragment projecting in front, when displacement exists, and feeling less sharp and angular than in case of a broken bone; indeed, being slightly convex and rather smooth, it may easily be mistaken for the head of the bone. 7. Same as in preceding variety. 8. Length of arm not changed unless the fragments are overlapped, or both fragments are tilted upon each other. When the fragments are overlapped, the arm is shortened. 9. This accident is almost peculiar to infancy and childhood. It seldom occurs after the fifteenth year. There are other accidents about the shoulder-joint such as a pathological partial luxation of the humerus, dislocation of the tendon of the biceps, &c, which might possibly be confounded with fractures, but the consideration of which I shall reserve for another time. Treatment. —I have already spoken of the treatment of fractures of the neck of the scapula, and my remarks will now be confined to fractures of the upper end of the humerus. Fractures of the Anatomical Neck; Intra-capsular. —As has already been stated, these are generally compound fractures, and from the extent of the injury often demand amputation of the entire arm. If an effort is made to save the arm, splints will not be applied, and the treatment will have little or no reference to the existence of a fracture; it will be directed only to the reduction or prevention of the inflammation, &c. At a later period the head of the bone may escape spontaneously, or it may become necessary to remove it by an operation. Simple fracture of the anatomical neck, without any external wound communicating with the joint, and accompanied, as it often is, with impaction, frequently unites, or the upper fragment becomes encased in the lower. It is not proper in such cases to employ great violence for the purpose of detecting crepitus, lest the fragments should become displaced; and if the arm should be found to be a little shortened, it must not be extended, with a view to overcoming the shortening, since upon the impaction probably depends, in a great measure, the chances of union. The elbow and forearm may be suspended in a sling, while the arm is gently supported against the side, merely to insure quietude. No splints are necessary or useful. Treatment of Fractures through the Tubercles (Extra-capsular); Nonimpacted and Impacted. —In these cases, also, the fragments being seldom displaced, very little if any mechanical treatment is demanded. A sling is all that is usually required. If, however, on account of dis- 222 FRACTURES OF THE HUMERUS. placement of the fragments, a splint is thought necessary, it must be applied in the manner hereafter to be directed in cases of fractures of the surgical neck. If impaction, with shortening, exists, the same remarks are applicable here as in intra-capsular impacted fractures, namely, that we ought not to rotate the limb much, nor violently, in order to discover crepitus, nor make extension with the view of overcoming the shortening, since the fragments unite more promptly and certainly when the impaction remains, and its continuance in no way damages the usefulness of the limb. Treatment of Longitudinal Fractures of the Head and Neck, or of a Separation of the Greater Tubercle. —In the only instance which I have recognized as a fracture of the greater tubercle, and already referred to, the displacement was moderate, and could not be overcome either by change of position or by pressure with extension. The patient was therefore merely laid upon his back in bed. No dressings of any kind were employed, and the fragments seemed to unite promptly, and with no increase in the displacement. If the displacement is originally more considerable, attempts ought still to be made to reduce the fragments, by extension and abduction of the arm, with direct pressure; yet they will not generally prove completely successful, nor will it be found easy to retain them when reduced. Mr. Mayo treated a fracture of this character, which occurred in a man sixty years of age, with a figure-of-8 bandage, and a sling, with a lathe splint on the outer side of the humerus, the upper part of which was made to bear on the fragments, by uniting the upper part of the circular arm roller to the figure-of-8 bandage. " The fracture united favorably," he says, but we presume that he does not mean to affirm that it united without any degree of displacement; a result which, probably, ought never to be expected. Mr. Mayo adds, however, that " for a long time the patient had some difficulty in carrying the arm backward." 1 Treatment of Fractures of the Surgical Neck, including Separations at the Epiphysis. —I see no reason to suppose that the indications of treatment can essentially vary in separations at the epiphysis, from those in true fractures through any part of the surgical neck, since the relative action of the muscles remains the same, and the direction of the displacement is generally the same. My remarks, therefore, upon this point may be considered as equally applicable to fractures and epiphysary separations. In a considerable proportion of these cases not much displacement of either fragment takes place, and consequently we have only to apply such moderate retentive means as will insure quiet. Indeed, under such circumstances we might not hesitate to adopt the posture treatment practised by Dupuytren in two cases, both of which terminated favorably. The treatment consisted in placing the arm, semi-flexed, on a pillow, the pillow being arranged so as to form a pyramid, the ' B. Cooper's edition of Sir A. Cooper on Dislocations, &c, American edition, p. 835. FRACTURES THROUGH THE SURGICAL NECK. 223 summit of which was lodged in the axilla, while the elbow was secured to the side of the body by a bandage. 1 Unhappily, however, as we have seen, this condition is not always present; the most frequent form of displacement being that in which the lower fragment is drawn upwards and inwards, or toward the coracoid process. In such cases it will require, often, no little perseverance and skill to effect reduction, if it is not found to be actually impossible, and still more to retain the bones in place when once reduced. Indeed, it is proper to say that a complete reduction is seldom accomplished and permanently maintained, owing, probably, to the advantageous action of the muscles which tend to produce the displacement, and in part also to the difficulty of applying any apparatus or dressing which shall act efficiently upon the fragments. Sir Astley Cooper recommends for this accident a couple of splints, to be placed one in front of and one behind the shoulder, an axillary pad, a clavicular bandage, and a sling; the sling being made to suspend only the wrist and not the elbow, since he had observed that when the elbow was lifted the upper end of the shaft was inclined to fall forwards. Mr. Tyrrell informed Mr. Cooper that in a similar case he had found the bone best maintained in its natural position by its being raised and supported at right angles with the side, by a rectangular splint, a part of which rested against the side, while the arm reposed upon the other part; and until he had made use of this plan, he could not succeed in removing the deformity, or in keeping the bone in its place. Mr. Erichsen has found a very convenient apparatus to consist of " a leather splint about two feet long by six inches broad, bent upon itself in the middle, so that one-half of it may be applied lengthwise to the chest, and the other half to the inside of the injured arm, the angle formed by the bend, which should be somewhat obtuse, being well pressed up into the axilla." The following is the plan which I would, however, generally recommend :— The fragments having been reduced as completely as possible, a broad and firm gutta-percha splint should be moulded to the outside of the arm and shoulder. When it has become sufficiently hard and firm, it may be secured in place by a roller carried from the elbow to the axilla. If the splint covers well the top of the shoulder, and is sufficiently wide, it is not apt to become displaced; and by resting against the point of the acromion process, it enables the upper turns of the bandage to draw the broken end of the lower fragment outwards; at least, as effectually as any other dressing is capable of doing, and renders an axillary pad unnecessary. The sling may then be applied as recommended by Sir Astley Cooper, or the arm may be permitted to hang perpendicularly beside the body. The clavicular bandage also recommended by Sir Astley complicates the dressing very much, 1 Dupuytren on Bones, Sydenham edition, p. 99. 224 FRACTURES OF THE HUMERUS. and does not seem to me to answer any useful purpose; while the ax- illary pad exposes the brachial plexus to painful if not injurious pressure. As a substitute for gutta percha, a firm sheet of felt may be employed, a piece of sole leather, or a carved wooden splint, or the very complete shoulder and arm splint of Welch; but in either case the upper portion of the splint ought always to rest upon the shoulder, so as to prevent its sliding downwards. Dr. Waters read before the Society of the University of New York, a remarkable case of compound and comminuted fracture of the shaft and surgical neck of the humerus, in which the constant protrusion of the upper end of the middle fragment in the region of the axilla finally rendered resection of the head and neck necessary. This operation was made by Dr. Waters, on the eighteenth day; and four months after, the patient was so far recovered as to be able to write a letter with the limb upon which the operation had been made. 1 It may be regarded, therefore, as a signal triumph of conservative surgery, since the alter- illary pad exposes the brachial plexus to painful if not Fig. 54. injurious pressure. Welch'8 shoulder splint. native presented was only between amputation and resection. In a similar case, Dr. W. H. Yan Buren, of New York, was compelled to amputate at the shoulder-joint, after which the patient made a good recovery. 2 § 5. Shaft, below the Surgical Neck and above the Base of the Condyles. Causes. —In a record of eighteen cases in which the cause of the fracture is stated, I find this portion of the shaft broken from direct violence eleven times; from indirect blows, the concussion being received upon the elbow, twice; once it was a consequence of tertiary lues, once it occurred during birth, and three times in the same patient it has been broken from muscular action alone, each consecutive fracture occurring at a different point. The records of surgery furnish many examples of fracture of the shaft of the humerus from muscular action, as in throwing a stone, or a snowball; but the most singular examples are those in which the bone has been broken in a trial of strength between two persons, by grasping the hands palm to palm, with the elbows resting upon a table, and twisting, when the humerus has suddenly given way a little above the condyles. I have seen one case of this kind, which was under the care of Dr. Winne, and Malgaigne has collected five other similar cases, two of which were reported by Lonsdale. The example of fracture during birth, to which I have referred, occurred in a healthy female child, whose parents were also healthy. The 1 Waters, New York Journal of Medicine, May, 1847, p. 318, vol. viii. First Series. 2 Van Buren, ibid., January, 1854, p. 152, vol. xii. Second Series. 225 SHAFT BELOW THE SURGICAL NECK. mother was in labor six or eight hours, but the labor was not severe. She was attended by a midwife, and does not know whether violence was employed or not. Dr. Lockwood, of Buffalo, was called on the third day, and found the arm broken a little below its middle, and moving as freely as it did at the elbow-joint; he applied lateral splints, with bandages, &c. I saw the child on the seventeenth day after its birth, with Dr. Lockwood. There was then a perfect ferule of ensheathing callus surrounding the fragments, and which, owing to the softness of the flesh, could be easily detected and defined. The fragments were firm, and had been at least three or four days. Nearly a year after, I again examined the arm, and could not discover any traces of the accident. Dr. Lowenhardt has also reported a case in which the evidence was conclusive that the fracture was caused solely by the contractions of the uterus, which forced the arm against the pubes; the arm being heard distinctly to snap when it was passing this point, and while the hands of the accoucheur were not aiding in the delivery. In this case the humerus was broken in its upper third.' Seat and Direction of the Fracture. —The seat of the fracture is more often below than above the middle of the bone; thus I have found the fracture fourteen times near the middle, and the same number of times below the middle third, but only seven times above the middle third. The observations of Norris, who found four fractures of the shaft above the middle, and nine below, correspond with my own; 2 but M. Gueiretin, in the same number of fractures, found nine above the middle and four below. 3 The line of fracture is generally oblique, but more often transverse than in fractures of the clavicle, femur, or tibia. Displacement. —The direction of the displacement depends, no doubt, sometimes upon the precise point of the fracture and upon the action of the muscles operating upon the two fragments; thus, if the fracture takes place just above the insertion of the deltoid, the lower fragment is liable to be drawn upwards and outwards, in the direction of its fibres, while the upper fragment is carried toward the origin of the pectoralis major, &c; but, in a great majority of cases, the influence of these muscles is more than counterbalanced by the direction of the force, and by the direction of the fracture. Practically, therefore, it is seldom of much importance to determine the exact point of fracture, as to whether it is Fig. 55. just above or below the insertion of a particular muscle; nor, indeed, is it generally very easy to ascertain this point with much precision. The amount of displacement varies considerably in different persons, 1 Lowenhardt, American Journal of Medical Sciences, January, 1841, p. 250, from Medicin Zeit., Mai 6, 1840. 2 Norris, Am. Journ. of Med. Sci., January, 1842, vol. xix. p. 28. 3 Gueretin, Presse Medicale, vol. i. p. 45. 226 FRACTURES OF THE HUMERUS. and in fractures at different points, but it will average about threequarters of an inch. When the fracture is produced by muscular action alone it is generally transverse, and displacement seldom occurs. Such was the fact in every instance where my own patient broke the arm three times consecutively at different points; and union was speedily accomplished, and with no deformity. Dupuytren, however, saw a case which constituted an exception to this general rule. The fragments became completely separated, and were so movable that union could not be effected, and he was compelled, after three months, to resort to resection. Results. —In twenty-three examples, the average shortening is about one-quarter of an inch; but of these, thirteen are not shortened at all, so that the average of shortening in the remaining ten is three-quarters of an inch; the amount of overlapping varying from one-quarter of an inch to one inch and a quarter. In thirty-one examples, I have twice seen the humerus refuse to unite; once when the fracture was in the lower third of the shaft. This was an oblique, compound fracture, and no union had taken place at the end of five months. The man was intemperate, but in pretty good health. 1 In the second case, the fracture had occurred a little below the middle of the bone, and it was simple. Five months after the accident this patient consulted me, when I found the elbow anchylosed, the forearm being fixed at right angles with the arm. 2 Neither of these patients had been under my care previously, but I learned that an intelligent Canadian surgeon had treated one of them, and the other had been seen and treated by several surgeons. In two other cases, the elbow remained somewhat stiff a long time after the splints were removed; in one case, complete freedom of motion was not restored at the end of fifteen years. Generally, however, the motions of the elbow-joint have been very soon restored after the removal of the splints and sling. I ought to mention that, not unfrequently, fractures of the shaft of the humerus, and especially where they are occasioned by direct blows, are followed by great swelling, and sometimes by abscesses. In one instance the fracture having taken place within the insertion of the deltoid muscle, the sharp extremity of the lower fragment was made to penetrate the flesh, causing an abscess, and finally tetanus, of which my patient soon died. The following remarks of Malgaigne are too pertinent to be omitted in this connection : " When there is great obliquity, with overlapping, or a fracture with splintering, or a multiple fracture, a certain amount of deformity is inevitable, and the formation of callus demands one or two weeks more. With the inflammation comes also the danger of suppuration, and later, a rigidity of the articulations difficult to dissipate. In short, we must not forget that of all fractures, those of the humerus are most liable to fail of consolidation." On the other hand, we shall find, in the case of this bone, as in all others, some remarkable exceptions, where, although the fracture may ' Report on Deformities, &c, Case 33. * Ibid., Case 21. 227 SHAFT BELOW THE SURGICAL NECK. be compound, and badly comminuted, yet the limb has been saved and made useful. Ayres, of New York, reports a case of this kind, in which he removed a portion of the shaft, and although the brachial artery was probably obliterated, a good union took place; 1 and "Walker, of Boston, has noticed two or three similar examples. 2 For an account of two remarkable cases of compound fracture of the shaft of the humerus, illustrating the powers of Nature in childhood, in the restoration of broken and comminuted bones, the reader may consult, in the New York Journal of Medicine for November, 1849, a paper entitled "Amputations and Compound Fractures," by John 0. Stone, Surgeon to Bellevue Hospital. The accidents occurred in children, one of whom was four, and the other six years of age, both of whom recovered with useful arms. Fig. 56. Treatment. —In the treatment of fractures of that portion of the shaft of the humerus now under consideration, I have preferred generally a broad and thick splint of gutta percha—felt or sole leather may answer nearly as well—sufficiently long to extend from the neck to the wrist, moulded accurately, and applied to the outside of the shoulder and arm, while the limb is flexed to a right angle, and while extension is being made upon the humerus. This being properly padded, and secured in place by rollers, I place the arm in a sling beside the body. The sling must, however, be so arranged, by being looped under the wrists, and not under the elbow, as that the weight of the elbow and lower part of the arm may aid in making extension. Welch's splint will answer the same purpose; or three narrow splints of different lengths may be used, but I do not find them so convenient as Welch's, or gutta percha applied as I have directed above. Other surgeons have sought to make permanent extensions in these and certain other fractures of the humerus, by various contrivances. Mr. Lonsdale constructed an instrument which might be lengthened or shortened to suit the case; it was made of steel, and was worked with a screw operating upon cogs in a sliding bar; resembling in some respects, the arm portion of Jarvis's adjuster. In the second Fig. 57. Lonsdale's extension apparatus.—A Crutch. B. Shaft. C. Elbow re«t. E. Hook for attachment of bandage, opposite which is a crossbar for the same purpose. 1 Ayres, New York Journal of Medicine, January, 1857, p. 24, 3d series, vol. xi. 2 Walker: Essay on Compound Fractures, &c, by William J. Walker, of Boston, published in London in 1845. 228 FRACTURES OF THE HUMERUS. London edition of a series of plates illustrating the action of the muscles in producing displacement in fractures, by S. W. Hind, is a drawing of an apparatus invented by the author for the same purpose, which is very simple, and in some respects more complete than Lonsdale's, and which may be easily adapted to almost any form of armsplint. Indeed, nothing more is necessary than to attach to the ordinary long splint a movable crutch. I believe that all these contrivances may prove occasionally useful, but the common experience of surgeons has shown how difficult it is to accomplish much extension by means of pressure in the axilla; a mode, too, which I think must be wholly inadmissible when the fracture approaches the upper end, since the pressure by the crutch-head upon the pectoralis major and latissimus dorsi, which constitute the margins of the axilla, must tend to displace the fragments upon which they act, inwardly, and which seldom can be applied with much force to fractures near the condyles, on account of the probable existence of inflammation and swelling about the joint. Malgaigne, when speaking of the apparatus of Lonsdale, remarks: " But the surgeon should never lose sight of the fact that permanent extension is a resource always dangerous, often useless, and which demands in its application much caution and watchfulness." The following example will illustrate the practical difficulty of employing permanent extension in fractures of the humerus:— A laborer, aged thirty, was admitted into the Buffalo Hospital of the Sisters of Charity, on the second day of October, 1853, with a simple oblique fracture of the humerus, which had occurred three days before. The fracture was situated within the insertion of the deltoid, and having been produced by the rolling of a log upon the arm, the whole limb was much swollen. The night following his admission, in a fit of delirium tremens, he removed all of the dressings. When I visited the wards in the morning, I found the fragments displaced and the muscles contracting violently. The ordinary dressings were applied, and continued until the fifth day, when, as the delirium had not ceased, and the muscles continued to contract with great violence, it was determined to attempt permanent extension. For this purpose we lifted the elbow upwards and outwards, to relax the deltoid, and then, having made extension with the forearm placed at a right angle with the arm, we fitted carefully a large gutta-percha splint to the forearm, arm, axilla, and side, in such a manner that when the splint was secured to these several parts, the arm could not fall to the side of the body completely, and in proportion as it did fall downward, it would make extension upon the arm. This splint was well padded, and secured in place by rollers. On the sixth day the delirium had ceased, and never returned. The dressings were well in place, and seemed to accomplish the indication we had in view; but, on the seventh day, although he had kept very quiet, everything was disarranged, and the whole had to be readjusted. On the eighth and ninth, the same thing occurred. During this time we had varied the dressings, position, &c, each day, to meet, if possible, the difficulties, but it was at length deemed unwise to pur- 229 SHAFT BELOW THE SURGICAL NECK. sue the attempt any further, and we returned to the use of the ordinary splints, laying the arm against the side of the body. The union was finally completed without either overlapping or angular displacement. Something may always be accomplished when the patient is walking about, by allowing the elbow to escape from the sling, so that its weight shall make constant traction upon the lower fragment; and the plan which I suggested some years since, of treating certain cases of delayed union of the humerus, namely, extending the arm at full length by the side of the body, so that the lower fragment shall receive the whole weight of the forearm and hand, might occasionally prove valuable in recent fractures where the tendency to override was very great. In two instances, I have already put this plan sufficiently to the test to determine its safety and utility. The precise plan, and my reasons for its adoption in certain cases of delayed union, were set forth in the following paper, read before the Buffalo City Medical Association, and published in the Buffalo Medical Journal for August, 1854. " I have observed that non-union results more frequently after fractures of the shaft of the humerus, than after fractures of the shaft of any other bone. " Comparing the humerus with the femur, between which, above all others, the circumstances of form, situation, &c, are most nearly parallel, and in both of which non-union is said to be relatively frequent, I find that of forty-nine fractures of the humerus, four occurred through the surgical neck, twelve through the condyles, and twenty-nine through the shaft. In one of the twenty-nine the patient survived the accident only a few days. In four of the remaining twenty-eight, union had not occurred after the lapse of six months, and in many more it was delayed beyond the usual time. Two of the four were simple fractures, and occurred near the middle of the humerus; the third was compound, and occurred near the middle also; the fourth was compound, and occurred near the condyles. " This analysis supplies us, therefore, with four cases of non-union, from a table of twenty-eight cases of fractures through the shaft. " Of eighty-seven fractures of the femur, twenty occurred through the neck, one through the trochanter major, and one through the condyles. The remaining sixty-five occurred through the shaft, and generally near the middle, and not in one case was the union delayed beyond six months. " To make the comparison more complete, I must add that of the twenty-eight fractures of the shaft of the humerus, six were compound; and of the sixty-five fractures of the shaft of the femur, six were either compound, comminuted, or both compound and comminuted. The six compound fractures of the shaft of the humerus furnished two cases of non-union. The six cases of either compound or comminuted, or compound and comminuted fractures of the femur, furnished no case of non-union. " I beg to suggest to the Society what seems to me to be the true explanation of these facts. ' It is the universal practice, so far as I know, in dressing fractures 230 FRACTURES OF THE HUMERUS. of the humerus, to place the forearm at a right angle with the arm. Within a few days, and generally, I think, within a few hours, after the arm and forearm are placed in this position, a rigidity of the muscles and other structures has ensued, and to such a degree that if the splints and sling are completely removed, the elbow will remain flexed and firm; nor will it be easy to straighten it. A temporary false anchylosis has occurred, and instead of motion at the elbow-joint, when the forearm is attempted to be straightened upon the arm, there is only motion at the seat of fracture. It will thus happen that every upward a ad downward movement of the forearm will inflict motion upon the fracture; and inasmuch as the elbow has become the pivot, the motion at the upper end of the lower fragment will be the greater in proportion to the distance of the fracture from the elbow-joint. " No doubt it is intended that the dressings shall prevent all motion of the forearm upon the arm; but I fear that they cannot always be made to do this. I believe it is never done when the dressing is made without angular splints, nor is it by any means certain that it will be accomplished when such splints are used. The weight of the forearm is such, when placed at a right angle with the arm, and encumbered with splints and bandages, that even when supported by a sling, it settles heavily forwards, and compels the arm-dressings to loosen themselves from the arm in front of the point of fracture, and to indent themselves in the skin and flesh behind. By these means the upper end of the lower fragment is tilted forwards. If the forearm should continue to drag upon the sling, nothing but a permanent forward displacement would probably result. The bones might unite, yet with a deformity. "But the weight of the forearm under these circumstances is not uniform, nor do I see how it can be made so. It is to the sling that we must trust mainly to accomplish this important indication. But you have all noticed that the tension or relaxation of the sling depends upon the attitude of the body, whether standing or sitting; upon the erection or inclination of the head; upon the motions of the shoulders; and in no inconsiderable degree upon the actions of respiration. Nor does the patient himself cease to add to these conditions by lifting the forearm with his opposite hand whenever provoked to it by a sense of fatigue. " This difficulty of maintaining quiet apposition of the fragments while the arm is in this position, at whatever point it may be broken, becomes more and more serious as we depart from the elbow-joint, and would be at its maximum at the upper end of the humerus, were it not that here a mass of muscles, investing and adhering to the bone, in some measure obviates the difficulty. Its true maximum is, therefore, near the middle, where there is less muscular investment, and where, on the one hand, the fracture is sufficiently remote from the pivot or fulcrum to have the motion of the upper end of the lower fragment multiplied through a long arm, while, on the other hand, it is sufficiently near the armpit and shoulder to prevent the upper portion of the splint and arm-dressings from obtaining a secure grasp upon the lower end of the upper fragment. SHAFT BELOW THE SURGICAL NECK. 231 "It must not be overlooked that the motion of which we speak belongs exclusively to the lower fragment, and that it is always in the same plane forwards and backwards, but especially that it is not a motion upon the fracture as upon a pivot, but a motion of one fragment to and from its fellow. This circumstance I regard as important to a right appreciation of the difficulty. Motion alone, I am fully convinced, does not so often prevent union as surgeons have generally believed. It is exceedingly rare to see a case of non-union of the clavicle. Of forty-seven cases of fracture of the clavicle which have come under my observation, and in by far the greater proportion of which considerable overlapping and consequent deformity ensued, only one has resulted in non-union, and in this instance no treatment whatever was practised, but from the time of the accident the patient continued to labor in the fields and hold the plough as if nothing had occurred. I have, therefore, seen no case of non-union of the clavicle where a surgeon has treated the accident. Indeed, what is most pertinent and remarkable, its union is more speedy usually than that of any other bone in the body of the same size. Yet to prevent motion of the fragments in a case of fractured clavicle with complete separation and displacement, except where the fracture is near one of the extremities of the bone, I have always found wholly impracticable. Wherever bandages or apparatus has been applied, I have still seen always that the fragments would move freely upon each other at each act of inspiration and expiration, and at almost every motion of the head, body, or upper extremities. It is probable, gentlemen, that you have made the same observation. " From this and many similar facts I have been led to suspect, for a long time, that motion has had less to do with non-union than was generally believed. " I find, however, no difficulty in reconciling this suspicion with my doctrine in reference to the case in question; and it is precisely because, as I have already explained, the motion, in case of a fractured humerus, dressed in the usual manner, is peculiar. " In a fracture of the clavicle through its middle third (its usual situation), the motion is upon the point of the fracture as upon a pivot; although, therefore, the motion is almost incessant, it does not essentially, if at all, disturb the adhesive process. The same is true in nearly all other fractures. The fragments move only upon themselves, and not to and from each other. I know of no complete exception but in the case now under consideration. " Aside from any speculation, the facts are easily verified by a personal examination of the patients during the first or second week of treatment, or at any time before union has occurred, both in fractures of the humerus and clavicle. The latter is always sufficiently exposed to permit you to see what occurs, and as soon as the swelling has a little subsided in the former case you will have no difficulty in feeling the motion outside of the dressings, or, perhaps, in introducing the finger under the dressings sufficiently far to reach the point of fracture. I believe you will not fail to recognize the difference in the motion between the two cases. Such, gentlemen, is the explanation which I 232 FRACTURES OF THE HUMERUS. wish to offer for the relative frequency of this very serious accident— non-union of the humerus. " I know of no other circumstance or condition in which this bone is peculiar, and which, therefore, might be invoked as an explanation. Overlapping of the bones, the cause assigned by some writers, is not sufficient, since it is not peculiar. The same occurs much oftener, and to a much greater extent, in fractures of the femur, and equally as often in fractures of the clavicle, yet in neither case, are these results so frequent. Nor can it be due to the action of the deltoid muscle, or of any other particular muscles about the arm, whether the fracture be below or above their insertions, since similar muscles, with similar attachments, on the femur and on the clavicle, tending always powerfully to the separation of the fragments, occasion deformity, but they seldom prevent union. " If I am correct in my views, we shall be able sometimes to consummate union of a fractured humerus where it is delayed, by straightening the forearm upon the arm, and confining them to this position. A straight splint, extending from the top of the shoulder to the hand, constructed from some firm material, and made fast with rollers, will secure the requisite immobility to the fracture. The weight of the forearm and hand will only tend to keep the fragments in place, and if the splint and bandages are sufficiently tight, the motion occasioned by swinging the hand and forearm will be conveyed almost entirely to the shoulder-joint. Very little motion, indeed, can in this posture be communicated to the fragments, and what little is thus communicated, is a motion which experience has elsewhere shown not disturbing or pernicious, but a motion only upon the ends of the fragments, as upon a pivot. " I do not fail to notice that this position has serious objections, and that it is liable to inconveniences which must always, probably, prevent its being adopted as the usual plan of treatment for fractured arms. It is more inconvenient to get up and lie down, or even to sit down, in this position of the arm, and the hand is liable to swell. But I shall not be surprised to learn that experience will prove these objections to have less weight than we are now disposed to give them. Remember, the practice is yet untried—if I except the case which I am about to relate, and in which case, I am free to say, these objections scarcely existed. The swelling of the hand was trivial, and only continued through the first fortnight, and the patient never spoke of the inconvenience of getting up or sitting down, or even of lying down. " The following is the case to which I have just referred: ' Michael Mahar, laborer, ast. 35, broke his left humerus just below its middle, Dec. 14th, 1853. The arm was dressed by a surgeon in Canada "West, and who is well known to me as exceedingly 'clever.' After a few days from the time of the accident, 'the starch bandage was put on as tight as it could be borne, and brought down on the forearm, so as to confine the motions of the elbow-joint.' Six weeks after the injury, Jan. 29th, 1854, Mahar applied to me at the Hospital. No union had occurred. The motion between the fragments was very BASE OF THE CONDYLES. 233 free, so that they passed each other with an audible click. There was little or no swelling or soreness. In short, everything indicated that union was not likely to occur without operative interference. The elbow was completely anchylosed. I explained to my students what seemed to me to be the cause of the delayed union, and declared to them that I did not intend to attempt to establish adhesive action until I had straightened the arm. They had just witnessed the failure of a precisely similar case, in which I had made the attempt to bring about union without previously straightening the arm. "' On the 6th of Feb. 1854, we had succeeded in making the arm nearly straight. I now punctured the upper end of the lower fragment with a small steel instrument, and, as well as I was able, thrust it between the fragments. Assisted by Dr. Boardman, I then applied a guttapercha splint from the top of the shoulder to the fingers, moulding it carefully to the whole of the back and sides of the limb, and securing it firmly with a paste roller. March 4th (not quite four weeks after the application of the splint) we opened the dressings for the second time, and carefully renewed them. A slight motion was yet perceptible between the fragments. March 18th, we opened the dressings for the third time, and found the union complete. This was within less than forty days. The patient was now dismissed. On the 29th of April following, the bone was re-fractured. Mahar had been assisting to load the "tender" to a locomotive. As the train was just getting in motion, he was hanging to the tender by his sound arm, while another laborer seized upon his broken arm to keep himself upon the car, and with a violent and sudden pull wrenched him from the tender and reproduced the fracture. The next morning I applied the dressings as before, and did not remove them during three weeks; at the end of which time the union was again complete. The splint was, however, reapplied, and has been continued to this time —a period of about six week."" Since the date of the above paper, I have twice had opportunities to test the value of this mode of treatment in cases of somewhat delayed union of the humerus, and in each case with the same favorable result. § 6. Base of the Condyle. (Fractures de Vextremite inferieure de Vhumerus. —Dupuytren. Fractures sus-condyliennes de Vhumerus.—Malgaigne.) Causes. —Of thirteen fractures at this point, nine occurred in children under ten years of age, the youngest being two years old. In nine cases, the fracture had been produced by a fall, and it is presumed that the blow was received upon the elbow; in the remaining four cases the cause is not stated. I believe, therefore, that this fracture is generally the result of an indirect blow, inflicted upon the extremity of the elbow; in a few examples, it has been produced by a blow received directly upon the point of fracture, as by the kick of ' Buffalo Med. Journ., vol. x. pp. 14-147. 16 234 FRACTURES OF THE HUMERUS. a horse, &c., but I have never, save in a single instance, been able to trace it to a fall upon the hand. Fig. 58. Fracture at the fcase of the condyles. Direction of the Fracture, Displacement, and Symptoms. —I think this fracture is generally oblique, and its line of direction upwards and backwards; in eight of the ten cases where this point was determined, such has been its apparent direction, and the lower fragment has been found drawn up behind the upper. Once I have found the lower fragment in front, and once on the outside of the upper. Three of the thirteen were compound, comminuted fractures, this being a larger proportion of serious complications than is usually found in connection with fractures of long bones. I have never met with what I supposed to be a separation of the lower epiphysis, but surgical writers have occasionally spoken of this accident, and Dr. Watson, of New York, believes that he has seen one example in an infant not quite two years old. The limb had been violently wrenched by the mother, in attempting to lift her. She was not seen by Dr. Watson until the fourth day, at which time the swelling was such that the diagnosis could not be easily made out; but on the ninth day " it was apparent that the shaft of the humerus had been separated from its cartilaginous expansion at the condyles, near the elbow." By the use of angular pastebord splints, the reduction was maintained, and the fragments became united after about four or six weeks. 1 The diagnosis of this fracture is attended with peculiar difficulties, and it has occasionally been mistaken for a dislocation of the radius and ulna backwards. Dupuytren says: " There is nothing so common as to see a fracture of the lower end of the humerus, immediately above the elbow-joint, mistaken for a dislocation backward;" and he mentions three cases which have come under his own observation. I have found an opposite error, however, by far the most frequent, namely—a dislocation of both bones backwards has been supposed to be a fracture. The sources of this embarrassment are found in the proximity of the fracture to the joint, in the rapidity with which swelling occurs, and in the striking similarity of the symptoms which characterize the two accidents. 1 Watson, New York Journ. Med., Nov. 1853, p. 430, second series, vol. xi. BASE OF THE CONDYLES. 235 It will be necessary, therefore, to establish with care the differential diagnosis. The following are the signs of fracture :— 1. Preternatural mobility, which, owing to the rapidity of the swelling and the contraction of the muscles whose tendons are stretched over the projecting ends of the bones, is often soon lost, being succeeded, sometimes after a few hours, by a rigidity equal to that which is usually present in dislocations, or even greater. It is especially difficult to flex the arm, owing to the pressure by the upper fragment into the bend of the elbow. 2. Crepitus. This can usually be detected at any period if the arm is sufficiently extended, so as to bring the broken surfaces again into apposition. 3. When the extension is sufficient, reduction is easily effected, and the natural length of the arm is restored, but the limb immediately shortens when the extension is discontinued—especially if at the same moment the elbow is bent. This is a very important means of diagnosis. 4. A careful measurement, made from the point of the internal condyle to the acromion process, declares a positive shortening of the humerus. 5. By flexing and extending the forearm upon the arm, while the fingers are placed upon the lower portion of the humerus, the projecting fragments can be felt. Generally, the upper fragment being in front of the lower, and pressing down into the bend of the elbow, its end cannot be so easily recognized; but the upper end of the lower fragment can easily be made out when the forearm is considerably flexed. The lower end of the upper fragment feels more rough, and is less wide, than in dislocations. 6. The whole of the lower fragment is carried backwards, and with it the radius and ulna, producing a striking prominence of the elbow and olecranon process. Efforts to straighten the forearm upon the arm, when no extension is used, increase rather than diminish this projection. 7. The forearm is slightly flexed upon the arm; the angle made at the elbow being about 25 or 30 deg. 8. The hand and forearm are pronated. 9. The relations of the olecranon process with the two condyles remain unchanged. Signs of a dislocation of the radius and ulna backwards. 1. Preternatural rigidity. 2. Absence of crepitus. It is in this joint especially that surgeons have been deceived by the chafing of the dislocated bones upon the inflamed joint surfaces, and have supposed that they discovered crepitus when no fracture existed. The rapidity with which inflammation develops itself after dislocations of the elbow-joint, and the consequent abundant effusion of lymph, afford the probable explanation of this frequent error. 3. When reduced, the bones are not generally disposed to become again displaced, even though the elbow should be flexed. 236 FRACTURES OF THE HUMERUS. 4. The humerus is not shortened, but the olecranon process approaches the acromion process. 5. There are no sharp projecting points of bone. The lower end of the humerus may not always be felt in the bend of the elbow; but when it is felt, it is found to be relatively smooth, broad and round. 6. A remarkable prominence of the elbow and olecranon process, which prominence is sensibly diminished when an effort is made to straighten the forearm on the arm. 7. Forearm flexed upon the arm to about the same degree as in fracture. 8. Hand and forearm pronated, precisely as in fracture. 9. Eelations of the olecranon process to the condyles changed very greatly. The most constant diagnostic signs are, then, in the case of a fractur —crepitus, shortening of the humerus, projection of the sharp ends of the fragments, and an increase of the projection of the elbow when an attempt is made to straighten the arm; and in the case of a dislocation, the absence of crepitus, humerus not shortened, while the olecranon approaches the acromion process; the smooth, round head of the humerus lost, or indistinctly felt in the bend of the elbow and the projection of the point of the elbow diminished when an attempt is made to straighten the forearm on the arm. It is proper, also, to repeat here what we have already said in relation to the causes of this fracture. A fracture at this point is produced almost always by a fall upon the elbow, but a dislocation of the radius and ulna backwards can never be. On the other hand, a dislocation is produced in almost every instance by a fall upon the palm of the hand, while I have never known but one fracture above the condyles to be thus produced. Results. —Eight times have I found the arm shortened from half an inch to one inch, or a little more. Muscular anchylosis is almost always present when the apparatus is first removed, and it is seldom completely dissipated until after several months; but I have found more or less anchylosis at seven and nine months; and twice after the lapse of three years the motions of the joint have been very limited. A few years since, I examined the arm of a gentleman who was then twenty-seven years old, and who informed me that when he was four years old he broke the humerus just above the condyles. There still remained a sensible deformity at the point of fracture—he could not completely supine the arm. The whole arm was weak, and the ulnar nerve remarkably sensitive. The ulnar side of the forearm, and also the ring and little fingers, were numb, and have been in this condition ever since the accident. I know the surgeon very well who had charge of this case, and I have no doubt that the treatment was carefully and skilfully applied. In June, of 1850, I operated upon a lad, nine years old, by sawing off the projecting end of the upper fragment, whose arm had been broken nine months before. This fragment was lying in front of the lower, and the skin covering its sharp point was very thin and tender. 237 BASE OF THE CONDYLES. There was no anchylosis at the elbow-joint, but the hand was flexed forcibly upon the wrist, the first phalanges of all the fingers extended, and the second and third flexed. Supination and pronation of the forearm were lost. The forearm and hand were almost completely paralyzed, but very painful at times. The median nerve could be felt lying across the end of the bone. In the hope that some favorable change might result to the hand by relieving the pressure upon the nerve, yet with not much expectation of success, I exposed the bone and removed the projecting fragment. The nerve had to be lifted and laid aside. About one year from this time I found the arm in the same condition as before the operation. Non-union is a result not so frequent in fractures at this point as higher up; but Stephen Smith, of the Bellevue Hospital, New York, reports a case of non-union in a young man of twenty-three years. He was admitted to the hospital on the seventh day after the accident. The fracture was simple and transverse, yet at the end of four months he was dismissed "with perfectly free motion at the point of fracture." 1 The failure to unite was attributed to a syphilitic taint. A case was recently tried in the Supreme Court at Brooklyn, N. Y., in which, after a simple fracture at this point, the arm being dressed with splints and bandages, the little finger sloughed off, in a condition of dry gangrene, and the adjacent parts of the hand were attacked with humid mortification. Drs. Parker and Prince believed that this serious accident was the result of bandages applied too tightly and suffered to remain too long, while Drs. Valentine Mott, Rogers, VVood, Ayres, Dixon, and others, believed that the gangrene might have been due to other causes over which the surgeon had no control. 2 A few years ago, a similar case occurred in the town of Spencer, Tioga Co., N. Y.; a boy, six years old, having broken his humerus just above the condyles. The fracture was oblique. The surgeon who was called to treat the case was an old and highly respectable practitioner. I am not informed of the plan of treatment any farther than that a roller was applied. On the eighth day, a secdhd surgeon was employed, who, finding the hand cold and insensible, removed all of the dressings; after which the thumb and forefinger sloughed, with other portions of the skin and flesh of the hand and arm. The surgeon who was first in attendance was prosecuted, and the case was tried in the Supreme Court of that county, but the jury found no cause of action. Dr. Hawley, of Ithaca, and the late Dr. Webster, of Geneva Medical College, testified that, in their opinion, the death of the fingers was owing to the pressure of the fragment upon the brachial artery, and not to the tightness of the bandages. Dr. Gross has also informed us of still another case of the same character, which occurred in Warren Co., Ky. A boy, ten years old, had broken his arm above the condyles, and his parents having employed a surgeon residing at some distance, the dressings were applied, 1 S. Smith, New York Journal of Medicine, May, 1857, p. 386, third series, vol. ii. 2 New York Medical Gazette, vol. xii. pp. 46, 80, 111. 238 FRACTURES OF THE HUMERUS. and directions given to send for the surgeon whenever it became necessary. The parents saw the arm swell excessively, and knew that the boy was suffering very much, but did not notify the surgeon until the tenth day, when the hand was found to be in a condition of mortification, and at length amputation became necessary. Long afterward, in the year 1851, when the boy became of age, he prosecuted his surgeon, but with no result to either party beyond the payment of their respective costs. While I would not deny that in all of these cases the sloughing might have been solely due to the tightness of the bandages, against which cruel and mischievous practice we cannot too loudly declaim, a knowledge of the anatomy of these parts, and the opinions of the very distinguished gentlemen who testified in defence of these surgeons, must compel us to admit the possibility of such accidents where the treatment has been skilful and faultless. Treatment. —The splints generally employed in this country, in fractures about the elbow-joint, are simple angular side splints, without joints, such as those recommended by Physick. 1 Fig. 59. Fig. 60. Fergusson's dressing for lower part of arm. Physick's elbow splints. Angular pasteboard splints, felt, gutta percha, &c, or angular splints with a hinge, such as Kirkbride's, 2 Thomas Hewson's, Day's, or Rose's, Fig. 61. Kirkbride's elbow splint. or the more perfect and elegant angular splint of Welch. Kirkbride's splint, which has been used in the Pennsylvania Hospital in several instances, is composed of two pieces of board, connected together by a circular joint, and having eyes on the inner edge, two inches apart, and holes through the splint 1 Elements of Surgery, by John Syng Dorsey, Philadelphia edition, vol. i. p. 145 2 American Journal of the Medical Sciences, vol. xvi. p. 315. 239 BASE OF THE CONDYLES. at graduated distances between them. There is also a swivel eye, passing through the upper part of the splint, and riveted below. A wire is fastened to the swivel, and bent at right angles at its other extremity, of a size to fit the eyes and holes in the splint. This splint, Fig. 62. Fig. 63. Rose's splint. Welch's splint. The hinges may be transferred to splints of different sizes. properly supported by pads, is to be placed either upon the outside or inside of the arm, and secured by rollers. When the angle is to be changed, the wire is unhooked and removed to another eye, or to some of the intermediate holes upon the side of the splint. Dr. Kirkbride reports two cases of fracture of the lower part of the humerus treated by this plan, one of which resulted in anchylosis, but the other was much more successful. H. Bond, of Philadelphia, has contrived a very ingenious splint for Fig. 64. Bond's elbow splint. 240 FRACTURES OF THE HUMERUS. the elbow-joint, and which is designed also to afford a complete support to the forearm. For myself, I generally prefer gutta percha, moulded and applied accurately to the limb, in the same manner as I have already directed in fractures of the surgical neck and shaft of the humerus, except that it shall be extended beyond the elbow to the wrist, so as to support the whole length of the arm, elbow, and forearm. Some experience in the use of wooden angular splints has convinced me that they cannot be very well fitted to the many inequalities of the limb ; and neither pasteboard nor binder's board has sufficient firmness, especially Fig. 65. The author's elbow splint. in that portion which covers the joint. Angular splints, furnished with a movable joint, possess the advantage of enabling us to change the angle of the limb at pleasure, and of keeping up some degree of motion in the articulation without disturbing the fracture or removing the dressings; but the cross-bars of Day's and Rose's splints render them complicated, and are in the way of a nice application of the rollers; while they are all equally liable to the objection stated against angular wooden splints without joints, viz., that they seldom can be made to fit accurately the many irregularities of the arm, elbow, and forearm. Welch's splints, made of a material possessing a slight amount of flexibility, approach more nearly the accomplishment of these indications than any other manufac- tured splint with which I am acquainted, but the number of cases in practice to which they are applicable will be found to be limited, while gutta percha has no limit in its application. Whatever material is employed, a pretty large pledget of fine cotton batting ought to be laid in front of the elbow-joint, to prevent the roller from excoriating the delicate and inflamed skin, and great care should be taken to protect the bony eminences about the joint, or, rather, to relieve them from pressure, by increasing the thickness of the pads above and below these eminences. At a very early day, so early, indeed, as the seventh or eighth day, the splint should be removed, and, while the fragments are steadied, gentle, passive motion should be inflicted upon the joint. This practice should be repeated as often as every second or third day, in order to prevent, as far as possible, anchylosis. If much swelling follows the injury, it is my custom to open the dressings, without removing FRACTURE AT THE BASE OF THE CONDYLES. 241 the splints, on the second or third day after the accident, or at any time when the symptoms admonish us of its necessity. Occasionally it is well to change the angle of the splint before reapplying it. If the angular splint with a movable joint is used, slight changes may be made while the splint is on the arm; but if the angle is much changed without removing the rollers, they become unequally tightened over the arm, and may do mischief. When anchylosis has actually taken place, we may more or less overcome the contraction of the muscles and of the ligaments by passive motion, or by directing the patient to swing a dumb-bell or some heavy weight in his hands, as first recommended by Hildanus. § T. Fracture at the Base op the Condyles, complicated with Fracture between the Condyles, extending into the Joint. This fracture, which is but a variety or complication of the preced ing, is even more difficult of diagnosis; and its signs, results, and proper treatment differ sufficiently to demand a separate consideration. I have recognized the accident six times. Confined to no period of life, it seems to be the result of a severe blow inflicted directly upon the lower and back part of the humerus, or upon the olecranon process. Dr. Parker, of New York, was inclined to regard an obscure accident about the elbow-joint, which he saw in a lad sixteen years old, as a longitudinal fracture of the humerus, with separation of one condyle, but which had been occasioned by a fall upon the hand. 1 For myself, I should regard this latter circumstance' as presumptive evidence that it was not a fracture of this character, yet Fig. 66. Fracture at the base of, and between the condyles. I do not mean to deny the possibility of its occurrence in this way. Its characteristic symptoms are, increased breadth of the lower end of the humerus, occasioned by a separation of the condyles; displacement upwards and backwards of the radius and ulna; crepitus and mobility at the base of the condyles, with crepitus also between the condyles, developed by pressing the condyles together; or when the radius and ulna are drawn up, by restoring these bones first to place by extension, and then pressing upon the opposite condyles; shortening of the humerus. Its consequences are, generally, great inflammation about the joint, permanent deformity and bony anchylosis. An opposite result must be regarded as fortunate, and as an exception to the rule. Of the treatment, we can only say that it must be chiefly directed to the prevention and reduction of inflammation, at least during the first few days. Nor is this inconsistent with an early reduction of the fragments, and moderate efforts, by splints and bandages, such as we have 1 Parker, New York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 242 FRACTURES OF THE HUMERUS. directed in case of a simple fracture at the base of the condyles, to keep the fragments in place. No surgeon would be justified in refusing altogether to make suitable attempts to accomplish these important indications; but he must always regard them as secondary when compared with the importance of controlling the inflammation. When splints are employed, the same rules will be applicable both as to their form and mode of application, as in cases of simple fracture above the condyles. The following examples will more completely illustrate the character, history, and proper treatment of these cases, than any remarks or rules which we can at present make. A woman living in this city, set. 44, fell upon the sidewalk in January, 1850, striking upon her right elbow. I saw her a few minutes after the accident, but the parts about the joint were already considerably swollen, and it was not without difficulty that the diagnosis was made out. The forearm was slightly flexed upon the arm, and pronated. On seizing the elbow firmly, a distinct motion was perceived above the condyles, and a crepitus. I could also feel, indistinctly, the point of the upper fragment. While moderate extension was made upon the arm, the condyles were pressed together, when it was apparent that they had been separated. On removing the extension, they again separated, and the olecranon drew up. She was in a condition of extreme exhaustion, and the bones were easily placed in position. An angular splint was secured to the limb, and every care used to support the fragments completely, but gently. From this date until the conclusion of the treatment, the dressings were removed often, and the elbow moved as much as it was possible to move it. Seven months after the accident, the elbow was almost completely anchylosed at a right angle. The fingers and wrist also were quite rigid. Six years later, the anchylosis had nearly disappeared; she could now flex and extend the arm almost as much as the other; the wrist-joint was free, and the fingers could be flexed, but not sufficiently to touch the palm of the hand. The line of fracture through the base could be traced easily, but the humerus was not shortened. There was, moreover, much tenderness over the point of fracture through the base, and at other points. Occasionally, a slight grating was noticed in the radio-humeral articulation. She experienced frequent pains in the arm, and especially along the back and radial border of the ring finger. During the first year or two after the accident, the arm perished very much, but although the hand remained weak, the muscles were now well developed. A gentleman was struck with the tongue of a carriage with which a couple of horses were running. The blow was received directly upon the back of the left elbow. Dr. Sprague and myself removed some small fragments of bone, and while opening the wound for this purpose, we could see distinctly the line of fracture extending into the joint as well as across the bone. The condyles were not separated. The subsequent treatment consisted only in the use of such means as would best support the limb, and most successfully combat inflam- 243 FRACTURE AT THE BASE OF THE CONDYLES. mation. The arm and forearm were laid upon a broad and well cushioned angular splint, covered with oil-cloth, to which they were fastened by a few light turns of a roller. Twelve years after, I found the humerus shortened one inch and a half. During the" first year, he says, there was no motion in the elbowjoint, but he can now flex and extend the forearm through about 45°; when flexed to a right angle, it seems to strike a solid body like bone. Rotation of the forearm is completely lost, the hand being in a position midway between supination and pronation. He suffers no pain, and his arm is quite strong and useful. No means have been employed to restore the functions of the limb but passive motion at first, and subsequently constant, active use of the hand and arm. The late Dr. Thomas Spencer, of Geneva, used to relate a case in which a surgeon was called to what he supposed to be a fracture of the lower end of the humerus, and which he treated accordingly, with splints, &c. On the second or third day, another surgeon was called, who removed the splints and bandages, and pronounced it a dislocation of the radius and ulna backward; but he was unable to reduce it. After some time, the first surgeon was prosecuted for having treated as a fracture what proved to be a dislocation. Dr. Spencer, who had examined the arm carefully, gave his testimony last, and at a time when, from the evidence, it seemed almost certain that the surgeon must be mulcted in heavy damages; but he declared his belief that both surgeons were right, since, on measuring the breadth of the humerus through its two condyles, he found that the humerus of the injured arm was three-quarters of an inch wider than the opposite. His conclusion, therefore, was that the condyles had been split asunder and were now separated; that the first surgeon properly reduced this fracture, but that when, on the second or third day, the second surgeon removed the splints and the dressings, a contraction of the muscles had taken place and the dislocation occurred, the bones of the forearm being drawn up between the fragments. Dr. Spencer believed this was an example of the variety of fracture now under consideration, but it is not quite certain that there was anything more than an oblique fracture extending into the joint, followed by a dislocation. In either case, the first surgeon was entitled to an acquittal, and so the jury promptly declared by their verdict. In a case of compound comminuted fracture of the character now under consideration, Dr. Stone, of the Bellevue Hospital, New York, removed the condyles and sawed off the sharp end of the humerus. The woman was twenty-six years old and intemperate. The operation was made as a substitute for amputation. No serious complications followed. On the ninety-sixth day, the wounds were completely healed, and she could bend the forearm to a right angle with the arm, the action of the muscles having drawn up the radius and ulna against the lower end of the shaft of the humerus, so that the motions were natural and free. 1 The practice, as the result sufficiently shows, was eminently judicious; and its practicability ought always to be well 1 Stone, New York Journ. of Med., May, 1851, p. 302, vol. .vi. 2d series. 244 FRACTURES OF THE HUMERUS. considered before resorting to the serious mutilation of amputation. The great principle upon which the success of resection is here based is the shortening of the bone, whereby the reduction may be accomplished without painful tension to the muscles; a principle which will demand of us hereafter a more careful consideration and a wider application. Fractures of the Condyles. Chaussier described that portion of the lower end of the humerus which articulates with the ulna as the trochlea, and that portion which articulates with the radius as the condyle; naming the apophyses which arise from them, respectively, epitrochlea and epicondyle. Some of the French writers have adopted this nomenclature, but I prefer, as being more familiar to my own countrymen, the terms external and internal condyle, to which it will be convenient to add the terms external epicondyle and internal epicondyle, as indicating the extreme lateral projections, which are formed from separate points of ossification, and which do not become united to the condyles until about the seventh year of life, and sometimes much later. When, therefore, we speak of a fracture of the epicondyle, we refer only to a separation of the epiphysis, such as it is in early life; or to its true fracture, when, at a later period, it has become an apophysis. § 8. Fractures of the Internal Epicondyle (Epitrochlea. Chaussier.) This is the fracture which Granger first dscribed in the Edinburgh Medical and Surgical Journal, 1 and which he ascribed solely to muscular action. " A distinguishing circumstance attending this fracture is that of its being occasioned by sudden and violent Fig. 67. muscular exertion; and it will be recollected that that of its being occasioned by sudden and violent muscular exertion; and it will be recollected that from the inner condyle those powerful muscles which constitute the bulk of the fleshy substance of the ulnar aspect of the forearm have their principal origin. The way in which the muscles of the inner condyle are involuntarily thrown into such sudden and excessive action I take to be this: the endeavor to prevent a fall by stretching out the arm, and thus receiving the percussion >from the weight of the body on the hand." 2 It is a fact, perhaps of some significance in this connection, that most of these fractures occur in children, before the union of the epiphysis is completed, when muscular contraction might more often prove adequate to its separation, and when the epicondyle is less prominent, and, therefore, less exposed to direct blows than in adult life; thus, of five fractures which I have distinctly recognized as fractures of the epicondyle, all, except one, occurred between the ages of two and fifteen years. But then it is equally true that a large majority 1 "On a Particular Fracture of the Inner Condyle of the Humerus," by Benjamin Granger, Surgeon, Burton-upon-Trent. Op. cit., vol. xiv. pp. 196-201, April, 1818. 2 Ibid., p. 196. • FRACTURES OF THE INTERNAL EPICONDYLE. 245 of all the fractures of the internal condyle, including those which enter the articulation, as well as those which do not, belong to childhood and youth. I have seen but two exceptions in fifteen cases. Since, then, direct blows generally produce those fractures which penetrate the joint, no good reason can be shown why they should not produce fractures of the epicondyle. One of the exceptions to which I have referred as not having occurred in early life, is sufficiently rare to entitle it to especial notice. On the 16th of May, 1856, a laborer, thirty-four years of age, fell from an awning upon the side-walk, dislocating the radius and ulna backwards; the dislocation was immediately reduced by a woman who came to his assistance, but when he called on me, soon after, I found a small fragment of the inner condyle, probably the epicondyle alone, broken off and quite movable under the finger. It was slightly displaced in the direction of the hand. I could not learn positively whether in falling he struck the elbow or the hand, but there was presumptive evidence that he struck the hand; if so, then probably the fracture was the result of muscular action, which is the more extraordinary as having taken place in a man of his age. It is pretty certain, however, that the theory of causation adopted by Granger is too exclusive. A lad was brought to me in October, 1848, aged eleven, who had just fallen upon his elbow, the blow having been received, as he affirmed, and as the ecchymosis showed pretty conclusively, directly upon the inner condyle. The fragment was quite loose, and crepitus was distinct. He could flex and extend the arm, and rotate the forearm, without pain or inconvenience. I am quite sure the fracture did not extend into the joint; the result seemed also to confirm this opinion, for in three months from the time of the accident the motions of the elbow-joint were almost completely restored. Indeed, Mr. Granger has failed to establish, by any particular proofs, that in more than one or two of his cases the fracture was the result of muscular action; but, on the contrary, I am disposed to infer, from the violent inflammation which generally ensued in his cases, from the frequency of ecchymosis, and especially from the injury done to the ulnar nerve in at least three instances, that most of them were produced by direct blows inflicted from below in the fall upon the ground. Fractures produced by muscular action are seldom accompanied with much inflammation or effusion of blood, and it is much more probable that the ulnar nerve should have been maimed by the direct blow which caused the fracture, than by the displacement of the apophysis, which is, as we shall presently show, almost always carried downwards, and oftener slightly forwards than backwards. It is only when the fragment is forced directly backwards that the ulnar nerve could be made to suffer; a direction which, it does not seem to me, it could ever take from muscular action alone. Direction of Displacement, Symptoms, &c. —I have seen this fragment displaced in the direction of the hand, or downwards, very manifestly, twice, and in two other examples a careful measurement showed a 246 FRACTURES OF THE HUMERUS. slight displacement in the same direction. The greatest displacement occurred in a boy fifteen years old, who was brought to me from St. Catharine's, Canada West. He had fallen upon his arm in wrestling, and his surgeon found a dislocation of the bones of the elbow-joint, which he immediately reduced. The fracture was not at that time detected, the arm being greatly swollen. No splints were applied. It was three months after the accident when I saw him, at which time I found the internal epicondyle broken oft' and removed downwards toward the hand one inch and a quarter; and at this point it had become immovably fixed. Partial anchylosis existed at the elbowjoint, but pronation and supination were perfect. In one instance I believed the fragment to be carried about three lines upwards and two backwards toward the olecranon; in each of the other examples the fragment has not seemed to suffer any sensible displacement. Granger found, also, in the five examples which came under his notice, the epicondyle carried toward the hand, with more or less variation in its lateral position, so that while in some instances it touched the olecranon, in others it was removed an inch or more in the opposite direction. It is probable that, except where controlled by the force and direction of the blow, or by some complications in the accident, the fragment, if displaced at all, always moves downwards towards the hand, or downwards and a little forwards in the direction of the action of the principal muscles which arise from this apophysis; and when the fracture or separation is the result of muscular action alone, this form of displacement seems to me to be inevitable. In addition to the mobility, crepitus, and generally slight displacement of the fragment, which are the principal signs of this fracture, it may be noticed that there is usually some embarrassment in the motions of the elbow-joint, which may be due in part to the swelling, and in part to the detachment of the point of bone from and around which most of the pronators and flexors of the forearm have their rise. In one instance, already quoted, that of the lad aged eleven years, who broke the epicondyle from a direct blow, the motions of pronation, with flexion, were not at all impaired, neither immediately nor at any subsequent period, but the fragment was never sensibly, or only very slightly displaced. Granger has recorded another class of symptoms, to which I have already alluded, his explanation of which, however, I am not prepared to admit. One of these cases he describes as follows: A boy, eight years old, fell with violence, and broke off completely the whole of the inner epicondyle of the right humerus. The lad said he had fallen on his hand. The fragment was displaced toward the hand. Severe inflammation followed, but he recovered the free and entire use of the elbow-joint in less than three months after the accident. No splints or bandages were ever employed. From the moment of the accident, the little finger, the inner side of the ring finger, and the skin on the ulnar side of the hand, lost all sensation. The abductor minimi digiti and two contiguous muscles 247 FRACTURES OF THE INTERNAL EPICONDYLE. of the little finger were also paralyzed. This condition lasted eight or ten years, after which sensation and motion were gradually restored to these parts. As a consequence of this paralyzed condition of the ulnar nerve, also, successive crops of vesications, about the size of a split horse-bean, commenced to form on the little finger and ulnar edge of the hand some weeks after the accident, leaving troublesome excoriations. This eruption did not entirely cease for two or three months. In two other cases, Mr. Granger remarks that he has found "the same paralysis of the small muscles of the little finger, the same loss of feeling in the integuments, and the same succession of crops of vesicles on the affected parts of the hand, as is described to have occurred in the preceding case." Without intending to intimate a doubt of the accuracy of Mr. Granger's statement, that such phenomena have followed in three cases out of the five which he has seen, I must express my belief that it was only a remarkable concurrence of circumstances, since the same phenomena have never been seen by myself, nor do I know that they have been observed by any other surgeon. Results. —As in all other accidents about the elbow-joint, a temporary rigidity is almost inevitable. The mere confinement of the arm in a flexed position is sufficient to determine this result without the interposition of a fracture; but when inflammation occurs, more or less contraction of the tendons, muscles, &c, about the joint must ensue. To this circumstance, therefore, added to the confinement, rather than to the fracture, will be due the anchylosis. If the fragment is not displaced, the fracture cannot certainly be responsible for the loss of motion, since it does not in any way involve the joint; and if displacement exists, its ultimate effect in diminishing the power of the muscles which arise from the apophysis must be only trivial and scarcely appreciable. We might, therefore, reasonably conclude that where the accident has been properly treated, permanent anchylosis would be the exception and not the rule. This view of the matter seems also to be sustained by the recorded results. In Granger's cases, the full range of flexion and extension of the forearm has been finally restored, or with so trifling an exception as not to be observable without close attention, in every instance; except in the one already mentioned, which was originally complicated with dislocation; and even in this case the ultimate maiming was inconsiderable. Malgaigne, who says "it ought to be understood that in this accident articular rigidity is almost inevitable," seems nevertheless to admit the justness of Granger's observations as to the final result, if the proper means are employed to prevent it. I have myself found only once any considerable impairment of the motions of the joint after the lapse of a few years. Treatment. —This accident does not constitute an exception to the rule which experience has established, that apophyseal projections when once displaced can seldom be restored completely to position or maintained in position, until a bony union is consummated. Granger remarks : "I have purposely avoided saying one word about replacing the detached condyle (epicondyle), and for these reasons: during the 248 FRACTURES OF THE HUMERUS. state of tumefaction of the limb, no means could be adopted for confining the retracted condyle in its place, beyond that of the relaxation of the muscles; and both before the tumefaction has commenced, and after it has subsided, all endeavors to replace the condyle, or even to change the position of it, have failed." He even proceeds so far as to declare that, while attention ought to be given to the reduction of the inflammation by appropriate means, we ought, nevertheless, to instruct the patient to flex and extend the arm daily from the moment the accident occurs until the cure is completed, and without any regard to the consolidation of the fragment; "the exercise of the joint in this manner must constitute the principal occupation of the patient for several weeks; and should it be remitted during the formation and consolidation of the callus, much of the benefit which may have been derived from this practice will be lost, and will with difficulty be regained." With only slight qualifications I would adopt the advice of Mr. Granger. The limb ought, at first, to be placed in a position of semiflexion, so that if anchylosis should unfortunately ensue, it should be in the condition which would render it most serviceable, and also because in this position the muscles which tend to displace the fragment would be most completely relaxed. While thus placed an attempt ought to be made, by seizing the apophysis, to restore it to position; and if the effort succeeds, as it certainly is not very likely to do, a compress and roller ought to be so applied as to maintain it in position; provided, always, that it shall not be found necessary to apply the roller so tight as to endanger the limb, or increase the inflammation. An angular splint would be an almost indispensable part of the apparel, at least with children, where this indication is in view. In no case, however, ought more than seven or fourteen days to elapse before all bandaging and splinting should be abandoned, and careful, but frequent flexion and extension be substituted. In three cases seen by me, a displacement of the fragment, either forwards or backwards, has occurred whenever the arm was flexed, and it has been necessary, therefore, to treat the case with the arm in a straight position. These are plainly only exceptions to the rule. 1 § 9. Fractures op the External Epicondyle. (Epicondyle, Chaussier.) I have only mentioned this supposed fracture, of which some writers have spoken as a fact, in order that I may declare my conviction that its existence has never been made out. If we admit the possibility, that, while in a state of epiphysis, it might, like the corresponding internal epiphysis, be separated by muscular action, we must yet deny its probability, since it is so exceedingly small; and we must, for the same reason, be permitted to doubt whether the fact of its separation could be recognized in the living subject. Moreover, if a true fracture occurs at this point as the result of external violence, it is sufficiently plain, from an examination of the anatomical structure, that it must more or less extend into the joint and involve the condyle itself. > New York Med. Times, April 13,1861. 249 FRACTURES OF THE INTERNAL CONDYLE. § 10. Fractures op the Internal Condyle. (Trochlea, Chaussier.) B. Cooper, South, Sir Astley Cooper and others, speak of fracture of the internal condyle as very common, and more so than fracture of the external condyle; while Malgaigne, who admits its existence, has never met with a single living example, and regards its occurrence as exceedingly rare. In a record of fifteen fractures I have found no difficulty in recognizing five as fractures of the inner condyle; five, I have already said, were fractures of the epicondyle, and the remainder were undetermined, while my records furnish eigh- Fig. 68. teen examples of undoubted fractures of the external condyle. It is probable that Sir Astley did not intend to make any distinction between fractures of the condyle and epicondyle, and this might explain somewhat his opinion of the relative frequency of these accidents; but even rejecting this important distinction, it has happened to me to see more examples of fracture of the outer condyle than of the inner. Causes. —It has already been stated that fractures of the internal condyle, as well as fractures of the epicondyle, belong almost exclusively to infancy and childhood, only two instances having come under my notice after the eighteenth year of life. I have seen no instance which could be traced to any other cause than a direct blow, such as a fall upon the elbow, the force of the concussion being received directly upon the condyle. Line of Fracture, Displacement, Symptoms. —The direction of the line of fracture is tolerably uniform, namely, commencing about one-quarter or half an inch above the epicondyle, it extends obliquely outwards through the olecranon and coronoid fossae, and enters the joint through the centre of the trochlea. Displacement of the lower fragment can take place only in a direction upwards, backwards, forwards and inwards (to the ulnar side). The fragment cannot be carried downwards, in the direction of the hand, nor outwards, in the direction of the radius, unless the radius also is broken or dislocated. The most common form of displacement is upwards and backwards, and perhaps at the same time a little inwards; the ulna remaining attached to the lower fragment, and following its movements. I have seen one instance in which the fragment was carried directly downwards toward the hand, but this accident was originally complicated with a dislocation of the radius backwards. The dislocation was immediately reduced. Five years after, when the young man was twenty-three years old, I found the condyle displaced downwards and forwards about half an inch, so that when the forearm was extended it became strikingly deflected to the radial side. The symptoms which characterize this fracture are crepitus, almost always easily detected; mobility of the fragment, discovered especially by seizing upon the epicondyle, or by flexing and extending the 17 250 FRACTURES OF THE HUMERUS. arm; displacement of the smaller fragment and a projection of the olecranon process, this latter being very marked when the forearm is extended upon the arm, but almost completely disappearing when the elbow is bent; projection of the lower end of the humerus in front when the arm is extended; the humerus shortened when measured along its ulnar side, from the internal epicondyle; the breadth of the humerus, through its condyles, generally increased slightly, sometimes half an inch or more; if the lesser fragment is carried upwards it will also be found that when the limb is extended, the forearm will be deflected to the ulnar side. Sir Astley Cooper remarks that it is frequently mistaken for a dislocation ; and Thomas M. Markoe, of New York, has shown that it is, in fact, frequently complicated with a dislocation of the head of the radius backwards ; indeed, he expressed a belief that this dislocation of the radius seldom or never occurs without a fracture of the internal condyle. 1 I shall refer to his views again when considering dislocations of the head of the radius. Results. —It is probable that in a majority of cases no permanent displacement exists; although the irregularity of the bony deposits around the base of the condyle, which generally may be easily felt, would lead to a contrary opinion. The fact that the lower fragment usually follows the motions of the olecranon, renders its replacement and retention comparatively easy, unless some complication exists. It is not from displacement, therefore, so much as from permanent muscular, and especially bony anchylosis, that serious maimings so often result. Under any treatment bony anchylosis will very often ensue, and under improper treatment it is almost inevitable. Treatment. —The arm must be immediately flexed to nearly or quite a right angle, when, without much manipulation, the fragments will be made to resume their place. A gutta-percha, right-angled splint, such as I have already directed for fractures occurring just above the condyles, well and carefully cushioned, may now be applied, and secured by rollers. Suitable pads must also aid the splint and roller, in keeping the fragments in place. Markoe prefers keeping the forearm in a position about ten degrees short of a right angle, believing that in this position the ulna itself will act as a splint, and by its support on the uninjured portion of the trochlea, hold in its place the broken condyle. Very properly, also, he prefers to lay the angular splint, made of tin and fitted to the arm and forearm, upon the back of the limb instead of upon the front or sides. If it is upon the inside, it covers the broken condyle, and we are unable to know so well its position; if upon either side, it is apt to press injuriously upon the epicondyles; and if it is in front, the fragments cannot be so well adjusted or supported. Upon this point, however, surgeons are not very well agreed, and no doubt more will depend upon the care with which the splint is applied than upon the surface against which it is laid. Considerable swelling is almost certain to follow, and no surgeon ought to hazard the Chances of vesications, ulcerations, &c, by neglect- 1 Markoe, New York Journal of Medicine, May, 1855, p. 382, second series, vol. xiv. FRACTURES OF THE EXTERNAL CONDYLE. 251 ing to open or completely remove the dressings every day. "Within seven days, and perhaps earlier, passive motion must be commenced, and perseveringly employed from day to day until the cure is accomplished ; indeed, in a majority of cases it is better not to resume the use of splints after this period: for although at this time no bony union has taken place, yet the effusions have somewhat steadied the fragments, and the danger of displacement is lessened, while the prevention of anchylosis demands very early and continued motion. When the fracture is compound, or otherwise complicated, these simple rules will seldom be found applicable; indeed, fractures attended with no such complications will occasionally be found difficult to reduce, or to maintain in position after reduction. §11. Fractures of the External Condyle. Causes. —All the fractures (18) of the external condyle which I have seen, occurred in children under fourteen years of age, except one; in which instance a woman, eighty-eight years of age, fell upon her elbow while intoxicated, breaking off the outer condyle. Two months after the accident I found the fragment, displaced half an inch upwards, and firmly united. In a large majority of these cases the patients themselves have affirmed, and the surface of the skin has furnished conclusive evidence, that the fracture was produced by a direct blow, generally by a fall upon the elbow. Line of Fracture, Displacement, and Symptoms. —The direction of the fracture is generally such that, commencing always above and without the capsule, it descends obliquely and enters the joint either just within or through the "small head" or articulating surface upon which the radius is received; or else it penetrates more deeply in its progress, and passing through the olecranon fossa, it enters the joint through the middle of the trochlea. In the first of these classes of examples, which I think also is the most common, the condyle alone is broken off, and it is liable only to become displaced backwards, forwards, or outwards; generally, I have found it displaced a little outwards, sufficiently to increase manifestly the breadth of the condyles; or it has been carried backwards; once slightly forwards; it is also, in some cases, carried upwards in a small degree, although the action of the supinators and extensors would seem to render a downward displacement more common. These displacements are usually not considerable, and in a few cases there is none at all. Whatever may be the direction or degree in which the fragment is moved, however, the head of the radius is found almost always to accompany it; but in the case which I am about to relate, the head of the radius became completely separated from the condyle. Frederick Keaffer, set. 11, fell from a load of hay, and he is confident that he struck the ground with the back of his elbow. Six hours after the accident, he was brought to me by the physician who was first called to him. The arm was much swollen, and the external condyle could not be distinctly felt, but when pressure was made directly 252 FRACTURES OF THE HUMERUS. upon it, crepitus and motion became manifest. The head of the radius was at the same time dislocated backwards, and separated entirely from the condyle; its smooth button-like head being very prominent. It is difficult to conceive how a blow from behind should leave the head of the radius dislocated backwards, or how the radius could have separated from the broken condyle; but as the examination was repeated several times, and while the patient was under the influence of ether, I have no doubt of the fact. Several other surgeons who were present concurred with me in opinion fully. While prosecuting the examination, I reduced the dislocation of the radius, but it would not remain in place a moment when pressure or support was removed. The lad recovered with a very useful arm, the motions of flexion and extension, with pronation and supination, after the lapse of a year, being nearly as complete as before the accident; the radius remaining unreduced. Sometimes it will be noticed that while the portion of the condyle which is attached to the radius falls backwards, its upper and broken extremity pitches forwards; and this attitude it is especially prone to assume when the forearm is extended. It is even possible, when the fracture traverses the trochlea, for the ulna also to become displaced backwards along with the radius and the lesser fragment. Crepitus, which is usually very distinct, is most easily obtained by rotating the radius, or by seizing upon the condyle with the thumb and fingers, and moving it backwards and forwards. Results. —Ordinarily, this fragment unites promptly, and by the interposition of a bony callus; but in four cases, I have noticed that either no union has occurred, or the union has been accomplished only through the medium of fibrous structure, and the fragment continued afterward to move with the radius. As a consequence, probably, of the displacement of the lesser fragment upwards, the forearm, when straightened, is occasionally found deflected to the radial side. The surgeon must not, however, confound the deflection which is natural, and which is greater in some persons than in others, with the unnatural radial inclination which is occasioned sometimes by this accident. I have met with this phenomenon three times in children under three years of age, in one of which I could not discover that the condyle was carried toward the shoulder, but only outwards; in each of the other cases the fragment had united by ligament. The following is one of the examples referred to: — A girl, set. 8, fell and broke the external condyle of the left humerus; the fracture extending freely into the joint; crepitus distinct; forearm slightly flexed; prone. Lesser fragment displaced outwards and a little backwards, carrying with it the radius. On the second day I was dismissed on account of the unfavorable prognosis which I gave, or rather because I refused to guarantee a perfect limb, and an empiric was employed. July 2, 1857, several months-after the, accident, the father brqught her to me for examination. There was no anchylosis, but the lesser fragment had never united, unless by ligament, moving freely with 253 FRACTURES OF THE EXTERNAL CONDYLE. the head of the radius. When the forearm was straightened upon the arm it fell strongly to the radial side, but resumed its natural relation again when the elbow was flexed. The two other examples are reported at length in the second part of my Report on Deformities after Fractures as Cases 57 and 59 of fractures of the humerus. In one other example, however, mentioned also in my report as Case 56, the deflection was to the opposite side. I examined the lad one year after the accident, he being then five years old, and I found the external condyle very prominent and firmly united, but not apparently displaced in any direction except outwards. The radius and ulna had evidently suffered a diastasis at their upper ends, but all of the motions of the joint were free and perfect. Dorsey 1 speaks of this lateral inclination as being always to the ulnar side, but does not indicate to what particular fracture of the elbow it belongs. He has also described a splint, contrived by Dr. Physick, intended to remedy the deformity in question. Chelius also speaks of the same deformity as occurring after fractures of the internal, but does not mention it in connection with fractures of the external condyle, that is, an inclination of the forearm to the ulnar side. In more than half of the cases of fracture of this condyle some degree of anchylosis has resulted, lasting at least several months. I have seen it remaining after a lapse of from one to twenty years, but generally it gradually diminishes, and, in a majority of cases, completely disappears after a few years. Treatment. —I do not know that I need add much to what has already been said in relation to the treatment of fractures of the opposite condyle, and at the base of the condyles, since the measures applicable to the one are, in general, applicable to the other. Generally, the forearm ought to be flexed upon the arm, especially with a view to overcome the usual tendency in the upper end of the lower fragment to pitch forwards, and which form of displacement is greatly increased by straightening the arm. A remarkable exception to this rule, and the only one I have seen, must be mentioned. James Cronyn, aged six, was brought to me in March, 1857, having, a few minutes before, fallen from a height of four or five feet to the ground. His father said the elbow had been broken at the same point two years before, and from that time had remained stiff and crooked. I found the external condyle broken off, and, with the head of the radius, carried backwards. This was the position which it occupied constantly, though it was easily restored and maintained in position when the arm was straight, but not by any possible means when the elbow was flexed. I dressed the arm, therefore, in an extended position, with a long felt splint, and the fragments remained well in place until a cure was accomplished. In certain examples, I have no doubt also that advantage might be 1 Elements of Surgery, by Philip Syng Dorsey, Phila. ed., 1813, vol. i. p. 146. 254 FRACTURES OF THE HUMERUS. derived from the use of Physick's splint, intended to obviate the outward or inward inclination of the forearm. Fig. 69. Physick's splint. It is especially deserving of notice that, in the three cases in which I have observed bony union to fail, and the fragments to continue movable, the motions of the elbow-joint have, in a very short time, been completely restored. If it does not prove that Granger was correct in his views as applied to fractures of the internal epicondyle, namely, that it was of little or no consequence whether the fragment united or not, and that the elbow-joint ought to be submitted to free motion from the beginning to the end of the treatment—if it does not absolutely prove, I say, the correctness of his views, it at least must abate our apprehensions of the supposed evil results of non-union in the case of the fracture now under consideration. I shall take the liberty of quoting also, with a qualified approval, the opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris in his Report on Surgery, made to the American Medical Association in 1848. " In the treatment of fractures of the condyles of the os humeri, a course is usually recommended which he believes to be hurtful, inasmuch as it favors the worst consequences of the injury, namely, loss of motion in the joint. By this mode of treatment, the fractured piece becomes sufficiently fixed to create partial anchylosis; and there is so much pain afterwards in the proposed passive movements as to cause the omission of these measures until permanent stiffness takes place. The proper course in the management of these accidents, he conceives to be, 1st. To apply no splints, but in the earlier days to make use of the proper means to prevent inflammation. 2d. To accustom the patient to early and daily movements of flexion and extension. 3d. When the action of the joint becomes limited, to overcome the resistance by force, and repeat it daily, until the tendency of the joint to stiffen ceases. " The accomplishment of this process, he adds, is so very painful that few patients have courage to submit to it, and few surgeons firmness to prosecute it. The consequence has been that in a great number of cases the use of the articulation to a greater or less extent has been lost. The introduction of etherization, by preventing the pain, gives us, in the opinion of Dr. Warren, the means of overcoming the resistance. By its aid he has restored the motion of a considerable number of anchylosed elbows, and has successfully applied the same 255 FRACTURES OF THE NECK OF THE RADIUS. measures to other joints, particularly to the shoulder and knee. This has now become his settled practice, with the results of which he is entirely satisfied. The inflammation consequent upon the forced movements of an anchylosed joint is not to be lost sight of. By a reasonable abstraction of blood, and other anti-inflammatory treatment, he has never found it alarming." 1 My respect for the distinguished surgeon whose opinion is here given does not permit me to question the correctness of his practice; but I cannot avoid a belief that his language does not convey a precise idea of his views. If he intends to say that he would move the joint freely when it is suffering from acute inflammation, and when motion occasions great pain, I must protest against the practice as likely to do vastly more harm than good in any case; but if he would move the joint from the first, when the inflammation and swelling are trivial, and when it occasions only an endurable amount of pain, then his views are just and his practice worthy of imitation. CHAPTER XXI. PEACTUEES OF THE RADIUS. Of seventy-one fractures of the radius which have come under my observation, three belonged to the upper third, two to the middle third, and sixty-six to the lower third. Two were compound, and sixty-nine simple. Forty-three are recorded of males, and twenty-five of females; thirty-three as having occurred in the left arm, and twenty in the right. Fracture of the neck of the radius, as a simple accident, uncomplicated with any other fracture or dislocation, is exceedingly rare; yet, owing to the depth of the superincumbent mass of muscles, and the difficulty of determining, where so many bones and processes approach each other, precisely from what point the crepitus, if any is found, proceeds, surgeons have often been deceived, and they have believed that they were the fortunate possessors of this rare pathological treasure, when the autopsy has too soon disclosed their error. Both B. Cooper and Robert Smith have alluded to this difficulty, and the case reported by Dr. Markoe to the New York Pathological Society, and published in the April number of the American Medical Monthly, will serve to illustrate the same point; in which case the signs of a fracture of the radius at its neck were such as to deceive that experienced surgeon, yet the autopsy disclosed the fact that it was a dislocation of the head of the radius forwards, with a fracture of the ulna. Indeed, its existence as a form of fracture was doubted by Sir Astley Cooper, and by 1 Transactions of the American Medical Association, vol. i. p. 174. 256 FRACTURES OF THE RADIUS. others has been actually denied. I have seen no specimen obtained from the cadaver, except the doubtful one contained in Dr. Watts' cabinet, and of which I have furnished an account, accompanied with a drawing, in my report to the American Medical Association, 1 and the specimen owned by Dr. Mutter, of Philadelphia, of which he has kindly furnished me the following description: " History unknown. Fig. 70. Fracture of neck of radius (Mutter's cabinet.) a. Original articulating facet, b, b. New articulating facets, c. Projecting fragments. The line of fracture seems to have passed through the neck of the left radius, just at the upper extremity of the bicipital protuberance. Union with deformity has resulted. Owing to the fracture having taken place within the insertion of the biceps, that muscle appears to have drawn forward and upward the lower end of the short upper fragment. In consequence of this movement, the articulating facet of the head of the radius is tilted backwards, so as no longer to be in contact with the humerus. As a secondary consequence, the anterior edge of the head of the radius rests permanently against the articulating surface of the humerus. At this new point of contact a new surface of articulation is seen to have been formed, while the original articulating facet is directed backwards, and lies at right angles to the one of more recent formation. At the inner edge of the new articulation of the head of the radius with the humerus, contact with the ulna has developed another surface of articulation. The upper and lower fragments are united at an angle, and the radius does not appear to have lost in length." Velpeau has once demonstrated the existence of this fracture in a dissection, but the fracture was accompanied with a fracture also of the coronoid process; and Berard obtained possession of a similar specimen. I do not remember to have seen a notice of any others. Malgaigne affirms, with his usual frankness, that although he has occasionally believed that he had met with it, the autopsy, whenever it has been obtained, has shown that it was rather a subluxation than a fracture. On the other hand, Mr. South calls it a "not unfrequent accident," but in confirmation of this declaration he cites no examples. While, therefore, the presence of what appear to be the rational diagnostic signs has compelled me to record one case as an uncomplicated fracture of the neck of the radius, and two others as fractures at this point accompanied either with a fracture of the humerus or a dislocation of the ulna, I am prepared to admit that some doubt remains 1 Transactions, vol. ix. pp. 157 and 229. 257 FRACTURES OF THE HEAD OF THE RADIUS. in my own mind as to whether in either case the fact was clearly ascertained ; nor do I think, speaking only of the simple fracture, that it will ever be safe to declare positively that we have before us this accident, lest, as has happened many times before, in the final appeal to that court whose judgment waits until after death, our decisions should be reversed. Nothing, perhaps, could more fully illustrate the difficulty of diagnosis in the case of injuries received in the neighborhood of the head of the radius than the testimony given in the case of Noyes vs. Allen, tried in the Supreme Court at Cambridge, January, 1856, before Judge Bigelow. Mr. Noyes injured his elbow, January 7, 1854, and Dr. Allen, who was called immediately, believed that the ligaments of the joint had been torn, but that no bones were broken or displaced. On the following morning he was dismissed, and Mr. Noyes went home. Three weeks later it was seen by Dr. Dow, who also thought there was no fracture. About eight weeks after the accident a physician examined the arm, and declared the neck of the radius broken and the fragments displaced; and when the case was finally brought to trial, he testified still that such was certainly the fact: and five other physicians, not one of whom, however, we are told, was a member of the State Medical Society, testified positively that the radius was broken at its neck, producing a bony protuberance; that such an injury only could account for the symptoms manifested at the time of the accident, and that no other fractures or injuries of the joint could explain so well the present appearances of the arm. While, on the part of the defence, six of the most intelligent medical gentlemen of the State, Drs. Kimbal and Huntington, of Lowell, and Drs. Townsend, Lewis, Clark, and Gay, of Boston, testified that the head and neck of the radius were not displaced, nor was there any evidence that this bone had ever been broken. There is every reason to believe that these latter gentlemen were correct; yet it is to be presumed that the gentlemen who first testified were not without some grounds for their opinions, so confidently expressed. The case was given to the jury after a trial of five days, who promptly returned a verdict for the defendant. 1 When this fracture occurs, the upper end of the lower fragment will probably be carried forwards by the action of that portion of the biceps which has its insertion into the tubercle; and the displacement in this direction must necessarily be increased in proportion as the arm is straightened. In the cabinet specimen belonging to Dr. Mutter, the line of fracture, commencing in the neck, has terminated in the tubercle; consequently the biceps, having still some attachment to the upper fragment as well as the lower, has drawn them both forwards. The same anterior displacement I have noticed in all of the supposed living examples, but whether both fragments or only one had suffered displacement I am unable to say. A girl, set. 11, living in Ontario Co., N. Y., fell from a tree and 1 Amer. Med. Gazette, vol. vii. p. 299. 258 FRACTURES OF THE RADIUS. injured her right arm. Her surgeon, who regarded it as a fracture of the neck of the radius, reduced the fragments, and placed the forearm at a right angle with the arm. On the twenty-eighth day, all dressings were removed, and the patient was dismissed; the fragments seemed to be in place. The parents, finding the elbow stiff, now made violent and successful efforts to straighten the arm. Fig. 71. Fracture of head of radius. (Miltter's collection. Specimen A., No. 105.) Fifteen months after the accident, the child was brought to me. There was at this time a bony projection in front, opposite the neck of the radius, which I believed to be the point of fracture. The hand was forcibly pronated, and she had only a limited amount of motion at the elbow-joint. The anchylosis was probably due to inflammation directly resulting from the severe contusion; but it is quite probable that the forward displacement of the fragments was alone due to the too early and too violent attempts to straighten the arm; at least, this was the explanation which I ventured to give to the parents at the time. The second case occurred in a lad eight years old, living in "Wyoming Co., N. Y. His parents brought him to me ten weeks after the injury was received, and I then found the forearm bent to a right angle with the arm, and anchylosed at the elbow-joint. The hand was also forcibly pronated, and could not be supinated. In front, and opposite the neck of the radius, there was a distinct bony projection, which I believed to be the point of union of the bony fragments. The external condyle seemed also to have been broken. The third example, treated originally by Dr. Nott, of Buffalo, was seen by me six months after the accident. The upper end of the lower fragment seemed to be displaced forwards. There was very little motion at the elbow-joint, and both pronation and supination were completely lost. I have seen, in Dr. Mutter's cabinet, two specimens of fracture of the outer half of the head of the radius. In one case, the small fragment is slightly displaced downwards in the direction of the axis of the bone; and, in the other, the fragment is thrown outwards, or to the radial side. Both are firmly united in their new positions. In the treatment of fractures of the neck of the radius, we must not neglect to flex the forearm upon the arm, so as to relax, as completely as possible, the biceps, whose advantageous insertion into the tubercle of the radius would be certain to produce displacement, unless this 259 FRACTURES OF THE HEAD OF THE RADIUS. position was adopted. A single dorsal splint, properly padded, should support the forearm, while the surgeon, having placed a compress over the upper end of the lower fragment, proceeds to secure the whole with a roller. Especial care must also be taken to prevent the forearm from being extended before the bony union is fairly consummated, lest the biceps, now firmly contracted, should draw the lower fragment forwards, as it must inevitably do while the bony union is imperfect; an accident which, there is some reason to believe, occurred in one of the examples which I have already cited. If the patient be a child, or if there is any reason to suppose that these rules will not be faithfully complied with, it would be well to secure the arm in this position with a right-angled splint. When the fracture occurs in any portion of the radius below the insertion of the biceps, and above the insertion of the pronator radii teres, Mr. Lonsdale suggests the propriety of placing the forearm in a condition of supination, at least so far as is practicable, for the purpose of securing a proper apposition of the fragments. His argument in favor of this practice is ingenious, and deserves consideration. When the bone is broken anywhere in this portion, the action of the pronators upon the upper fragment ceases; while that of the biceps, which is a powerful supinator, continues; consequently the upper fragment becomes at once, and completely, rotated outwards or supinated. Now, if the hand, to which the lower end of the radius alone remains attached, should be forcibly pronated, the radius will also be rotated inwards upon its own axis; and although it might be possible in this condition to bring the broken ends into contact, and a bony union, without deformity, might be consummated, yet the power of supination must be forever lost; since the union has been effected while the head and upper fragment are already in a state of complete supination, and if such is the fact it is evident that the whole bone, together with the hand, will be incapable of any further supination. It is not, indeed, the practice with any surgeons, so far as I know, to treat this fracture with the hand placed in a position of extreme pronation; but the case has been supposed for the purpose of rendering the argument more intelligible. The usual practice is to place the forearm and hand in a position midway between supination and pronation, and then to lay it across the body at a right angle with the arm; but it is plain that the same objection, differing only in degree, will apply to this position as to that of pronation. The axes of the two fragments are not made to correspond, since, while the lower fragment is only half rotated outwards, the upper fragment is completely, and the result of the union must be the loss of one-half the power of supination in the hand. It is only, then, by complete supination of the hand during treatment that this difficulty can be avoided, and I have no doubt that we ought to adopt this plan whenever it is practicable to do so, or whenever we are not hindered by serious obstacles; and the only obstacle which occurs to me as likely to interpose itself, is the practical one which most surgeons must have experienced in treating all injuries of the 260 FRACTURES OF THE RADIUS. forearm, whether fractures, or only severe contusions of the muscles, &c, namely, the constant and almost uncontrollable tendency of the hand to assume the prone or semi-prone position. This is due, no doubt, to the great preponderance of power in the pronators; and such is the resistance which they afford to supination that it is often quite impossible to lay the hand upon its back while the forearm is across the body, and if accomplished, the position generally becomes in a few hours so painful as to be intolerable. By extending the arm, however, and laying it upon a pillow, the hand will be found again to rest easily upon its back, because in this way we avail ourselves of the outward rotation of the humerus at the shoulder-joint. It has already been stated that of the whole number of fractures of this bone seen by me, amounting in all to seventy-one, only two be- Fig. 72. Fracture of the shaft of the radius, longed to the middle third. An observation which is in striking contrast with the remark of Chelius, that it is broken most frequently in its middle. Generally the fragments incline toward the ulna, but they may also be carried either forwards or backwards, according to the direction and force of the blow, or the seat of the fracture. A laboring man, set. 35, broke the radius near the lower end of the middle third. On the same day I replaced the fragments as well as I could in the midst of the swelling which had already occurred, and applied two broad and well-padded splints, one to the palmar and one to the dorsal surface of the forearm. On the twenty-eighth day I first discovered that the fragments were projecting in front, and I at once proposed to thrust them back by force, but the patient declined allowing me to do so. I then applied a compress near the summit of the projection, but not exactly upon it, lest it should produce ulceration, and secured over this a firm splint. At first this seemed to produce a change in the fragments, but after a couple of weeks I found there was no improvement, and it was discontinued. About six months after the fracture occurred, this man had the same arm terribly lacerated in a rail- - — - - -J road accident, and I was Obliged to amputate near the shoulder-joint; and I thus obtained the broken radius. The bone was firmly united, but with an angle, salient forwards, of about ten degrees. There was no inclination toward the ulna. My impression is that these fragments were never completely replaced, a point which I could not well determine at first on account of the rapid effusion. If they had been, I think they could have been retained in place with the appliances used. Almost every day the limb was examined, and as often as every fourth or fifth day the dressings were removed and carefully reapplied. And only once did they become so loose as not to afford the requisite support, and this at a period too late to have occasioned the deformity. We ought not to be deceived, therefore, and promise too confidently COLLES' FRACTURE. 261 a perfect limb, even when but the middle of the radius is broken, since we may not always be certain that the ends are well replaced, or perhaps they may become displaced subsequently, and in either case we are not likely to discover the deformity until the swelling has subsided, and it is too late to apply the remedy. In the treatment of fractures of the middle third, the same rules, with only slight modifications, will be applicable, as in fractures of both bones. Two straight, long, and broad splints must be applied after being carefully padded; and especial attention should be paid to the tendency of the fragments to become displaced forwards and toward the ulna through the action of both the biceps and the pronator radii teres; a tendency which may in some measure be provided against by flexion of the arm, but which must be overcome chiefly by steady and well-adjusted pressure, near, but not upon, the ends of the fragments. Fractures of the lower third, occurring above the line of Colles' fracture, are almost as rare as fracture of the middle or upper thirds. I have met with five; one of which it will be proper to relate as a representative example. Geo. Yogel, aet. 30, was admitted to the Buffalo Hospital of the Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius about three and a half inches above its lower end. The hand was prone, and inclined to the radial side; while the broken, ends of the radius fell against the ulna, from which it was found difficult to separate them. The lower end of the ulna was prominent, and projecting upon the ulnar margin of the hand. I was unable completely to separate the fragments of the radius from the ulna, by either pressure with my fingers between the bones, or by seizing upon them with my thumb and fingers. Having, however, adjusted them as well as possible, I flexed the arm, and applied a broad and well-padded splint to the palmar surface of the forearm, securing it in place with a paste bandage. These dressings were finally removed at the end of four weeks, when I found scarcely any displacement or deformity remaining. Most of these fractures, when properly treated, result in perfect limbs. In a certain proportion, however, it will be found impossible effectually to resist the action of the pronator radii teres and of the quadratus, and the fragments will unite at an angle resting against the ulna, and sometimes, by the interposition of intermediate callus, they will become firmly united to the ulna. Occasionally, also, especially where the fracture has been produced by a fall upon the hand, and the radioulnar ligaments of the wrist have been torn or stretched, the lower end of the ulna will be found to project permanently, and the hand to fall more or less to the radial side. Of the sixty-six fractures belonging to the lower third of the radius fifty-six traversed the bone completely, and were near the lower end, or within from half an inch to one inch and a half from the articular surface, all being included in those fractures called " Colles' fractures," most of which were no doubt true fractures, and probably a small proportion separations of the epiphysis. Colles described this fracture as occurring always about one inch 262 FRACTURES OF THE RADIUS. and a half above the carpal end of the bone; but Robert Smith, who has carefully examined all of the cabinet specimens he conld find, about twenty-three in number, has never seen the line of fracture removed farther than one inch from the lower end of the bone, and in several specimens it was within one-quarter of an inch of this extremity. Dupuytren has also described the fracture as occurring from three to twelve lines above the joint. I think I have found the fracture generally as low as these latter surgeons have placed it, but occasionally as high as it was placed by Colles. Fig. 73. Fracture of the radius near its lower end. Case. A woman, Eet. 40, fell upon the side-walk, striking upon the palm of her left hand. She was brought immediately to my office, and I found the radius was broken about one inch and a half above the wrist. The lower fragment was tilted back considerably. Hand prone. Placing my thumb against the back of the lower fragment, it was easily restored to position, and with only a slight crepitus. When my thumb was removed it manifested no tendency to displacement. The arm was dressed with a curved palmar splint, secured in place with a roller applied moderately tight. On the seventh day a straight splint was substituted for the curved. The arm was examined almost every day, and the dressings occasionally renewed until the twentysixth day, when the splint was finally removed. The wrist was at this time only slightly anchylosed, and there seemed to be no deformity or imperfection remaining. Passive motion, which had been practised at each removal of the dressings, was directed to be continued. Case. A boy, set. ll r was brought to me having just fallen from a pair of stilts. His right radius was broken transversely, three-quarters of an inch above the wrist, and the lower fragment was much tilted back; the lower end of the ulna was prominent, and the hand fell to the radial side. Pushing from behind, the lower fragment was made to resume its place, and the deformity immediately disappeared. It was noticed, however, that it required unusual force to accomplish this, but it was not found necessary to use extension. There was also, accompanying the reduction, a slight crepitus. The treatment was the same as in the first case, except that the curved splint was employed throughout. Little or no deformity existed when the dressings were removed. Case. George Lofinch, aet. 42, fell upon an icy side-walk, striking colles' fracture. 263 upon the palm of his left hand. Fracture three-quarters of an inch above the lower end. Fragment displaced backwards. A friend had partially replaced the fragment by pushing upon it, before he came to me. Within half an hour after the accident he was at my office, and I restored the lower end of the bone very easily to place by pushing from behind with my thumb. No extension was necessary. It would not, however, remain in place unless the forearm was pronated so that the weight of the hand could aid in the retention. I applied my own palmar splint. The recovery was rapid and complete. Case. Lewis Brittin, set. 60, fell from a fourth story window, breaking, among other bones, the radius of the right arm three-quarters of an inch above the joint. This fracture was not discovered until the fourth day. Crepitus and motion were then distinct, but there was no displacement. The wrist was considerably swollen. No splints were applied; and the bone united promptly, leaving no deformity or anchylosis. Case. Margaret Read, set. 48, fell, September 23, 1855, striking on the palm of the left hand, and breaking the radius about one inch from its lower end. One week after, she came under my care at the hospital. The arm had been previously dressed carefully by one of my colleagues, with curved dorsal, and palmar splints; but, on examination, we found the fragments a good deal displaced. It was found necessary now to use both extension and pressure from behind to restore the lower fragment to position. This we finally succeeded in doing, and immediately splints were again snugly applied. Two days after, on opening the dressings, the lower fragment was a second time found displaced backwards. It was again reduced, but only by using great force. Fifteen days later, we were pleased to find the bone firm and without deformity. Margaret left the hospital on the 4th of November, with her hand and wrist still swollen, and with a good deal of stiffness at the elbow and wrist-joints. Case. Charles Stratton, a healthy and temperate laborer, set. 36, fell forwards from a wagon, Nov. 22, 1854, striking upon the palm of his hand, and breaking the radius a little more than one inch above the joint. I found the lower fragment displaced backwards, and it was easily reduced by pressure in the opposite direction. The fore part of the wrist being quite tender to pressure, the splint was applied to the dorsal surface of the forearm. The splint was curved (pistol-shaped), and the surface which was applied to the arm was padded with care; it was secured in place by a few light turns of a roller, and laid across the body in a sling. The arm was seen by me on each of the succeeding seven days, and on the third, fifth, and seventh days, the splint was removed completely ; but on this last day an erysipelatous inflammation had commenced in the neighborhood of the wrist. The splint and roller were therefore not reapplied, but the limb was laid upon a broad board, cushioned and covered with oiled silk, and cool water irrigations were directed. The inflammation soon subsided, but the splint was never 264 FRACTURES OF THE RADIUS. resumed, as the fragments were found to stay in place perfectly without its aid. At the end of five weeks, union seemed to be consummated ; and one year later the bone was found to be perfectly straight, yet the wrist-joint and the finger-joints remained stiff) so much so that he was unable to perform any labor. The stiffness was, however, gradually disappearing; while all swelling and tenderness had long ceased. The observations of M. Yollemier also have shown that, instead of being oblique, as has generally been supposed, the fracture is almost uniformly transverse from the palmar to the dorsal surfaces of the bone, and only occasionally slightly oblique in its other diameter, or from the radial to the ulnar side. I have seen, however, in the museum of the College of Physicians of Philadelphia, a specimen of this fracture in which the line of fracture is transverse, from side to side, but very oblique from before backwards, and from below upwards. There is also a line of incomplete fracture extending into the joint. It is united by bone, with the usual displacement backwards. The observations of both R. Smith and Yollemier have shown, moreover that the displacement of the lower fragment is seldom sufficient to enable it to escape completely from the upper; and that where, in extremely rare instances, and in consequence of extraordinary violence, such complete separation does occur, a disruption of those ligaments which attach the lower fragment to the ulna occurs also, and the deformity becomes at once very great, so that it no longer presents the peculiar features of Colles' fracture, but resembles a dislocation. In the so-called Colles' fracture, the lower and outer border of the radius, or its styloid apophysis, is swung around or tilted, as it were, upon the ulna; the lower and inner border of the same fragment being retained in place by the radio-ulnar ligaments, which do not usually suffer a complete disruption, but only a stretching or partial laceration. The upper or broken margin of the lower fragment, and also the ulnar margin, undergo very little displacement; while the lower or articular surface, and the radial margin, are carried backwards, upwards, and outwards. Surgeons have spoken of a falling in of the upper end of the lower fragment toward the uma, as an almost inevitable result of the action of the pronator quadratus, and against which tendency they have sought carefully to provide; but there is much reason to believe that any considerable degree of displacement in this direction is a rare event, and that, when it does exist, it is in consequence mostly of the direction of the force which has produced the fracture, rather than of the action of this muscle, only a few of the fibres of which are usually attached to the lower fragment, and, in some instances, when the fracture is within a half or a quarter of an inch of the articulation, not any. Besides, there is actually in these latter cases, no interosseous space into which the fragment may fall, and its displacement toward the ulna becomes, therefore, impossible. Still, however, if one were disposed to speculate upon the condition of these parts after the fracture, it might perhaps be easy to persuade colles' fracture. 265 ourselves that the action of the pronator quadratus upon the upper fragment, whose broken extremity was not completely, or at all disengaged from the lower, would carry both fragments together toward the ulna. But whatever might be the result of our speculations, still the fact, as proved by specimens, is not generally so ; and this is not the first time that facts and theories have disagreed. The truth is, that it is unusual to find in any of the museums specimens of this fracture having thus united. But they may be found constantly tilted back in the manner I have described, occasionally tilted forwards, and, still more rarely, slightly displaced upon their broken surfaces antero-posteriorly. The general absence of this internal displacement may find its explanation in the direction of the force which generally produces this fracture, in the occurrence of the fracture sometimes at a point so low as to render its displacement in this direction impossible, and in the breadth of the bone, at the seat of the fracture, which does not permit it to fall laterally without actually increasing its length; a circumstance which its secure ligamentous attachment to the ulna at its opposite extremities, and its complete apposition to the wrist and elbowjoint, do not allow. The mistake of those surgeons who have attempted to describe this fracture, has originated in the appearance presented in nearly all recent fractures occurring at this point. The hand falls to the radial side, and seems to carry the lower end of the lower fragment with it, while the lower end of the ulna becomes unnaturally prominent in front and to the ulnar side; a condition of things which has naturally enough been ascribed to the displacement of the upper end of the lower fragment in the direction of the interosseous space. But this same radial inclination of the hand, and prominence of the ulna, are present frequently when the radius is broken at its lower end and no displacement in any direction has taken place; and I have even observed it in simple sprains of the wrist, and in the hands of old or feeble persons where all the ligaments have become relaxed. It is seen, however, in a more marked degree when the bone is actually both broken and displaced backwards in its usual direction. In short, the deformity in question is due, in a large majority of instances, to the relaxation, stretching, or more or less disruption of the radioulnar ligaments, which permits the hand to fall to the radial side by a simple rotatory movement over its articular surface. For this reason, also, because these ligaments once lengthened or broken can never, or only after a lapse of many years, be completely restored, this deformity may be expected to continue, however exact and perfect may be the bony union. It must be added, however, that, so long as the tilting of the fragment remains, the articular surface is actually presenting somewhat to the radial side. While in the normal condition it presents downwards, forwards, and inwards, it now presents, when the displacement is considerable, downwards, backwards, and outwards. Diday maintained that there existed usually in this fracture an overlapping or shortening of the bone in its entire diameter, and Yollemier 18 266 FRACTURES OF THE RADIUS. thought that the specimens which he had examined proved that an impaction was almost universal. Both of these opinions, it seems to me, have been successfully combated by Robert Smith; the shortening observed by Diday being found only on that side of the bone to which the hand inclines, and being the result of the motion of the lower fragment already described; and the appearance of impaction being clue to the ensheathing callus which is deposited usually, if the displacement is allowed to continue, in the retiring angle opposite the seat of fracture. These are questions, however, requiring for their decision a very careful study of specimens, and in relation to which further observations may be necessary. Meanwhile there is no doubt that occasional examples may be found illustrating one or more of all these varieties of displacement, and that to the impaction is sometimes added a comminution of the lower fragment, the lines of the fracture extending freely into the joint. One of the most curious examples of which has been reported by Dr. Bigelow, of Boston. The patient had fallen, and being otherwise seriously injured, ultimately died in the Massachusetts Hospital. At first he had only complained of lameness at the wrist, as if it had been severely sprained; but at the end of several days the joint became swollen, and from the persistence of the swelling Dr. Bigelow was led to diagnosticate a stellate crack in the articulating extremity of the radius, he having Fig. 74. Bigelow's case of comminuted fracture of the lower end of the radius. met with a similar case two years before, when a patient with the same symptoms had died of other injuries, and exhibited a crack in the same place, but less extensive than in this case. There was found in this last example, a star-shaped fissure on the articulating surface, without displacement. These fissures penetrated the shaft for an inch or more. Dr. Bigelow thought that the bones of the wrist acted as a wedge to spread the corresponding hollow of the articulating extremity ; and that this specimen would explain the persistence of some cases of sprained wrist. 1 Robert Smith has described a fracture occurring at the same point, and.probably possessing the same characters as Colles' fractures; in which the lower fragment is thrown forwards instead of backwards, and which has generally been the result of a fall upon the back of the hand. There is no such specimen, however, in any of the pathological collections in Dublin, nor has Mr. Smith ever seen a specimen obtained from the cadaver, although he reports a case which fell under his observation in practice. I have myself seen one such case, 2 but I regret to say that my examination of the condition of the arm was not such as to enable 1 Boston Med. and Surg. Journ., vol. lviii. p. 99. 2 Trans. Am. Med. Assoc., vol. ix. p. 145. 267 colles' fracture. me to add anything to the information already possessed upon this subject; indeed, until we have an opportunity of studying it in the cadaver, we cannot speak very definitely of its anatomical characters. Nelaton observes that all the varieties of this fracture which he has seen are often accompanied with fracture of the styloid apophysis of the ulna, and with a tearing of the triangular ligament. I am not aware that any other writer has made the same observation in relation to the frequent occurrence of a fracture of the styloid apophysis of the ulna, and I think the accident is not so common as the remark of Nelaton would lead us to suppose. Dr. Butler, House Surgeon to the Brooklyn Hospital, reports a case of fracture of the right radius at the junction of the middle and lower thirds, accompanied with a fracture also of the styloid apophysis in the same bone. The accident occurred in a lad fourteen years old, who had fallen from a height of thirty feet upon the pavement. The lower fracture commenced at the base of the styloid process of the radius, and extended down obliquely into the wrist-joint, breaking off about one-fifth of the articular surface. The process was drawn up on the posterior surface of the radius, about one inch and a half, by the supinator radii longus muscle. It was movable, but in consequence of the contusion and swelling, could not be returned to its place. The hand occupied the same position that it does in Colles' fracture. On the eighth day an attempt was made to force down the process with a compress secured by adhesive plaster straps; but it could not be done. The hand and arm were confined also to a pistol shaped splint; ulcerations ensued from the pressure of the compress, and the process was laid bare, but it finally became united in its abnormal position; the motions of the wrist, however, were not impaired, and the power of pronation and supination soon returned. 1 I believe I have seen two examples of a fracture commencing on the radial side of the bone and terminating in the joint, the separated fragment including considerable more than the apophysis; but neither of these cases has been verified by an autopsy. A boy, set. 18, fell twelve feet, striking upon the right hand and wrist. I examined him at the hospital soon after, and thought I could distinctly feel the line of fracture extending very obliquely downwards, from the radial side into the joint, and without traversing the entire diameter of the bone. The fragment thus separated fell backwards, and the hand inclined to the radial side. Reduction was immediately accomplished by pushing the fragment forwards, and the arm was dressed with straight palmar and dorsal splints, with compresses, &c. He was soon dismissed. Five months after I found the bones united without displacement, and the motions of the joint were perfect. A man, set. 38, fell upon the palm of his left hand. On the same day he was admitted to the Buffalo Hospital of the Sisters of Charity, and the diagnosis was confirmed by Drs. Lay and Lemon. The symptoms were the same as in the first case, and we adopted the same treat- 1 New York Journ. of Med., 1857. 268 FRACTURES OF THE RADIUS. ment. On the thirty-first day, it was noted in the hospital record, that " the splints have been for some time removed, but the wrist remains swollen and stiff. The lower end of the ulna is prominent, but the fragments of the radius seem to be in exact line." In the first volume of the Philadelphia Medical Examiner (1838) will be found a description by J. Rhea Barton, of Philadelphia, of a form of fracture occurring through the lower end of the radius, which is probably much less common than Colles' fracture, and which had hitherto escaped the notice of surgeons. Its peculiarity consists in the line of fracture extending very obliquely from the articulation, upwards and backwards, separating and displacing the whole, or only a portion, as the case may be, of the posterior margin of the articulating surface. I have not recognized this fracture in any instance which has come under my own observation, nor have I been able to find a cabinet specimen in any pathological collection. Dr. Barton, was not able to prove the correctness of his diagnosis by an autopsy, and the only well-authenticated example which I can find upon record is that to which Malgaigne has alluded, as having been seen by M. Lenoir, and of which an account was published in the Archives Generates de Medecine in 1839. M. Lenoir believed it to be a simple luxation of the hand backwards, but the patient having died, he was able to correct his diagnosis by an autopsy. A considerable fragment had been broken from the posterior lip of the articular surface, the line of fracture being from below upwards, and from before backwards. This fragment had become displaced upwards and backwards, carrying with it the carpal bones, and producing thus, the appearance of a simple dislocation. 1 I believe that the accident so carefully described by Barton was either a Colles' fracture, or a fracture simply of the radial margin, of which I have given two supposed examples, with the usual signs of which his account so exactly coincides, and that it was not a fracture of the posterior lip of the articulating surface, as he believed. Sixty examples of simple fracture near the lower end of the radius have furnished no cases of non-union, nor indeed do I remember ever to have seen the union delayed; yet only seventeen are positively known to have left no perceptible deformity or stiffness about the joint: it is probable, however, that the number of perfect results might be extended to twenty. In one example, the case of a man whose arm was broken in Germany, when he was only ten years old, the fragments of the radius were driven to each other, or overlapped one inch, and the ulna had been displaced downwards toward the fingers the same distance. This was examined twelve years after the accident, and he had then a very useful arm. Twice I have found the wrist and finger-joints quite stiff after a lapse of one year; in one case I have found the same condition after two years; in one case after three years, and in two cases after five years. If we confine our remarks to Colles' fracture, the deformity which has been observed most often, and, indeed, with only rare exceptions, Malgaigne, Traite des Frac, etc., torn. ii. p. 700. colles' fracture. 269 being found in some degree more or less in several of those cases which I have marked as perfect, consists in a projection of the lower end of the ulna inwards and generally a little forwards. In a large majority of cases this is accompanied with a perceptible falling of the hand to the radial side, while in a few it is not. After this, in point of frequency, I have met with the backward inclination of the lower fragment. Eobert Smith found this displacement almost constant in the cabinet specimens examined by him; and it is very probable that nearly all of the examples examined by myself would present more or less of the same deviation upon the naked bone; but in the living examples a slight deviation would be concealed by the numerous tendons which convey this part of the arm, and perhaps by some permanent effusions, of which I shall speak more particularly presently. There remains for a long time, in a majority of cases, a broad, firm, uniform swelling on the palmar surface of the forearm, commencing near the upper margin of the annular ligament and extending upwards two inches or more. This swelling continues much longer in old and feeble persons than in the young and vigorous. It is pretty generally proportioned to the amount of anchylosis existing at the wrist and finger-joints, and it disappears usually, pari passu, with these conditions. There can be no doubt that this phenomenon is due to an effusion, first serous, and subsequently fibrinous, along the sheaths of the tendons ; and it is as often present after sprains and other severe injuries about this part, as in fractures. In many cases however, its prolonged continuance and its firmness have led to a suspicion that the bones were displaced, a suspicion which only a moderate degree of care in the examination ought easily to dispel. A similar effusion, but in less amount, is frequently seen also on the back of the hand, below the annular ligament. When both exist simultaneously the appearances of deformity and of displacement are greatly increased. Here, then, we shall find a partial explanation of the anchylosis in the wrist and finger-joints, which continues occasionally many months, or even years, if, indeed, it is not permanent. An anchylosis produced in a few instances by extension of the inflammation to these joints, but much more often by the inflammatory effusion and consequent adhesions along the thecae and serous sheaths, through which the tendons all pass in their course to the hands and fingers; and by simple contraction of the articular ligaments as a consequence of disuse. The fingers are quite as often thus anchylosed after this fracture as the wrist-joint itself, a circumstance which is wholly inexplicable on the doctrine that the anchylosis is due to an inflammation in the joints. Indeed, I have seen the fingers rigid after many months, when, having observed the case throughout myself, I was certain that no inflammatory action had ever reached them. Nor is it any more difficult to show, I think, that the anchylosis of the wrist-joint is not often due to a malposition of its articular surfaces, as has often been asserted in the written treatises. The most superficial examination of the mechanism of this joint ought to satisfy us that any moderate or even considerable malposition of the lower fragment after a fracture of the radius is not sufficient 270 FRACTURES OF THE RADIUS. in itself to occasion anchylosis. It is true that in the fracture now under consideration, the direction of the articular surface of the radius is changed, and that, while it was directed downwards, forwards, and to the ulnar side, it is now, perhaps, directed downwards, backwards, and to the radial side. But of what consequence is this so long as the carpal bones, with which alone this bone is articulated, preserve their relations to the radius unchanged ? If any other evidence be demanded, it may be supplied by the experience of most surgeons in examples of anchylosis without displacement ; in examples of displacement without anchylosis, but in which the anchylosis has yielded gradually to the lapse of time, while the displacement has continued. To what I have said as to the prognosis in these accidents, I may be permitted to add the opinion of our distinguished countryman, Dr. Mott, given in a clinical lecture before his class in the University of New York. "Fractures of the radius within two inches of the wrist, where treated by the most eminent surgeons, are of very difficult management so as to avoid all deformity; indeed, more or less deformity may occur under the treatment of the most eminent surgeons, and more or less imperfection in the motion of the wrist or radius is very apt to follow for a longer or shorter time. Even when the fracture is well cured, an anterior prominence at the wrist, or near it, will sometimes result from swelling of the soft parts." To which the reporter, himself a surgeon in the city of New York, adds:— " As the above opinion of Professor Mott coincides with my own observations, both in Europe and in this city, as well as with many of our most distinguished surgical authorities, I venture to hope that it may assist in removing some of the groundless and ill-merited aspersions which are occasionally thrown on the members of our profession by the ignorant or designing." 1 Of gangrene as an occasional result of this fracture, I shall speak presently, in connection with the subject of treatment. The peculiar character of the displacement which characterizes Colles' fracture, and the constant difficulty experienced by surgeons in obviating deformity, have led to much speculation and ingenious invention; and modern surgeons, especially, have thought it necessary to introduce here an essential modification of the usual apparel for broken forearms. This modification consists in employing a pistolshaped splint, instead of a straight splint, by means of which the hand may be thrown more or less strongly to the ulnar side. Heister 2 speaks of inclining the hand toward the ulna, while reducing a fracture of the radius, but when the reduction has been effected he recommends a straight splint. Among the first to advocate the permanent confinement of the hand 1 Boston Med. and Surg. Journal, vol. xxv. p. 2S9. 2 De Lavrentii Heisteri, Institutiones Cliirurgica?, pars prima, p. 203, Amsterdam ed., 1739. 271 colles' fracture. in this position, were Mr. Cline, of London, 1 and M. Dupuytren, of Paris. 2 Mr. Cline, and after him Bransby Cooper, 3 and Mr. South, 4 recommend the ordinary straight splints for the forearm, but the rollers by which the splints are secured in place are not permitted to extend lower than the wrist; so that when the forearm is suspended in a sling, in a state of semi-pronation, the hand shall fall by its own weight to the ulnar side. Dupuytren, and, after him, Chelius, adopt, in addition to the palmar and dorsal splints, the "attelle cubitale," or ulnar splint; which is a gutter, composed of steel, iron, tin, or some other metal, and made to fit the ulnar margin of the forearm and hand, when the hand is drawn forcibly to the ulnar side. Blandin,* Nelaton, 6 and Coyraud, 7 also, under certain contingencies employ the same. Most surgeons, however, employ either a palmar or a dorsal splint; or both palmar and dorsal splints, constructed with a knee, or pistolshaped, and they thus avoid the necessity of the ulnar splint. Thus, Fig. 75. Ndlaton's splint for fracture of the radius. Nelaton, 8 Robert Smith, 9 and Erichsen, 10 recommend this peculiar form only in the dorsal splint; while Bond, 11 Hays, 12 E. P. Smith, 13 Gr. F. Fig. 76. Bond's splint. 1 Malgaigne, Traite de Frac, etc., torn. i. p. 614, Paris ed. 2 Dupuytren, on Bones, London ed., p. 140. 3 B. Cooper, Lectures on Surg., p. 232, Amer. ed. 4 Chelius's Surg., vol. i. p. 613. 5 Malgaigne, op. cit., torn. i. p. 614. 6 Nelaton, Elem. de Path. Chir., torn. i. p. 747. 7 Ibid., p. 746. 8 Nelaton, op. cit., p. 747. 9 R. Smith, op. cit., p. 168. 10 Erichsen, Surgery,p. 215. 11 Bond, Amer. Journ. Med. Sci., April, 1852. 12 Ibid., Jan. 1853. 13 E. P. Smith, Buffalo Med. Journ., vol. ix. p. 225. 272 FRACTURES OF THE RADIUS. Shrady, 1 and others, especially among the Americans, place the pistol shaped splint against the palmar surface of the forearm and hand. Fig. 77. Hays' splint. Fig. 78. E. P. Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with incurvated margins. Fig. 79. E. P. Smith's splint. B. Opposite surface. T>, the hand-Mock, is connected with the forearm piece by two circular brass plates, which move upon each other, in order that the hand-block may assume any desired angle with the arm. In this way it may be adapted to either the right or left arm. It is fixed by a nut seen on the brass plate. The letters C C indicate the extent of motion allowed to the hand-block. Fig. 80. Geo. F. Shrady's splint. To be applied to the palmar surface of forearm and hand; the hand being deflected towards the ulna. A strip of adhesive plaster encircles the forearm and splint near the elbow. A loop is also formed for the ulnar margin of the wrist by passing one end of a strip of plaster, 3 inches in width, between the palmar surface of the wrist and the splint, over on the dorsum of the wrist; both ends being then brought around and made adherent to the under surface of the splint. Lastly, the hand is secured to the hand-piece by a circle of plaster; the dorsal splint, if required, can then be applied in the usual way. Passive motion is made every second or third day, by grasping the apparatus at wrist, and freeing the hand. 1 Shrady, Am. Med. Times, 2 cases, Dec. 22,1860. colles' fracture. 273 A few modern surgeons have not seen fit to adopt this peculiar principle of treatment, or this form of dressing under any of its modifications. Colles 1 recommends a straight palmar and dorsal splint, and does not incline the hand. Barton 2 advises the same, and Skey, having declared his preference for a couple of broad, straight splints, adds: " Great care should be taken to prevent the hand falling, and this object will be attained by inclosing the entire forearm and hand in a well-applied sling." 3 Professor Fauger, of Copenhagen, has undertaken to treat this fracture in some sense without any splint, the forearm and hand being simply laid over a double inclined plane, so as to bring the wrist into a state of forced flexion. "The hand having been brought into a position of strong flexion, the forearm is placed, pronated, on an oblique plane, with the carpus highest, the hand being permitted to hang freely down the perpendicular end of the plane." 4 M. Yelpeau, in a report of his surgical clinic at La Charite for the year ending September, 1846, says this plan has been tried during the year, and " the result has not been very satisfactory. The experiment, however, has not been decisive upon this mode of treatment." 5 Notwithstanding these exceptions, the practice seems to be pretty well established among the leading surgeons everywhere to employ in the treatment of this fracture the principle of adduction of the hand, and always to the attainment of the same purpose, namely, rotary extension, by which they hope to retain more securely the lower fragment in place. We come now to consider how far this peculiar treatment is capable of answering the special indications of the case we are studying. It is assumed, as I have already intimated, that, by bearing the hand strongly to the ulnar side, the fragments of the radius are brought more exactly into apposition, and more easily and effectually retained; an assumption which supposes two things to have been determined; first, that there exists an overlapping of the fragments, either through the whole extent of their broken surfaces or especially toward the radial side, or that the upper end of the lower fragment is inclined to fall against the ulna, or that all of these several conditions co-exist; and, secondly, that if such displacements do exist, they can be remedied by this manoeuvre. The first of these suppositions seems to have been sufficiently considered and fully controverted by all those gentlemen who have particularly examined the specimens contained in the various pathological collections, and to whose careful investigations I have already frequently adverted. My own observation confirms also their statements. With rare exceptions, none of these displacements have been found to exist, although, as has been observed, a casual inspection of the arm when recently broken would often lead to an opposite conclusion. 1 Colles, Lectures on Surgery, p. 325. * Barton, Phil. Med. Exam., 1838. 8 Skey, Operative Surgery, p. 161. * Fauger, London Lancet, May 8,1847. 5 Velpeau, Boston Med. Journ., vol. xxxv. p. 213. 274 FRACTURES OF THE RADIUS. In regard to the second supposition, namely, that where such displacements do exist, a forced adduction will aid in the retention of the fragments, I shall have to speak more cautiously, because, so far as I know, my opinions have received as yet no public and authoritative indorsement. In order that adduction may prove effective, there must be some point upon which to act as a fulcrum. It is of no use that we rotate the hand for the purpose of making extension unless there can be found a resistance or fulcrum upon which the rotary motion may be performed. Such a fulcrum exists, no doubt, but to determine its availability we must ascertain its character and position. It is not in the lower end of the ulna, for the ulna has no point of contact with the carpal bones, and when, in the natural state of these parts, the hand is inclined to the ulnar side, the lower end of the ulna rides freely downwards upon the wrist until arrested by the ligaments which unite it with the carpus, or by the capacity of the joint to admit of motion in this direction. When the lower end of the radius is broken, and the ligaments of the joint are more or less torn, the ulna, although thrust downwards much farther perhaps than it could ever descend in its normal state, still fails to find a support, and spreading wider and wider from the radius as it is thrust further upon the hand, no limit can be given to its progress in this direction. It was thus that, in one example already mentioned, I found the ulna carried downwards one inch or more. The resistance will, in nearly all cases, be found to - be in those ligaments which bind the lower fragment to the lower end of the ulna, and the ulna to the carpal bones, viz: the radio-ulnar, and the internal lateral ligaments, which in the normal state of the parts constitute the centre upon which forced adduction expends its power, and which still continue to be the point of resistance when the radius is broken. But how feeble and uncertain must be a resistance which depends solely on these broken ligaments! And how painful to the patient must be an extension sufficient to overcome the action of nearly all the muscles of the wrist, which is borne entirely by a few lacerated and inflamed fibres! even in health this position, when forced, cannot be endured beyond a few seconds, and it must be difficult to estimate the sufferings which the same position must occasion when the ligaments are torn and inflamed. I am not to be told that surgeons have not intended to advocate this extreme practice; that they have never recommended forced adduction, but only a moderate and easy lateral inclination, such as can be comfortably borne. If they have not, then they should not have spoken of making extension by this means. An easy lateral inclination has no power to do good so far as extension is concerned, any more than it has power to do harm. But the fact is, while a majority of surgeons have no doubt used less force than was hurtful, some have used more than was useful or safe; indeed, the sharpness of the curve given to the splints figured and recommended by Dupuytren, Nelaton, and others, sufficiently indicate that their distinguished inventors intended to accomplish by these means a forced and violent adduction. Malgaigne, speaking of other means of extension applied to the colles' fracture. 275 forearm, suggested by Godin, Diday, and Velpeau, intended to operate only in a straight line, and alluding especially to the modes devised by Huguier and Velpeau, remarks: "Without discussing here, the comparative value of the two forms of apparatus, I believe that they could scarcely be endured by the patients; and M. Diday tells us that in the trials which he has made, the pain produced by the extension was so great that he was compelled to renounce it." Which observations cannot but apply equally to this plan of extension by adduction, or to any other which might be adopted. After all, it must not be inferred that I have concluded to reject this mode of dressing in all of its modifications; for although I am far from being persuaded of its utility as a means of extension and retention in any case, yet I am not prepared to deny to it some very considerable value in another point of view; and when judiciously employed it can certainly do no harm. It is, I repeat, for another reason altogether than the one heretofore assigned, that I would recommend its continuance, a reason which I cannot so well explain, or hope to render intelligible, except to the practical surgeon. This position throws the whole lower end of both radius and ulna outwards toward the radial margin of the splints, and by keeping the radius more completely in view, it enables the surgeon better to judge of the accuracy of the reduction, and to recognize more readily the condition and situation of the compresses, etc. This alone I have always considered a sufficient ground for retaining the angular splint; although I have treated a number of arms satisfactorily with the straight splints alone. Finally, while surgeons have been seeking to accomplish an indication, the existence of which is at least rendered doubtful, and by means which appear to me totally inadequate, if it did exist, they have probably too often overlooked or regarded indifferently an indication which is almost uniformly present, namely, to press forwards the tilted fragment by a force applied upon the wrist from behind, and to retain it in place by suitable compresses. And I cannot help thinking that if they had regarded this as the sole indication, an indication generally so easily accomplished, they would have made fewer crooked arms, and have saved their patients much suffering and themselves much trouble. It only remains for us to determine the precise form of splint which ought to be preferred, and to describe its mode of application. The narrow " attelle cubitale" of Dupuytren, is inconvenient; nor can I give the preference to the curved dorsal splint recommended by Nelaton, and employed by Eobert Smith, Erichsen, and others. It is not to me a matter of entire indifference, in case only one curved splint is employed, whether this be applied to the palmar or dorsal surfaces of the forearm. Foreign surgeons, so far as I know, have applied this splint to the dorsal surface, and the straight splint to the palmar; while American surgeons have adopted almost as uniformly the opposite rule—to whose practice, in this respect, I acknowledge myself also partial. It is to the curved splint rather than to the straight, that we mainly trust; not simply, or at all, perhaps, because of its form, 276 FRACTURES OF THE RADIUS. but because the curved splint is also the long splint. This is the splint, therefore, which ought to be the most steady and immovable in its position. Now, the very irregularities of surface upon the palmar aspect of the forearm and hand, instead of constituting an embarrassment, enable us, when the splint is suitably prepared and adjusted, to fix it more securely. Moreover, upon it alone, after a few days, the surgeon may see fit to rely, and in that case it ought to be applied to that surface of the arm which is most tolerant of continued pressure. The palmar surface, as being more muscular, and as having been more accustomed to friction and to pressure, must necessarily have the advantage in this respect. The palmar splint terminating also at the metacarpo-phalangeal articulations, instead of at the wrist, as the short straight splint must do when the hand is adducted, enables the hand to be flexed upon its extremity over a handblock, or pad of proper size. Such are the not insignificant advantages which we claim for this mode, over that pursued by our transatlantic brethren. The block suggested first by Bond, of Philadelphia, is a valuable addition; since the flexed position is always more easy for the fingers, and in case of anchylosis this position renders the whole hand more useful. For myself, I am in the habit of preparing extemporaneously a splint from a wooden shingle, which I first cut into the requisite shape and length; the length being obtained by measuring from the front of the elbow-joint, when the arm is flexed to a right angle, to the metacarpo-phalangeal articulations. It ought, indeed, to fall half an inch short of the bend of the elbow, to render it certain that it shall make no uncomfortable pressure at this point; and the direction to measure with the arm flexed, is of sufficient importance to warrant a repetition. The breadth of the splint Flg ' should be in all its extent just equal L . , * The author's splint. repetition. The breadth of the splint should be in all its extent just equal to the breadth of the forearm in its widest part, so that there shall be no lateral pressure upon the bones. If the splint is of unequal breadth, the roller cannot be so neatly applied, and it is more likely to become disarranged. Thus constructed it is to be covered with a sack of cotton cloth, made to fit tightly, with the seam along its back; and afterwards stuffed with cotton batting or with curled hair. These materials may be passed in and easily adjusted, wherever they are most needed, from the open extremities of the sack. While preparing, the splint must be occasionally applied to the arm until it fits accurately every part of the forearm and hand, only that the stuffing must be rather more firm a little above the lower end of the upper fragment. The open ends of the sack are then to be neatly stitched over the ends of the splint, after which the splint may be laid directly upon the skin without any intermediate compresses or rollers. The advantages of this form of splint are easily comprehended. 277 FRACTURES OF THE RADIUS. They consist in facility and cheapness of construction, accuracy of adaptation, neatness, permanency and fitness to the ends proposed. The extemporaneous splint recommended by Dr. Isaac Hays, of Philadelphia, is very similar, but it lacks the neatness and permanency of that which I have now described. In all cases it is better to employ, also, at least during the first fortnight, a straight dorsal splint, of the same breadth as the palmar splint, and of sufficient length to extend from the elbow to the middle of the metacarpus. This should be covered and stuffed in the same manner as the palmar splint, except that here the thickest and firmest part of the splint must be opposite the carpus and the lower end of the lower fragment. It will answer the indications also a little more completely if, at this point, the padding is thicker on the radial than on the ulnar side. Having restored the fragment to place, in case of Colles' fracture, by pressing forcibly upon the back of the lower fragment, the force being applied near the styloid apophysis of the radius, the arm is to be flexed upon the body and placed in a position of semi-pronation; when the splints are to be applied and secured with a sufficient number of turns of the roller, taking especial care not to include the thumb, the forcible confinement of which is always painful and never useful. I cannot too severely reprobate the practice of violent extension of the wrist in the efforts at reduction when no overlapping of the fragments exist, and that, whether this extension be applied in a straight line, or with the hand adducted. It has been shown that in a great majority of cases no indication in this direction is to be accomplished, and to pull violently under these circumstances upon the wrist is not only useless but hurtful. It is adding to the fracture, and to the other injuries already received, the graver pathological lesion of a stretching, a sprain, of all the ligaments connected with the joint. I am persuaded that to this vio- Fig. 82. The author's dressing complete. The curved palmar splint is not in view, only the dorsal. The faint white linos represent the roller. The sling is omitted for the purpose of bringing the other dressings into view. lence, added to the unequal and too firm pressure of the splints, are, in a great measure, to be attributed the subsequent inflammation and anchylosis, in very many cases. The first application of the bandages ought to be only moderately tight, and as the inflammation and swelling develop in these struc- 278 FRACTURES OF THE RADIUS. tures with rapidity, the bandages should be attentively watched and loosened as soon as they become painful. It must be constantly borne in mind that, to prevent and control inflammation, in this fracture, is the most difficult and by far the most important object to be accomplished, while to retain the fragments in place when once reduced, is comparatively easy and unimportant. During the first seven or ten days, therefore, these cases demand the most assiduous attention; and we had much better dispense with the splints entirely than to retain them at the risk of increasing the inflammatory action. Indeed, I have no doubt that very many cases would come to a successful termination without splints, if only the hand and arm were kept perfectly still in a suitable position until bony union was effected. I must also enter my protest against many or all of those carved splints which are manufactured, hawked about the country, and sold by mechanics, who are not surgeons; with a fossa for each styloid process, a ridge to press between the bones, and various other curious provisions for supposed necessities, but which never find in any arm their exact counterparts, and only deceive the inexperienced surgeon into neglect of the proper means for making a suitable adaptation. They are the fruitful sources of excoriations, ulcerations, inflammations and deformities. In reference to the treatment of these fractures, the following cases and the accompanying remarks, by that great surgeon Dupuytren, are too pertinent not to merit a place in every treatise of this character. " The two succeeding cases are not only interesting as fractures of the radius, but they are further deserving of attentive consideration on account of the serious complications which accompanied them, and which were the consequence of forgetting an important precept. More than once, indeed, it has occurred that the surgeons have been so intent on preserving fractures in their proper position, that the extreme constriction employed has actually caused destruction of the soft parts. A piece of advice which I have very frequently given, and which I cannot too often repeat is, to avoid tightening too much the apparatus for fractures during the first few days of its being worn; for the swelling which supervenes is always accompanied by considerable pain, and may be followed by gangrene. It cannot therefore be too urgently impressed on young practitioners, to pay attention to the complaints which patients make; and to visit them twice daily, and relax the bandages and straps as need may be, in order to obviate the frightful consequences which may spring from not heeding this necessary precaution : by carefully attending to this point I have been saved the painful alternative of ever having to sacrifice a limb for complications which its neglect may entail. "Antoine Rilard, set. 44, fractured his right radius whilst going down into a cellar, in Feb. 1828, and went at once to the Hospital of La Charite*. "When the fracture was reduced (it was near the base of the bone) an apparatus was applied, but fastened too tightly; and, notwithstanding the great swelling, and the acute pain which the patient endured, it was not removed until the fourth day, when the 279 FRACTURES OF THE RADIUS. hand was cold and cedematous, and the forearm red, painful, and covered with vesications. Leeches, poultices, and fomentations were applied, and followed by some alleviation of the local symptoms, though there was much constitutional disturbance. At the close of a fortnight from the accident, the palmar surface of the forearm presented a point where fluctuation was supposed to exist; but when a bistoury was plunged into it no matter followed. Portions of the flexor muscles subsequently sloughed, and the skin subsequently mortified. The only resource was amputation, which was performed above the elbow, six weeks after his admission; and he afterwards recovered without the occurrence of any further untoward symptoms. "R., set. 36, was at work boring an artesian well in 1832, when he was struck by part of the machinery on the right forearm ; he was instantly knocked down and thrown violently on the right thigh. A surgeon who was sent for detected a fracture of the radius, and applied the usual apparatus, consisting of pads and splints, confined by a roller extending from the extremities of the fingers to the elbow, which compressed the arm so tightly as to give rise to very great suffering. The fingers, hand, and forearm were numbed almost to insensibility, and yet the surgeon in attendance did not think proper to loosen the apparatus. Such was the condition of the patient until he came to the Hotel Dieu, four days after the accident; the fingers were then black, cold, and insensible, and when I removed the splints I found the hand likewise black, especially on its palmar surface. The lower part of the forearm was a shade less livid, but equally cold and insensible; and several vesicles filled with pink-colored serum were apparent on both its surfaces where the splints had pressed; the upper part of the forearm was inflamed, swollen, and very painful. He was bled and leeches were applied to the inflamed part of the arm; camphorated spirit was applied to the fingers. " On the following day heat was restored as low as the wrist, but the hand remained for the most part livid and cold, and the radial artery did not pulsate. Seventy leeches were applied to the forearm, and the local application was continued." On the second day after admission thirty more leeches were applied. On the fourth day the hand looked a little better, so as to " encourage some hope of its being saved ; but this was again blighted on the sixth day, by the entire loss of heat and sensibility in the part, and increased pain and swelling in the forearm, to which the gangrene subsequently extended. On the twelfth day amputation was performed at the elbow-joint; but the patient did not survive the operation more than ten days, the immediate cause of death being acute pleurisy. There was a considerable quantity of purulent serosity poured out on the right side of the chest; and abscesses were found in the lungs and liver. On examining the arm, there was found to be a simple fracture of the radius about its centre. " The above case presents a painful illustration of the neglect to which I have alluded. In nearly every instance the swelling of the limb requires that careful attention should be paid to the bandage or straps, by which the apparatus is confined. Similar accidents are 280 FRACTURES OF THE RADIUS. likely to result from the employment of an immovable apparatus, of which an example occurred in the practice of M. Thiery, one of my pupils. He was summoned to visit a young girl, on whom such an apparatus had been applied for supposed fracture of the radius. After suffering excruciating torment, the forearm mortified, and amputation was the only resource; on examining the limb no trace of fracture could be discovered. Had. a simple apparatus been here employed, and properly watched, this patient's limb would not have been sacrificed." 1 Robert Smith mentions, also, the case of a boy, set. 18, who had a fracture of the lower extremity of the radius, through the line of the junction of the epiphysis with the diaphysis, caused by being thrown from a horse. A surgeon applied, within an hour, a narrow roller tightly around the wrist. On the following day the limb was intensely painful, cold and discolored; still the roller was not removed, nor even slackened. On the fourth day he was admitted into the Richmond Hospital, when the gangrene had reached the forearm. Spontaneous separation of the soft parts finally occurred, and the bones were sawn through twenty-four days after the fracture was produced, from which time "everything proceeded favorably." 2 Nov. 21, 1851, a boy, ten years old, living in the town of Andover, Mass., had his left hand drawn into the picker of a woollen mill, producing several severe wounds of the hand and a fracture of the radius near its middle. One of the wounds was situated directly over the point of fracture, but whether it communicated with the bone or not was not ascertained. A surgeon was called, who closed the wounds, covered the forearm with a bandage from the hand to above the elbow, and applied compresses and splints. This lad made no complaint, his appetite remaining good and his sleep continuing undisturbed, until the third day, when he began to speak of a pain in his shoulder; on the same day also it was noticed that his hand was rather insensible to the prick of a pin. Early on the morning of the fourth day his surgeon being summoned, found him suffering more pain and quite restless ; and on removing the dressings, the arm was discovered to be insensible and actually mortified from the shoulder downwards. Opiates and cordials were immediately given to sustain the patient, and fomentations ordered. On the sixth day a line of demarcation commenced across the shoulder, and on the twenty-first day, the father himself removed the arm from the body by merely separating the dead tissues with a feather. Subsequently a surgeon found the head of the humerus remaining in the socket, and removed it, the epiphysis having become separated from the diaphysis. The boy now rapidly got well. In the year 1853, this case became the subject of a legal investigation, in the course of which Dr. Pilsbury, of Lowell, Mass., declared that in his opinion this unfortunate result had been caused by too tight bandaging, and by neglecting to examine the arm during four days. 1 Dupuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7. 2 R. Smith, Treatise on Fractures, &c, Dublin, 1854, p. 170. 281 FRACTURES OF THE RADIUS. On the other hand, Drs. Hayward, Bigelow, Townsend, and Ainsworth, of Boston, with Kimball, of Lowell, Drs. Loring, and Pierce, of Salem, believed that the death of the limb was due to some injury done to the artery near the shoulder joint; and in no other way could they explain the total absence of pain during the first two days; nor could they regard this condition as consistent with the supposition that the bandage occasioned the death of the limb. 1 I cannot but think, however, that these gentlemen were mistaken, and that the gangrene was alone due to the bandages. In a similar case which came under my own observation, and in which both the radius and ulna were broken, the roller extended no higher than just above the elbow, and the patient complained of no pain until the bandages were unloosed, yet the arm separated at the shoulder-joint. I shall refer again to this example in the chapter on fractures of the radius and ulna; and I shall take occasion then also to speak more fully of the causes of these terrible accidents. Norris mentions another case of compound fracture of the lower end of the radius which came under his notice at the Pennsylvania Hospital in August, 1837, the arm having been dressed by a country surgeon within half an hour after the accident, with bandages and splints. When these bandages were removed at the hospital, on the fifth day, "the soft parts around the fracture were found to have sloughed, an abscess extended up to the elbow-joint, and sloughs existed over the condyles. Several constitutional symptoms arose, making amputation of the arm necessary." 3 A lady, get. 50, was also seen by Thierry, who, having broken the radius near its lower end, lost her fingers by the sloughing consequent upon a tight bandage. 3 The remarks which have now been made in relation to the treatment of Colles' fracture, are applicable, with only such slight modifications as would naturally be suggested, to fractures of the lower end of the radius commencing upon the radial side of the bone and extending obliquely downwards into the joint; and it is to this form of fracture especially, that the pistol-shaped splint must be found applicable. If the fracture actually extends into the joint, it must not be forgotten that, in order to the prevention of anchylosis, the wrist should be early subjected to passive motion. The following example of a compound, comminuted fracture of the radius, may serve to illustrate the value of a somewhat novel mode of treatment under certain circumstances:— William Croak, of Buffalo, set. 30. Jan. 29, 1856, a large piece of iron casting fell upon his arm, crushing and lacerating the wrist, and comminuting the lower part of the radius; he was immediately taken to the Hospital of the Sisters of Charity. I found the whole of the soft parts torn away in front of the joint, and the fragments of the radius projected into the flesh in every direction. The hope of saving 1 Boat. Med. and Surg. Journ., vol. xlviii. p. 281. 2 Norris, note to Liston's Surgery, p. 54. 3 Amer. Journ. Med. Sci., vol. xxv. p. 461, from L'Experience for 1838. 19 282 FRACTURES OF THE ULNA. the hand seemed to be scarcely sufficient to warrant the attempt; at least by the ordinary mode of procedure. I, however, stated to the gentlemen present, among whom were Dr. Rochester, my colleague, and the house surgeon, Dr. Lemon, that I believed it could be saved if, having removed the fragments of the radius, we practised resection of the lower end of the ulna, and allowed the muscles to become completely relaxed. Accordingly, after placing my patient under the influence of chloroform, I enlarged the wounds so as to enable me to remove six or seven fragments of the radius, leaving others which were broken off but not much displaced. I then removed with the saw one inch and a half of the lower end of the ulna. The hand was immediately drawn up by the contraction of the remaining muscles, but their tension was completely relieved. The wounds were closed and dressed lightly, and the whole limb was placed on a broad and well-padded splint covered with oiled cloth. The hand, which was very pale and exsanguine, was covered with warm cotton batting. The subsequent treatment was changed from time to time to suit the indications; but his recovery was rapid and complete, nor was there at any time excessive inflammation in any part of the limb. I have seen this man frequently since he left the hospital, and while he has recovered only a little motion in the wrist-joint, his hand and lingers are nearly as useful as before the accident. He is able to perform all ordinary kinds of labor with almost as much ease as most other men; and what is always gratifying to the humane surgeon, he does not fail to appreciate fully the service which has been conferred upon him by the preservation of his somewhat mutilated hand. I have recently adopted the same treatment with equal success in a case of gunshot wound of the lower end of the radius. CHAPTER XXII. FRACTURES OF THE ULNA. § 1. Shaft of the Ulna. Causes. —The shaft of the ulna is generally broken by a direct blow. I have never seen an exception to this rule; but Yoisin has related in the Gazette Medicate for 1833, a single exception in which it was said to have been broken by a fall upon the palm of the hand. Malgaigne thinks it is most often broken when one seeks to ward off a blow with the arm; but it has happened most often to me to see it broken by a fall upon the side of the arm. Point of Fracture, Direction of Displacement, &c. —In an analysis of twenty-seven cases, I find the shaft has been broken nine times in 283 SHAFT OF THE ULNA. its upper third, ten times in its middle third, and eight times in its lower third. All portions seem, therefore, to be about equally liable to fracture. I think, also, the fractures have generally been oblique. Contrary to what has been observed by other writers, I have noticed that no law prevailed as to the direction in which the fragments have become displaced; the broken ends being found directed forwards, backwards, inwards, or outwards, according to the direction of the blow which has occasioned the fracture; and this is in accordance with the general rule in other fractures occasioned by direct blows. No doubt, however, other things being equal, the tendency of the lower fragment would be toward the interosseous space, in consequence of the action of the pronator quadratus in this direction, while the upper fragment, owing to its broad and firm articulation at the elbow-joint, can only be displaced forwards or backwards, at least to any great extent. Complications. —In no case of the shaft of a long bone have I found serious complications more frequent than in fractures of the shaft of the ulna. Four have been compound; eight complicated with a forward dislocation of the head of the radius; one with a partial dislocation of the lower end of the radius backwards, and one with a dislocation of both radius and ulna backwards at the elbow-joint. It will be seen, therefore, that thirteen, or more than one-half of the whole number, have been seriously complicated. Fig. 83. Fracture of the shaft of the ulna. Symptoms. —Occasionally this fracture is found to exist without sensible displacement. In such cases the diagnosis is sometimes difficult, and can only be determined by the crepitus and mobility. If, however, the ulna is firmly seized above and below the point which has suffered contusion, and pressed in opposite directions, these signs will generally be sufficiently manifest, and will render the diagnosis certain. But in cases where there is considerable displacement, the inner surface of the bone is so superficial as to enable us to detect its deviations with the eye alone, or, when swelling has already occurred, by the fingers carried firmly and slowly along this margin. If the head of the radius is dislocated also, the displacement of the broken ends of the ulna must always be considerable, and the consequent deformity palpable. I have known one instance, however, in which a surgeon living in the neighboring Province of Upper Canada, recognized and reduced a dislocation of the radius and ulna backwards, but did not detect a fracture of the ulna two inches above its lower end. Six months after, in the month of March, 1856, the patient called upon me with a marked deformity near the wrist, occasioned by the backward projection of the broken ulna, and with a complete loss of the power of supination. It will not surprise us that 284 FRACTURES OF THE ULNA. this fracture was overlooked when we learn that the man had fallen fifty-five feet. Prognosis. —In simple fractures the prognosis is generally favorable, since no overlapping can occur, and the lateral displacements are not usually sufficient to produce a marked deformity, or to interfere materially with the functions of the arm; yet it is not unfrequent to find the fragments inclining slightly forwards or backwards, inwards or outwards. If the fragments fall toward the radius, I have noticed in three or four instances a slight projection of the lower end or styloid process of the ulna to the ulnar side; but not interfering in any degree with the motions of the wrist-joint. I have seen the radius left unreduced four times after a fracture of the ulna, and in each example the forearm was shortened. A boy, set. 17, was struck by a locomotive, and severely injured in various parts of his body, June 5, 1855. I saw him with two very intelligent country practitioners, a few hours after the accident. The whole left arm was then greatly swollen. Crepitus was distinct, and we easily recognized the fracture of the ulna about three inches below its upper end, with which an open wound was in direct communication. We suspected, also, a dislocation of the head of the radius forwards, but as we could not make ourselves certain, and finding that the arm was in such a condition as to preclude any further manipulation without greatly diminishing the chance of saving the limb, we made no attempt at reduction, but laid the arm upon a pillow and directed cool water lotions. At no subsequent period, in the opinion of the medical gentleman who was left in charge, did a favorable opportunity occur to reduce the radius; and at the end of two months I found the ulna united, with the fragments bent forwards and outwards toward the radius, while the head of the radius lay in front of the humerus. The forearm was shortened three-quarters of an inch. He could flex his arm freely to a right angle and a little beyond; and he could straighten it perfectly. Hand slightly pronated, with partial loss of supination. Whole arm nearly as strong and as useful as before the accident. The second case occurred in the person of a man set. 26, residing about twenty miles from town, and was occasioned by the kick of a horse. This was also a compound fracture. It does not appear that his surgeon discovered the dislocation of the radius, but supposed that it was a fracture of both bones. On the ninth day the patient became dissatisfied and dismissed his surgeon, but employed no other. Oct. 1, 1849, eleven weeks after the accident, he called upon me. I found the ulna united with a manifest displacement, but I could not discover that there had been any fracture of the radius. The head of the radius was in front of the external condyle, and a depression existed where it formerly articulated. When the arm was flexed, the head did not strike the humerus so as to arrest the flexion, but it glided upwards and outwards along the inclined base of the external condyle. He had already begun to use his arm considerably in labor. The forearm was shortened one inch. I found the ulna much bent forwards a little below its middle, the SHAFT OF THE ULNA. 285 head of the radius displaced forwards, and the forearm shortened one inch. Three times I have noticed affcerthe lapse of several years that the forearm could not be perfectly supinated; but pronation was never permanently impaired. I think, also, that the motions of flexion and extension have always, except where the radius has remained dislocated, been completely restored soon after the splints were removed; and even in these latter cases, it is only extreme flexion which has been hindered. Treatment. —In simple fracture we must look carefully to the lateral deviation of the fragments, and if they are found to be salient forwards or backwards, pressure made directly upon or near their extremities, restores them to place, but it often requires considerable force to accomplish this. A gentleman fell and broke the right ulnar near its middle. He came immediately to me, and I found the fragments displaced backwards. Pressing strongly with my fingers, they sprung forwards with a distinct crepitus, and I thought they were now in exact line. A broad and well-padded splint was applied to the forearm, and I took especial pains with compresses nicely adjusted; from day to day, to keep everything in place. The arm was placed in a sling. Eight months after the accident this gentleman died of cholera, and I was permitted to dissect the arm. I found the fragments well united, but with a very palpable projection of the fragments backwards, in the direction in which they were at first. If the displacement is in the direction of the radius, it is more difficult to overcome, but its necessity is much more urgent, since if the fragments fall completely against the radius, a bony union may take place, occasioning a complete loss of the power of pronation and of supination. While moderate extension is being made, and the hand is firmly supinated, the fingers of the surgeon should be pressed firmly, and in spite sometimes of the complaints of the patient, between the radius and ulna, and the fragments of the broken ulna fairly pushed out from the radius. The forearm may now be laid in the usual position against the front of the chest, midway between supination and pronation, and the same splints applied and in the manner which we shall hereafter describe for fractures of the shaft of both bones. We ought, however, especially to bear in mind the danger of thrusting the fragments against the radius, by allowing the sling or the bandage to rest against the middle of the ulnar side of the bone. To prevent this, the sling ought to support the arm by passing only under the hand and wrist, or the forearm may be laid in a firm gutter which will touch the forearm only at the elbow and wrist, or it may be laid upon its back as suggested and practised by Fleury, who, according to Malgaigne, had a case which had been treated in the position of semi-pronation, and which remained not only displaced but refused to unite; but when the arm was supinated, the fragments came at once into contact and bony union speedily took place. This position may be adopted whenever it is found to be practicable; but the position of 286 FRACTURES OF THE ULNA. demi-pronation is generally much more comfortable to the patient, at least when the forearm is laid across the chest, and very few patients will submit to a position of complete supination. In fractures accompanied with dislocation of the head of the radius forwards or backwards, nothing should prevent the immediate reduction of the dislocation but a demonstration of its impossibility, or a condition of the limb which would render manipulation hazardous. It can be reduced, generally, by pushing forcibly upon the head of the bone in the direction of the socket, while the arm is moderately flexed so as to relax the biceps, and while extension is being made at the forearm by an assistant. In making the counter-extension, care should be taken to seize the lower end of the humerus by the condyles, rather than by its anterior aspect, by which precaution we shall avoid pressing upon and rendering tense the tendon of the biceps. July 29, 1845, a lad, eat. 9, fell from his bed, breaking the ulna and dislocating the head of the radius. Dr. Austin Flint was called on the following morning, and at his request I was invited to see the patient with him. We found the ulna broken obliquely near its middle, and the head of the radius dislocated forwards. While Dr. Flint seized the elbow in front of the condyles, I made extension from the hand, the forearm being slightly flexed upon the arm, and at the same moment I pushed forcibly the head of the radius back to its socket. The reduction was accomplished easily and completely. We then dressed the arm with Rose's angular splints, constructed with a joint opposite the elbow. This was laid upon the palmar surface, and the whole was nicely padded, especially in front of the head of the radius. In two weeks pasteboard was substituted for the angular splint. At the end of six weeks I was permitted to examine the arm and found the head of the radius perfectly in place, but the points of fracture slightly salient. All of the 1 motions of the arm were fully restored. June 2, 1845. C. C, aet. 9, fell upon his arm, breaking the ulna obliquely near , its middle, and dislocating the head of the radius forwards. Dr. J. P. White being called, requested me to visit the patient also with him. We found one of the broken fragments protruding through the skin, on the inside of the arm. With great ease, and by simply pressing with considerable force upon the head of the radius, it was made to slide into its socket. The case was left in charge of Dr. White. Five weeks after, I found all of the motions of the forearm completely restored, except that he could not extend it perfectly. The head of the radius was also a little more prominent in front than in the opposite arm. Four or five years afterwards, the projection of the head of the radius had disappeared, and the functions of the arm were perfect. The following example of compound and comminuted fracture of the ulna will illustrate how much may be accomplished by conservative surgery:— A German lad, set. 10, was run over by a railroad car, Sept. 4,1857. Drs. C. F. Gay and Austin Flint, Jr., were summoned immediately; 287 CORONOID PROCESS OF THE ULNA. but the limb presented such a discouraging appearance as induced them to send for me also. We found the ulna very much broken near its lower end, and about two inches of it entirely gone. The radius was sound. The skin and muscles were extensively lacerated and torn off in shreds. After a careful examination, finding that the radial and ulnar arteries continued to pulsate, we agreed to attempt to save the limb. It was accordingly laid upon a board covered with a soft and nicely adjusted cushion; such vessels as were bleeding were tied; the skin was loosely stitched together, and the whole covered with a cotton cloth smeared with simple cerate. Cool water dressings were directed, and the boy was left in charge of Drs. Gray and Flint. The skin subsequently sloughed extensively, and also more or less of the muscular tissue; but on the 1st of May, 1858, about eight months from the time of the accident, it had nearly or quite closed over, and although his arm was very much deformed and maimed, it was still very useful ; indeed, to one who must earn his living by his hands alone, its value is beyond estimate. § 2. Coronoid Process of the Ulna. Dissections have established the possibility of this fracture as a simple accident in the living subject; but I have not myself seen any example of which I can speak positively. In the two following cases, the existence of such a fracture was at first suspected, but I have now very little doubt but that my diagnosis was incorrect. I shall relate them, however, as examples of those accidents which are likely to be mistaken for fracture of this process. A laboring man, aged about twenty-five years, had been seen and treated by another surgeon, for what was supposed to be a simple dislocation of the radius and ulna backwards. The surgeon thought he had reduced the dislocation very soon after the accident. On the following day he found the dislocation reproduced, and he requested me to see the patient with him. The arm was then much swollen, but the character of the dislocation was apparent. By moderate extension, applied while the arm was slightly flexed, and continued for a few seconds, reduction was again effected; the bones returning to their places with a distinct sensation; but on releasing the arm the dislocation was immediately reproduced. These attempts to reduce and retain in place the dislocated bones were repeated several times during Fig. 84. Fracture of the coronoid process. this day, and on subsequent days, but to no purpose, and the patient was dismissed after about two weeks with the bones unreduced. The impossibility of retaining the bones in place, and the existence 288 FRACTURES OF THE ULNA. of an occasional crepitus during the manipulation, inclined me to believe at the time that the dislocation was accompanied with a fracture of the coronoid process. Another similar case has since presented itself in a child nine years old, and in which the subsequent examinations not only demonstrated the non-existence of a fracture, but also rendered doubtful the justness of the conclusions which I had drawn in the case just related. This lad fell, Nov. 4, 1855, and his parents immediately brought him to me; but as he lived many miles from town, I did not see him until eighteen hours after the injury was received. I found the arm much swollen, slightly flexed and pronated. Flexion and extension of the arm were very painful; the pain being referred chiefly to the front of the joint, near the situation of the coronoid process; and at this point also there was a discoloration of the size of a twenty-five cent piece. Flexing the forearm moderately upon the arm and making extension, the bones came readily into place, but without sensation of any kind, either a snap or a crepitus. That the bones had now resumed their position, however, I made certain by a very careful examination with the hand and by measurement; yet they would not remain in place one moment when the extension was discontinued. The reduction was made several times, and constantly with the same result. We then applied a right-angled splint to the arm, having first reduced the bones, and thus were able to retain them in position. I believed that the coronoid process was broken, and so informed the surgeon to whose care the boy was returned. Five months after, he was brought again to me, and I then found that the radius and ulna had been kept in place; the motions of the joint were perfect, and if the coronoid process had ever been broken it was now again in its natural position, and with every structure about it in a condition as complete as it was before the accident. For myself, I do not believe that so perfect a union of this process can happen—at least in a case where, as must have been the fact in this example, the separation and displacement of the process are such that it no longer offers an obstacle to the dislocation of the ulna backwards and upwards. Malgaigne thinks that the fracture is more frequent than the small number of reported examples would lead us to suppose, especially because he has noticed how often the summit of the process is broken off, when dislocation of the radius and ulna backwards is produced artificially on the dead subject. In three or four cases, also, of dislocations of these bones backwards and inwards, which had come under his notice, he was unable to feel this process, and he therefore thought it probable that it was broken off. Other surgeons have thought, also, that it was a not infrequent accident; and they have constantly made use of this supposition to explain those cases in which, the radius and ulna having been dislocated backwards, would not afterward remain in place when, well reduced. Fergusson has indeed made the extraordinary statement in relation to dislocations of the radius and ulna backwards generally, that in these cases "the coronoid process will probably be broken." But, in my opinion, these fractures are exceedingly rare; and I think 289 CORONOID PROCESS OF THE ULNA. these gentlemen need to have furnished some more conclusive evidence of the correctness of their opinions, than can be found in their writings, or in the writings of any other surgeons, which I have seen. Malgaigne mentions three reported examples, namely: one published by Combes Brassard, an Italian surgeon, in 1811, which Brassard saw only after a lapse of three months; one seen by Penneck, and published in the Lancet in 1828, the patient then being sixty years old and the accident having occurred while he was a young man; the third was seen by Sir Astley Cooper, several months after the accident and is reported by himself in his excellent treatise on Fractures and Dislocations. Says Mr. Cooper: " It was thought, at the consultation which was held about him in London, that the coronoid process was detached from the ulna." This was the only living example seen by Mr. Cooper in his long and immensely varied surgical practice; and even here we cannot fail to notice the apparent reserve with which he expresses his opinion—" It was thought at the consultation." To these examples our own researches have added a few others. Dorsey says that Dr. Physick once saw a fracture of the coronoid process. The symptoms resembled a luxation of the forearm back-' wards, " except that when the reduction was effected, the dislocation was repeated, and by careful examination, crepitation was discovered. The forearm was kept flexed at a right angle with the humerus. The tendency of the brachieus internus to draw up the superior fragment was counteracted in some measure by the pressure of the roller above the elbow. A perfect cure was readily obtained." 1 In 1830, Dr. Wm. M. Fahnestock reported a case occurring in a boy, who, having fallen from a haymow, received the whole weight of his body " on the back part of the palm of the left hand," while the arm was extended forwards. It seemed to be a dislocation of the forearm backwards, but when reduced it was again immediately displaced, with an evident crepitus. The arm was secured in the angular splint of Dr. Physick, and " recovered very speedily." 2 Dr. Couper, of the Glasgow Infirmary, also has reported a dislocation of the forearm backwards and outwards, occurring in a young man aged seventeen, and which he thinks was accompanied with this fracture. The dislocation was easily reduced, but returned again immediately on ceasing the extension. The fragment was not felt, nor does he speak of crepitus; the existence of the fracture being inferred from the fact that the bones would not remain in place without help. The forearm was placed across the chest, with the fingers pointing toward the opposite shoulder, and secured in this position with splints and a bandage. At the end of four weeks union had taken place, with only slight deformity, although with some stiffness of the joint. In relation to this example, the editor remarks that the symptoms were not to his mind conclusive in determining the existence of a fracture of the coronoid process, and he inclines to the belief that it was rather an oblique fracture of the lower extremity of the humerus. 1 Dorsey, Elements of Surgery, vol. i. p. 152. Philadelphia, 1813. * Fahnestock, Amer. Journ. Med. Sci., vol. vi. p. 267. 290 FRACTURES OF THE ULNA. "In cases like these," he adds, "where very rare accidents are suspected, we think that unless the diagnosis is clear, the leaning should always be the other way: we mean, that, ceeteris paribus, the symptoms should rather be referred to the common than the extraordinary injury. The contrary practice introduces a dangerous laxity in diagnosis." 1 In the American Medical Monthly for October, 1855, also, I find the report of a trial for malpractice, in which a lad nine years old received some injury about the elbow-joint which resulted in a maiming. The defendant claimed that there had been a dislocation of the forearm backwards, accompanied either with a fracture of the trochlea of the humerus, or of the coronoid process of the ulna. Dr. Crosby, of Dartmouth College, testified that he had never met with a fracture of this process, yet he would not say that it did not exist in this case. He was not able to decide positively. Dr. Peaslee, of the same college, thought it altogether probable that it had been broken, and Dr. Spaulding was of the opinion fully that it had been broken. The jury did not agree, and a non-suit was finally allowed by the court. The defendant, in his report of the trial, seems to me to have justly complained that Mr. Fergusson has said, that in a dislocation of the forearm backwards " the coronoid process will probably be broken." This was urged in the trial by the plaintiff's counsel as contradicting the medical testimony, and as evidence of a conspiracy on the part of the surgeons to defeat the ends of justice; since they constantly affirmed that the accident was so rare as not to have been reasonably expected, and that a failure to look for or to discover it did not imply a lack of ordinary skill or care. a Says Mr. Liston : " The coronoid process is occasionally pulled or pushed off from the shaft, more especially in young subjects. I saw a case of it lately, in which the injury arose in consequence of the patient, a boy of eight years, having hung for a long time from the top of a wall by one hand, afraid to drop down ;" 3 after whom, Miller, Erichsen, Skey, Lonsdale, and most of the Scotch and English surgeons have repeated the assertion that this process may be broken in this manner by the action of the brachialis anticus alone, yet no one of them has to this day seen another example. The explanation of the accident in the case of the boy, given by Liston, implies two anatomical errors: first, that the coronoid process is an epiphysis during childhood; and second, that the brachialis anticus is inserted upon its summit. The coronoid process is never an epiphysis, but is formed from a common point of ossification with the shaft; the olecranon process and the lower extremity of the ulna having also separate points of ossification. Moreover, the brachialis anticus has its insertion at the base of the process and partly upon the body of the ulna, but in no part upon its summit; indeed, the process seems rather to be intended as a pulley over which the bra- 1 Couper, Lond. Med.-Chir. Rev., new ser., vol. xi. p. 509. * Op. cit., vol. iv. p. 339. » Liston, Practical Surgery, p. 55. 291 CORONOID PROCESS OF THE ULNA. chialis anticus may play; resembling also somewhat, in its function, the patella; serving to protect the joint and perhaps the muscle itself from becoming compressed in the motions of the joint. Certainly it could never have been broken by the action of this muscle, and the case mentioned by Mr. Liston must find some other explanation. It may have been a rupture of the brachialis anticus itself, or of the biceps, or possibly a forward luxation of the head of the radius. Either of these suppositions is more rational than the statement made by Mr. Liston, because either one of them is possible, while his supposition is impossible. These, if I except my own, constitute all of the supposed examples seen in the living subject, of which I find any record; eight in all. The first two were not entirely satisfactory to Malgaigne; the third is spoken of cautiously by Sir Astley Cooper, as if it needed, in addition to his own great name, the indorsement of the " London council." Dorsey reports his case upon hearsay, and the result is quite too satisfactory to give it much claim to credibility. Fahnestock's case is to our mind far from being fully proven. Couper's case is doubted by Dr. Johnson; and the New Hampshire case was not made out satisfactorily to either the jury or the medical men. Liston's case was simply impossible. Certainly it is not upon such testimony as this that we can rely to sustain Mr. Fergusson's opinion that it is likely to occur in all dislocations of the forearm backwards, or of Malgaigne's conjecture that it is of more frequent occurrence than the published cases would seem to show. Nor will it be regarded as conclusive, that the beak of the process is often found broken after luxations made upon the subject; since between luxations thus produced and luxations occurring in the living subject there exists this important difference: that in the case of the latter, muscular action is the principal agent in the production of the dislocation, while in the former it is the external force alone which drives the bone from its socket. The fact, therefore, that so few cases have ever been reported, and that most of these are far from having been clearly made out, remains presumptive evidence that the actual cases are exceedingly rare; but if to this we add such negative evidence as is furnished by actual dissections, and by examinations of the pathological cabinets of the world, we think the testimony is almost conclusive. Only four specimens have been mentioned by any of the surgical writers known to me. Sir Astley Cooper says that a person was brought to the dissecting room at St. Thomas's Hospital, who had been the subject of this accident. " The coronoid process, which had been broken off' within the joint, had united by a ligament only, so as to move readily upon the ulna, and thus alter the sigmoid cavity of the ulna so much as to allow in extension that bone to glide backwards upon the condyles of the humerus." 1 Mr. Bransby Cooper adds in a note that the external condyle of the humerus was also broken and united by ligament. 1 A. Cooper, Dislocations and Fractures, p. 411. 292 FRACTURES OF THE ULNA. Samuel Cooper describes, rather obscurely, a specimen contained in the University College Museum, " in which the ulna is broken at the elbow, the posterior fragment being displaced backwards by the action of the triceps; the coronoid process is broken off; the upper head of the radius is also dislocated from the lesser sigmoid cavity of the ulna, and drawn upwards by the action of the biceps. In this complicated accident, the ulna is broken in two places." Malgaigne says that Velpeau has also established by an autopsy the existence of a fracture of the coronoid apophysis, but without having given any further particulars in relation to the case. In addition to these examples, Charles Gibson, of Richmond, Va., has stated to me by letter that he has in his possession a specimen of this fracture, evidently belonging to an adult. The process was broken transversely near its extremity, and has united again quite closely and without any displacement, and without ensheathing callus. We must subject these specimens to analysis also. The first two were complicated with other fractures, and the second, especially, seems to have been a general crushing of all the bones concerned in the formation of the elbow-joint: neither of them could have been occasioned by contractions of the brachialis anticus, while only that one described by Sir Astley Cooper could have been the result of a dislocation of the forearm backwards. Of the specimen said to have been seen by Velpeau, I am unable to speak without more circumstantial knowledge of its condition. Nor can I speak very confidently of that belonging to my distinguished friend, Dr. Gibson, of Virginia. Notwithstanding the respect which I entertain for his opinion, I cannot avoid a suspicion that the bone was never broken at all, since I find it more easy to believe that he is deceived by certain appearances, than that it should have united by bone again, and so perfectly as not to leave any line of separation or degree of displacement. Certainly the fracture was too high to have been produced by the action of the muscle, if such a thing were ever possible; and if broken by a dislocation, which must have forced it violently from its position, as the ulna was driven upwards, it is to me incredible that it should ever be made to unite again so perfectly. We are therefore left as before with no evidence that the coronoid process was ever broken by the action of a muscle, and with only one example in which it is probable that a fracture occurred as a consequence of a dislocation of the radius and ulna backwards. If then it does happen that in this dislocation it is pretty often found difficult or impossible to retain the bones in place without aid, it will be the part of prudence to ascribe this troublesome circumstance to some more common accident than a fracture of the coronoid process: perhaps to a fracture of some portion of the lower end of the humerus, or to a disruption, more or less complete, of the tendons of the biceps and brachialis anticus, together with the ligaments which surround the joint. Causes. —It is probable that this process will be sometimes broken in a fall upon the palm of the hand; the force of the blow being received directly upon the lower end of the radius, and through its 293 CORONOID PROCESS OF THE ULNA. numerous muscles and ligamentous attachments being indirectly conveyed to the ulna, producing a violent concussion of the coronoid process against the trochlea of the humerus, and resulting finally in a fracture of this process and a dislocation of both bones of the forearm backwards. The gentleman seen by Sir Astley had fallen upon his extended hand while in the act of running. Brassard's patient had fallen also upon his hand with his arm extended in front. Penneck's patient, an old man of sixty years, had fallen upon the palm of his hand, and Fahnestock's fell upon the " back of the palm." In no other case is the point upon which the blow was received particularly mentioned. In two of the examples mentioned by Malgaigne there was a luxation of the forearm backwards; such was also the fact in the case seen by Fahnestock; in Couper's case it was dislocated backwards and outwards, and in Sir Astley's case I infer that there was only a subluxation of the ulna backwards. We know of no other causes, therefore, than such as equally tend to produce dislocations at the elbow-joint, unless we except direct crushing blows, which of course may break the bones at any point upon which the force happens to be applied. Symptoms. —Partial or complete displacement of the ulna, or of the radius and ulna backwards, accompanied with the usual signs of these luxations; to which may be possibly added crepitus; and it is fair to presume that in some examples the fragment carried forwards by being driven against the trochlea, may be felt displaced and movable in the bend of the elbow. Brassard affirms that it was so with the patient whom he saw. If only the summit is broken off, the brachialis anticus could have no influence upon it, but if it were broken fairly through the base, it might be displaced slightly in the direction of the action of this muscle. The symptoms, however, which have been regarded as most diagnostic are the disposition to re-luxation manifested in most of these examples when the extension has been discontinued; and especially the fact that the olecranon was particularly prominent when the arm was extended, but that it resumed its natural position when the arm was flexed to a right angle. But I am unable to understand how either of these circumstances can be better explained upon the supposition of a fracture of this apophysis, than without such a supposition. If the reduction of both bones is once effected, even though the support of the coronoid process is completely lost, the head of the radius ought to prevent a re-luxation unless the arm is disturbed again; nor can I understand why, when the elbow is bent, the re-luxation is less likely to occur; since, although in this position the humerus bears less directly upon the process, the difference in this respect must be very little, for in whatever position the arm is placed, so long as the radius retains its position the ulna cannot be drawn very forcibly against the humerus; while, on the other hand, by flexing the arm the power of the biceps and of such fibres of the brachialis as remain attached to the ulna, to aid in the maintenance of reduction is completely lost; and at the same moment the resistance, and consequent power of the triceps to produce the luxation, are greatly increased. 294 FRACTURES OF THE ULNA. In short, we must confess that we are here, also, notwithstanding the confidence with which writers have spoken of the signs of this accident, very much in doubt; nor do we see how these doubts can be removed until we have in detail the symptoms of at least one example, the indubitable existence of which has been subsequently verified by dissection. Prognosis. —In the case of Cooper's patient, seen several months after the accident, the ulna projected backwards while the arm was extended, but it was without much difficulty drawn forwards and bent, and then the deformity disappeared. He thought that during extension the ulna slipped back behind the inner condyle of the humerus. Brassard's patient, seen after three months, retained the power of pronation and supination, with also extension, but flexion was completely impossible, the forearm being arrested in this direction by the small, slightly movable fragment of bone in front of the elbow-joint, and which was supposed to be the process itself. Penneck's old man, who had met with the accident in boyhood, had still the radius luxated forwards and outwards, and the olecranon more salient backwards than in the sound arm. Extension and flexion were nearly but not quite complete. Fahnestock informs us that his patient " recovered completely," but whether without deformity or maiming we are not told. Couper says the bone was united in four weeks, and that only a slight deformity and a little stiffness remained. Physick's patient made a perfect recovery. Let us come again to the dissections. Rejecting the doubtful specimen belonging to Dr. Gibson, we have an exact account of only two, and, indeed, Sir Astley Cooper alone has described the mode of union. Samuel Cooper says that in the ease of the University College specimen the radius is dislocated forwards and upwards, and the olecranon is displaced backwards, but he does not say whether the coronoid process has united, nor describe its position; but Sir Astley informs us that in the example seen and dissected by him the process was united by ligament, which was sufficiently long and flexible to allow the fragment to move upwards and downwards in the motions of flexion and extension. In the absence of any other testimony, we may be allowed to express an opinion that when the fracture has taken place across the summit or above the insertion of the brachialis anticus, nothing but a ligamentous union can be regarded as possible, since the fragment can only derive nourishment from a few untorn fibres of the capsule and perhaps of the internal lateral ligaments; and although it may not be displaced, it cannot have the advantage of impaction, upon which alone, I suspect, a fracture of the neck of the femur within the capsule must rely for a bony union, if it ever does so unite. If, however, the fracture has taken place at the base, and fortunately it has not become much displaced by the force of the concussion against the humerus, it does not seem to me so impossible that under favorable circumstances a bony union might now and then occur. It will be remembered that a good portion of the attachment of the brachialis anticus is still below the fracture, and the remaining fibres are not 295 FRACTURES OF THE OLECRANON PROCESS. therefore very likely to displace the fragment, especially when the arm is sufficiently flexed, so as to properly relax this muscle. It will be of small importance, however, whether the union is bony or ligamentous, provided only there is not great displacement. Treatment. —Whatever view we take of the pathology of this accident, the rational mode of treatment would seem to consist in flexing the arm at a right angle, and retaining it a sufficient length of time in that position; not forgetting, however, the danger of anchylosis from long-continued confinement in one position. An angular splint may be useful in preventing motion at first, but I think it ought not to be continued beyond seven or ten days at the most. After this, a simple sling is all that can be necessary, since from this period some motion must be given to the joint if we would take the proper precautions to prevent stiffness. Sir Astley Cooper thought the limb ought to be kept immovable three weeks, and Velpeau preferred four; but I cannot agree with them, believing that the question of the future mobility of the elbow-joint is vastly more important than the question of a bony or ligamentous union between the fragments. Couper says that he adopted in the treatment of the case reported by him, extreme flexion, but both Physick and Fahnestock placed the arm at right angles, and Sir Astley Cooper has recommended the same position. The latter position has always the advantage in case permanent anchylosis occurs, and the former cannot add much to the chance of complete replacement of the fragment. Bandages are only serviceable to retain the splint in place, and they may be thrown aside as soon as the splint is removed. § 3. Fractures of the Olecranon Process. Causes. —So far as I have been able to ascertain, all the fractures of this process which I have seen were occasioned by falls upon the elbow, or by blows inflicted directly upon the part. Malgaigne has, however, been able to collect accounts of six examples of fracture of the olecranon, produced, as is affirmed, by the violent action of the triceps; as in pushing with the arm slightly flexed, in throwing a ball, in plunging into the water with the arms extended, etc.; but only four of these reported examples does he think are sufficiently authenticated to entitle them to be received as facts; nor do I think it possible to affirm positively that in any instance, where the whole process is broken off, the triceps alone has occasioned the separation. For example, Capiomont reports the case of a cavalier, who, being intoxicated, was thrown head foremost from his horse, and striking probably upon his hand, was found to have broken the olecranon process. We do not, in this example, see evidence alone of a forcible contraction of the triceps, but also of violent pressure against the hand and in the direction of the axis of the forearm toward the elbow-joint, by which the olecranon process might have been so thrown forwards against the fossa of the humerus as to cause its separation. The same explanation might apply to several of the other examples. Point and Direction of Fracture; Displacement, etc. —The process may 296 FRACTURES OF THE ULNA. be broken at its summit, at its base, or intermediate between these two extremes, the last of which is the most common. It is probable that when the action of the triceps alone has produced the fracture, it will be found that only the summit, or that portion which receives the insertion of the triceps, has been broken off'. Malgaigne, who has been able to find upon record only two cases of a fracture of the extreme end of the process, declares that they were both occasioned by muscular action. Fractures of the middle are generally transverse, or only slightly oblique, occurring in the line of the junction of the epiphysis with the diaphysis. ¥e think, also, we have reasons for believing that these only occur as a consequence of a fall upon the elbow, or of a blow upon the extreme point of the elbow, when the forearm is considerably flexed upon the arm; the direction of the obliquity, when Fig. 85. Fracture at the base. any is found to exist, being generally from above downwards and from behind forwards, indicating that the direction of the force was also from behind. Fractures through the base are generally quite oblique, the line of fracture extending from before downwards and backwards, so that not only the whole of the process, but a portion of the back of the shaft is carried away; and this accident can scarcely happen, ex- cept by a blow received upon the lower end of the humerus, directly in front of the process; or, what would amount to the same thing, by a blow from behind, received upon the ulna just below the olecranon process, or by wrenching the forearm violently back, while the humerus is fixed. The only displacement to which the upper fragment seems to be liable, is in the direction of the triceps; and the degree of this displacement does not depend so much upon the point at which the fracture has taken place as upon the violence which has occasioned it, the extent of the disruption of the ligaments, aponeurosis of the triceps and of the capsule, and upon whether, since the accident, the arm has been flexed or kept extended. In three instances, I have found distinct crepitus immediately after the fracture had occurred, produced by only moving the fragment laterally, showing plainly that little or no displacement had taken place. The following example will show also that this displacement does not always happen even after the lapse of several days, and where no surgical treatment has been adopted. Samuel Duckett, set. 14, fell upon the point of the elbow, and two days after was admitted to the Buffalo Hospital of the Sisters of Charity. The elbow was then much swollen, but no crepitus could be detected, and he could nearly straighten his arm by the action of the triceps. On the sixth day, the swelling having sufficiently subsided, a distinct 297 FRACTURES OF THE OLECRANON PROCESS. crepitus was discovered when the olecranon process was seized between the fingers, and moved laterally. We extended the arm immediately, and applied a long gutta-percha splint to the whole front of the arm and forearm, securing it in place with a roller. On the eleventh day, five days after the first dressing, the splint was taken off, and its angle at the elbow-joint slightly changed; and this was repeated every day until the twenty-second from the time of the accident. The splint was then finally removed, when the fragment was found to be united without any perceptible displacement, and the motions of the joint were unimpaired. It must not be inferred, however, that it is always prudent to leave this fracture thus unsupported, since it has occasionally happened that the displacement, which did not exist at first, has taken place to the extent of half an inch or more, after the lapse of several days. Mr. Earle mentions a case in which the separation did not take place until the sixth day, when it was occasioned by the patient's attempting to tie his neck-cloth. /Symptoms. —The usual signs of a fracture of the olecranon process, are, when the fragments are not separated, crepitus discovered especially by seizing the process, and moving it laterally; or, when displacement has actually taken place the crepitus may be discovered sometimes by extending the forearm, and pressing the upper fragment downwards until it is made to touch the lower fragment; the existence of a palpable depression between the fragments, partial flexion of the forearm, and total inability, on the part of the patient, to straighten it completely, or even to flex the arm in some cases. If the fragments do not separate, gentle flexion and extension of the arm, while the finger rests upon the process, may enable us to detect the fracture. It will sometimes happen that, owing to the rapid occurrence of tumefaction, the evidences of a fracture will be quite equivocal; but, in all cases where a severe injury has been inflicted upon the point of the elbow, it will be well to suspend judgment until, by repeated examinations, made on successive days, the question is determined. Meanwhile, the arm ought to be kept constantly in an extended position, as if a fracture was known to exist. Prognosis. —In a large majority of cases, this process becomes reunited to the shaft by ligament, which may vary in length from a line to an inch or more, and which is more or less perfect in different cases. Sometimes it is composed of two separate bands, with an intermediate space, or the ligament may have several holes in it; at other times it is composed in part of bone and in part of fibrous tissue; but most frequently it is a single, firm, fibrous cord, whose breadth and thickness are less than that of the process to which it is attached. If the fragments are maintained in perfect apposition, a bony union may occur, yet it is not invariably found to have taken place, even under these circumstances. Malgaigne thinks, also, he has seen one case in which there was neither bone nor fibrous tissue deposited between the fragments. This was an ancient fracture at the base of the olecranon; the superior fragment remained immovable during the 20 298 FRACTURES OF THE ULNA. flexion and extension of the arm, yet it could be moved easily from side to side. In my own cases, I have three times found the fragments united Fig. 86. Union by ligament, without any appreciable separation, and have presumed that the union was bony. One of these examples I have already mentioned; the second, was in the person of a lady aged about forty years, who, having fallen down a flight of steps on the 8th of September, 1857, sent for me immediately. I found a large bloody tumor covering the elbow-joint, but there was no difficulty in detecting a fracture of the olecranon process. It was easily moved from side to side, and this motion was accompanied with a distinct crepitus. During the first week, the arm was only laid upon a pillow, but as it was found to become gradually more flexed, and the swelling having in a great measure subsided, the arm was nearly, but not quite, straightened, and a long gutta-percha splint applied to the palmar surface of the forearm and arm. The fragments united in about twenty or twenty-five days, and without separation, so far as could be discovered in a very careful examination. The third example to which I have referred, occurred in a boy fourteen years old, and was treated by Dr. Benjamin Smith, of Berkshire, Massachusetts. Sixty-nine years after, he being then eighty-three years old, I found the olecranon process united apparently by bone, but to that day he had been unable to straighten the arm completely, or to supine it freely. In one instance I found the fragment, after the lapse of one year, united by a ligament, which seemed to be about one-quarter of an inch in length, and the arm appeared to be in all respects as perfect as the other. He could flex and extend it freely. In the two following examples, also, the bond of union was ligamentous :— John Carbony, set. 18, having broken the olecranon, it was treated with a straight splint. Nine years after, I found the process united by a ligament half an inch in length, and he could nearly, but not entirely, straighten the arm. In all other respects the functions and motions of the arm were perfect. A lad, set. 15, was brought to me by Dr. Lauderdale, a very excellent surgeon in the town of Geneseo, Livingston Co., N. Y., whose olecranon process had been broken by a fall six months before, and at the same time the head of the radius had been dislocated forwards. I found the radius in place, and the olecranon process united by a ligament about half an inch in length. He was not able to straighten the arm completely, the forearm remaining at an angle of 45° with the arm. Treatment. —It will surprise the student who is yet unacquainted with the literature of our science, to learn that in relation to the treatment of a fracture of the olecranon process, a wide difference of opinion 299 FRACTURES OF THE OLECRANON PROCESS. has been entertained as to what ought to be the position of the arm and the forearm, in order to the accomplishment of the most favorable results; and that, while some insist upon the straight position as essential to success, others prefer a slightly flexed position, and still others have advocated the right-angled position. Thus, Hippocrates, and nearly all of the earlier surgeons, down to a period so late as the latter part of the last century, directed that the arm should be placed in a position of demi-flexion; Boyer, Desault, and, after them, most of the French surgeons of our own day, prefer a position in which the forearm is very slightly bent upon the arm; while Sir Astley Cooper, and a large majority of the English and American surgeons, employ complete or extreme extension. The arguments presented by the advocates and antagonists of these various plans deserve a moment's consideration. In favor of the position of demi-flexion, requiring no splints, and, in the opinion of some writers, not even a bandage, but only a sling to support the forearm, it is claimed that it leaves the patient at liberty at once to walk about and to move the elbow-joint freely, so soon at least as the subsidence of the swelling and pain will permit, and that in this way the danger of anchylosis is greatly diminished; that moreover, if anchylosis should unfortunately occur, the limb is in a much better position for the proper performance of its most ordinary functions than if it were extended. Some have also added to this argument a statement that a fibrous union, under any circumstances, is inevitable, and that it is a matter of little consequence whether the ligament thus formed is long or short, since in either condition it will be equally serviceable. In reply to these statements, it may be said briefly that they are nearly all based upon false premises, or that they have been proven in themselves to be essentially erroneous. Anchylosis is always a serious event, which by all possible means the surgeon will seek to prevent, but position has nothing to do with determining this result; when it does occur, it may usually be ascribed either to the severity and complications of the original injury, to the violence of the consequent inflammation, or to having neglected, at a proper period, and with sufficient perseverance, to move the joint. That a fibrous union is inevitable under any circumstances, has been fully proven to be an error; and it has been equally proven that the functions of the arm are generally impaired in proportion to the length of the uniting medium. The only argument which remains, and which really possesses any weight, is, that, if permanent anchylosis does actually occur, the arm, when demi-flexed, is in a better position for the performance of its ordinary functions; and this, considered as an argument in favor of the universal or even general adoption of the flexed position, is successfully met by a statement of the infrequency of permanent anchylosis after a simple fracture, when the case has been properly treated, whether by the flexed or straight position; while, if the limb is flexed, a maiming, as a result of the great length of the intermediate ligament, is almost inevitable. 300 FRACTURES OF THE ULNA. Yet if, in any case, from the great severity and complications of the injury, especially in certain examples of compound and comminuted fracture, it were to be reasonably anticipated that permanent bony anchylosis must result, or even where the probabilities were strongly that way, the surgeon might be justified in selecting for the limb, at once, the position of demi-flexion; or he might leave the arm without a splint, and at liberty to draw up spontaneously and gradually to this position, as it is always very prone to do. In favor of moderate, but not complete extension, it is claimed that it is less fatiguing than the latter position, while it accomplishes a more exact apposition of the fragments, if they happen to be brought actually into contact. I am unable, however, to understand how the apposition can be rendered less exact by complete extension, unless by this is meant a degree of extension beyond that which is natural, and which, I am well aware, is permitted to the elbow-joint when this posterior brace is broken off. It would certainly derange the fragments to place the arm in this extreme condition of natural extension; indeed, perhaps we may admit that, in order to perfect apposition, the extension ought to be less by one or two degrees than what is natural, sufficient to compensate for the trifling amount of effusion which may be presumed to have occurred in the olecranon fossa, and which would prevent the process from sinking again fairly into its fossa. As to its being less fatiguing, it is well known to those accustomed to treat fractures of the thigh by permanent extension that the muscles rapidly acquire a tolerance, which soon dissipates all feeling of fatigue, and that, after a few hours, or days at most, the patients express themselves as being more comfortable in this position than in the flexed. Finally, the advocates of complete extension claim that in this position alone, is the triceps most perfectly relaxed, and consequently the most important indication, namely, the descent of the olecranon, most fully accomplished. In this opinion we also concur; and regarding all other considerations, in the early days of the treatment, as secondary to this one, we unhesitatingly declare our preference for what has been called the "position of complete extension." It only remains for us to determine by what means the limb can be best maintained in the extended position, and the olecranon process most easily and effectually secured in place. For this purpose a variety of ingenious plans have been devised; Fig. 87. Sir Astley Cooper's method. such as the compress and "figure-of-8" bandage of Duverney, without splints; or a similar bandage employed by Desault, with the addition 301 FRACTURES OF ffHE OLECRANON PROCESS. of a long splint in front; the circular and transverse bandages of Sir Astley Cooper, with lateral tapes to draw them together, to which also a splint was added; and many other modes not varying essentially from those already described, but nearly all of which are liable to one serious objection, namely, that if they are applied with sufficient firmness to hold upon the fragment, and Boyer says they " ought to be drawn very tight," they ligate the limb so completely as to interrupt its circulation, and expose the limb greatly to the hazards of swelling, ulceration, and even gangrene. How else is it possible to make the bandage effective upon a small fragment of bone, scarcely larger than the tendon which envelops its upper end, and with no salient points against which the compress or the roller can make advantageous pressure? If, then, these accidents, swelling, ulceration, and gangrene, are not of frequent occurrence, it is only because the bandage has not been generally applied " very tight," and while it has done no harm, it has as plainly done no good. The dangers to which I allude may be easily avoided, without relaxing the security afforded by the compress and bandage, by a method which is very simple, and the value of which I have already sufficiently determined by my own practice. The surgeon will prepare, extemporaneously always, for no single pattern will fit two arms, a splint, from a long and sound wooden shingle, or from any piece of thin, light board. This must be long enough to reach from near the wrist-joint, to within three or four inches of the shoulder, and of a width equal to the widest part of the limb. Its width must be uniform throughout, except that, at a point corresponding to a point three inches, or thereabouts, below the top of the olecranon process, there shall be a notch on each side, or a slight narrowing of the splint. One surface of the splint is now to be Fig. 88. Fig. 89. The author's method. thickly padded with hair or cotton-batting, so as to fit all of the inequalities of the arm, forearm, and elbow, and the whole covered neatly with a piece of cotton cloth, stitched together upon the back of the splint. Thus prepared, it is to be laid upon the palmar surface 302 FRACTURES OF THE ULNA. of the limb, and a roller is to be applied, commencing at the hand and covering the splint, by successive circular turns, until the notch is reached, from which point the roller is to pass upwards and backwards behind the olecranon process and down again to the same point on the opposite side of the splint; after making a second oblique turn above the olecranon, to render it more secure, the roller may begin gradually to descend, each turn being less oblique, and passing through the same notch, until the whole of the back of the elbowjoint is covered. This completes the adjustment of the fragments, and it only remains to carry the roller again upwards, by circular turns, until the whole arm is covered as high as the top of the splint. The advantage of this mode of dressing must be apparent. It leaves, on each side of the splint, a space upon which neither the splint nor bandage can make pressure, and the circulation of the limb is, therefore, unembarrassed, while it is equally effective in retaining the olecranon in place, and much less liable to become disarranged. Before the bandage is applied about the elbow-joint, the olecranon must be drawn down, as well as it can be, by pressure with the fingers, and a compress of folded linen, wetted to prevent its sliding, must be placed partly above and partly upon the process; at the same time, also, care must be taken that the skin is not folded in between the fragments. This dressing ought, no doubt, to be applied immediately, since, if we wait, as Boyer seems to advise, until the swelling has subsided, it will be found much more difficult to straighten the arm completely than it would have been at first, and the olecranon process will be more drawn up and fixed in its abnormal position. Something will be gained by these means, adopted early, even if the bandage cannot be applied tightly, and moderate bandaging will not in any way interfere with the proper and successful treatment of the inflammation. We must always keep in mind, however, the fact that the fracture being usually the result of a direct blow, considerable inflammation and swelling about the joint are about to follow rapidly; and on each successive day, or oftener if necessary, the bandages must be examined carefully, and promptly loosened whenever it seems to be necessary. For this purpose it is better not to unroll the bandages, but to cut them with a pair of scissors, along the face of the splint, cutting only a small portion at a time, and as they draw back, stitch them together again lightly; and thus proceed until the whole has been rendered sufficiently loose. As soon as the inflammation has subsided, and as early sometimes as the fifth or seventh day, the dressings ought to be removed completely ; and while the fingers of the surgeon, resting upon a compress, sustain the process, the elbow ought to be gently and slightly flexed and extended two or three times. From this time forward, until the union is consummated, this practice should be continued daily, only increasing the flexion each time, as the inflammation and pain may permit. If it is thought best, at length, to change the angle of the arm, and to flex it more and more, it may be done easily by substituting a very thick sheet of gutta percha for the board. FRACTURES OF THE RADIUS AND ULNA. 303 Dieffenbaeh has several times, in old fractures of both the olecranon and patella, where the fragments were dragged far apart, divided the tendons, so as to be able to bring the two portions together, and, by friction of them one upon the other, has endeavored to excite such action as might end in the formation of a shorter and a firmer bond of union. In some instances, it is said, considerable benefit was obtained, after all other means had failed; in others, the result was negative. One example of an old ununited fracture of the olecranon is mentioned, in which he divided the tendon of the triceps, secured the upper fragment in place, and every fourteen days rubbed it well against the lower one; in three months " the union was firm." 1 The practice, not without its hazards, needs further observations to determine its value. CHAPTER XXIII. FRACTURES OF THE RADIUS AND ULNA. Causes. —In a large majority of the examples of this fracture seen by me, which have been of such a character as to warrant an attempt to save the limb, the accident has been occasioned by a fall upon the palm of the hand while the arm was extended in front of the body. Yet this cause is not so constant as in fractures of the radius alone, since a considerable number have been occasioned by direct blows; and if we were to add to this estimate all of those bad compound fractures which have demanded immediate amputation, the proportion of fractures occasioned by direct and indirect blows might be found to be pretty nearly balanced. Point of Fracture, Character, Direction of Displacement, &c. —In a record of fifty-seven fractures of both bones, I have noticed but three examples in the upper third; while I have found that twenty-three happened in the middle third, twenty-nine in the lower third; and Fig. 90. Fracture in the middle third. in one case the radius was broken three-quarters of an inch above its lower end, and the ulna about one inch below the coronoid process. 1 Dieffenbaeh, American Journal of Medical Science, vol. xxix. p. 478 ; from Casper's Wochenschrift, Oct. 2d, 1841. 304 FRACTURES OF THE RADIUS AND ULNA Fig. 91. Fracture in the lower third. Four of the fractures belonging to the lower third were probably epiphyseal separations. Forty-eight were in males, and nine in females. Twenty-one are known to have occurred in the right arm and fourteen in the left. Forty-five were simple, seven compound, one was comminuted, three both compound and comminuted, one complicated with a fracture of the humerus, and one with a partial luxation of the lower end of the radius. With three exceptions, all of these more serious accidents were arranged among fractures of the lower third, and generally the bones had been broken near the wrist. Partial fractures have been frequently observed, but having treated of these fractures freely in another chapter, I shall not think it necessary to make any further allusion to them in this place. Prognosis. —Generally these bones unite in from twenty to thirty days; but I have seen the union occasionally delayed considerably beyond this time, and this delay has occurred especially in the case of the radius. Thus, in three cases of compound and comminuted fracture, the ulna united within four or five weeks, while the radius did not unite until the ninth or tenth week. Twice in simple fractures the ulna has united in the usual time, but the radius not until the sixteenth week. Once Fig 92. Union with Blight lateral displacement. the ulna has united promptly and the radius remained ununited at the end of two years, at which time I practised resection of the broken ends of the radius, and union was speedily established. On the other hand I have once seen the union delayed four months in the case of the ulna, when the radius had united in the usual time; and in one example of compound fracture both bones refused to unite until after the fifth month. Thirty-two of the whole number have united without any appreciable deformity, and fifteen are known to have left some marked defect, while two have resulted finally in the loss of the arm. I have seen the fragments deviate slightly in almost every direction, but most often it has been noticed that the deviation was to the radial or ulnar sides. Thus, in three examples, two of which had been compound fractures, the bones have united in such a position as that from the point of fracture downwards the forearm has been deflected to the ulnar side, and a marked projection has been left at the seat of fracture on the radial side; while in two examples, both of which were simple fractures, exactly the opposite condition has obtained, the lower part of the forearm being deflected to the radial side. 305 FRACTURES OF THE RADIUS AND ULNA. In a majority of cases the hand has been left with some tendency to pronation; in many instances this tendency was very slight and scarcely appreciable, but in others it has been quite marked, so that the patients have been wholly unable to supine the forearm except by a motion of the humerus in its socket. From what has been said it must be seen that the prognosis in these accidents takes the widest range: for while a larger proportion than in the case of almost any other of the long bones, unite without any appreciable deformity, a considerable number delay to unite or do not unite at all, and some, even where the fracture is most simple, result in the complete loss of the limb. I am not now speaking of those more severe accidents in which the limb is at once condemned to amputation, and which, in the case of the arm, are numerous; but as I have already mentioned, our observations here apply only to cases which came under treatment with a view especially to the fracture. I shall state the facts more fully, and then perhaps we shall think it proper to inquire why, when, as a rule, the treatment is found to be so simple and successful, occasionally, and pretty often indeed, it results so disastrously. A boy, aged about ten years, fell from a tree, April 22, 1856, fracturing the right forearm near the lower end of the middle third. It was evident that he had fallen upon the palm of his hand, as the lower fragments were inclined backwards, and one of the bones had been thrust through the skin on the front of the arm. It was at first dressed carefully by Dr. Wilcox, but the father of the lad on the following day placed him under the care of an empiric. Six days after the fracture occurred, I was called to see him, with several other gentlemen. He was then suffering under a severe attack of tetanus which had commenced the night before. His arm was much swollen and very painful. He died the same evening. I was unable to learn very particularly what had been the treatment since the patient was seen by Dr. Wilcox, except that the bandages had been most of the time very tight, and that the empiric had applied stimulating liniments, the boy constantly complaining greatly of the pain. I found the arm done up in a most slovenly manner with several narrow splints, underlaid with loose and knotty fragments of cotton batting. We removed all of these immediately, and laid the arm upon a cushion supported by a board, to both of which the arm was lightly secured by a few turns of a bandage; cool water lotions were diligently applied and chloroform administered by inhalation; but the fatal event was delayed only a few hours. I shall not stop to inquire the case of a result so unfortunate, where the treatment has been so palpably unskilful. I have already mentioned one case of gangrene of the hand, after a fracture of the lower part of the humerus; Norris, in a note to the American edition of Listoris Surgery, mentions a case which came under his observation in the Pennsylvania Hospital, the fracture having taken place just above the condyles, and still another has been related to me lately. I have brought together also no less than five 306 FRACTURES OF THE RADIUS AND ULNA. cases of sloughing of the arm, after fracture of the radius, and one of sloughing from tight bandaging, where the radius was supposed to be broken, although the dissection proved that it was not. Robert Smith says, that similar cases have been recorded in the Gazette Medicate. To these I shall now add two examples of sloughing after fracture of both radius and ulna; making a total of eleven cases in the upper extremities, in addition to those reported in the Gazette Medicate, an exact account of which I have not seen. John McGrath, set. 9, fell, July 2, 1847, from a ladder, about thirty feet to the ground, breaking the right radius and ulna in their middle thirds. A surgeon was in attendance about four or five hours after the accident occurred. He then reduced the fractures and applied two broad splints, one on the palmar and one on the dorsal surface of the forearm. Whether a roller was first applied to the arm, or not, I am unable to say. The splints were secured in place by a roller and the arm laid in a sling. The third day was our national holiday, and the patient was not visited. Nor was he seen on the fourth day, not being found at home. On the fifth day the surgeon removed the bandages and found the arm gangrenous; and within an hour afterwards I was requested to see it also. I found him lying in a miserable apartment, with his right arm resting upon a pillow. The arm, forearm, and hand were gangrenous through their whole extent; and the skin of the right side, on the front of the chest, had assumed a dusky color, the extreme margin of which was indicated by an abrupt crescentic line. The thumb and fingers were black. His countenance was bright and cheerful, and his mind intelligent; pulse 75, and soft; tongue clean. He had slept undisturbed the night before, and he had all along felt perfectly well, except that he had a slight diarrhoea. I was assured by the surgeon and by all of the family, that the bandages had not been applied tightly; but we were told that on the third day of the accident, having been locked into the house by his mother, who was a peddler, he climbed out of the window, and that during all of that, and most of the following day he was running about the streets firing crackers, during most of which time his arm was removed from his sling and hanging by his side. On the morning of the fourth day, his mother noticed that his fingers were black, but she thought they were stained with powder. We ordered him to take one-quarter of a grain of opium every four hours, and applied a yeast poultice to the arm. On the seventh day the gangrene was still extending, and the pulse was 124; yet he continued to feel well and to eat as usual. On the tenth day, the line of demarcation had commenced opposite the shoulder-joint; and the crescentic discoloration on the breast, which had at first spread rapidly until it covered nearly the whole upper half of the chest, was quite faint, in some parts almost lost. In a few days more he was removed to the county almshouse, the separation continuing rapidly to take place until the arm fell off at the shoulder-joint; after which he made a good recovery. FRACTURES OF THE RADIUS AND ULNA. 307 A child two years and three months old, had fallen from a chair upon the floor, a distance of about two feet. A German physician being called, found, as he believes, a fracture of both bones of the left arm. The fracture was near the middle. He immediately applied a roller from the fingers to the elbow, and over this three narrow splints made of the wood of a cigar box. One of these was laid upon the palmar, one upon the dorsal, and one upon the radial side of the forearm, and the whole were bound together by another roller. From this time until the tenth day the child continued to play about on the floor. Ten days after the accident occurred the doctor noticed that the ulnar side of the little finger was blue. The bandages were immediately removed, and were never again applied tightly. Three or four days after I was requested to see the arm with the attending physician. The gangrene had continued to extend, involving now the whole of the little finger and most of the thumb. There were also gangrenous spots over the hand and forearm, extending to within one inch from the elbow-joint; these spots were more numerous in front and on the back of the forearm, and seemed to correspond to the pressure of the splints. The hand was much swollen, and also the arm above the line of the gangrene. The sloughs had already commenced to be thrown oftj and the gangrene was only extending in a few points. The child appeared well and rather playful, except when the arm was being dressed. I ordered a yeast poultice, and a nourishing diet. I have since learned that the arm and a large portion of the hand were finally saved. South also says that he has seen one or two instances of mortification produced by splints applied too tightly, and previous to the accession of the swelling after fracture, and which have not been loosened as the swelling increased. 1 How shall we explain the frequency of these accidents after fracture, especially of the forearm ? Malgaigne, speaking of fractures of both bones of the forearm, remarks that "when the displacement is considerable, or more especially when the outward violence has been excessive, we frequently see follow a very intense inflammatory swelling, and there is no fracture which complicates itself so easily with gangrene under the pressure of apparatus. 1 Says Nelaton: " If we make choice of the apparatus of J. L. Petit, it is necessary that it shall not be applied too tightly, for, as Professor Roux has long since remarked, fractures of the forearm are those which furnish most of the examples of gangrene in consequence of an arrest of the circulation. This is easily understood, if we consider on the one hand the superficial position of the two principal arteries of the forearm, and on the other the disposition of the appareil, which must almost infallibly compress the arteries to a great extent." 3 1 South, note to Chelius's Surg., vol. i. p. 69. * Malgaigne, Frac. et Disloc, torn. i. p. 589. ¦ Nelaton, Pathologie Chirurgicale, p. 735. 308 FRACTURES OF THE RADIUS AND ULNA. I do not think that this accident is due always to the negligence of the surgeon. It may be due many times to the carelessness of the parents or of the patient himself; as in the case of the boy who came under my own observation, and who lost his arm at the shoulderjoint. Sometimes also it may be due rather to the severity of the original injury, which, the experience of every surgeon will prove, is occasionally competent to the production of such bad results. A number of unfortunate circumstances may have concurred, such as a severe injury, especially where the skin has remained unbroken and the effused blood has had no opportunity to escape—the broken bone may have rested against the trunk of a main artery causing an arrest of its circulation—the constitution may be impaired by previous illness, or it may be suffering under the shock of the injury; yet that it may be and too often is the result of maltreatment, on the part of the surgeon, is undeniable. It is proper, however, to discriminate between the responsibility which attaches to the surgeon as the true exponent of the state of his art, and that which attaches to the art itself as taught by the masters. The old surgeons applied first a roller to the hand and forearm, and over this their various splints. J. L. Petit thought he had made a valuable improvement upon this simple plan in laying over the roller a compress, supported by a splint, designed to press between the bones, and to antagonize thus the action of the roller in drawing the fragments toward each other. Duverney believed that this object would be best accomplished by placing the pad against the skin, and under a circular compress; while Desault declares all of these modes inefficient, and announces a method which he regards as accomplishing at once and completely all of the indications; the sole peculiarity of which method consists in placing the graduated pads against the sldn, and securing them in place by a roller. Boyer adopts the same method without any modifications, and Mr. Hind, in his illustrations of fractures already referred to, has seen fit to recommend the same, at least in fractures of the radius. It is quite obvious that between these various methods there remains very little if anything to choose, the differences being too trifling and unessential to claim serious consideration. Each alike is inadequate to accomplish any amount of useful pressure between the fragments; each alike is calculated to bind the bones one against the other, and each alike exposes to the danger of ligation and of gangrene. Says M. Dupuytren: " The practice of rolling the arm before the splints are applied, whether internal or external to the pads and compresses, is eminently mischievous; and instead of fulfilling, directly counteracts, the indications which it is most important to keep in view in the treatment of fractures of the forearm." And notwithstanding the same sentiment has been reiterated by Velpeau, Malgaigne, Nelaton, Samuel Cooper, Bransby Cooper, Erichsen, Amesbury, Gibson and others, yet we find to-day the great surgeon of Heidelburgh, Chelius, recommending the roller to be applied under the splints, after the manner of Desault: while Liston, Syme, and Fergusson, who perhaps represent the Edinburgh school, 309 FRACTURES OF THE RADIUS AND ULNA. use only pasteboard splints above the compresses, over which is immediately applied the roller; a practice which differs very little from that recommended by Desault, and is equally obnoxious to criticism. Among the American surgeons, I believe, the advice and practice of Dupuytren have received almost universal assent, only that we have always employed splints much wider than those recommended by this distinguished surgeon. I cannot therefore agree with my accomplished countryman, Dr. Eeynell Coates, if in the following paragraph he means to imply that American surgeons generally adopt Desault's treatment. Such at least is not my experience. " It would be wrong," says Dr. Coates, " not to bear testimony, on every possible occasion, against the folly so universally prevalent, that induces surgeons to apply a bandage directly to the forearm before applying splints in injuries of this character. We have often asked for a rational explanation of this practice, without effect. It is directly at war with the acknowledged indications in the coaptation of the fragments, and when the object of the whole apparatus is to thrust asunder their extremities, it commences by binding them together. Few plans in surgery are more generally followed; none can be more absurd." Of the estimate placed upon the roller by M. Mayor, the reader will judge by a reference to the passage which I shall quote further on, when I shall speak of the value of the interosseous compresses. Amesbury and Bransby Cooper use no rollers at all—not even to secure the splints in place, they being made fast to the forearm by straps or tapes; a practice which, I am happy to say, has found hitherto, except perhaps among the English, very few followers. Mr. Amesbury and Mr. South also endeavor to give to their splints an appropriate shape, by having them constructed with more or less convexity. It must be noticed, however, that the practice of these two gentlemen is very dissimilar, for while Mr. South applies the convex surface of his splint to the interosseous space, Mr. Amesbury reverses this plan, and applies the concave surface directly to the skin. As to the width of the splints, surgeons are also very generally agreed, at the present day, that they ought to be at least wider than the arm, so as to prevent the roller or the tapes from resting against its sides. I do not intend to deny peremptorily, and without qualification, the value of the graduated compresses, which, as we have seen, are usually laid along the interosseous space to press the fragments asunder. It is necessary, however, to caution the surgeon against their injudicious use. M. Nelaton has well remarked of the apparel employed by J. L. Petit, that it must inevitably compress, to a great extent, the arteries of the forearm; and the remark is applicable, in only a less degree, to all of those other plans in which the compress is employed. And I suspect that to this portion of the dressing, quite as much as to any other cause, are due those frightful accidents of which we have already spoken. The arteries are not only exposed, from their superficial position, to pressure from a compress, but, in addition to this, it will be noticed that the two principal arteries, the radial and the ulnar, 310 FRACTURES OF THE RADIUS AND ULNA. are situated upon a broad and flat surface of bone, along which this pressure must operate most advantageously. So early as the year 1833, M. Lenoir, in his inaugural thesis, at Paris, called attention to this danger, and from time to time surgeons have continued to advert to it, but they have seldom given to its consideration that prominence which its importance deserves. I have observed another fact in this connection: when this compress is extended low down on the palmar surface, within an inch or two of the wrist-joint, it soon becomes excessively painful, and sometimes even wholly insupportable, in consequence of the pressure made upon the median nerve; and I find myself always obliged to exercise great care in the adaptation of the pads at this point. For this reason alone I believe, in case of a fracture near the base of the radius, the lower fragment, if it were thrown toward the ulna, could not be retained in its place by graduated compresses. In short, finding that broad splints, properly covered and padded, answer very well to crowd the muscles into the interosseous space, so far as it is proper to do so, and believing that this mode is less painful and less dangerous, I seldom resort to graduated compresses, nor can I appreciate their necessity, or, indeed, their utility. Mr. Lonsdale also concurs with me in attaching very little value to this part of the accustomed apparel. But listen to the surgeon of Lausanne, M. Mayor: "What signify graduated compresses placed between the bones of the forearm for the purpose of separating them from each other ? These bones will not have that constant tendency to approach each other which has been supposed, provided, first, that they have been well reduced; second, that for the purpose of maintaining them in position we do not make use of a preliminary circular bandage, whose action is an absurdity; and, in short, provided we make the retentive means act chiefly upon the palmar and dorsal surfaces of the forearm." 1 M. Mayor proceeds to declare these convictions to be the result of his own experience, both in the treatment of simple and compound fractures of the forearm, and he intimates that in the use of the cir- cular bandage with compresses, surgeons seem to have rolled the arm into a cylinder and drawn the bones together, in order that they might tax their ingenuity to discover some means to again separate them. Surgeons have generally, after the splints have been applied, placed the forearm in a position of semi-pronation, or midway between supination and pronation, so that the radius should be uppermost; it being assumed that in this position the two bones are most nearly parallel, and least inclined to displacement. Such, indeed, was the practice of Hippocrates, Paulus Celsus, Albucasis, and of most surgeons down to this day; but Lonsdale, Eobert Smith, Nelaton and South have lately called in question the correctness of this mode of dressing, at least when it is adopted as a universal rule. 1 Bandages et Appareils a Pansements, ou Nouveau Systeme de Deligation Chirurgicale, par M. Mathias Mayor, Chirurg. en Chef de l'Hopital de Lausanne, Switzerland. Paris ed. 1838, p. 345. 311 FRACTURES OF THE RADIUS AND ULNA. I have before mentioned, when treating of fractures of the ulna, that M. Fleury had, in one instance, been unable to bring the fragments into apposition except by forced supination of the forearm; and in certain fractures we have seen the same position recommended by Lonsdale. Says Mr. South, in a note to Chelius: " In fractures of both bones the forearm is best laid supine;" and Nelaton declares that in fractures of the radius and ulna at any point of their upper thirds it will be necessary to supine the arm, both in the reduction and during the subsequent treatment; but that in fractures of the inferior two-thirds we may place the limb in a condition of semi-pronation. It seems very probable, however, that both of these gentlemen have received their suggestions from Mr. Lonsdale, who, as we have already seen, has treated the question very much at length, and who has finally declared his decided preference for the supine position in the treatment of all fractures of the forearm. His arguments are certainly very ingenious, and as applied to fractures of the radius above the insertion of the pronator radii teres, they seem altogether conclusive; and, indeed, they commend themselves very strongly to our judgment, as applied to all fractures of the forearm. They are sustained also by the results of his own experience, and I see no good reason why they should not be more thoroughly examined and tested by other surgeons. The advantages which he claims for this method are more perfect coaptation of the broken ends, less liability of the fragments to encroach upon the interosseous space, and consequently less danger of anchylosis between the bones, and of non-union of the fragments, more complete restoration of the power of supination, and less tendency to lateral distortion, or of falling off to the ulnar or radial sides. My own cases, treated by the usual method, have shown that while supination is frequently impaired, and sometimes entirely lost, pronation is rarely affected; and that lateral displacements are much more common than displacements forwards or backwards. How this position, semi-pronation, may tend to the production of a permanent pronation, I have fully explained when speaking of fractures of the head of the radius; and the influence of the same position, the forearm resting upon its ulnar margin in the sling, in the production of a lateral deviation is also easily understood. If the arm rests upon the sling so that its weight bears more upon the point of fracture than upon the extremities of the bones, then the ulna, or both ulna and radius, will incline gradually to the radial side, and the hand will fall off to the ulnar side; or if the sling rests under the wrist or hand chiefly, the hand will ascend to the radial side, and the broken ends of the two bones will project to the ulnar side. If this plan is adopted, viz : laying the hand and forearm upon its back, instead of upon its ulnar margin, the elbow should remain at the side, the humerus falling perpendicularly from its socket; and the forearm should rest in the sling directed forwards from the body. Or, if it is found impossible or inconvenient, owing to the resistance of the pronator muscles, to supine the arm while it is suspended in a 312 FRACTURES OF THE CARPAL BONES. sling, it will be best to keep the patient in the recumbent posture with the arm extended upon a pillow. Finally, whatever may be the mode of dressing, let me repeat the injunction to examine the arm frequently. No surgeon can do justice to himself, or to his patient, who does not look at the arm at least once in twenty-four hours during the first ten or fourteen days, and in some cases the patient ought to be seen twice daily. When the fracture is compound, it is often quite impossible to retain the forearm in the half-pronated position; since, when thus placed, and only slightly supported, as it must necessarily be, it inevitably falls over upon its palmar surface. There can be no doubt that in such a case we ought from the first, if it is found practicable, to place it upon its back, in a position of complete or nearly complete supination. For this purpose, a single broad splint, carefully cushioned and covered with oiled cloth, is the most suitable. Upon this the forearm is to be laid and secured gently with a few turns of the roller. If the patient is able to do so, and wishes to walk about, the board may be suspended to the neck, as recommended by M. Mayor. I have said that we ought in case of a compound fracture to lay the forearm upon its back if practicable. I am sure, however, that the surgeon will find very many patients who cannot endure this position, and he may be compelled therefore to lay the limb upon its palmar surface, or to leave it to assume any other position in which it may be the most at ease. CHAPTER XXIV. FRACTURES OF THE CARPAL BONES. The few cases of fracture of the carpal bones which have come under my observation were, without exception, compound and complicated, and have resulted in the complete loss of the hand, or in some less serious, but never inconsiderable mutilation or maiming. In no case has a treatment been adopted which might be regarded as having reference to the fracture, or the purpose of which was to insure apposition and union of the fragments. It may be proper to assume, in a matter so easily comprehended, what actual and recorded experience has not proven, namely, that simple fractures of these bones will demand very little surgical interference, and that they will unite generally without much displacement, and without any considerable maiming. It is, indeed, quite probable that some degree of anchylosis between their adjacent surfaces will occur, yet ev%n in the normal condition they enjoy so little motion as to render it doubtful whether its complete loss would be very sensibly felt. FRACTURES OF THE METACARPAL BONES. 313 In cases of comminuted, compound, and otherwise complicated fractures of the carpal bones, which accidents are sufficiently common, the surgeon has only, I conceive, to follow carefully those general or special indications which may happen to be present, the precise character of which it would be difficult to anticipate, and for the treatment of which it would be unsafe to attempt in a written treatise to provide. CHAPTER XXV. FRACTURES OF THE METACARPAL BONES. Causes. —These bones, also, are generally broken by direct blows ; and in that case the injury is often of such a character as to demand amputation, and does not therefore belong to that class of accidents of which it is the purpose of this volume to treat. Not an inconsiderable number, however, are the results of indirect blows, and especially of blows upon the knuckles received in pugilistic encounters. Thus, in a record of thirteen fractures, I find this cause assigned in six; in one other instance it was occasioned by falling upon the clenched fist, and in one by striking a board; so that the fracture has resulted from a blow upon the ends of the bones in eight of the thirteen examples. Dorsey, in his Elements of Surgery, mentions also that he has known the metacarpal bones to be fractured in pugilistic contests. Point of Fracture; Direction of Displacement; Symptoms. —Once the fracture has occurred in the metacarpal bone of the thumb; five times in the metacarpal bone of the index finger; once in the second finger; three times in the ring finger, and three times in the metacarpal bone of the little finger. Two of those belonging to the ring finger, and the three occurring in the little finger, were produced by blows with the clenched fist, and in each instance the fracture was in the lower or distal third of the bone. Two of the fractures of the metacarpal bone of the index finger were produced also in the same way; but the fractures were near the middle of the bone. Of the whole number, six were broken through the lower third, five through the middle, and two through the upper third. In every instance where the bone is known to have been broken by a blow upon the knuckles, the lower end of the lower fragment was thrown toward the palm, and this fragment was salient backwards at the point of fracture. In the following case the bone was probably separated at the epiphysis. Thomas Rose, set. 8, fell down a flight of steps, Sept. 11, 1855, breaking the metacarpal bone of the index finger of the right hand near its lower extremity, and apparently at the junction of the epiphysis with the diaphysis. 21 314 FRACTURES OF THE METACARPAL BONES. I saw the lad about sixteen hours after the accident. The lower fragment, projecting abruptly into the palm of the hand, could be easily replaced, or with only moderate effort, yet immediately when the support was removed it would become displaced. There was no crepitus. It was dressed very carefully with a splint and compress; but notwithstanding our continued efforts to keep the fragments in place, the epiphysis united considerably depressed toward the palm. In one instance, also, I think the bone was rather bent, or partially fractured, than broken completely. This was the case of fracture of the metacarpal bone of the ring finger, produced in a gymnasium by striking with the clenched fist against a board, and to which I have already alluded. I did not see the young man until four weeks after the accident, when I found the lower end of the bone depressed toward the palm and the angle made at the point of fracture was rather rounded and quite smooth; it was also tender at this point, but the bone was firm and unyielding. Four years after I was permitted to examine it again, and I found the same slight deformity still continuing. A partial explanation of the fact that the joint end of the lower fragment is generally displaced toward the palm, may be found in the natural curve of these bones, which is such that when the fracture has been produced by a counter-stroke, the distal end would almost necessarily be driven in this direction; and a further explanation has been suggested by Mr. B. Cooper, namely, the action of the interossei. Results. —Generally, when the fracture is simple, and the displacement is not considerable, the nature of the accident is overlooked, and some deformity must inevitably ensue. In a majority of the cases which have come under my observation this has been the fact, and the bone has remained slightly bent at the seat of fracture, but without affecting in any degree the value of the hand. The following example has furnished the most serious result of any case of simple fracture of these bones which has come under my notice. Louis Mooney, set. 25, struck a man with his clenched fist, Nov. 4, 1856, breaking the metacarpal bone of the index finger of the right hand, near its middle. Great swelling and suppuration followed the injury. February 21, 1857, nearly four months after the injury was received, he consulted me. There existed at this time a complete anchylosis at the wrist-joint, and partial anchylosis in the fingers. The hand was deflected forcibly to the radial side. At the point of fracture the fragments were salient backwards and quite prominent, but firmly united. Even when the existence of the fracture is recognized, it is not always easy to retain the fragments in place, as the case of epiphyseal separation already mentioned, and the following case, will illustrate. Miss E., of Erie Co., N. Y., aat. 18, fell, Aug. 7,1853, striking upon her right hand with her fingers forcibly bent into the palm of the hand. On the following day she consulted me at my office, and I FRACTURES OF THE METACARPAL BONES. 315 found the metacarpal bone of the ring finger broken about threequarters of an inch from its lower end, and the distal extremity of the fragment depressed toward the palm. A feeble crepitus, with distinct motion, completed the diagnosis. The young lady was very anxious to have a perfect hand, and I was determined if possible to accomplish it. Finding that the lower fragment was constantly disposed to fall toward the palm, I constructed a gutta-percha splint for the hand and fingers, and after placing a pad directly underneath this fragment, I secured it firmly with a roller. From this time until the end of four weeks she remained under my care, visiting me as often as once or twice a week; and at each dressing I found the lower fragment slightly displaced in the same direction as at first, nor was I able ever to make it resume completely its position. Ordinarily, however, no such difficulty is experienced, and the bone, supported by such simple means as we shall presently direct, unites quickly and without deformity. An engineer, residing in this city, was struck by a piece of iron in such a way as to break his right forearm and the second metacarpal bone of the same hand. The fracture of the metacarpal bone was compound and about three-quarters of an inch from its proximal extremity. When he called upon me, which was immediately after the injury was received, I found the proximal fragment projecting directly backwards, its sharp point rising above the skin; into which position it was evidently drawn by the action of the extensor carpi radialis longior muscle. By pressure alone it could be replaced, but it was much more easily reduced when the hand was forcibly carried backwards on the forearm. I therefore secured the hand in this position with appropriate splints, and it was maintained in this posture during most of the subsequent treatment. Union finally took place, but not without some backward displacement. Four months after the accident occurred, on the 31st of Dec, 1858, I examined the hand, and found the skin healed over completely, the end of the fragment having become rounded and smooth so as not to give him any degree of annoyance. His wrist was as flexible and as strong as before. No doubt the projection of the fragment might have been prevented entirely by cutting at the point of its attachment the tendon of the extensor muscle, but this would have sensibly weakened the wrist-joint, and I preferred the alternative of a projection of the fragment. Treatment —With moderate extension made upon the finger corresponding to the broken bone, while the fragments are forced home by firm pressure, the bone may generally be brought at once into line, and we may now proceed to adapt a gutta-percha, felt, or thick pasteboard splint, to either the whole surface of the back or palm of the hand and fingers, while they are held in a position of easy flexion. It is not very material to which of these surfaces the splint is applied; or rather, I may say, it ought to be applied to the one or the other according as circumstances seem to indicate. It should be well padded, and especially at certain points, in order to the more effectual support of the fragments. It is then to be secured in place with several turns of a roller. When either of the metacarpal bones, ex- 316 FRACTURES OF THE FINGERS. cept those of the great or ring finger, is broken, the splint must be wide enough to secure the sides of the hand against the pressure of the roller. Thus dressed, the hand may be laid in a sling beside the chest, or while sitting it may rest upon a table. The apparel must be examined daily, and readjusted as often as it shall become disarranged, or as a doubt shall arise as to the condition of the parts. When the fracture is followed by much inflammation, or occurs near, and especially if it actually involves a joint, the same precautions must be adopted to prevent anchylosis as in the case of similar fractures in other bones. CHAPTER XXVI. FRACTURES OF THE FINGERS. Causes. —I do not remember to have seen a fracture of one of the phalanges produced by a counter-stroke; I am aware, however, that they are occasionally produced in this way, as by falling upon the ends of the fingers, and especially by the stroke of a ball in the game of base. The fact, however, that they are generally the consequence of a direct blow, and that the finger bones are small and only protected by a thin covering of skin and tendons, renders them peculiarly liable to comminution and to other serious complications. Thus, in a record of thirty fractures, only eighteen were sufficiently simple to warrant an attempt to save them; and only five are recorded as simple fractures without complications. The majority of those fingers which were saved were broken through the first phalanx. Twice the fracture has seemed to be a mere separation of the epiphysis. The first was in the person of a boy twelve years old, the separation having taken place, in consequence of a crushing injury, at the distal end of the first phalanx of the second or large finger. A peculiar crepitus, with motion, was easily detected, but there was no displacement. A splint was applied and union occurred in a few days, and without any deformity. The second was in a lad four years old, who was admitted to the Hospital of the Sisters of Charity, Dec. 24, 1849, with a simple fracture of the first phalanx of the ring finger of the left hand; the fracture being at the proximal end of the bone, and at the junction of the epiphysis with the shaft. The finger was so much swollen at first, that no dressings were applied until the fifth day, at which time a gutta-percha splint was moulded to it carefully, it resulted in a perfect cure. 317 FRACTURES OF THE FINGERS. I have never seen the fragments much overlapped, except in one instance. Frequently there has been no perceptible displacement whatever; but generally there will be found a slight displacement in the direction of the diameter of the bone. The case to which I refer as presenting an extraordinary overlapping, was that of an Irish laboring woman, aged about thirty-five years, who, having fallen down a flight of steps, broke the first phalanx of the thumb below its middle. Dr. Congar was first called on the day following the accident, but was unable to reduce the fracture, and on the same day invited me to see the patient with him. The distal fragment was displaced backwards, overlapping the proximal fragment a little more than one-quarter of an inch. We made repeated efforts, by pulling upon the thumb with a sliding noose, and with all the strength of our four hands, but to no purpose. The fragments could not be reduced for one moment; and we left the patient as we had found her, only somewhat the worse for our violent and repeated extensions and manipulations. The finger was already considerably swollen when we began our efforts, and we cannot therefore say what might have been accomplished at an earlier moment, but I confess that our defeat was unexpected, and does not seem to me to be satisfactorily explained. Results. —At least ten have left no appreciable lameness or deformity, and possibly several more. It is therefore probably true that these consequences may be avoided with proper care in one-half of the examples in which we attempt to save the finger; and perhaps it will occasion surprise that a perfect result may not be claimed in a larger proportion; but when we consider how frequently the accident is compound, and that even when it is not, the blow having generally been received directly upon the point of fracture, how promptly swelling ensues, it will be easily understood that it will be often found difficult to determine whether the bone is exactly in line or not, or to maintain it in this position after absolute coaptation has been once secured. I have seen the finger in two or three cases deviate laterally, or become permanently deflected to one side or the other; and once I have found it united, but rotated on its own axis. This latter case is not without instruction. A girl, set. 6, had her little finger caught by a door violently shut, breaking one of the phalanges, and nearly severing the finger. I closed the wound and dressed the finger with a moulded pasteboard splint. My dressings were repeated often, and applied carefully; nor did I detect the rotation which the lower fragment had made upon its own axis until the union was consummated. I then found the extremity of the finger turned so that its palmar surface presented diagonally toward the ring finger. If the surgeon believes that this ought to have been prevented, and that the result evinces a lack of skill or of care, its record may still serve one of the purposes for which it was designed, and secure to the patient sometimes hereafter more faithful and assiduous attention. Treatment. —Boyer, and after him Bransby Cooper, have taught that 318 FRACTURES OF THE FINGERS. when the extreme phalanx is broken, from the small size of the bone, and from its having attached to it the nail and its matrix, it is better, in all cases, to amputate at once, as the process of reparation is in such case extremely slow and uncertain. "Whether in any of the cases treated by myself, or which have been seen by me, the fracture involved the last phalanx, I am not now able to say, but my impression is that such cases have come under my notice which have been successfully treated, and I cannot but regard the rule established by these gentlemen as much too stringent. Examples must, no doubt, sometimes occur, in which the fracture is so simple in its character as to render prompt reunion pretty certain; and even though the restoration should prove tedious, this ought scarcely to be regarded as a sufficient justification for so serious a mutilation as these surgeons propose, since the loss of even an extreme phalanx is not only a deformity, but must prove in many occupations a troublesome maiming. Prof. J. Lizars, of the Toronto school of medicine, C. W., has reported to me a case exactly in point. "A man in the employ of the Toronto Eolling Mills Company fractured the distal extremity of the ring-finger of the right hand. The fracture was transverse, and the nail was severely bruised, the accident being caused by a direct blow. Crepitus distinct. A dorsal splint and bandage were applied, and in a short time the fragments were united firmly by bone. The nail subsequently fell off, and a new one was formed." The rule ought still to be held inviolate, which surgeons have so often repeated in reference to injuries inflicted upon the hand and fingers, namely, that we should save always as much as possible. It is remarkable, too, how much nature, assisted by art, can do toward the accomplishment of this purpose. If the bone of a finger is not only severed completely, but also all of its soft coverings, save only a narrow band of integument, are torn asunder, a chance remains for its restoration. And it is especially interesting to observe what recuperative powers are possessed by the articular surfaces of these smaller joints, so that although they may be broken into, or sawn through, or comminuted, and although small fragments be entirely removed, a complete restoration of their functions is sometimes permitted. I have seen and reported some such examples. It is true, however, that such fortunate results are rare, and they are rather to be hoped for than anticipated. Since, in the case of these delicate bones, the slightest deviation from the natural form or position determines in the end an ugly deformity, it becomes exceedingly necessary, especially with females, that we should open and examine the fingers carefully from day to day, so that, as the swelling subsides, we may discover and correct any displacement which may happen to exist. As a splint, I have found nothing so convenient as gutta percha, or felt, moulded accurately to either the dorsal or palmar aspect of the finger; and the form of which I have found it generally necessary to change slightly every third or fourth day, until consolidation is nearly, or quite completed. 319 PUBES If the fracture is near, or extends into a joint, the finger ought to be a little flexed so as to place it in the most useful position in the event that anchylosis should occur; and as early as the end of the second week the joint surfaces should be slightly moved upon each other in order to the prevention of fibrous or bony adhesions. Nor is there much danger of preventing the union of the bone by moving the joints at this early day. Union occurs between these fragments very speedily, and I have never met with a case of non-union of the phalanges, nor do I remember to have seen a case reported. It is the lateral inclination of the distal end of the finger which, according to my experience, it will be found most difficult to obviate, and which may, perhaps, in some cases be most successfully combated by laying the two adjoining sound fingers against the broken finger, and then applying a moulded splint to the palmar surface of the whole. In other cases it will be more convenient to apply the splint only to the broken finger. Rotation of the lower fragment on its own axis is especially to be guarded against, as the deformity which it occasions is more unseemly, and the impairment of utility more decided, than that occasioned by a lateral deviation. It may be well also to remind the surgeon of the convenience of extending the splint beyond the end of the last phalanx, and moulding it to this extremity, in order that the finger may be protected against injuries, and that when, from time to time, the splint is removed, it may be reapplied with accuracy. In all cases the splint should be lined with two or three folds of cotton cloth, or soft flannel, or patent lint, and secured in place with narrow and neatly cut cotton rollers. Bandages of this width should never be torn, but carefully cut with scissors. CHAPTER XXVII. FRACTURES OF THE PELVIS, AND TRAUMATIC SEPARATIONS OF ITS SYMPHYSES. § 1. PUBES. Lente, in his reports from the New York Hospital, mentions the case of a young man, set. 18, who was crushed between a couple of cars, in consequence of which he died two days after. The autopsy disclosed a separation at the symphysis pubis, unaccompanied with any other fracture. The right side was displaced backwards about half an inch, so that the fingers could be passed between the bones. There was also a wound in the top of the bladder large enough to 320 FRACTURES OF THE PELVIS. admit the thumb. 1 Similar accidents have been several times met with by surgeons. Hall reports a case in the Provincial Medical and Surgical Journal, May 1, 1844, in which the pubes thus separated, was actually thrust into the bladder; but in this example the ilium was broken also. I need scarcely add that this patient died; 3 but Sir Astley Cooper has furnished us with an example of a simple fracture or traumatic separation at the symphysis, from which the patient after a long time almost completely recovered. The following is Sir Astley's account of the case:— "Case 79. Richard White, set. 22, was admitted into Guy's Hospital on the 30th of July, 1832, having sustained a severe injury in consequence of a large quantity of gravel having fallen upon his back while in the act of stooping. It knocked him down; and on rising, which he did with considerable difficulty, he attempted to walk; this produced violent pain in the region of the bladder, extending upwards in the course of the ureters to the kidneys. Upon inquiry, he stated that the urine he had voided since the accident was bloody and passed with difficulty. "On examination, a fissure was found at the symphysis pubis, producing a separation of about two fingers' breadth. On pressure being made upon any part of the ilium, he complained of increased pain in the region of the pubes, and of numbness down the left thigh. "A catheter was immediately passed, and the urine which was drawn off* was clear and healthy. Leeches were applied over the pubes, and a broad belt was firmly buckled around the pelvis, sufficiently tight to bring the separated pubes nearly in contact, and the patient ordered to be kept perfectly quiet in the recumbent posture, on low diet. The leech-bites ulcerated, and some slight degree of fever resulted, which, however, readily yielded to the usual treatment. " He remained in the hospital for three months without any check to the progress of his cure; the length of time it required being accounted for by the difficulty of reparation in an amphiarthrodial articulation ; and when he left there was some slight separation of the pubes remaining; nor were the two lower extremities, or the anterior and superior spinous processes of the ilia, perfectly symmetrical, although he could walk very well." 3 Malgaigne has collected four cases of simple separations at the symphysis pubis occasioned by external violence, and in three of the four cases, it was occasioned by pressing out the thighs with great force; the separation being directly due, therefore, to muscular action. Two of these patients succumbed to the accidents. The same author has brought together, also, seventeen cases of separations of this symphysis occurring in childbirth, of which only seven survived. It is much more common, however, to find the pubes broken through its horizontal or ascending ramus; and Clark, of the Massachusetts General Hospital, has described a case of simultaneous fracture of the 1 Lente, New York Journ. Med., 2d ser., vol. iv. p. 286. 2 Hall, Amer. Journ. Med. Sci., vol. xxxiv. p. 248. 3 Sir Astley Cooper, Frac. and Disloc, Amer. ed., p. 144. 321 PUBES pubes and ischium in three places. The man, aat. 29, had been caught between two heavy timbers, and on the following day, May 7, 1852, he was brought to the hospital. No crepitus could be detected, but he was unable to lie upon the right side, and the right limb was nearly paralyzed. It was evident that the bladder or urethra had been ruptured, and on the third day Dr. Clark opened the bladder through the perineum, evacuating a large amount of blood and urine, and affording to the patient very sensible relief. On the first of June, however, he died, having survived the accident twenty-five days. The autopsy disclosed several fractures, all of which belonged to the right os innominatum. First, a fracture of the pubes, near the symphysis; second, a fracture near the junction of the pubes and ilium; third, a fracture through the ramus of the ischium anterior to the tuberosity 1 Sir Astley mentions a case (Case 83) of fracture of the "ramus of the pubes," unaccompanied with injury to the bladder or urethra, which resulted in a complete recovery; and in another case (Case 84) the patient recovered in eight weeks, and was able to walk nearly as well as before; but he soon after died of disease of the chest. The os pubis was found, at the autopsy, to have been broken in three places; there was also a fracture extending in two directions through the acetabulum, with an extensive comminuted frac- Fig. 93. Clark's case of fracture of the pelvis. ture of the ilium accompanied with great displacement. Maret has even found it necessary after a fracture to remove nearly the whole of the body of the pubes by incision, in a girl of 18 years, and who not only recovered completely, but having subsequently married, she gave birth to two children in easy and natural labors. 3 Cappelletti relates that a man, set. 54, jumped from a carriage, the horses having run away, and alighted with his feet to the ground, but with one limb in the greatest possible degree of abduction. A surgeon, who saw him immediately, found an enormous swelling at the superior part of the thigh, accompanied with very acute pain. When seen by Cappelletti, at Trieste, six months after, there still remained a slight swelling near the ramus of the ischium and pubes, under which a careful examination detected a fragment of bone two and a half inches long and of the "size of the finger." The patient was able to walk, but not without pain and limping. Cappelletti soon began to suspect 1 Clark, Boston Med. and Surg. Journ., vol. liii. p. 185. 2 Maret, from Malgaigne, op. cit., p. 646. 322 FRACTURES OF THE PELVIS. that this fragment of bone consisted of a part of the ramus of the ischium and pubes detached by muscular contraction. On examining it anteriorly he found this part of the pelvis defective, and the loose portion of bone had all of the anatomical characters of the defective part. He felt distinctly the circular projection indicating the point where the ascending branch of the ischium unites with the descending branch of the pubes. 1 Whitaker, of Lewiston, N. Y., saw the body of the left os pubis broken in a female while in the seventh month of pregnancy. She had fallen down a pair of stairs, striking astride the edge of an open, upright barrel. The fracture was oblique, and with but little displacement, yet she complained of excruciating pain in the left pubic region on the least motion. The accident was followed by no positive attempt at miscarriage. 2 The danger in these accidents consists not so much in the fracture, as in the injury done to the bladder, and other pelvic viscera. If the bladder is opened into the peritoneal cavity, death is almost inevitable, and even when the bladder or urethra has suffered laceration lower down or at any point above the deep perineal fascia, extensive urinary infiltrations, followed by abscesses and gangrene, generally expose these patients to the most imminent hazards. The practice pursued at Guy's Hospital in the case of separation at the symphysis pubis, commends itself both by its simplicity and by its success. Antiphlogistic remedies steadily pursued, rest in the recumbent posture, the use of the catheter when necessary, and in certain cases the girding the pelvis with a firm belt or band, are measures which seem to meet all of the important indications. If the fracture is accompanied with displacement, it will be proper to attempt to restore the fragments, but except in the case of separation at the symphysis very little aid can be expected from a band or any similar means, in retaining them in place. It will be sufficient, generally, in such examples to place the patient quietly upon his back, with his thighs flexed upon his body, and to treat the accident in all other respects as a case of inflammation. If the urine has become extravasated underneath the pelvic fascia, no time ought to be lost in opening freely through the perineum, and in extending the incisions, if necessary, into the urethra and bladder. § 2. Ischium. When speaking of fractures of the pubes we have already noticed some examples of fractures of the ischium also; indeed, it is seldom that one of the bones of the innominata is broken without a coincident fracture of one or both of the others. The records of surgery furnish several other examples, produced generally by a fall upon the tuberosities; but perhaps the most remarkable instance is that mentioned by Maret as having occurred in a female during labor. 1 Cappelletti, Ranking's Abstract, No. viii. p. 83; from Giornale per servire al Progressi della Patologie della Teraputica, 1847. 2 Whitaker, Amer. Journ. Med. Sci., July, 1857, p. 283. 323 ISCHIUM. The following summary of a case of fracture of the ischium, reported by Sir Astley Cooper, will serve to illustrate one of the most fortunate terminations of these accidents when accompanied with a rupture of the urethra:— A young man who was driving a cart, was thrown down and a wheel passed over him. On the following morning he was found to have a fracture of the left leg and a contusion of the inner side of the left thigh. There was also great swelling and ecchymosis of the scrotum, with a slight appearance of injury over the pubes and left hypochondrium. No fracture of the pelvis was at that time discovered. The patient was suffering great pain, and was cold and exhausted. Bloody urine escaped from the bladder. On the eighth day an abscess had pointed on the left side of the perineum, which, being opened, discharged a great quantity of pus having the odor of urine; extensive sloughing occurred, and the patient sank very low. On introducing the finger into the wound, the ascending ramus of the ischium could be distinctly felt, and the fracture traced in an oblique course, the upper fragment being slightly displaced forwards. When the catheter was introduced into the urethra it was found to enter this wound, and could be felt resting against the naked bone. From this time until the twenty-sixth day, the urine continued to escape freely through the wound. In about six weeks more the fistulous opening had entirely closed, and after several months his recovery was complete. 1 The signs of this accident are generally even more obscure than those of fracture of the pubes, but in a case of doubt the bones ought not only to be carefully examined from without, but the finger should be introduced freely into the rectum and the anterior surface explored; or the tuber ischii may be grasped between the thumb and finger and moved laterally in order to determine the existence of motion or crepitus. If the patient is a female, this exploration can be best made through the vagina. By flexing and extending the thigh, also, crepitus may sometimes be discovered. The examination will generally be made while the patient lies upon his back, but if turning is not found too painful, it will be well to lay him upon his face that the tuberosities of the ischium may be more plainly brought into view. A considerable proportion of the fractures of both the pubes and the ischium are accompanied with lesions of the bladder or of the urethra, either of which circumstances will render the prognosis very unfavorable; but in simple fractures recoveries may generally be expected, yet only after a tedious confinement. It is not usual, except in cases which must almost necessarily prove fatal, to find much displacement of the fragments; nor is it probable that by any manoeuvres the slight displacements which are found to exist can be entirely overcome. Instances may occur, however, in which careful pressure from without, or the introduction of a finger into the rectum or vagina may aid in the restoration. The posture best suited to these cases will be indicated usually by the sensations of the patient himself. Ordinarily he will prefer to lie • A. Cooper, by Bransby Cooper, Amer. ed., p. 140. 324 FRACTURES OF THE PELVIS. upon his back with his thighs flexed and supported by pillows; and his hips slightly elevated by a firm cushion laid under the upper part of the sacrum. His knees ought also to be gently bound together; but if the patient finds this position painful or excessively irksome, as sometimes he will, he may be permitted to occupy any position which he finds most comfortable. § 3. Ilium. Fractures of the ilium are much more common than fractures of either the ischium or pubes, and they assume a great variety of forms, directions, and degrees of complications. In the two following examples the anterior superior spinous process alone was broken off:— John Kelly, set. 36, admitted to the Hospital of the Sisters of Charity, Dec. 28, 1852, having just fallen and broken the anterior superior spinous process of the ilium. The fragment was displaced downwards about one-quarter of an inch. Motion and crepitus distinct. A slight ecchymosis existed over the point of fracture, and other signs of contusion about the hip were present. He was intoxicated at the time of the accident, and could not tell how or where he fell. He was laid upon his back in bed, with his thighs flexed upon his body; and in this position we attempted to reduce the fragment and retain it in place with a bandage, but finding this impossible, we left him with only instructions to remain quietly in bed. In about two weeks the fragment was firmly fixed in its new position, and he was allowed to get up and walk about, which he was able to do without inconvenience. July 13,1853, Matthias Morrison was caught under a bank of falling earth, and on the following day Dr. Mixer, his attending surgeon, requested me to see the case with him. He was unable to stand upon his feet. There was a lacerated wound and an extensive bruise on his left hip; but the thigh was not shortened nor everted, and he could flex it slightly upon his body. Noticing a swelling and discoloration in the region of the anterior superior spinous process of the ilium, I pressed upon it and felt it recede with a distinct crepitus; the fragment, however, immediately resumed its place when the pressure was removed. I was able also, by a careful manipulation, to trace the line of fracture, and to determine that it included a small portion of the anterior extremity and wing of the pelvis. We directed the patient to remain quietly upon his bed with his legs drawn up. He soon recovered, but I am unable to say what is the present position of the fragment. More frequently, however, the fracture involves a still larger portion of the crest, as in the following examples:— Joseph Joquoy, set. 40, was caught by the bumpers between, two cars, Feb. 10, 1854, breaking obliquely the anterior superior portion of the ilium. I saw him within an hour, and found him greatly prostrated; the fragment of the pelvis broken off was quite movable, and 325 ILIUM crepitus was easily detected. His abdomen was very tender and slightly bloated. He was laid upon his back with his legs drawn up, and hot fomentations of hops and vinegar were directed to be applied to his belly. He took also one grain of morphine. The broken ala did not seem disposed to become displaced. With no other treatment, his recovery was rapid; and the bones seemed to have united without displacement. James Roche, set. 41, fell, March 7, 1854, from a height of fourteen feet, breaking off the anterior superior portion of the right ala of the pelvis. On the following day, I found him at the Hospital of the Sisters of Charity. The fragment, which was quite large, was movable, and occasionally a crepitus could be detected. It was displaced downwards and forwards about three-quarters of an inch. He was laid upon his back, with his thighs and legs moderately flexed. At the end of two weeks he found himself able to walk without much difficulty, and he immediately left the hospital. At this time the fragment was displaced in the same manner and direction as at first, but I cannot say whether it had united or not. I have once seen a fracture of the posterior superior spinous process, and I do not know of any other example. Miss B., set. 16, was thrown from her horse backwards, striking with her back upon the ground. She was at first attended by Dr. Coan, of Ovid, N. Y.; and she did not come under my care until two weeks after the accident. I found a small fragment broken from the posterior superior spinous process of the ilium, and displaced backwards in the direction of the spine about half an inch. It was movable, and by pressure it could be partially restored to place, but it would immediately return to its abnormal position when the pressure was removed. The injured hip was painful, and occasionally it felt numb. She had previously suffered from spinal irritation. I laid a compress behind the fragment, and secured it in place with a roller, enjoining perfect rest. She recovered from her lameness in a few weeks, but I believe the fragment remains displaced. Extensive comminuted fractures of the ilium are generally accompanied with so much injury of the pelvic viscera as to prove rapidly fatal; but the following example will show that this rule admits of exceptions. June 5, 1854, Bernard Duffie, set. 32, was crushed under a very heavy stone which fell upon his back. I found the left ala of the pelvis broken into several fragments, between the different portions of which motion and crepitus were distinct. The fractures were near the superior part of the bone, commencing about two inches back of the anterior superior spinous'process, and extending backwards irregularly. There was a narrow wound communicating with the fracture, from which I removed a loose fragment of bone. The right leg was also broken. Four months after, he was still confined to his bed, and a fistulous opening continued opposite the point of fracture; there existed also a 326 FRACTURES OF THE PELVIS. large and irregular mass of ossific matter or callus around the fragments. He soon after left the hospital. Dr. Sargent, of the Massachusetts General Hospital, has reported a case in which a man received a compound fracture of the left ilium, and several small fragments were removed. He was discharged at the end of three months with a fistulous Opening still remaining, but in other respects he was quite well. 1 The following case illustrates the more fatal injuries of this character :— John O'Keaf was crushed under a heavy stone Oct. 23, 1851, breaking and comminuting the alas of the pelvis on both sides, and wounding also the iliac vein. He was taken to the Hospital of the Sisters of Charity, and died in a few hours, partly from the shock to his system and partly from the hemorrhage. Lente, of the New York Hospital, has reported a case of dislocation of the hip, which was accompanied with a fracture also of the ala of the pelvis upon the same side. The dislocation was reduced on the third day, and the patient soon after died. The autopsy disclosed what had not been suspected during life, namely, that the left ilium was broken horizontally about through its middle, and vertically through the crest; and also that there was a fracture extending through the sacro-iliac synchondrosis, accompanied with considerable comminution of the articular surfaces. It was also found that a portion of the small intestine was ruptured, and probably by one of the sharp fragments of the broken pelvis. 2 It is seldom, I think, that the fragments become much displaced; such, at least, has been my experience; and I have noticed in Dr. Neill's cabinet three specimens of fracture of the crest of the ilium, all of which had united without any appreciable displacement. Dr. Neill also called my attention to the fact that in two of these specimens the ensheathing callus was confined to the outer surface of the bone, an observation which this gentleman assures me he has had frequent occasion to make before where the fracture belonged to a flat bone. The same cabinet contains a specimen of gunshot fracture of the ilium, the ala being perforated by a smooth, round hole, about one inch below the crest. If any displacement exists, the upper or loose fragment is generally carried slightly inwards; occasionally, however, it is found displaced upwards, outwards, or downwards. Treatment. —In a large majority of cases the fragments, if displaced, cannot be replaced. Occasionally, however, as where the anterior superior spinous process is broken oft' with only a small portion of the crest, the fragment may be seized with the fingers and carried outwards or upwards, or in whatever direction may be necessary; but to retain it in this position is generally quite impossible. The bandage or broad belt which we have recommended in certain fractures of the pubes would be in these cases not only useless, but absolutely mis- 1 Sargent, Boston Med. and Surg. Journ., vol. liii. p. 121. 2 Lente, New York Journ. of Med., Jan. 1851, p. 29. 327 ACETABULUM. chievous, since its effect must be to press inwards the fragments, and thus to create a displacement which might not otherwise exist. The surgeon ought to determine by a careful examination the extent and direction of the fracture, and, having done what was in his power to replace the fragments, he should lay his patient upon his back with the thighs drawn up and supported. This is the position which will generally be found most comfortable; but, as in other fractures of the pelvis, it may be well always to try the effect of other positions, and especially to determine their influence upon the fragments, and finally to adopt that precise posture which accomplishes the indications best. If the fracture is compound, and the fragments have penetrated the belly, the wound should be enlarged, and, as far as possible, every piece of bone should be removed; but if the fragments cannot be found, the external opening should be allowed to remain so as to favor their escape when suppuration shall have taken place. § 4. Acetabulum. Although, strictly speaking, fractures of the acetabulum belong always to one or all of those bones of the pelvis whose lesions have already been described, yet the peculiar relations of this cavity to the femur render it necessary that they should be considered as a separate class of accidents. Fractures of the acetabulum divide themselves naturally into two varieties. First, Fractures of the base of the cavity, with or without displacement. Second, Fractures of the rim, with or without displacement. In fractures of the base of the cavity, not accompanied with displacement, nothing but crepitus can be present as a sign of the accident; and this will scarcely be sufficient, in itself, to enable the surgeon to distinguish it from a fracture of the neck of the femur within the capsule without displacement. It is probable, therefore, that its existence will only be determined by dissection. Nor is it of much importance that the diagnosis should be made out; since in either case neither splints nor any other surgical appliances could be of service. An injury so severe as to fracture the acetabulum will necessarily so much bruise the body, and concuss the viscera of the pelvis as to compel the patient to remain quiet for a number of days, and this is all that would be thought necessary if the nature of the accident was exactly determined. Dr. Neill's cabinet contains a specimen of this kind, in which the fracture, commencing near the centre, extends in three directions across the cotyloid margins; and in which perfect bony union has occurred without displacement. M. Bouvier related to the Academy the case of a man, set. 71, who, in consequence of a fall from his bed, remained for three weeks unable to walk, and never was able afterwards to walk without crutches. No fracture could be discovered during life, but after his death, which occurred some months subsequent to the accident, a fracture was 328 FRACTURES OF THE PELVIS. found extending from the ilio-pectineal eminence to the spine of the ischium, and traversing the centre of the acetabulum. The fragments were not displaced, but remained slightly movable. 1 The following case was reported by Mr. Earle, to the London Medico-Chirurgical Society, and will be found in the nineteenth volume of its Transactions. It is also referred to by Sir Astley, in his Treatise on Fractures and Dislocations. In the month of October, 1829, a man, set. 40, was admitted into St. Bartholomew's Hospital, with a severe injury caused by having fallen from a height of thirty-one feet and striking upon the left side. The left leg was powerless, and shortened. The foot was everted. Any attempt to rotate the limb caused great pain, and was accompanied with a sensible crepitus. The left trochanter was very much depressed, and when it was pressed upon the patient complained of deep-seated pain in the hip-joint. He recovered in eight weeks, and was able to walk nearly as well as before; but he soon after died of disease in the chest. On dissection, a fracture was found extending in two directions through the acetabulum; there was an extensive comminuted fracture of the ilium, with great displacement, and the os pubis was broken in three places. The repair was very complete, and Mr. Earle remarked how nature had guarded against any considerable deposit of new bone within the articulation, which might have interfered with the functions of the joint, while there was an abundant deposit of callus around the other parts of the fractured bone. Fractures of the base of the acetabulum, with displacement of the femur into the pelvic cavity, constitute a much more formidable, and unfortunately a more common form of accident. Like the preceding variety of acetabular fractures, they are duced generally by falls upon the trochanter major, but the force of the concussion has been greater. Even here, it is not often that the diagnosis has been clearly made out during life; and indeed, generally, the true character of the accident has not even been suspected, the surgeons believing that they had to do with a fracture of the neck of the femur, or with a dislocation. In two examples (Cases 71 and 72) mentioned by Sir Astley Cooper as having been presented at St. Thomas's Hospital, the thigh was thought to be dislocated backwards. In the following example, reported by Lendrick, of Dublin, the patient was supposed to have a fracture of the neck of the femur:— An old man, well known as the " "Wandering Piper," was admitted into the Mercer Hospital in January, 1839, suffering under phthisis pulmonalis and acute inflammation of the hip-joint. Some years before, he had received a severe injury by the upsetting of a coach, and was under treatment several months for what was supposed to be a fracture of the neck of the femur. Since that time he had been 1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486; from Bullet, de l'Acad. Roy. de Med., August 15, 1838. 329 BASE OF THE ACETABULUM. lame, but still able to take a great deal of exercise on foot both in Great Britain and in America. The acute disease of the joint commenced about two months before his admission, and he was at first under the care of Sir Philip Crampton, who remarked that the thigh was only shortened about half an inch, and expressed his surprise at this fact. This man died on the 17th of February, and the dissection showed that there had been no fracture of the femur, but its head and neck were affected with "morbus coxse senilis." The head was also thrust through a rent in the acetabulum into the cavity of the pelvis; but the head had again been covered by a bony case, complete, except in a small portion about the size of a shilling piece, and at this point the covering was ligamentous. The os pubis had also been broken at the same time, and it had united so much overlapped that the space between the inferior anterior spinous process and the symphysis pubis was shortened nearly an inch. A portion of intestine was found protruding through an opening in the pelvis and adherent to the bone, in which situation it seemed to have been caught by the broken fragments and retained. 1 Morel-Lavalle'e, in his thesis upon complicated luxations, mentions a case which had come under his observation, and which had been treated as a fracture of the neck of the femur. The patient survived the accident many years; during a part of which time he suffered such pain in the hip-joint as to induce a belief that it was itself diseased. At his death he was found to have had a multiple fracture of the bones of the pelvis, and the head of the femur had penetrated more than an inch into the cavity of the pelvis, pressing upon the obturator nerve to such a degree as to have, no doubt, caused the severe pain from which he had suffered, and which had been ascribed to coxalgia.' In the two cases mentioned by Sir Astley, as having been received into St. Thomas's Hospital, the toes were turned in. In the example mentioned by the same author as having been presented at St. Bartholomew's Hospital, the toes were everted; the two persons seen by Lendrick and Morel-Lavalle'e were supposed before death to have had a fracture of the neck; it is probable, therefore, that in both of these cases the toes were also everted. While Moore has dissected a subject whose pelvis was broken into many fragments—the left os innominatum was divided into three portions, corresponding to the three bones of which it was composed in infancy; the head of the femur had completely penetrated the basin—the limb was shortened two inches, and in a position of slight flexion and adduction, but neither rotated outwards nor inwards. 3 There seems, therefore, to be no certain rule in relation to the position of the limb; but it is found to take the one position or the other, 1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv. p. 481 ; August, 1839; from London Med. Gazette, March, 1839. 2 Morel-Lavall6e, from Malgaigne, op. cit., vol. ii. p. 881. 3 Moore, Med.-Chir. Trans., vol. xxxiv. p. 107,1851. 22 330 FRACTURES OF THE PELVIS. probably according to the direction of the force which has inflicted the injury, and perhaps in obedience to circumstances not always easily explained. The shortening has been observed to vary from half an inch to two inches or more; the trochanter is also usually driven in toward the pelvis. .Pressure upon the trochanter occasions a deep seated pain. If the limb is drawn down to the same length with the other, it immediately resumes its position when the extension is discontinued. Crepitus is more uniformly present than in fractures of the neck of the femur, and it is especially felt while the limb is being extended or while it is again shortening, and not so much in flexion or rotation. If, in addition to all of these phenomena, we learn that the accident has occurred from a severe blow, or a fall from a great height upon the trochanter; and that the viscera of the pelvis, and especially the bladder, seem to have suffered considerable injury; or if we detect at the same time a fracture of some other portion of the pelvis, we may reasonably conclude that the head of the femur has penetrated the acetabulum. Yet it must be confessed that no one of these symptoms is positively distinctive of this accident, and that they are seldom found sufficiently grouped to render the diagnosis certain. The old " Piper" mentioned by Lendrick, and the man dissected by Morel-Lavellee, lived many years, and managed to walk about, but not without considerable pain; the other three, to whom I have alluded, died soon after the injuries were received. Some have thought of treating these cases by extension and counterextension ; the latter being accomplished through the aid of a perineal band; but it is not probable that after an injury of this character, any patient will be able to endure the requisite pressure about the perineum or groins. It will be better to lay the patient upon Daniel's invalid bed, or some bed similarly constructed, so that it may be converted into a double-inclined plane; allowing the knees to be suspended over the angle thus formed, in order that the weight of the body may have some effect to draw away the pelvis from the femur. Fractures of the rim of the acetabulum have frequently been discovered in dissections, and the records of surgery abound with cases of unreduced dislocations of the femur, in which the failure to reduce or to retain the bone in place has been ascribed, not always with sufficient reason, perhaps, to this fracture. Dr. M'Tyer, of the Glasgow Eoyal Infirmary, published in the Glasgow Medical Journal, for February, 1830, four cases of this fracture. The first was that of a man, set. 27, on whose back a number of bricks had fallen while he had his right knee placed on the bank of a trench. His right leg was found shortened about one inch and a half, bent, and the toes turned a little outwards. The limb could be moved without much difficulty, but every motion gave him pain; motion was also attended with crepitus. On making extension, the limb was easily brought to the same length with the other, but it became shortened again immediately when the extension was discontinued. The symptoms, differing but little, if at all, from those which are usually present in a case of fracture of the neck of the femur, led to 331 RIM OF THE ACETABULUM. the supposition that this was actually the nature of the accident. Subsequently, the toes became slightly turned in, but this circumstance was not regarded as sufficiently distinctive to warrant a change in the diagnosis. Having succumbed to the injuries after a few days, the autopsy revealed a fracture extending through the bottom of the right acetabulum, and about one inch and a half of the rim at its upper and posterior margin completely detached, except as it was held in place by a portion of the capsular ligament. The head of the bone could be easily pushed upwards and backwards upon the dorsum, the fragment of the acetabular margin being moved aside and swinging upon its fibrous attachment as upon a hinge, but resuming its place again perfectly when the head of the femur was restored to the socket. The femur was not broken. In the second case the limb was found shortened, the knee slightly bent, and turned a little forwards and inwards, and the toes pointing to the tarsus of the other foot. It was thought to be a fracture also of the neck of the femur, but the autopsy disclosed only a fracture of the upper margin of the rim of the acetabulum. In the third case, seen only after death, the limb was not shortened much, but the toes were stretched downwards, and turned slightly inwards. It was supposed at first to be a simple dislocation, but on dissection the posterior and inferior margin of the acetabulum was found to be broken and displaced toward the coccyx, while the head of the femur rested upon the pyriformis muscle, over the ischiatic notch. The fourth example was found in the dissecting-room, and the history of the case is not known. A fragment of the superior and posterior margin of the acetabulum had been broken off and had reunited slightly displaced. 1 Several other similar examples have been established by dissection, and we are able, therefore, to determine pretty accurately what are the usual phenomena and terminations of this accident, though we are far from having arrived at a satisfactory means of diagnosis; indeed, the accident has seldom been recognized before death. Its causes are generally the same with those which produce dislocations of the hip, but in most instances the violence has been greater than in the case of dislocations. The symptoms are, first, such as indicate a dislocation, to which must be added crepitus and a difficulty, if not impossibility, of retaining the head of the femur in its place when it is reduced. The crepitus is sometimes discovered the moment we begin to move the limb, and this will aid us to distinguish it from a fracture of the neck of the femur accompanied with much displacement, since, in the latter case, crepitus is not felt usually until the extension is complete and the fragments are again brought into apposition. The majority of these accidents, either from a failure to recognize them or from the impossibility of maintaining the head of the femur 1 MTyer, Amer. Journ. Med. Sci., vol. viii. p. 517, Aug. 1831. 332 FRACTURES OF THE PELVIS. in place when once it has been reduced, have resulted in a permanent dislocation of the hip and a serious maiming. The following case was recognized and reduced, but it was found impossible to maintain the reduction. February 3, 1847, a strong German laborer was crushed under a mass of iron weighing several tons. Drs. Sprague and Loomis, of this city, were called and found the left thigh dislocated upwards and backwards, and by the aid of six men they succeeded in reducing it, the reduction being attended, as the gentlemen have informed me, with a slight sensation of crepitus. The legs were then laid beside each other, and the knees tied together, the patient lying on his back; and now the two limbs appeared to be of the same length. On the second and third days the injured limb was examined by the same gentlemen and there was no displacement. On the fourth day I was invited to meet these gentlemen, the patient having had muscular spasms during the previous night, and the thigh being reluxated. I found the limb shortened one inch and a half, adducted, and the toes turned in. "We immediately applied the pulleys and soon drew the trochanter down to a point apparently opposite the acetabulum, and a careful measurement showed that the two limbs were of the same length. The pulleys being removed, the leg did not draw up again, nor did the foot turn in, yet we had felt no sensation to indicate that the bone had slipped into its socket, nor had we felt crepitus. The legs and thighs were now laid over a double inclined plane, and well secured. He remained in this condition three days more, during which time Dr. Sprague saw him each day and found nothing disarranged. On the night of the seventh day the spasms returned, and in the morning the thigh was displaced. The next day we again applied the pulleys, but soon found that the bone would not remain in place one minute after the pulleys were removed. At this time, while moderate extension was being made at the foot by rotating the foot inwards, we could distinctly feel a slight crepitus. A straight splint was applied and as much extension made as he could conveniently bear, and in this condition the limb was kept several weeks. Seven years after I found the thigh still displaced upon the dorsum ilii. He limped badly, but he could walk fast and perform as much labor as before the accident. In one case mentioned by Mr. Keate the bone had become dislocated downwards and could be felt lying against the tuber ischii, arid the presence of a " distinct grating as of ruptured cartilage" led him to conclude that the cartilaginous labrum of the socket was broken off; but as the fracture was in the lower margin of the socket no difficulty was experienced in retaining the bone in position. 1 If the diagnosis is satisfactorily made out, and upon complete reduction the femur will not remain in place, the treatment ought to be the same as for a fracture of the thigh, except that no lateral splints or bandages to the thigh will be necessary. The limb ought to be kept drawn out to its proper length, as far as this shall be found to be 1 Keate, Amer. Journ. of Med. Sci., vol. xvi. p. 225. SACRUM. 333 practicable, by extending and counter-extending apparatus. A band around the pelvis, so adjusted as to press the head of the bone into its socket, may also be of service in preventing the tendency to displacement ; and in case the bone manifests little or none of this tendency, the hip bandage will probably alone be sufficient, yet even here no harm could come of applying the long straight splint and the extending apparatus, secured moderately tight, simply as a measure of precaution. § 5. Sacrum. Simple fractures of the sacrum, known to be exceedingly rare, 1 are occasioned either by such injuries as break at the same time the other bones of the pelvis, and which may act in any direction, or by blows or falls received directly upon the sacrum. It may be broken at any point, and in any direction, when the fracture is produced by the first of this class of causes; but if the fracture is the result of a direct blow upon the sacrum, it will generally be transverse, and below the sacroiliac symphysis. The direction of the displacement is almost invariably the same, the coccygeal extremity being simply carried forwards, and this is seldom sufficient to interfere in any degree with the functions of the rectum and anus; but in one case seen by Bermond it nearly closed the rectum. Sometimes, also, there is a slight lateral deviation. There is also in the Dupuytren museum, at Paris, a specimen in which the whole of the lower fragment is displaced a little forwards. The signs of this fracture are pain at the seat of injury, aggravated greatly in the attempts to flex or elevate the body, and especially in the efforts at defecation ; swelling and discoloration of the soft parts covering the sacrum; displacement of the coccyx forwards; an angular projection at the point of fracture, with a corresponding retiring angle upon the opposite side ; mobility. Ambrose Pare 1 declared that he had many times seen patients recover after fractures of the sacrum, but if the fracture reaches the spine, "scarcely," says he, "can the patient escape death." Later experience has shown, moreover, that where the fracture of the sacrum is accompanied with other fractures of the pelvis the patients seldom recover; and only because so extensive an injury implies usually great force in the cause which produced the fractures, and of necessity, greater lesions among the pelvic viscera. Simple fractures, from direct blows, or falls upon the sacrum, occurring below the sacro-iliac symphysis, are generally followed by speedy recoveries although the inward displacement is not often completely overcome. By introducing a finger into the rectum, the lower fragment can be easily pressed back to its natural position, but the difficulty consists in finding any means of retaining it there until bony union is effected. Judes succeeded to his satisfaction with a wooden plug, which he compelled the patient to wear forty-five days; removing it, however, every 1 Malgaigne has referred to eight cases; and I have not been able to find a record of any others. 334 FRACTURES OF THE PELVIS. third day, in order to cleanse the rectum with an enema. Bermond introduced first a linen bag, which he immediately proceeded to fill with lint, but during the night it was forced away in an involuntary effort to empty the bowels of wind and stercoraceous matter. He now substituted a silver canula covered with a shirt, which latter he filled with lint in the same manner as before. This was retained without much inconvenience nineteen days; having only been removed once during this time. The union now seemed to be firm, and the apparatus was removed. Plugging the rectum in this manner may be necessary whenever the inward inclination of the lower fragment is found to be considerable, but not otherwise; ordinarily, it will be sufficient to lay the patient upon his back, with a firm cushion above the point of fracture, so as to prevent the bed from pressing in the lower fragment, and having emptied his rectum thoroughly by an enema of warm water, he should be placed under the influence of an opiate sufficiently to restrain the action of the bowels for several days, or for as long a time as may be consistent with health or comfort. To the same end, also, the diet ought to be light and dry; nothing should be allowed which might prove laxative. By constipating the bowels, two ends may be gained. We shall prevent that frequent action of the sphincters, which might tend to disturb the union; and the hardened feces, by their accumulation in the rectum may serve to press back the lower fragment of the sacrum, in a manner much more natural and quite as effective as any apparatus which can be contrived. I have already mentioned a case of separation of the bones at the sacro-iliac symphysis, reported by Lente (p. 326), but which was accompanied also with a fracture of the ilium and a dislocation of the hip. Several other similar examples have been reported, in some of which both of the sacro-iliac symphyses have been separated, or displaced. Such accidents are the results only of great violence, and the subjects of them seldom recover* In a few instances, however, this articulation has been known to give way during labor, while the symphysis pubis has suffered little or no diastasis; and in these cases recovery has generally taken place. § 6. Coccyx. Cloquet mentions two cases as having come under his notice, one produced by a kick, and the other by a fall. In the latter case one thigh and both legs were also broken, and the coccyx having become carious in consequence of the fracture was gradually exfoliated. 1 The symptoms, mode of diagnosis and the treatment in case of a fracture of the coccyx will scarcely demand of us consideration after having treated fully of these points in their relation to fractures of the sacrum. It is more common, however, to meet with examples of separations of the coccyx from the sacrum, which may be regarded in some cases as veritable fractures, and in others as a species of luxation. 1 Cloquet, art. Basiin, of Diet, en trente vol. 335 FRACTURES OF THE FEMUR. Due to the same causes which produce fractures of the coccyx itself, its symptoms differ only in the increased length of the movable fragment, and its consequent greater projection in the direction of its displacement. If it is thrown forwards, as it usually is, the rectum may be almost or completely blocked up by its presence; or, if it is carried backwards, its pointed extremity presses almost through the skin. Its mode of reduction and retention is the same as in fractures of the coccyx and sacrum. CHAPTER XXVIII. FRACTURES OF THE FEMUR. Division. —Of 127 fractures of the femur which have come under my observation, 48 belong to the upper third, 55 to the middle third, and 21 to the lower third; or, if we confine our analysis to the shaft alone, 21 belong to the upper third, 55 to the middle, and 21 to the lower. The femur constitutes, therefore, a striking exception to the rule which my observations have established, that in the case of the long bones the lower third is most often the seat of fracture. The femur is most often broken in its middle third, and generally near the upper end of this third; that is to say, above its middle. § 1. Neck of the Femur. Twenty-six of the whole number were fractures of the neck; either intra or extra-capsular. The youngest of these patients was thirtynine years, the oldest eighty-four, and the average age was about sixty. Fourteen were males and twelve females. Ten occurred in the right femur and thirteen in the left. All were simple. Seven were believed to be without the capsule, and nine were believed to be within; the remainder were undetermined. Surgeons have differed in their opinions as to the relative frequency of fractures of the neck of the femur within or without the capsule. This has arisen, no doubt, in part from the difficulty and probable inaccuracy of many of the diagnoses. Malgaigne, who has adopted a mode of deciding this question which, it must be conceded, is much less liable to error than simple clinical observation, namely, an examination of cabinet specimens, finds in four large collections sixtyone intra-capsular fractures, and only forty-two extra-capsular. So that, according to his observations, they stand in the proportion of about three to two; the intra-capsular being the most common. On the contrary, Nelaton believes that extra-capsular fractures are much the most common, and Bonnet, of Lyons, affirms that they constitute the immense majority. Bonnet made four dissections, and in each 336 FRACTURES OF THE FEMUR. case he found the fracture extra-capsular. This testimony, so far as it goes, is positive, but the number is not sufficient to establish anything more than a probability in favor of the greater frequency of extra-capsular fractures. Clinical observations are too uncertain to be made available in so nice a question. Cabinet specimens may have been collected for a special purpose, and this is well known to have been the fact with the celebrated Dupuytren collection, the specimens in which constitute nearly one-third of the whole number referred to by Malgaigne. I allude to the effort which was made while the controversy was pending between Dupuytren and Sir Astley Cooper as to the probability of bony union in intra-capsular fractures, to accumulate cabinet specimens of this fracture; and which effort extended itself, no doubt, both to London and Dublin, from which sources alone Malgaigne has gathered the balance of his figures. In Dr. Mutter's collection, at Philadelphia, I think there are only three examples of intra-capsular fracture, to seven extra-capsular. Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve examples of fractures of the neck of the femur without the capsule, and only ten within. We ought, therefore, to regard the question of relative frequency as still undetermined. (a.) Neck of the Femur within the Capsule. Causes. —In no other fractures do the predisposing causes play so important a part as in fractures of the neck of the femur, and this Fig. 94. Fracture within the capsule. whether within or without the capsule; indeed, experience has shown that without the concurrence of those pathological changes which usually accompany old age, these fractures can scarcely occur. Sir Astley Cooper thought that the majority of fractures of the neck after the fiftieth year were intra-capsular ; but Robert Smith has given us the ages of sixty persons having fractures of the neck of the femur, and the average age of thirty-two in whom the fractures were within the capsule, is sixty-two years, while the average age of twenty-eight in whom the fractures were extra-capsular, is sixty-eight years. Malgaigne has referred to this testimony in proof of the inaccuracy of the opinion held by Sir Astley Cooper; but I trust it will not be regarded impertinent or hypercritical for us to inquire how Mr. Smith became possessed of the ages of all these persons from whom these specimens were obtained; 337 NECK, WITHIN THE CAPSULE. for more than half of the whole number, that is, just thirty-two, have their ages set down in round decimals, such as 50, 60, 70, &c, and it would be easy to show by the inevitable law of chances that this could not possibly be a true statement. If Mr. Smith does not pretend to have given the ages with accuracy, but only to have arrived as near to the truth as his sources of information would permit, then I protest that these tables do not constitute proper evidence in relation to this point; and until better evidence is furnished I shall continue to think, with Sir Astley Cooper, that fractures within the capsule belong generally to an older class of subjects than fractures without the capsule. This opinion, confirmed by my own experience, does not, however, as Malgaigne seems to think, imply that fractures within the capsule may not occasionally occur in persons much younger than the average limit, namely, under fifty years. It is also believed that intra-capsular fractures are more frequent in women than in men. The position of the neck of the femur and the great thickness of its muscular coverings render its fracture from a direct blow a very rare circumstance; indeed, it can only happen as the result of gunshot accidents, or other similar penetrating injuries. It is broken therefore usually by indirect blows, such as a fall upon the bottom of the foot, upon the knee, or upon the trochanter major; or by muscular action alone, as has sometimes happened with very old people, who, in walking across the floor, have tripped upon the carpet, breaking the bone in the effort to sustain themselves. We must not always infer, however, because the patient has tripped, that the bone was broken by muscular action; since it is quite as likely that the fall, consequent upon the tripping, has occasioned the fracture ; and we ought in such cases to make a careful examination of the hip over the trochanter to ascertain whether it has been bruised, and to interrogate the patient as to the manner of the fall. Rodet has attempted to show by a series of experiments made upon the dead subject, and by other observations, that the direction in which the force has acted will determine the situation and direction of the fracture. Thus he maintains that when the person has fallen upon the foot or knee, the fracture will be intra-capsular and oblique; that if the front of the trochanter receives the blow, the fracture will be intra-capsular also, but transverse; if the back of the trochanter is struck, the fracture will be partly intra and partly extra-capsular; and if the person falls directly upon the side or receives the blow fairly upon the outer side of the trochanter, the fracture will be entirely without the capsule. 1 Without intending to give my unqualified assent to these propositions so ingeniously maintained by Rodet, I am ne vertheless prepared to admit their general accuracy; and especially has my experience led me to believe that falls upon the feet or knees in most cases produce intra-capsular fractures, and that falls upon the outside of the hip, or upon the great trochanter, generally produce extra-capsular fractures. ' L'Experience, March, 14,1844. 338 FRACTURES OF THE FEMUR. I have seen also the intra-capsular fracture produced by so slight a cause as stepping down unexpectedly two or three inches upon an irregular surface. Pathology. —I have already, when speaking of partial fractures, expressed my conviction of the possibility of a partial fracture, or a fissure of the neck of the femur, and I have referred to the case reported by Dr. J. B. S. Jackson, of Boston, as having determined this question beyond all possibility of a doubt; yet its occurrence must be regarded as an exceedingly rare, and, we may say, improbable event. It is much more common to meet with examples of complete fracture of the neck both within and without the capsule, unaccompanied with a rupture of either the periosteum or the reflected capsule. Such was the fact in eight cases examined by Colles; in three of which, however, he believed the fracture not to have been complete, but Robert Smith thinks they were all of them examples of complete fracture. 1 Stanley has also related a case of complete separation of the bone unaccompanied with laceration or injury of either the periosteum or capsular ligament. This was in the person of a man aged sixty years, who had been knocked down in the street. On being admitted into St. Bartholomew's Hospital, shortly after the injury, he complained of pain in the hip, but there was neither shortening nor eversion of the limb, and its several motions could be executed with freedom and power. A fracture was not suspected; but five weeks after this he died of inflammation of the bowels. The dissection showed a fracture extending through the neck accompanied with a slight bloody effusion, but no displacement of the fragments or laceration of the soft parts. 8 In other examples the bone is not only broken but displaced to such an extent that the capsule is completely torn in two. But in a large majority of cases both the capsule and the periosteum are only partially torn asunder. The fracture is generally somewhat oblique, and its direction is usually from above downwards and from within outwards. Sometimes its direction is such as to include a portion of the head; occasionally it is quite transverse. In one example of an old fracture I have seen the ends dove-tailed upon each other, the fracture having a double obliquity, and not admitting of displacement. There may occur also a species of impaction, the lower portion of the neck entering the cancellous structure of the head, while its upper portion rides upon the articular surface, a circumstance which is well illustrated by the annexed woodcut (Fig. 95), copied by Mr. Smith from a specimen in the Dupuytren Museum at Paris; or the impaction may occur without any degree of either upward or lateral displacement. Mr. Liston says: " Even in children separation of the head of the bone may, on good grounds, be supposed occasionally to take place;" 3 by which we understand him to mean that a separation of the epiphy- 1 Colles, Dublin Hosp. Reports, vol. ii. p. 339. * Stanley, Med.-Chir. Trans., vol. xiii. * Liston, Elements of Surgery, Phila. ed., 1837, p. 480. 339 NECK, WITHIN THE CAPSULE. sis which completes the head of the femur, may occur. Mr. South relates a case in a boy ten years of age, who had fallen out of a first floor window upon his left hip. The limb was slightly turned out, but scarcely at all shortened. The thigh could be readily moved in any direction' without much pain, but on bending the limb and rotating it outwards, a very distinct dummy sensation was frequently felt, apparently within the joint, as if one articular surface had slipped off another. This was regarded by both Mr. South and Mr. Green as an example of epiphyseal separation, and he was placed upon a double inclined plane, but lie felt so little inconvenience from it that he several times left his bed and walked about. We have no information as to the result or as to the farther progress of the case. 1 A girl, aat. 18, was brought before Dr. Parker, of New York, at his surgical clinic, Nov. 1850, who had been injured by a fall upon a curb-stone, when eleven years old. The accident was followed by suppuration and a fistulous discharge, from which, however, she finally recovered, but with the foot everted, and a shortening of one inch and a half. "Flexion and rotation of the joint occasioned no inconvenience." Dr. Parker thought this circumstance alone sufficient to distinguish it from hip disease in which anchylosis is the termination. 2 Fig. 95. Impacted fracture within the capsule. At a meeting of the Kappa Lambda Society, held in New York, March 25,1840, Dr. Post mentioned a case which he had seen in a girl sixteen years old, who, in taking a slight step with a child in her arms, made a false movement, and feeling something give way, she was obliged to lean against a wall. Dr. Post saw her the next day, when he found the affected limb one inch shorter than the opposite one, movable, the toes turned outwards, no swelling, some slight pain at the upper part of the thigh. The trochanter major moved with the shaft. There was also crepitus. From the age of the patient and the slight amount of violence by which the injury was produced, Dr. Post thought a separation of the epiphysis of the head had taken place. The extending apparatus was applied, but the limb remaiDs from a quarter to half an inch shorter than its fellow. 3 These three constitute the only examples of this accident which I find reported, and although there may be much reason to suppose that the diagnosis was correct in each instance, I cannot regard any one of them as actually proven; nor can I admit the accident as fairly established, or the diagnostic signs as being properly made out until these important points have received the confirmation of at least one dissection. 1 South, Note to Chelius's Surgery, vol. i. p. 619. 2 Parker, Amer. Med. Gazette, vol. i. p. 342, Nov. 30, 1850. * Post, New York Journ. Med., vol. iii. p. 190, July, 1840. 340 FRACTURES OF THE FEMUR. Symptoms. —"Whether the limb will be shortened or not must depend upon whether the fragments have become displaced in the direction of the axis of the shaft of the femur. It is well established that in this fracture the broken ends frequently remain in contact for several hours or days, or until the gradual contraction of the muscles or the weight of the body upon the limb occasions a separation, and that consequently there is often at first no appreciable or actual shortening of the limb. To determine, however, its existence, it is not sufficient to lay the patient upon his back, and place the limbs beside each other; we ought also to measure carefully with a tape line from the pelvis to the leg or foot, and from various other points, until we have placed this question beyond a doubt. If shortening occurs, it may vary from one-quarter of an inch to two inches, or even more; but this extreme shortening is not reached usually, except after the lapse of several weeks or months, when the ligaments have gradually given way under the weight of the body in walking, or not until the neck has undergone a partial or almost complete absorption. Sir Astley Cooper has stated that a shortening to this degree may occur at once; but Boyer, Earle, and others, doubt the accuracy of this opinion, and Robert Smith declares that he does not think the capsule would admit of such an amount of immediate displacement, unless it were extensively torn, an occurrence which he thinks very rare indeed. With this qualification, the opinion of Mr. Smith does not differ from that entertained by Sir Astley, who only admits its possibility as a rare event; in a large majority of cases the shortening does not exceed one inch. Crepitus, unlike shortening, is generally absent when the displacement of the fragments is complete; but under no circumstance is it easily developed. When the fragments remain in apposition and the femur is rotated for the purpose of moving the broken surfaces upon each other, the small acetabular fragment, resting in a smooth cup-like socket, and holding upon the opposite fragment by denticulations or by the untorn periosteum or capsule, glides about in obedience to the motions of this latter, and no crepitus can be produced. Nor is the difficulty rendered less by pressing firmly upon the trochanter, as some surgeons have recommended, since, while this pressure tends, no doubt, to fasten the upper fragment in the acetabulum, it tends much more to fasten the broken ends together, and thus defeats the purpose in view. When, on the other hand, the fragments have become completely separated, it is almost impossible to bring them again into contact. The limb may, perhaps, be easily brought down to the same length with the other, but it must by no means be inferred that, consequently, the broken ends are in apposition. It is almost certain, indeed, that in its progress downwards the trochanteric fragment has caught upon the acetabular fragment and pushed its floating and broken extremity downwards before it. Under these circumstances, the discovery of a crepitus must be accidental, and is scarcely to be looked for. Sometimes, however, we may recognize a sound not unlike crepitus, but less harsh, produced by the friction of the trochan- 341 NECK, WITHIN THE CAPSULE. teric fragment against the rim of the acetabulum or dorsum of the ilium. One thing we ought never to forget, namely, that by extraordinary efforts to obtain a crepitus we may lacerate the capsule or produce a displacement of the fragments which we never can remedy, and which, without such unwarrantable manipulation, might never have occurred. Bversion of the foot is almost uniformly present in some degree, taking place immediately or more gradually, in proportion as the fragments become displaced, and the external rotators contract. The opposite condition or an inversion of the foot is occasionally present, and sometimes also the foot is neither turned in or out, but the toes point directly forwards. In sixty cases of fracture of the neck seen by Cloquet the foot was never turned in, and Boyer never met with such an example in all of his immense experience; but Langstaffj Guthrie, Stanley, and Cruveilhier have each seen one example, and Robert Smith has seen two. 1 The explanation of the fact that the foot is usually turned out is simple. It is owing in part, no doubt, to the natural position and form of the foot and leg, which incline them to fall outwards by their own weight, but mainly to the powerful action of the external rotators, which are so feebly antagonized upon the opposite side. But those rare examples of fracture of the neck of the femur both within and without the capsule, accompanied with a permanent or a temporary inversion of the foot, are of more difficult explanation; and, indeed, a complete solution of this phenomenon does not seem to have been yet satisfactorily reached. Fracture of the neck of the femur within the capsule is not usually attended with much pain when the patient is at rest, but any attempt to move the limb produces intense suffering, and especially when an attempt is made to rotate the limb inwards, or to carry it upwards and inwards. Occasionally, also, during the first few days or hours after the fracture, a spasmodic action of the muscles compels the patient to cry out from the severity of the pain which it produces. At first, the sufferer is unable to indicate clearly the seat of this pain, or, perhaps, it is diffused and uncertain in its position, but after a time he is able to refer it chiefly to the region of the groin, opposite the neck of the bone, or to near the point of attachment of the psoas magnus and iliacus internus. There is also usually in this region a great degree of tenderness and an unusual fulness. If now the limb be seized, and extension gradually but firmly applied, it will soon be made of the same length with the opposite thigh; but, the moment the extension is discontinued, the shortening and eversion will recur, accompanied with pain, and perhaps crepitus. The trochanter major is less prominent than upon the opposite side, and if eversion of the limb exists, the trochanter may be felt indistinctly upwards and backwards from its usual position. The patient having been placed under the influence of an anaesthetic, we may 1 Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. cit., p. 151, note. 342 FRACTURES OF THE FEMUR. prosecute the investigation still further, and by rotating the limb inwards and outwards as far as it will admit, we shall notice that the trochanter describes the arc of a smaller circle than in the opposite limb, or that the length of its radius has been shortened. The patient is generally unable to move his limb, or to bear the least weight upon it; but many examples are on record of persons who walked some distance after the fracture had taken place, the capsule, and perhaps, also the periosteum not being torn, and consequently the fragments not being displaced; or, possibly, it was at first an impacted fracture. Finally, after having examined the patient as well as we are able to do, in the recumbent posture, if any doubt remains, and it is found practicable for the patient to be elevated upon his sound foot, this should be done. The broken limb can now be examined thoroughly on all sides, and a more accurate opinion formed of the amount of shortening and eversion. It will be especially noticed that if the weight of the body is allowed to rest upon the limb in the slightest degree, it produces insupportable pain. Prognosis. —The question of bony union after a complete fracture of the neck of the femur within the capsule, has occupied the attention of the ablest surgeons and pathologists for a long period; and while great differences of opinion have been expressed as to the probability of the occurrence, and as to the value of the testimony on the one side or the other, very few have ventured to deny its possibility. Among these latter are found, however, the distinguished names of Cruveilhier, Colles, Lonsdale, and Bransby Cooper. It has been affirmed, also, that Sir Astley Cooper taught the same doctrine, but with how much show of reason, the following paragraphs from his own pen will determine:— " In the examinations which I have made of transverse fractures of the cervix femoris, entirely within the capsular ligament, I have only met with one in which a bony union had taken place, or which did not admit of a motion of one bone upon the other. To deny the possibility of this union, and to maintain that no exception to the general rule can take place, would be presumptuous, especially when we consider the varieties of direction in which a fracture may occur, and the degree of violence by which it may have been produced. For example, when the fracture is through the head of the bone, with no separation of the fractured ends; when the bone is broken without its periosteum being torn; or, when it is broken obliquely, partly within and partly externally to the capsular ligament, I believe that bony union may take place, although at the same time I am of opinion that such a favorable combination of circumstances is of very rare occurrence. Much trouble has been taken to impress the minds of the public with the false idea that I have denied the possibility of union of the fracture of the neck of the thigh-bone; and therefore I beg at once to be understood to contend for the principle only, that I believe the reason that fractures of the neck of the thigh-bone do not unite, is that the ligamentous sheath and periosteum of the neck of the bone are torn through, that the bones are consequently drawn asunder by the mus- 343 NECK, WITHIN THE CAPSULE. cles, and that there is a want of nourishment of the head of the bone; but I can readily believe that if a fracture should happen without the reflected ligament being torn, that as the nutrition would continue, the bone might unite; but the character of the accident would differ; the nature of the injury could scarcely be discerned, and the patient's bone would unite with little attention on the part of the surgeon. " In proof of the correctness of my opinion, I enumerated, in the early editions of this work, forty-three specimens of this fracture, in different collections in London, which had not united by bone. At the present day these might be multiplied were it necessary. " Such has been the accumulated evidence of the want of power of the neck of the femur to unite by bone, in my practice of forty years, during which period I have seen but two or three cases which militate against this opinion, for many of the preparations which have been brought for my inspection as specimens of united fractures of this part, have proved to be nothing more than the result of the changes concomitant with old age; and in many of them the two thigh-bones of the same subject had undergone the same alteration in texture and in form." 1 The following passages from a communication made by Sir Astley to the London Medical Gazette, for the 25th of April, 1834, are equally pertinent. " I find in a report of the Baron Dupuytren's lecture that he attributes to me the opinion that fractures of the neck of the thigh-bone, within the capsular ligament, not only ' never unite, but that it is impossible that they should unite by bone.' " It is quite true that, as a general principle, I believe that those fractures unite by ligament, and not by bone, as do those of the patella and olecranon. But I deny that I have ever stated the impossibility of their ossific union; on the contrary, I have given the reason why they may occasionally unite by bone. " The following are my words: ' To deny the possibility of their union, and to maintain that no exception to this general rule may take place, would be presumptuous,'" &c. &c. In conclusion, Sir Astley remarks: " I should not have given you this trouble, nor should I have taken it myself, but for the respect I bear my friend, the Baron Dupuytren; for although I have already submitted myself to be misrepresented by many individuals, yet I should be sorry to be misunderstood by so excellent a surgeon and so valuable a friend as Le Baron Dupuytren." 2 What apology can now be found for a writer who, in a public lecture before an audience of surgeons, in London, delivered so late as the year 1858, uses the following language:— "It is well known that Sir Astley Cooper always taught the doctrine that fractures of the neck of the thigh-bone were incapable of 1 Sir Astley Cooper, on Dislocations and Fractures of the Joints, edited by Bransby Cooper, Amer. ed., p. 15o'. 2 See also Sir Astley's letter to Prof. Cox, written in 1835, and published in the Prov. Med. and Surg. Journ. for July 12, 1848, and New York Journ. Med. for Sept. 1848. 3 See appendix to Cooper on Dis. and Frac, Amer. ed., 1851, p. 482. 344 FRACTURES OF THE FEMUR. being repaired by osseous matter, and that in the whole course of his practice he had never met with a single instance, nor could he meet with any one who had seen a case where such an occurrence had happened; and that union within the capsular ligament (when any such union takes place) is always by membrane. However, it appears that he had no sooner published the last edition of his work On Fractures and Dislocations, than Mr. Swan forwarded to him a specimen of the thigh-bone, in which the fracture of the neck had become reunited by osseous matter. Sir Astley retained the specimen until his death, and it appears that he never had the courage or policy to promulgate the discovery of the error of that doctrine which had so pervaded his mind, and which had misled the profession during a period of forty years." 1 What pusillanimity is apparent in this repetition of a slander which had been refuted a hundred times by Sir Astley,- but who, being now dead, might be assailed with impunity! Do not those surgeons who listened to these ungenerous insinuations, know well enough their falsity? or is it possible that they derived a secret pleasure in hearing these insults cast upon one who, although he had done more than any other man to exalt the fame of English surgery, had, nevertheless, been only lately their rival, and from the shadow of whose colossal form they were just beginning to emerge into light. Sir Astley, so far from denying, frankly admitted its possibility, and explained the circumstances under which he believed it might occur. The true point in dispute was, whether certain cabinet specimens were actually examples of complete fractures, wholly within the capsule, united by bone. Some of them Sir Astley thought were only examples of chronic rheumatic arthritis, or of interstitial and progressive absorption. Some were partial rather than complete fractures; others were partly within and partly without the capsule; and for this he was accused of wilful blindness or stupidity, chiefly by those who themselves being the owners of these rare pathological treasures, might possibly have felt somewhat annoyed at seeing their value thus depreciated, and who, no doubt, would be quite as apt to fall into blindness and partisanship as Sir Astley himself. The truth is, however, that although the claim has been set up and stoutly maintained for more than thirty cabinet specimens, in one part of the world or another, a majority of these, including several whose claims were urged upon Sir Astley, have been at length declared by all parties unsatisfactory, or absolutely fictitious, and only a fraction of the whole number continue to be mentioned by any surgical writer as probable examples. 2 1 Lettsomian Lectures on the Physical Constitution, Diseases and Fractures of Bones, by John Bishop, F. R. S. London, 1855, p. 55. 2 The following European surgeons have claimed to have in their possession, each, one example : Langstaff (Med.-Chir. Trans., vol. xiii. 1827); Brulatour (Ibid., vol xiii. 1827); Stanley (Ibid., vol. xviii.); Swan (Swan on Diseases of Nerves, p. 304); Adams (Todd's Cyclop., p. 813); Jones (Med.-Chir. Trans., vol. xxiv.); Chorley (Amesbury on Frac.,p. 125); Field (Ibid., p. 128); Soemmering (Chelius's Surgery by South, vol. i. p. 621); South (Ibid., p. 621). South also mentions another example as being in the museum of St. Bartholomew's Hospital. This is probably Jones' case, which Robert Smith says is preserved in this museum, and which has already been enumerated. 345 NECK, WITHIN THE CAPSULE. Eobert Smith, reduces the number to seven, but Malgaigne recognizes only three, namely: Swan's case, admitted by Sir Astley himself ; Stanley's case, and one specimen in the Dupuytren museum. In neither of these cases, he affirms, has the neck lost anything of its form or length by absorption, from which we are to infer that he would reject as doubtful all such specimens as had undergone these pathological changes. Indeed, I think we are not left in doubt as to Malgaigne's opinion upon this point. Six of the nineteen cases which I have enumerated are declared by him to resemble much more rachitic alterations of the neck than true fractures; and yet Robert Smith admits three of the six as well established examples; but as to the precise grounds upon which he rejects these cases, he shall speak for himself: "And it is sufficient that we consider the beautiful drawings designed by Sir Astley Cooper, to illustrate certain varieties of the alterations, to place us on our guard against every pretended consolidation which presents itself, accompanied with a shortening and deformity of the head and neck. When fractures unite by bone they do not suffer such enormous losses of substance which it would become necessary to admit for the neck of the femur.'" A reference to Stanley's case, as reported by Robert Smith, will show that, contrary to Malgaigne's statement, this was also shortened and deformed, and that, consequently, according to his own rules of exclusion, it also must be rejected; after which only two remain, namely, Swan's case, admitted by Sir Astley himself, and No. 188 of the Dupuytren museum. I should do injustice to my own convictions, moreover, were I not to refer my readers to the following judicious criticism upon Mr. Swan's case:— " Mr. Smith's notes are as follows: ' Mrs. Powel, above eighty years of age, fell down, November 14, 1824. Sir Astley Cooper, who saw her soon after, believed that there was a fracture of the neck of the femur, although there was no appreciable shortening of the limb, and only a slight inclination of the toes outwards; crepitus could not be perceived; the patient died about five weeks after the accident; upon examination of the joint after death, the fracture was found to have been entirely within the capsular ligament, and the greater part of it was firmly united. A section was made through the fractured part, and a faint white line was seen in one portion of the union, but the rest appeared entirely of bone. The cervical ligament had not been injured.'" (Smith, page 59.) In this case the patient was an old lady, above eighty years of age, with the fracture not certainly made out; Bryant (Memphis Med. Rec, vol. vi. p. 108, from British Med. Journ., March 14); Fawdington (Amer. Journ. Med. Sci., vol. xv. p. 534, from London Med. Gaz., Aug. 16, 1834); Harris (Ibid., vol. xviii. p. 246, from Dublin Journ., Sept. 1835). Robert Hamilton says that Prof. Tilanus showed him three specimens in the museum of the Hospital of St. Peter, at Amsterdam (Ibid., vol. xxxi. p. 470, from Lond. Med. Gaz., Jan. 6, 1843). Malgaigne says there are three specimens in the Dupuytren museum which have been described with the same interpretation. The whole number claimed by transatlantic surgeons is therefore nineteen. 1 Malgaigne, Traite des Fractures et des Luxations, torn. i. p. 678. 23 346 FRACTURES OF THE FEMUR. there was no appreciable shortening of the limb; no crepitus; and only a slight inclination of the toes outwards. The strongest point in favor of there having been a fracture, was the opinion of Sir Astley Cooper, which opinion is entitled to great weight; but there are no satisfactory facts given upon which he formed that opinion. This slight eversion of the foot might be given by the patient to relieve the tension on the bruised and inflamed part. We may well query if the vessels of the ligamentum teres would not have shown evidences of having performed an increased function? Would five weeks have been sufficient time for them to furnish osseous union, and resume their original size? "Again, the old woman died in five weeks after the receipt of the injury. Now, it seems to us quite improbable, nay, impossible, that bony union of an intra-capsular fracture of the femur in an old woman, about eighty years of age, in whom there was not left vitality enough to sustain life, should take place, in five weeks after the injury, in less time than is allowed for the ordinary union of a fracture of the shaft of the femur in a'healthy person in the prime of life." 1 On this side of the Atlantic, the number of specimens for which the honor is claimed is nearly equal to the original number in Europe; but they have not yet, all of them, been subjected to the same sifting process as their foreign congeners; and it remains to be seen how many of them will come successfully out of a similar fifty years' contest. Three of the specimens belong to the venerable and distinguished surgeon, Reuben D. Mussey, Professor of Surgery in the Miami Medical College, at Cincinnati, Ohio, and whose many valuable contributions to the science which he has so long adorned are familiar to all American surgeons. He has also himself furnished a complete history and description of the specimens, accompanied with drawings, which are published in the April number for 1857 of the American Journal of the Medical Sciences. The first patient was a Mr. S., set. 78, a hardy yeoman from one of the hilly districts of Northern New England. When more than one hundred miles from home, his two-horse wagon was upset, and falling upon his hip he was so much injured as to be unable to rise. Dr. J. C. Dalton, of Lowell, Massachusetts, a highly distinguished gentleman, examined the limb, and pronounced it a fracture of the neck of the thigh-bone, and accordingly he applied a modified Desault's apparatus. On the fourth or fifth day, contrary to the remonstrances of his surgeon, the man had himself, apparatus, and bed placed in a long box, and the whole being laid in a country wagon he started for home. On the eighteenth day of the accident, after reaching home, and while yet in the box and apparatus, Dr. Mussey was called to see him. On removing the bed-clothes Dr. Mussey noticed that the foot and knee were turned considerably outwards. He immediately took off the splint, and moved the hip-joint; finding that it gave him no pain, he flexed the thigh to a right with the body, and kept it a minute 1 An inaugural thesis on intra-capsular fractures of the cervix femoris, by John Geo. Johnson, New York, 1857, p. 23. New York Journ. Med., 3d ser., vol. ii. p. 295. 347 NECK, WITHIN THE CAPSULE. or two in that position, still occasioning no pain, but on flexing it a little further he complained that it hurt him in his groin. Pressure with the finger at this point and behind the trochanter gave him decided uneasiness. No shortening could be detected. Fig. 96. Fig. 97. Left, or injured femur of Mr. S. Vertical section of the same. Dr. Mussey now felt so confident that the bone was not broken that he asked the old gentleman if he wished to get up, and upon his reply- ing in the affirmative he was helped into a chair and sat for some time. He also bore the weight of his body for a minute or two upon his limb. From that day onward he wore no splint, and was got from his bed daily. In the course of four months the patient was able to walk with a cane, but he remained lame, and was never able again to ride on horseback as he had been accustomed to do. Dr. Dalton hearing of Dr. Mussey's opinion, wrote to him that on his visit to the patient he found the limb not only everted but shortened more than an inch, and that he had detected crepitus. Yet this does not seem to have changed Dr. Mussey's belief that it was not broken. Two or three years after this the man died of an acute disease. Both Fig. 98. Right, or sound femur of Mr. S. thigh-bones were obtained. The right femur was sound (Fig. 98), but on being carefully cleaned the neck of the left femur was found to be shortened, so that in front it measured from the head to the inter- 348 FRACTURES OF THE FEMUR. trochanteric line one inch and three-eighths, and behind only one-third of an inch, the shaft being rotated outwards. The head was sunk below the level of the top of the trochanter major, occasioning a shortening of more than half an inch. "A vertical section" (Figs. 96, 97), says Dr. Mussey, "made by a saw, shows a consolidation of the fracture by a deposit of a mass as compact and white as ivory." " In the year 1830," he continues, " I showed this to Messrs. Roux and Amussat, and some other professional gentlemen in Paris; they regarded it as a fair specimen of bony union of intra-capsular fracture. In London I also showed it to Mr. Lawrence, Mr. Travers, Mr. Stanley, and Dr. Hodgkin, who was then Curator of the Museum at Guy's Hospital. These gentlemen were interested with the specimen, and considered it as a satisfactory example of bony union within the capsular ligament. On my presenting it for inspection to Sir Astley Cooper, he remarked, 'This bone never was broken.' I said, 'Sir Astley, please to look at the interior of the bone.' He separated the two halves, and said, ' This does look a little more like it, to be sure; but I do not think it is wholly within the capsular ligament.' It is well known that Sir Astley, for some years, had taught the doctrine that bony union does not take place in intra-capsular fracture. His views, among the surgeons of Great Britain, were extensively admitted as correct." At Edinburgh, Dr. Mussey also showed the specimen to John Thompson, author of the great work on inflammation, who called it an example of absorption, &c, consequent upon old age, and affirmed, " upon his truth and honor," that it never had been broken. Dr. Mussey says, moreover, that the surgeons in this country, " who have examined these specimens, unhesitatingly pronounce this to be a case of union by bone of intra-capsular fracture." There are one or two points in this case which give it extraordinary claims to attention. The first circumstance is the shortening discovered by Dr. Dalton, and which was absent on the eighteenth day, when the limb was examined by Dr. Mussey. One of these two gentlemen was mistaken. If it had united, the bones were never completely displaced, and it could not have been shortened when Dr. Dalton first saw it. This position I need not now attempt to defend; the testimony of all surgeons who have written upon this subject will warrant me in assuming thus much. Again, if it had been thus displaced, and Dr. Dalton had restored it to place, it seems impossible that, after a journey of one hundred miles over a rough country in a wagon, on the eighteenth day it should not have been again displaced and shortened, and especially if at this time the thigh was not only flexed to an acute angle upon the body, but the patient was permitted to stand upon it. If, however, Dr. Mussey still maintains that the limb was not shortened when he examined it, it remains for him to show how the bone was brought to position, and afterward kept in place so effectually, under such unfavorable circumstances; or if he admits that the shortening existed at that time, but was overlooked by him, then we must inquire, "When (subsequently, of course) was the bone set? and how does it happen that it has united at all? There must have been a mistake 349 NECK, WITHIN THE CAPSULE. somewhere in relation to this matter of shortening ; and if so, with all my respect for Dr. Dalton, whose veracity and skill no man will dare to question, I am sceptical also as to the existence of crepitus. It is not entirely clear to me that he was not deceived. In the history of the case, then, we see no reliable evidence of a fracture either within or without the capsule, nor did Dr. Mussey before the death of the patient. The bone itself, however, has convinced Dr. Mussey that it was broken within the capsule, and that it is well united by ossific matter. I have not seen it, and therefore am an incompetent judge of its value; but I must acknowledge that neither the description nor the drawing furnishes me with any positive proof that it was ever broken, and still less that the fracture was wholly within the capsule. Sir Astley Cooper doubted whether, if it was a fracture at all, it was a fracture wholly within the capsule; and I am willing to leave the question between these distinguished gentlemen as they have themselves left it, each one of whom was, in my opinion, equally earnest and sincere in his convictions, and each one of whom was equally competent to decide the point at issue. Dr. Mussey's second specimen was obtained from a Mr. N., who, when fifty-one years old, fell, in alighting from his chaise, striking upon his left hip. He was unable to walk. Dr. Mussey saw him on the third day, and found him a corpulent man, lying with his foot everted, and the limb shortened from one inch to one inch and a third. He could extend the leg to within about one-third of an inch of its natural length, and when thus extended and rotated a distinct crepitus was produced. He applied Hartshorne's long splint, which was continued eighty-four days, the extension never being sufficient, however, to completely overcome the shortening. He ultimately walked with a cane, the shortening, which was about half an inch, being concealed by a highheeled shoe. This man survived the injury twelve years, and eight years after his death Dr. Mussey obtained the specimen of injured Fig. 99. The left, or injured femur of Mr. N. bone (Fig. 99), together with its fellow (Fig. 101). The head of the injured bone is elongated and depressed, or flattened, the neck is very much shortened, and the trochanter turned back as in the first specimen. A section (Fig. 100) shows a white, condensed tissue traversing the neck, near its junction with the head. Mrs. Mason, set. 73, was the subject of the third accident. She was a small, thin woman, and had fallen upon her side. Two days after, Dr. Mussey saw her in consultation with his friend, Dr. Judkins. The knee and foot were a little everted, with slight shortening and tenderness on pressure in the groin and behind the trochanter major. She 350 FRACTURES OF THE FEMUR. was averse to the application of any kind of splint, and, being in a delicate state of health, she was allowed to remain upon her couch, with the thigh and leg somewhat flexed and supported by a pillow. Vertical section of the injured femur of Mr. N. The right, or sound femur of Mr. N. She remained in this situation about three months, after which she could move with the aid of crutches. She died in a year and a half from the accident, worn out by age and exhaustion. Fig. 102. Fig. 103. The right, or injured femur of Mrs. M, Vertical section of the injured femur of Mrs. M The neck of the bone (Fig. 102) is shortened to seven-eighths of an inch anteriorly, and to half an inch posteriorly. A considerable ridge runs across the anterior part of the neck, between which and the head is an irregular superficial groove. A section of the bone (Fig. 103) presents "a narrow, white, eburnated line, corresponding with the aforesaid ridge, exhibiting a firm consolidation." I shall express no opinion of these two last described specimens further than to say that they seem to be liable to the same objections 351 NECK, WITHIN THE CAPSDLE. as several others of which I have already spoken, and that they do not belong to that class which has alone been accepted by Malgaigne. It is proper, however, to say that, according to Dr. Johnson, in the paper already referred to, some of the surgeons who have examined these specimens have declared to him that they were not satisfactory. Says Dr. Johnson, in the same paper:— " In regard to the Philadelphia specimens, my only source of information is the brief notice of them in the new work on surgery by Prof. H. H. Smith, of Philadelphia. His statement is as follows (page 399): 'There is, in the Wistar and Horner Museum of the University of Pennsylvania, a femur, apparently of an old woman, in which the neck has been fractured near the head, yet in which complete osseous union, though with some degree of shortening, has taken place. I have, moreover, in my own cabinet a specimen in which the bone has been fractured through the neck near the head, the fragment having slid down beneath its natural position, and the fracture travelled obliquely down the neck, though still within the capsule, splitting it off in the line of the inter-trochanteric ridge. In this case, which must have produced marked shortening of the limb, there is complete osseous union.' This report is so exceedingly brief that no inference can be drawn from it; in fact, the writer does not appear to know whether the specimen is from a male or female. If this is true, then he knows nothing of the history of it. He does not give us the direction of the fracture, or a drawing of it, or even a positive statement that it is entirely within the capsule. In regard to his own specimen he is more explicit; he gives a drawing and shows that the fractured head has slipped down, and even now the line of fracture can be traced to the inter-trochanteric line. If this is so now, it is probable that the end of the fractured bone extended below the capsule in the first place, as in all cases of fracture, where there is not perfect coaptation, the rough points become absorbed. If we allow for this absorption, it would make the end of the bone below the trochanteric line a point without the capsule, thus excluding it from this class. If we adopt Prof. Smith's view, that this was entirely within, we meet with this objection. He states that the head of the bone has slipped down beneath its natural position, and the fracture has traversed it obliquely. This, of course, could not have been an impacted fracture, for in an impacted fracture we should have had the shaft of the bone driven into the cancellated portion of the head, not the head of the bone ' slipping down' along the shaft. If this was a case of slipping down of the head, we leave Prof. Smith, of Philadelphia, to controvert the position taken by Mr. Smith, of Dublin, where he says that only impacted intra-capsular fractures can have an osseous union." Speaking of a specimen, also, which may be found in the Crosbystreet Medical College, of New York, he says:— " This belongs to Prof. Willard Parker, of this city. I am under obligations to Prof. Parker, for his kindness in explaining to me the various points which he considers the case presents. He loaned me the specimen to examine at my leisure, that I might become thoroughly acquainted with all the facts of the case. According to the description 352 FRACTURES OF THE FEMUR. of the case given by Prof. Parker, in his lecture, the patient was a maiden, about sixty years of age, an inmate of the almshouse of Barnard, Yt. One morning, while going out of doors, she fell, striking upon her hip. The doctor in attendance, who did not pretend to be a surgeon, or accurate in his diagnosis, came to the conclusion that there was a fracture. He was of the opinion that he obtained crepitus; accordingly he dressed the limb with the straight splint for six weeks, and at the end of that time found half an inch shortening. The specimen afterwards came into Prof. Parker's possession. The points Prof. Parker relies on to show that this was a fracture, are: 1. The supposed crepitus. 2. A ridge of bone along the inter-trochanteric line, termed the 'callus.' 3. The neck of the bone shortened on the outer side one-third of an inch more than on the inner side, this being accounted for on the supposition that it was produced by the position the limb was allowed to retain. 4. No such changes are to be found in the femur of the opposite side, which is pronounced healthy. " These specimens were procured four years after the injury. The capsule is entirely gone, and there is nothing to show positively where it was inserted; a line is pointed out about three lines below the socalled callus, as the line of insertion of the capsule. On examination of the interior of the specimen, there is nothing to indicate the line of fracture; no callus, such as is shown on internal examination of other fractures of long bones. " There is one point very marked on the inner edge of the compact structure of the shaft; it is what Sir Astley Cooper terms a 'buttress of bone' shooting up from the body into the neck and head, evidently as a support to the head in the new angle which it has assumed, with respect to the shaft. This buttress is formed apparently by the cancellated structure being more compact than in other points. On comparing this specimen with the femur of the well limb, a very marked difference is observable: this line or buttress is stronger, better developed, and is evidently for the purpose of giving support to the head of the bone in this new position. "The specimen is far from being satisfactory. If this rough line extending along the inter-trochanteric line, is in reality the line of callus, then it is extremely probable that the fracture was partially extra-capsular. For if the capsule extended along the line which runs below this line that is pointed out as the line of fracture, then the insertion of the capsule must have been as low down as the middle of the trochanter minor, an anomaly in regard to insertion of the capsule. If this really was the line of insertion, it is extremely unfortunate that the capsule was not left to show where it was inserted. "Again, there is no callus on the inside of the bone corresponding to this so-called external callus, but throughout the whole line corresponding to this external 'callus' the cancellated structure is perfect. If it should be admitted that crepitus was here obtained, a point which is extremely doubtful, as we have only the opinion of a doctor who practised many years ago in the small town of Barnard, Yt., a town which now numbers less than two thousand inhabitants —if it should be admitted on such authority that this was a fracture—still, it is by 353 NECK, WITHIN THE CAPSULE. no means established that this was an intra-capsular fracture, for this so-called callus extends along the inter-trochanteric line. The capsule itself is gone, so that it cannot be shown positively where it was inserted, and it is probable, if there was a fracture, it was partly extracapsular. " Again, the view which Prof. Parker takes of his specimen conflicts with that taken by Robert W. Smith, of Dublin, on fractures of this class, in his work already quoted. For if there was crepitus, then there must have been motion of one fragment on the other; and if there was motion, then the fracture was not impacted; and it is only this latter class which, Mr. Smith contends, can unite. My own impression is that there never was a fracture here at all. I think this is a case of interstitial absorption of the neck of the bone, the cause of this absorption being the contusion received by the fall. This view is sustained by analogy. Sir Astley Cooper says this is common in old people. ' As the shell becomes thin, ossific matter is deposited on the upper side of the cervix, opposite the edge of the acetabulum, and often a similar portion at its lower part, and thus the strength of the bone is in some degree preserved. This state of things may be frequently seen in very old persons.' ' When the absorption of the neck proceeds faster than the deposit on the surface, the bone breaks from the slightest cause; and this deposit wears so much the appearance of a united fracture, that it might be easily mistaken for it before the bone thus alters. We sometimes meet with a remarkable buttress shooting up from the shaft of the bone into its head, giving it additional support to that which it receives from the deposit of bone on its external surface.' " Mr. Liston says: ' Gradual shortening of the lower extremity often ensues upon contusions of the hip in persons advanced in life, in consequence of interstitial absorption of the neck of the thigh-bone, and alteration of the angle in which it is set upon the shaft. The head of the bone undergoes a change in form; it becomes flattened and expanded, and the cotyloid cavity is made to correspond. This cause of lameness ought to be kept in view. The risk of its occurrence ought to be explained to those who have suffered injury of the hip, and, if possible, it must be prevented.' "Mr. Gulliver, in the Edinburgh Medical and Surgical Journal, No. 128, July, 1836, et seq., has written very fully on this subject of interstitial absorption, and has adduced cases which we would copy if our limits would allow. He shows by his specimens that the head is enlarged at its lower part; that these cases may occur in young persons; that it is not disease of the joint, from the fact that there is no anchylosis ; and that the cartilages are not involved. The cases of John Lynn, J. McGrath, and J. Fox, etc., are adduced, and the specimens preserved from autopsies. We have abundant evidence of interstitial absorption occurring from contusion in persons like this maiden, and Mr. Gulliver says this shortening may take place as rapidly as in five or six days. Now, Prof. Parker's specimen corresponds to the facts we have given. 1. There is a ridge formed along the lower part of the neck, as Sir Astley Cooper states occurs in these cases of interstitial 354 FRACTURES OF THE FEMUR. absorption. 2. There is the buttress of bone shooting up from the shaft into the head as a means of support; this is clearly shown by comparing the two specimens, the one from the well limb, and the one from the contused limb. 3. There was a contusion sufficient for an exciting cause. 4. This occurs in one limb, and not in the other, as shown in the case of J. Fox, reported by Gulliver, where one limb was in every respect natural, and in the other interstitial absorption had taken place. This, we believe, is the case in Prof. Parker's specimen. If this specimen is in reality a fracture, it was most probably partly extra-capsular: if not, it was a case of interstitial absorption. 1 Dr. Alden March, the distinguished Professor of Surgery in Albany Medical College, has permitted me to examine two specimens belonging to his collection, which he regards as examples of bony union within the capsule. He has, however, rendered it unnecessary that I should describe particularly the appearances which they present, by having himself given an account of them, accompanied with drawings, in a paper entitled " Osseous Union of Intra-Capsular Fracture of the Neck of the Femur," published in the Transactions of the Medical Society of the State of New York, for the year 1858. The account of the first specimen is as follows:— " Of the two specimens here presented for examination, as examples of intra-capsular fracture of the femur united by bone, the smaller one, numbered 884, was procured in London some years since, and at that time was regarded by the curator of the old London Hospital Museum as a good specimen of fracture and bony union of the neck of the femur within the capsular ligament. I can give no history of the patient, or subject, from whom it was taken. I think it could not have belonged to an old person, and it is quite clear that he or she, as the case may be, lived long enough after the occurrence of the fracture for it to become thoroughly reunited by bony material. " The neck of the bone is very much absorbed, which will be found to be the case in almost all instances of intra-capsular fracture, whether united by bony or ligamentous material. This specimen with several others of various kinds of organic change, was submitted to the examination of an able professor of surgery, who has recently devoted much attention to the study of fractures, and who remarks upon it as follows: ' Specimen 884 is plainly enough a fracture, and I think there can be no doubt that on one side of the neck the fracture was within the capsule, but I have no means of determining whether it was also within the capsule on the opposite side, since the neck is almost completely absorbed.' "On close examination," continues Dr. March, "it will be found that about all the part of the bone that can be called neck is connected with the shaft, and that the fracture appears to be nearly transverse, and close to the articulating, or cartilaginous border of the head. It 1 This specimen is probably the same to which Prof. Parker has made allusion in his notes to the fourth American edition of Samuel Cooper's First Lines of Surgery, at page 354 of volume second. 355 NECK, WITHIN THE CAPSULE. strikes me that it is just as clearly altogether within the capsule as it is a fracture." In defence of the opinion already expressed by myself in relation to this specimen, and to which Dr. March has seen fit to refer in the passage above quoted, I will say, that the almost total absence of the neck posteriorly, where, in the natural condition of the parts, quite half an inch of the neck belongs outside of the capsule, renders it impossible, in my opinion, to determine whether the fracture was not in part without the capsule. This remark will apply to all similar examples, unless, indeed, the capsule itself remains to indicate precisely where this small portion of the neck belongs ; but the capsule is gone from this specimen, and the neck is lost posteriorly. If it is true, then, that the line of fracture can be shown to be close to the head of the bone, it is equally true that it hugs the trochanter; we have just as much right, therefore, to interpret its proximity to the trochanter in favor of an extra-capsular fracture, as has my distinguished friend to interpret its proximity to the head in favor of an intra-capsular fracture. Moreover, this specimen has never been sawn open, or subjected to the test of boiling, or of maceration, nor in any other way has the most important question of all been definitely settled, namely, whether the union is by bony or by fibrous tissue. The second specimen is described by Dr. March much more at length, rendering it necessary that our own account of it should be somewhat condensed. Fred. L. fell from a shed when ten or twelve years old, and, according to the testimony of respectable citizens, was attended by a surgeon, and treated, as they think, for a fractured thigh; but it does not appear probable that splints were used, as a woman was known to carry him up and down stairs on her shoulders during the time he was under the surgeon's care. It appears, also, that " immediately after getting about he was just about as lame, as much of a cripple, and as much distorted in his figure as he was at any time previous to his death." He is mentioned by one of the witnesses who knew him for many years after, as a "distorted cripple." Dr. March himself had known him twenty-five or thirty years, and describes him as a large framed man, with a " peculiar" gait, " a kind of side waddle, one limb appearing to be two or three inches shorter than the other, and with the hip of the shortened side greatly projecting laterally." He was about 58 years of age when he died. More or less of the skeleton of this man came subsequently into the possession of Dr. March, and he describes one of the thigh-bones as follows:— "A pretty large surface at its upper part and toward the trochanter major is a little flattened, and has the appearance of having been worn away, deprived of its cartilage, and becoming eburnated, or presenting at one point a porcelaneous polish." This change Dr. March regards as the result of interstitial and progressive absorption, aided by attrition, and as having occurred at an advanced period of life. On the anterior superior part of the neck is a ridge of bone, to 356 FRACTURES OF THE FEMUR. which a portion of the capsular ligament remains attached. Most of the cartilaginous covering of the head has been either entirely removed, or very much thinned, leaving at certain points a polished surface. That part occupied originally by the round ligament " seems to have been getting into a state of ulceration." The whole head is depressed and turned obliquely backwards. There is also a long spine or rib of bone extending upwards and inwards, which was imbedded in the fibres of the psoas magnus and iliacus, and "seems to have its attachment at its base, to the point where we should look for a trochanter minor." At first Dr. March thought that the shaft of the opposite femur had also been broken three inches below the trochanter minor, and that it had united with some slight deformity. He also found the ala of the pelvis on the right side bent inwards, so that the distance from the crest to the centre of the sacrum was three-fourths of an inch less than on the opposite side. This, too, he ascribed at first to the original injury, but further investigation has satisfied him that it was due to the action of the muscles, and that the opposite limb had never been broken. To this description, condensed from the paper alluded to, I need only add, that the whole head of the bone is very much flattened and changed in shape, and that there is scarcely anything which can be appropriately called a neck. The bone has been sawed in two, but Dr. March does not pretend that the bisection furnishes any additional evidence that it had been broken. My objections to this case are briefly:— It is not satisfactorily made out that there was ever a fracture, either by a reference to the original history, or by an examination of the bone. The age at which the accident occurred (10 or 12 years), is presumptive evidence against a fracture of the neck of the femur within the capsule, if not almost conclusive, unless it is claimed to be an example of epiphyseal separation with a bony union, a supposition which, so far as I can learn, no surgeon has yet ventured to make. Dupuytren says he never saw a fracture of the neck of the femur in a child. The youngest I have seen recorded is that mentioned by Sabatier, in which case the boy was fifteen years old. 1 Dupuytren has also well explained the causes of this infrequency of a fracture of the neck of the femur in early life. On the other hand, the age at which the accident occurred was favorable to the production of disease of the hip-joint. The whole history of the patient, from that time onwards, especially his peculiar "waddle," seems to indicate that his hip-joints were both diseased. The autopsy shows that they actually were diseased, and renders it quite probable also that all of the bones of his body were in an unhealthy condition. The specimen itself is in nearly all respects a counterpart of many others to be found in the museums of this and other countries, and which are now, by almost unanimous consent, declared to be examples of chronic rheumatic arthritis. 1 Dupuytren on Dis. and Injuries of Bones, p. 187. 357 NECK, WITHIN THE CAPSULE. Dr. Miitter thinks also that specimen B, 71, in his collection of bones, now lying in the Jefferson Medical College at Philadelphia, is a genuine example. It is a cleaned and dried specimen, from which the capsule, and all the soft parts, have been removed. The neck is very nearly absorbed, and the trochanter major is rotated backwards, as we see in nearly all examples of interstitial absorption, so that it almost touches the head. The interior has never been exposed, to determine the line of the supposed fracture, nor is there anything upon its external surface by which this point, so essential to the question at issue, can be decided. It may be an example in point, but the proof is not before us. Dr. Charles A. Pope, Professor of Surgery in the St. Louis University, Missouri, informs me that he has an example of "intra-capsular fracture of the neck of the femur, with concomitant fracture of the acetabulum. The union by bone is perfect, although the neck is, as it were, gone, the head being almost squarely set on the shaft of the bone. The head is much deformed, being an enlarged cone, and fitting into a similarly shaped acetabulum. The motions of the joints were well preserved." I have never seen this specimen, and I am therefore unable to speak of it authoritatively, but I confess I do not see how it is possible to know that the fracture was wholly within the capsule when the neck is gone. If the capsule remains attached to the specimen, it may aid in the elucidation of this point; but it does not appear from Dr. Pope's communication that such is the fact. I should be gratified if this distinguished surgeon would give the profession a more complete account of the case. From various sources, including several private letters, I have been able to gather a few of the particulars relating to a case which for some time attracted the attention of the profession in this country; but a full account of which, I regret to say, has never been published. 1 Somewhere about the year 1832, Mrs. William Nelson, of Derby, Vt., fell, and was slightly lamed. Dr. M. F. Colby, of Stanstead, Lower Canada, being consulted, declared that she had broken the neck of the thigh-bone. She was accordingly placed in a horizontal position, and an extending apparatus applied. This treatment was continued one month, during which time she became insane; but from this condition she ultimately recovered. At the end of one month the apparatus was removed, and she was able to walk after her recovery without much halt, and the limb did not seem to be much shortened. Subsequently the husband of Mrs. Nelson prosecuted Dr. Colby for causing insanity through unnecessary confinement, alleging that the bone was not broken; and, as evidence that it was not, testimony was presented to show that she was able to walk a few steps immediately after the injury was received; that she could draw up her legs; that she rode sitting upon the seat of a wagon; that the extending splint 1 Boston Med. and Surg. Journ., Jan. 26,1842; Amer. Journ. Med. Sci., April, 1857, p. 310. 358 FRACTURES OF THE FEMUR. was continued only four weeks, and that, although it was loosened occasionally by the friends, the limb did not shorten; and, finally, that she had a perfect, or nearly perfect, limb. The case remained in court several years, until both parties were nearly ruined; but ten years after the accident Mrs. Nelson died, and both femurs, says Dr. Mussey, were secured by Dr. Colby. The one believed to have been broken was then sent to several of our larger cities, and among others it was examined by Hay ward and one of the Warrens in Boston; Dixi Crosby, of Dartmouth; Willard Parker; one of the Rogers in New York; and Robert Nelson, of Canada. Robert Nelson and Rogers still denied that it had been broken, both of these surgeons affirming that the bone was perfect; but on the part of the defence, it was subsequently charged that a spurious bone had been laid before these latter gentlemen. Drs. Warren 1 and Hayward thought it had been a dislocation; Drs. Parker and Crosby believed it to have been a fracture within the capsule, and that it was united by bone. Dr. Mussey, to whom the specimen has been described, but who has never seen it himself, says that "the bone belonging to the injured limb had a ridge across the neck, while the head was so far depressed as to shorten the thigh-bone three-sixteenths of an inch." Dr. Colby finally received a judgment in his favor for one cent costs, and a bond, signed by the prosecuting attorney, to the effect that the bone, which was now in the possession of the prosecutor, should be given up to the defendant, and remain in his possession during a period of six months, in order that he might show it to the public; but this part of the contract has been broken, and the bone seems now to be lost to science. Whatever may be our opinion as to the probability of the fracture in this case, the absurdity and cruelty of the allegation of malpractice is too plain to admit of discussion or a doubt among intelligent medical men. If Dr. Colby thought there was a fracture—and he certainly had reasons to think so—his treatment was such as every judicious surgeon would have adopted, and for not adopting which he might justly have been held responsible. I have in my cabinet a cast which I made nearly twenty years since, from a femur then owned by Prof. James Webster, of Rochester, late Professor of Anatomy in the University of Buffalo, and which he believed to be a case of union by bone after a fracture within the capsule. The patient from whom this specimen was obtained was a female, and had been seen by him before death. Its resemblance to the specimen owned by Dr. March, and purchased by him in London, is so perfect, that I believed it to be the same, until Dr. March informed me that it was not. It is almost its exact counterpart, however, as I know by a comparison of the specimen with my own cast of Prof. Webster's. This fact will render it unnecessary that I should state my objections to it, since the same remarks will apply to it as to Dr. March's specimen. 1 Dr. Mussey says, " Dr. Warren decided there had been a fracture ;" but I have it upon the authority of Dr. Colby that Dr. Warren had called it a dislocation, or that a witness so testified. Perhaps it was not the same'Warren. 359 NECK, WITHIN THE CAPSULE. I have also in my own cabinet a femur of no inconsiderable pretensions, belonging clearly to that class of specimens recognized by Robert Smith. Its neck is greatly shortened, and this surgeon would regard it, I think, as an impacted intra-capsular fracture, but its claim would be promptly denied by Malgaigne, on account of the absorption and distortion of its neck. Its history is as follows:— About the year 1833 Mrs. "Wakelee, of Clarence, Erie County, New York, set. 68, who was then very low with tubercular consumption, and so ill as to be scarcely able to walk across the floor, tripped upon the carpet and fell, striking upon her left side. She was unable to rise, but was laid upon a bed by her son, Dr. Wakelee, a very intelligent physician, residing in the same house, who did not suspect a fracture. Dr. Bissel saw her on the following day, and on rotating the limb outwards, he says that he discovered a crepitus. His examination was greatly facilitated by her extreme emaciation. Mrs. W. was placed upon a double-inclined plane, with apparatus for extension, &c, and left in charge of Dr. Wakelee. On the fifth day the splint was removed, and from this time no dressings of any kind were applied. The reason for this change of treatment was, that she was likely to live but a few days, in consequence of the state of her lungs, and that such confinement would only hasten her death. Contrary, however, to all expectations, she gradually convalesced, so that after two or three years she could walk on crutches, her toes turning out and her limb becoming somewhat shortened. Four years after the accident she died, and Dr. Bissel obtained from Dr. Wakelee the specimen, of which the accompanying drawing is a faithful delineation. I am informed, also, that there are two specimens in the Boston Museums, but the descriptions which I have received of them are too imperfect to allow me to speak of their merits. Such is the present state of the testimony upon this interesting but difficult subject. In it all we think we see enough to warrant a belief that under certain Fig. 104. Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule. favorable circumstances bony union may occur, but not enough to establish it beyond all doubt. There are those who feel much more assured, and who are as confident of this fact as that the shaft of the femur will unite by bone; we do not accuse them of credulity, and we invoke for ourselves the same exercise of charity toward our scepticism. We have never yet seen a specimen which, upon a careful examination, proved satisfactory; but unless our want of conviction can be shown to be the result of a wilful blindness, we shall demand protection against the assaults and insinuations which have so fre- 360 FRACTURES OF THE FEMUR. quently fallen upon those who ventured to doubt the authenticity of every specimen which was laid before them. Within the last year, Dr. Geo. K. Smith, of the Long Island College Hospital, has made a most valuable contribution to our knowledge of the anatomy and pathology of the hip-joint, which will explain in a great measure the discrepancies of opinion which at present exist among surgeons as to the character of certain specimens, and may hereafter enable us to decide with more accuracy, and may lead to a better agreement of opinion. His observations prove that anatomists have not hitherto correctly described the attachment of the capsule; that the capsule is seldom, if ever, attached at the same point in different persons, while it is as uniformly found attached at the same point in the opposite femurs of the same person. In order, therefore, to determine whether the line of fracture in any given specimen was without or within the capsule, we must always compare the fractured bone with its congener, and not with the femur of another person. He has further shown that after a fracture, and the consequent absorption of the neck, the normal position of the capsule is almost constantly changed; so that its present attachment does not declare what were the points of its attachment before the fracture occurred, and finally that the absorption proceeds unequally and irregularly, yet with great rapidity, in the two fragments; and as the bony union, if it ever takes place, probably occurs subsequent to the arrest of the absorption, the line of union cannot in itself alone determine whether the fracture was near the head or near the trochanters. 1 I repeat that it seems to me probable that under certain favorable circumstances this union will occur; these favorable circumstances have relation to several conditions, such as age, health, degree of separation of the fragments, laceration of the periosteum and capsule, treatment, &c. Robert Smith thinks it is not likely to occur unless the fragments are impacted, but Sir Astley Cooper, as we have already seen, admitted its possibility whenever the reflected capsule and the periosteum were not torn, and at the same time the fragments were not displaced. If to these conditions we were to add moderate but not extreme age, with good health, we can see no sufficient reason why, under judicious treatment, bony union might not occasionally be expected. But such a combination of circumstances is probably exceedingly rare; and, what is more unfortunate, if they exist, the fracture is not likely to be recognized, and the surgeon will fail to avail himself of those advantageous coincidences which might, if understood and properly treated, secure a bony union. Dupuytren says, when the fragments are not displaced " its existence may be suspected, but cannot be positively asserted." There will not be wanting, however, examples in which surgeons will believe or affirm that they have recognized the fracture and wrought the cure. I have heard of many such instances, and Mr. Smith has referred to one, 1 Geo. K. Smith, Insertion of the capsular ligament of the hip-joint, and its relation to intra-capsular fracture. Medical and Surgical Reporter, Philadelphia, 1862. 361 NECK, WITHIN THE CAPSULE. which is quite pertinent, as having been reported in the Gazette des Hdpitaux. A woman, set. 64, was treated for an intra-capsular fracture of the neck of the femur at one of the hospitals in Paris, and "at the end of four weeks she was discharged perfectly cured, and without shortening." We fully partake of Mr. Smith's surprise at the impudence of this claim, yet we do not see in it much greater improbability than in Mr. Swan's case, received by both Mr. Smith and Sir Astley himself, where the neck was found almost wholly united by bone in five weeks, although the woman was 80 years old, and actually dying while the process was going on! Says Dupuytren, " I would lay it down as a general principle that all fractures of the neck of a cylindrical bone should be kept at rest twice as long as ordinary fractures of the same bone; and even after that period I have seen displacement take place. The term may, therefore, be lengthened to a hundred days, or even longer in aged and feeble persons, whose powers of reparation are much deteriorated." It is not the purpose of the writer to describe particularly all of the accidents or pathological conditions with which these fractures .may be confounded. It is sufficient to allude to them, and to leave to others the labor of a complete historical record; but I am tempted to devote a paragraph to what has been variously termed " morbus coxse senilis" (Robert Smith) ; "chronic rheumatic arthritis" (Adams)] "interstitial absorption of the neck of the thigh-bone" (B. Bell)] and by others " interstitial and progressive absorption," but the exact nature and cause of which morbid changes are not yet fully understood. Mr. Colles does not think this partakes of the nature of rheumatism. I have myself a specimen of what has been more generally called chronic rheumatic arthritis, occurring in the knee-joint, accompanied with a flattening and eburnation of the articular surfaces, and Gulliver has shown that similar changes of form in the neck of the bone may occur in tolerably young persons. Fig. 105. Section of a sound adult femur. I suspect also that it will be found to occur under a greater variety of circumstances, and to present a greater variety of forms than have yet been described; and we shall perhaps find a partial explanation of this diversity and frequency in one single circumstance, namely, the peculiar anatomical structure of the neck. The neck of the femur stands nearly at a right angle with the shaft, or at an angle so great as that the weight of the body, even in health, has the effect to gradually depress the head below the top of the trochanter major, and to diminish its length. This is seen constantly in the striking change of form which occurs between childhood and old age. Now, if from any cause whatever, such as a blow upon the trochanter or upon the foot, 24 362 FRACTURES OF THE FEMUR. the neck or head is made to suffer, and inflammation, or perhaps only a slight degree of increased action in the absorbents ensues, resulting in an equally slight softening of the bony tissue, these pathological circumstances may end, sooner or later, in a striking change of form in the neck or head. But it is not necessary to suppose an external injury to explain the occurrence of this inflammation, and consequent softening of the bone; a scrofulous, or rickety, or tuber- Fig. 106 Chronic rheumatic arthritis. (Miller.) culous constitution may occasion it, and we see no reason why these conditions are not as likely to lead to a change of form here as in the bones of the leg or of the spine. A change of form in the head may be the result of an ulceration of the cartilage, and a change of form in the neck, of ulceration of the neck. Among other causes, also, " chronic rheumatic arthritis" may operate in a large proportion of those examples which belong to advanced life. One case, reported by Gulliver, would seem to show that a deformity may occur here as a result of disease, and independently of pressure, 1 yet it is plain, from the direction which the deviation of the head and neck usually takes, that pressure performs an important part in the causation. From these various causes, operating in these diverse ways, we shall have the different deformities enumerated and described by surgical writers. The head flattened, irregularly spread out, depressed and polished; the neck shortened and irregularly thickened and expanded; the trochanter major rotated outwards and drawn upwards; sinuous chasms traversing the neck, produced by ulceration; and finally, shortening of the neck, by a true interstitial absorption, and with little or no increase in its breadth, the trochanter major also being 1 Gulliver, Loud. Med.-Chir. Rev., vol. xxxix. p. 544. 363 NECK, WITHIN THE CAPSULE. rotated outwards. It would be strange, moreover, if the interior of these bones did not present some changes in structure, such as have been frequently observed, namely—an irregular expansion or condensation of the cellular tissue, and which latter might easily be supposed by one who was inattentive to all of these circumstances, to indicate the line of an imaginary fracture. The following example will illustrate the incipient stage of one class of these cases, namely—that in which the neck is not only shortened, but its surface is irregularly seamed, as if it had been broken and imperfectly united. Wm. Clarkson, set. 43, was admitted into the Toronto Hospital, C. W., May 5, 1858, with tubercular consumption, of which he died on the 25th of the same month. He had been under the care of Dr. Scott, and it having been noticed that he complained of his right hip, at the time of admission, an autopsy was made on the 25th, at which I was, through the courtesy of the house surgeon, permitted to be present. We examined both hip-joints, and found the neck of the right femur shortened, especially in its posterior aspect. At the junction of the head with the neck, posteriorly, and extending about half way around, the bone was carious, and so far absorbed as to leave a sulcus of a line or two in depth, and of about the same width. Adjacent to this, also, the bone was quite soft, yielding under the slightest pressure of the knife. There was no other appearance of disease. The opposite femur was sound. The hospital record furnished the following account of his case, so far as the injury to his hip was concerned :— About nine months before admission, then laboring under the malady of which he finally died, he received a blow upon his right trochanter, ever since which he had been lame, and suffered pain in the region of the hip-joint. The pain was felt especially in the groin, when the trochanter was pressed upon, or when the sole of his foot was percussed. The thigh was slightly flexed; the toes a little everted; and he walked with some halt. The case of the soldier, Fox, reported by Gulliver, and who died of tuberculosis, presents a case also exactly in point, but illustrating a later stage, or the completion of the same process. Of the precise nature of the changes in the two following examples, I cannot be certain, since they have not been determined by dissection. They will serve, however, to illustrate the usual history and progress of a considerable number of cases. They certainly were not examples of fracture. Ephraim Brown, when twelve years old, fell from a tree and struck upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called. Of the particular symptoms at this time, I have only learned that the leg was not shortened. The doctor laid a plaster upon his hip, and left him without any further treatment. In three days he was able to walk on crutches; in three weeks he walked without crutches, and in four months was at work as usual. There was at this time no shortening or deformity of any kind. 364 FRACTURES OF THE FEMUR. Mr. Brown subsequently enlisted as a soldier in the war of the American Revolution, and experienced no difficulty in this hip until after a severe illness which followed upon an unusual exposure, when he was about thirty-five years old. At this period the leg began to shorten, but the shortening was unaccompanied with pain or soreness. He consulted me, July 17, 1845, at which time he was eighty-three years old, and a remarkably strong and healthy-looking man. The shortening, which had ceased to progress some years before, amounted at this time to two and a half inches. An officer in the United States army addressed to me the following letter, dated Nov. 13, 1849 :— "My mother-in-law, Mrs. S., of D., some three years since fell down a flight of stairs, striking on her side upon a stone, injuring the hipjoint severely; but upon examination, her physician declared that there was neither a fracture nor a dislocation, and said that she would gradually recover. Something like one year since the injured limb commenced shortening, so that she can now barely touch her toe to the floor as she walks. She can bear but little weight upon it, and is compelled to use a crutch or a cane constantly. So much time has now elapsed, and the limb is so little better, and constantly becoming shorter, I have proposed to ask your opinion," &c. I need scarcely say that I had no hesitation in pronouncing this a case of chronic inflammation of the bone, accompanied with softening and gradual change of form, either of the neck or head, or of both. It is proper that I should state briefly, before I leave this subject, what constitute the chief difficulties in the way of union by bone within the capsule. The persons to whom the accident occurs are generally advanced in life, and consequently the process of repair is feeble and slow. The head of the bone receives its supply of blood chiefly through the neck and reflected capsule, and when both are severed, the small amount furnished by the round ligament is found to be insufficient. When the fragments are once displaced, it is difficult, as I have already explained, if not impossible, to replace them. The direction of the fracture is generally such that the ends of the fragments do not properly support and sustain each other when they are in apposition. The fracture is at a point where the most powerful muscles in the body, acting with great advantage, tend to displace the broken ends. Aged persons, who are chiefly the subjects of this accident, do not bear well the necessary confinement, and especially as the union requires generally a longer time than the union of any other fracture; so that a persistence in the attempt to confine the patient the requisite time often causes death. Whether the absence of provisional callus as a bond of union, and the interposition of synovial fluid between the ends of the fragments, constitute additional obstacles, I am not fully prepared to say. In the opinion of many surgeons these circumstances constitute very serious, if not the chief, obstacles. It remains only to consider what is the usual result of this fracture. 365 NECK, WITHIN THE CAPSULE. The fragments, more or less displaced, undergo various changes. The acetabular fragment is generally rapidly absorbed as far as the head, and occasionally a considerable portion of this latter disappears also; while the trochanteric fragment appears rather as if it had been Fig. 107. Fracture of cervix femoris within capsule. Ununited. Opposite surfaces irregularly convex and concave, and polished ; movingslightly upon each other. (From a specimen in the possession of Dr. Crosby.) Fig. 108. Mayo'I specimen. United by ligament. Patient lived nine months after the accident. The trochanter minor arrested the descent of the head. (From Sir A. Cooper.) flattened out by pressure and friction, it having gained as much generally in thickness as it has lost in length. To this observation, however, there will be found many exceptions. Sometimes the trochanteric fragment forms an open, shallow socket, into which the acetabular fragment is received; or its extremity may be irregularly convex and concave, to correspond with an exactly opposite condition of the acetabular fragment. (Fig. 107.) Ordinarily the two fragments move upon each other, without the intervention of any substance; but often they become united, more or less completely, by fibrous bands (Fig. 108), which bands may be short or long, according to the amount of motion which has been maintained between the fragments while they are forming, or to the degree of separation which exists. The capsular ligaments are usually considerably thickened and elongated in certain directions, and not unfrequently penetrated by spicules of bone. They are also found sometimes attached by firm bands to the acetabular fragment. A permanent shortening, either with or without eversion of the limb, are the invariable consequences of this accident. Indeed, not a few succumb rapidly to the injury, perishing from a low, irritative fever, or from gradual exhaustion, within a month or two from the 366 FRACTURES OF THE FEMUR. time of its occurrence. Says Robert Smith: " Our prognosis, in cases of fracture of the neck of the femur, must always be unfavorable. In many instances the injury soon proves fatal, and in all the functions of the limb are forever impaired; no matter whether the fracture has taken place within or external to the capsule—whether it has united by ligament or bone—shortening of the limb and lameness are the inevitable results." Treatment. —In case, then, of a complete fracture within the capsule, existing without laceration of the reflected capsule, or displacement of the fragments, and equally in case of a fracture at the same point with impaction, the treatment ought to be directed to the retention of the bone in place, by suitable mechanical means, for a length of time sufficient to insure bony union, or for as long a time as the condition of the patient will warrant. The means which are best calculated to fulfil this important indication are, in my judgment, complete rest in the horizontal posture, the limbs being secured in straight splints constructed somewhat after the principle of Gibson's improvement of Hagedorn's apparatus; that is, Fig. 109. Gibson's modification of Hagedorn s splint. the sound limb being first secured to the foot-board, and the broken limb subsequently brought down to the same point. In this way we may dispense with the perineal band as a means of counter-extension, which is so painful, indeed insupportable often, when the fracture is at the neck, the hip of the broken limb being prevented from descending by the lateral pressure of the two long splints. This apparatus possesses also this advantage, namely, that it presses the broken fragments more firmly against each other, and thus operates to prevent their displacement in the direction of the axis of the shaft. Fig. 110. Gibson's splint applied. In treating this fracture, supposing no displacement to exist, no extension beyond that which is necessary to insure perfect quiet can 367 NECK, WITHIN THE CAPSULE. be proper, inasmuch as the fragments are not overlapped; and they need only a moderate assistance to enable them to maintain their position against the action of the muscles. Moreover, if the fragments are impacted, violent extension would disengage them and render their displacement and non-union inevitable. Of course no side splints are necessary, but both limbs should be secured through their whole length to the long lateral splints, and properly supported by junks and pads. I am prepared to affirm, from my own experience, that more patients will endure quietly this position for a length of time than the flexed position, whether in this latter the patient is placed upon his side or upon his back. How long the patient will submit to this, or to any other mode of securing perfect rest, is very uncertain, and the decision of this question must rest with the individual cases and the good sense of the surgeon. Not very many old and feeble people will bear such confinement many days without presenting such palpable signs of failure as to demand their complete abandonment. A mode of treatment similar to this was adopted in Jones' case, and also in the case reported by Fawdington, and is said to have been successful. In Brulatour's case the limb was kept extended two months; in Mussey's second case Hartshorne's straight splint for extension remained upon the limb eighty-four days; in Bryant's case a long splint was used "some weeks." It is true, however, that other plans of treatment seem to have been equally successful. In the case reported by Adams the limb was placed over a double inclined plane, made of pillows, five weeks; and in Mussey's third example the limb remained in the same position three months. Chorley laid his patient upon the sound side, with the thighs flexed, for a space of two weeks, and then turned him upon his back, still keeping the thighs flexed. At the end of six weeks he was placed in the straight position, &c. But in a majority of the examples reported, the existence of the fracture was either not suspected, or bony union was not anticipated or desired, consequently no treatment, having in view the confinement of the broken bone, was adopted. Yet the success was as great as that which has followed from either of the other plans. Harris' patient was simply laid on a sofa. Field's patient, who broke the neck of both femurs within the capsule at different times, was in each case left without treatment, except that she laid upon her bed. Mussey himself removed all dressings from Dr. Dalton's patient on the eighteenth day, and placed him upon his feet, and Dr. Wakelee removed the apparatus from his mother on the fifth day. Nor are we without evidence that the careful and judicious application of splints, long continued, and employed under the most favorable circumstances, will sometimes fail. The two following cases confirm these remarks. The first occurred in the practice of Dr. James R. Wood, of this city: "M. J., a young lady, set. 16 years; of vigorous constitution; perfectly free from any constitutional taint either of scrofula, syphilis, or cancer; was caught between the wheels 368 FRACTURES OF THE FEMUR. of two carriages, the one stationary, the other in motion. The blow was received directly on the trochanter major of the right side. The symptoms which presented themselves showed conclusively that there was a fracture. There was shortening, loss of voluntary motion, and eversion; by placing the finger on the trochanter major, and the thumb in the groin, a well-marked crepitus could be felt on extension and rotation being made. There was no laceration or other complication of the injury. She was placed on Amesbury's splint, with side splints accurately adjusted, and every precaution taken to insure a perfect union. The limb was kept on this splint without being disturbed for six weeks. At the end of that time, it was taken from the splint and examined with care. The signs of fracture still remained; the limb was replaced on the splint, and the dressings as before; everything was attended to in the general management of the case which the doctor thought would be conducive to perfect union. The patient was kept for three weeks longer on the splint, which was then removed. It was found that there was no union. Patient lived for three years, and was so lame that she was always obliged to use a crutch in walking. At the expiration of three years she died of an acute disease. " On examination of the cervix femoris, it was found that there had been a transverse fracture of the bone just at .the junction of the head and neck. The head of the bone was still attached to the acetabulum by the ligamentum teres. The process of absorption had been going on, and the head of the bone had already been absorbed below the level of the acetabulum, and what remained was soft and spongy, easily broken with the handle of the scalpel. The neck of the bone was rounded off, and covered with a fibrous deposit. This was not a case of diastasis, as has been suggested by an eminent surgeon, who judged simply from the age of the patient. She was full sixteen when the accident happened, and over nineteen when she died." The second was in the person of a man, set. 25 years, who was at the time of the accident robust and in good health: " He was dancing at his sister's wedding; while cutting a pigeon wing, he struck the foot upon which he was resting from under him, and fell, striking directly upon the trochanter major. He was unable to rise; a carriage was called and he was taken directly to the New York Hospital. There he came under the charge of Dr. J. Kearney Eodgers. A fracture was immediately diagnosticated, and for a few days he was kept on the double inclined plane. The straight splint was then used, and the dressings kept up for six weeks; at the end of that time they were taken off and the limb examined; there was no union. The limb was continued in the straight splints for three weeks longer, and again examined—there was still no union. The patient was again replaced in the straight splint for two weeks longer, but no union occurred. At the end of three months from his admission he was discharged; he was in good health, but so lame that he was obliged to use two crutches in walking. After his discharge the patient became very intemperate; and, in the course of a few weeks he applied for admission to Bellevue Hospital. He was much debilitated, and had an exhausting diarrhoea. NECK, WITHOUT THE CAPSULE. 369 Shortly after his admission, an immense abscess formed over the joint, which discharged profusely. The man died shortly after from exhaustion, and the specimen came into Dr. Van Buren's hands, the patient having been in his service. Dr. Van Buren was aware of the patient's previous history, the treatment, etc., at the New York Hospital, and a careful examination was made. " The capsular ligament was destroyed entirely by the suppurative process; there was a formation of callus upon the trochanter major; the ligamentum teres was entirely absorbed ; the head of the bone was spongy, as if worm eaten; the direction of the fracture was oblique, commencing just at the articulating surface of the head and ending just within the capsule; the upper end of the shaft of the bone showed this same appearance that was marked in the head. These points are beautifully shown in the specimen at the present time. The opinion of Charles E. Isaacs, M. D., the able Demonstrator of Anatomy of the University Medical College, is, that this fracture was entirely within the capsule." 1 The bone may be seen in the museum of Prof. Wm. H. Van Buren, of the University Medical College, New York. Such equal results from opposite plans, and unequal results from similar plans of treatment, are not calculated to increase our faith in the testimony which most of the foregoing examples are supposed to furnish of the possibility of bony union. On the contrary, they cannot fail to suggest a doubt as to whether some of them, at least, were not inaccurately diagnosticated. But admitting that they were not, the testimony which they furnish in relation to treatment is too inconclusive to be made available for instruction, and we are still at liberty to adopt that which seems most rational, without reference to the experience of others. The reasons why I would prefer Hagedorn's plan, have already been stated in part, to which I will now add, that if an error should occur in the diagnosis—if it should prove finally to have been a fracture without the capsule, then this treatment would be correct, and no injury would come to the patient from the error in diagnosis; but if we adopt Sir Astley Cooper's suggestion, namely, to get the patient upon crutches as soon as possible, perhaps as soon as fourteen days, an error in diagnosis might be followed by the most disastrous consequences. I ought to add, that if this plan for any reason is found inconvenient or inapplicable, nothing which I have seen will prove so comfortable and available an alternative as the fracture bed, invented by Dr. Daniels, of New York. (b.) Neck of the Femur without the Capsule. Causes. —Like fractures within the capsule, these also occur most frequently in advanced life; age may therefore be regarded as the grand predisposing cause. As to the immediate causes, we have already mentioned in the preceding section that fractures without the capsule seem to be the result 1 Johnson, op. cit., pp. 13-15. 370 FRACTURES OF THE FEMUR. generally of falls or of blows received directly npon the trochanter ; occasionally, also, they are produced by falls upon the feet or upon the knees. Pathology. —These fractures may occur at any point external to the capsule, but generally the line of fracture is at the base, corresponding very nearly with the anterior and posterior inter-trochanteric crests. Almost invariably the acetabular penetrates the trochanteric fragment in such a manner as to split the latter into two or more pieces. The direction of the lesions in the outer fragments preserves also a remark- Fig. 111. Fig. 112. Fig. 113. Impacted, extra-capsular fractures. (R Smith, and Erichsen.) able uniformity; the trochanter major being usually divided from near the centre of its summit, obliquely downwards and forwards toward its base, and the line of fracture terminating a little short of the trochanter minor, or penetrating beneath its base; while one or two lines of fracture usually traverse the trochanter major horizontally. In an examination of more than twenty specimens, I have noticed but two or three exceptions to the general rules above stated. In Dr. Mutter's collection, specimen marked B 115 is not accompanied with either impaction or splitting of the trochanteric fragment; but the neck having been broken close to the inter-trochanteric lines, has, apparently, slid down upon the shaft about one inch, at which point it is firmly united by bone. Dr. Neill has also a specimen of fracture at the same point, but without union of any kind, in which no traces remain of a fracture of the trochanters. The acetabular fragment has moved up and down upon the trochanteric until it has worn for itself a shallow socket three inches and a half long; the approximated surfaces being smooth and polished like ivory. The trochanter major is usually turned backwards, the shaft of the femur being rotated in this direction, the same as is usually observed in other fractures of the neck of the femur. I have seen one exception 371 NECK, WITHOUT THE CAPSULE. to this general rule in a specimen belonging to Dr. Mutter (No. 29); the trochanter in this instance is turned forwards, so that the neck is shorter in front than behind. The upper fragments of the trochanter major, whenever the lines of fracture are transverse, are generally inclined inwards toward the neck, as if displaced in this direction by the force of the blow, or perhaps by the resistance offered by certain muscles and ligamentous bands which find an insertion upon its summit. The neck is found, in most cases, standing inwards at nearly a right angle with the shaft, the head being much more depressed than the outer extremity of the neck, in consequence of which the lower margin of its broken extremity is driven much deeper into the trochanteric fragment than is the upper margin. Malgaigne believes that impaction with consequent fracture of the trochanters, is never absent in true extra-capsular fractures, unless it be in that very unusual variety in which the trochanter forms a part of the inner fragment (fractures through the trochanter major and base of the neck). Robert Smith entertains the same opinion, although Malgaigne does not seem to have so understood him. I cannot agree, however, with either of these gentlemen that the rule is so invariable, since I am confident that no such splitting has occurred in either of the two specimens to which I have referred as belonging respectively to Drs. Mutter and Neill. It is true these are both old fractures, and to some extent the signs of fracture may have become obliterated, but in Mutter's specimen an abundant callus indicates plainly enough where the shaft separated from the neck, while the trochanter major is smooth as in its normal condition, nor does its summit incline either way from its usual position. Neill's specimen, though less satisfactory, does not fail to convince me that neither impaction nor splitting of the trochanters ever occurred. It is certain, however, that impaction and comminution of the outer fragment are very constant, and that, whether the fracture is produced by a fall upon the feet or upon the trochanter major. But the impaction does not necessarily continue; sometimes, indeed, it does, and the position of the limb, whatever it may be at the moment, remains unalterably fixed; either very little or considerably shortened, according to the degree of rotated outwards or inwards, or in neither direction, perhaps, according to the direction of the force and of the fracture. In other cases, owing to the extreme comminution, and to the wide separation of the trochanteric fragments, or to the contraction of the muscles inserted into the top of the femur, or to the weight of the body in attempts to walk, or to injudicious handling on the part of the surgeon, such as forcible rotation, by which the neck is made to act as a lever, and to actually pry the fragments apart, or to violent extension, by which the impaction is overcome— owing to some one or' several of these causes it often happens that the fragments separate, and the leg becomes immediately more shortened, movable, and more inclined .to rotate outwards. Symptoms. —The symptoms which indicate a fracture of the neck of the femur without the capsule, are pain, mobility, crepitus, short- 372 FRACTURES OF THE FEMUR. ening and eversion of the limb. The trochanter major is not as prominent as upon the opposite side, and it rotates upon a shorter axis. There are also several other signs to which I shall refer when considering the differential diagnosis. The pain and tenderness, accompanied sometimes with swelling and discoloration, are situated chiefly in front of the neck of the bone. Mobility exists in a majority of cases, even when the fragments are impacted ; that is, the limb can be moved pretty easily in any direction by the surgeon, but not without producing pain or provoking muscular spasms, yet the patient himself is unable to move the limb by his own volition, or he can only move it slightly. Crepitus is present whenever there exists a moderate but not complete impaction. It is also present generally when, the trochanteric fragment having been extensively comminuted and loosened, the impaction becomes excessive; and it is only absent when the impaction is such that the fragments are completely and firmly locked into each other. A shortening is inevitable, at least in all cases accompanied with either temporary or permanent impaction, and we have seen that one of these conditions seldom fails. According to Sir Astley Cooper .the shortening varies from half an inch to three-quarter of an inch, but Robert Smith has established the following distinction. When the fracture is extra-capsular and impacted, that is, when it remains im- Fig. 114. Fracture of the neck of the Femur. (Fergusson.) pacted, the shortening is only moderate, varying from one-quarter of an inch to one inch and a half; in fourteen cases measured by him the average was a fraction over three-quarters of an inch; but when it does not remain impacted it ranges from one inch to two inches and a half; indeed, Mr. Smith mentions one example in which the shortening reached four inches, and forty-two cases gave an average shortening of something more than one inch and a quarter. Eversion of the toes is very constant; but in a few instances upon record the toes have been found turned in, or even directed forwards. In the specimen referred to as being found in Dr. Mutter's collection, with an inward or forward rotation of the trochanter major, the same relative position of the whole limb must have existed. The trochanter major usually seems depressed or driven in, and, when the two main fragments are completely separated, if the limb is rotated, the trochanter will be found to turn almost upon its own axis, or upon a very short radius. In enumerating the sign of extra-capsular fracture, it will be seen that I have, with only slight variations, repeated the signs of a fracture within the capsule. It will become necessary, therefore, to indicate, as far as possible, a differential diagnosis. And without pretending 373 NECK OF THE FEMUR. that all of the differential signs which I shall enumerate are thoroughly established, or that in every case, even after a careful grouping of all the symptoms, a satisfactory diagnosis can be made out, I shall state briefly my own conclusions, or, rather, what seem to me to be the probable facts. Signs of a fracture within the capsule. Produced by slight violence. A fall upon the foot or knee, or a trip upon the carpet, &c. Generally over fifty years of age. More frequent in females. Pain, tenderness and swelling less, and deeper. (The two following measurements to be made from the anterior superior spinous process of the ilium to the inner condyle of the femur.) Shortening at first less than in extracapsular fractures, often not any. Shortening after a few days or weeks greater than in extra-capsular fractures ; sometimes this takes place suddenly, as when the limb is moved, or the patient steps upon it. Measuring from the top of the trochanter to the inner condyle or to the malleolus internus the femur is not shortened. More mobility of limb, at joint. Trochanter major moves upon a longer radius. If the patient recovers the use of the limb, not restored under three or four months. No enlargement or apparent expansion of the trochanter major, after recovery, from deposit of bony callus. Progressive wasting of the limb for many months after recovery. Excessive halting, accompanied with a peculiar motion of the pelvis, such as is exhibited in persons who walk with an artificial limb. Signs op a fracture without the capsule. Produced by greater violence. A fall upon the trochanter major. Often under fifty years of age. Relative frequency in males or females not established. Pain, swelling and tenderness greater and more superficial. It is especially painful to press upon and around the trochanter. Shortening at first greater, almost always some. Shortening after a few days or weeks less than in intra-capsular fractures. That is, the amount of shortening changes but little, if at all; if the impaction continues, not at all; if it does not continue it may shorten more. Measuring from the top of the trochanter to the inner condyle or to the malleolus internus the femur may be found a little shortened. Less mobility. Trochanter major moves upon a shorter radius. If the patient recovers the use of the limb, restored in six or eight weeks. Enlargement or irregular expansion of trochanter, which may be felt sometimes distinctly through the skin and muscles. The limb preserving its natural strength and size. Slight halt, motions of hip natural. Prognosis. —In attempting to establish the differential diagnosis we have necessarily been led to consider most of the essential points of prognosis. Very little, therefore, remains to be said upon this subject. Union generally occurs as rapidly in this fracture as in fractures of the shaft, and perhaps, even sometimes more promptly, owing to the existence of impaction. But whether it occurs promptly or slowly, or, indeed, if it does not occur at all, a remarkable deposit of ossific matter almost invariably takes place along the inter-trochanteric lines, where the bone has separated from the shaft, and also, not unfrequently, along the lines of the other fractures of the trochanter. 374 FRACTURES OF THE FEMUR. This deposit is no less remarkable for its abundance than for its Fig. 115. Fracture of nock without the capsule, (Erichsen.) Fig. 116 irregularity, long spines of bone often rising up toward the pelvis and forming a kind of knobby or spiculated crown, within which the acetabular fragment reposes. In a few instances these osteophites have reached even to the bones of the pelvis, and formed powerful abutments which seemed to prevent any farther displacement of the limb in this direction, and, by some writers, they have been supposed thus to fulfil a positive design. A sufficient explanation of their existence, however, we think can be found in the fact that they proceed entirely from the trochanteric fragments, whose extensive comminution and great vascularity would naturally lead to such results. The same, but in a less degree, has already been noticed as occurring in impacted fractures at the anatomical neck of the humerus, where certainly such bony abutments could not serve any useful purpose. Fig. 117. Extra-capsular fractures. Union with excess of callus. (R. Smith.) Treatment. —The same principles of treatment are applicable here as in fractures of the neck within the capsule; by which I mean to say that, as in all of those examples of fracture within the capsule where the relation of the fragments is such as to warrant a hope that a bony union may be consummated, namely, where the fragments are not displaced or are impacted, the straight splint, with only moderate extension, constitutes the most rational mode of treatment; so also in this fracture, whenever the fragments are impacted and remain im- 375 NECK, WITHOUT THE CAPSULE. pacted, a straight splint, employed only as a retentive apparatus, is the most suitable. It is only by employing this plan of treatment, which no one has yet shown to be inapplicable to either of these two varieties of accidents—I do not speak of the opinions which men may have entertained, but of the practical testimony—it is only, I say, by employing this uniform plan of treatment in both cases that those serious misfortunes to the patient can be avoided which would necessarily continue to occur if Sir Astley Cooper's advice was followed, namely, to allow the patient in the one case to dispense with splints wholly, and to get upon his crutches as soon as the condition of his limb and of his body will permit, when it is certain that in the other case some retentive apparatus is generally Fig. 118. necessary. This conclusion is based upon the admitted difficulty of diagnosis. If, as is well understood, the diagnosis between these two varieties of fracture can seldom be made out satisfactorily during the life of the patient, then how shall we know in any given case which of the two plans to adopt. If we act upon the supposition that it is within the capsule, adopting Sir Astley Cooper's method, and it proves to have been a fracture without the capsule, we have, I fear, done irreparable injury to our patient. It is precisely here that this distinguished surgeon committed his great error, not in denying that certain specimens were fractures of the neck of the femur within the capsule united by bone, nor in constantly urging upon his contemporaries the improbability of such an event, but in that while he admitted its possibility, he chose to recommend a plan of treatment which was unlikely to insure such a union, and which, in the uncertainty if not impossibility of diagnosis, was liable, upon his supposed authority, to be adopted in many cases of extra-capsular fractures. Again, if the fracture be extra-capsular and not impacted, or the impaction has been, for any cause, overcome; or, if the fracture be intra-capsular and not impacted, or if the capsule is lacerated and the fragments are in consequence displaced; then again no injury need result from the treatment, if we adopt the straight splint with moderate extension, such as may be obtained from the use of Hagedorn's splint modified by Gibson. That it is not impacted we may know often, or generally, by the amount of displacement, although we may not easily decide whether the fracture is within or without the capsule. Now the amount of shortening will determine, properly enough, the amount of extension to be employed. In either case we shall not employ, because the patient will not permit, as much extension as in fractures of the shaft; and while in the one case we shall only gain a shorter and firmer ligamentous union, in the other we shall insure a better and more speedy bony union. 376 FRACTURES OF THE FEMUR. If any surgeon, acting upon the suggestions here made, shall confine a feeble or an aged person in the horizontal posture, and in a straight splint until the powers of nature have become exhausted, and death ensues, as our readers have already been admonished may happen, we are not to be held responsible for his want of judgment or Fig. 119. Miller's splint for extra-capsular fractures. (From Miller.) of skill. We have advised this plan of treatment only for so long a period as the condition of the patient renders it entirely safe. No doubt, then, in a large number of cases it will have to be abandoned very early, and in not an inconsiderable proportion all constraint will be plainly inadmissible from the beginning; and it is for such examples that the treatment recommended by Sir Astley Cooper for all intra-capsular fractures, ought to be reserved. (c.) Fractures of the Neck partly within and partly without the Capsule. It is scarcely necessary to say that the line of fracture through the neck of the femur may be such, that it shall be in part within and in part without the capsule; and such fractures will be even more difficult to diagnosticate than either of those forms of which we have just spoken. The symptoms will be mainly, however, those which characterize fractures within the capsule, while the treatment ought to be such as we would adopt in those fractures which are wholly without the capsule. The chances for bony union are increased in proportion as the line of separation extends outside of the capsule, and we ought to be diligent in our efforts, if we have made ourselves certain that the fracture is partly extra-capsular, to secure a good bony union; a result which experience has shown may be reasonably anticipated. The necessity for some extension, and of a firm retentive apparatus in this form of fracture, furnishes another argument in favor of the employment of the same means in fractures wholly within the capsule. We shall thus avoid the mischief which might arise from mistaking a fracture of the character of which we are now speaking, for a fracture wholly within the capsule. 377 BASE OF THE TROCHANTER MAJOR. § 2. Fracture through the Trochanter Major and Base op the Neck op the Femur. This fracture, which Sir Astley Cooper calls a "fracture of the femur through the trochanter major," 1 passes obliquely upwards and outwards from the lower portion of the neck, but instead of traversing the neck completely, it penetrates the base of the trochanter major; the line of fracture being such as to separate the femur into two fragments, one of which is composed of the head, neck and trochanter major, and the other of the shaft with the remaining portions of the femur. The following two examples are all in relation to which we possess any positive information, or in which the diagnosis has been confirmed by an autopsy. The first is thus related by Sir Astley Cooper. " The first case of this kind I ever saw, was in St. Thomas's Hospital, about the year 1786. It was supposed to be a fracture of the neck of the thigh-bone within the capsule, and the limb was extended over a pillow rolled under the knee, with splints on each side of the limb, by Mr. Cline's direction. An ossific union succeeded, with scarcely any deformity, excepting that the foot was somewhat everted, and the man walked extremely well. When he was to be discharged from the hospital, a fever attacked him, of which he died; and upon dissection, the fracture was found through the trochanter major, and the bone was united with very little deformity, so that his limb would have been equally useful as before." 2 The second example is reported by Mr. Stanley. " A woman, in her sixtieth year, fell in the street and injured her right hip. On examination, the limb was found slightly everted, and shortened to the extent of three-quarters of an inch, but movable in every direction. The extremity of the shaft of the femur was in its natural situation; but behind the femur, and at a little distance from it, a bony prominence was discovered, resting upon the ilium, toward the great sciatic notch, strongly resembling the head of the femur. Various opinions were entertained as to the nature of the injury, some believing it to be dislocation, and others a fracture. After a confinement of several months to her bed, the woman was sufficiently recovered to walk with the assistance of a crutch, and in this state she continued till her death, which took place about three years after the accident, during the whole of which period I had watched the progress of the case. Having obtained permission to examine the seat of the injury, I ascertained that there had been a fracture extending obliquely through the trochanter major, and through the basis of the neck into the shaft of the femur, and that the prominence which had been mistaken for the head of the bone was occasioned by the posterior and larger portion of the trochanter drawn backwards toward the ischiatic notch." 3 Sir Astley relates three other examples in which he believes the fractures to have been of the character above described; and he details 1 Sir Astley Cooper, op. cit., p. 183. * Op. cit., p. 184. 3 Stanley, Med.-Chir. Trans., vol. xiii. 25 378 FRACTURES OF THE FEMUR. the peculiar plans of treatment which, in each case, he saw fit to recommend. I can see no reason, however, why the treatment need differ from that which has already been recommended for fractures of the neck, since the indications are nearly identical in all of these cases; namely, moderate extension, and steady support of the limb in its natural position. § 3. Fracture of the Epiphysis of the Trochanter Major. So far as I know, the only well-authenticated example of this accident is the one reported by Mr. Key to Sir Astley Cooper. 1 The subject of this case was a girl, aged about sixteen years, who fell, March 15,1822, upon the side-walk, and struck her trochanter violently against the curb-stone. She arose, and, without much pain or difficulty, walked home. On the 20th she was received into Guy's Hospital, and the limb was examined by Mr. Key. The right leg, which was the one injured, was considerably everted, and appeared to be about half an inch longer than the sound limb. It could be moved in all directions, but abduction gave her considerable pain. She had perfect command over all the muscles, except the rotators inwards. No crepitus could be detected. Four days after admission she died, having succumbed to the irritative fever which followed the injury. The autopsy disclosed a fracture through the base of the trochanter major, but without laceration of the tendinous expansions which cover the outside of this process, so that no displacement of the epiphysis had occurred, nor could it be moved, except to a small extent upwards and downwards. A considerable collection of pus was found, also below and in front of the trochanter. The absence of displacement in the fragment, with its peculiar and limited motion, sufficiently explained why the fracture could not be detected during life. In the eighth volume of the Transactions of the Medical and Physical Society of Calcutta (1835), J. Clarke, Esq., reports a case of comminuted fracture of the trochanter major, which has been mentioned by Malgaigne as an example of simple fracture of the trochanter ; but, after reading the case carefully, I cannot avoid the conclusion that it was an example of fracture of the neck without the capsule, accompanied with impaction and extensive comminution. "Extravasation," says Mr. Clarke, "was discovered within the capsular ligament and around the trochanter major; and, on clearing away the muscles, the trochanter was found crushed and shattered, several pieces entirely detached, and fissures extending deeply into the shaft of the bone." 2 I shall venture to express the same opinion in relation to the case reported by Bransby Cooper. 3 The diagnosis was not confirmed by an autopsy, and the testimony drawn from Mr. Cooper's account of the case is far from being, to my mind, conclusive. It may, indeed, have been a simple fracture of the epiphysis; but there is nothing in 1 Sir Astley Cooper on Dislocations and Fractures, etc., Amer. ed., 1851, p. 192. 2 Clarke, Amer. Journ. Med. Sci., Nov. 1836, vol. ix. p. 181. 3 B. Cooper, A. Cooper on Dislocations, &c, op. cit., p. 192. 379 FRACTURES OF THE SHAFT OF THE FEMUR. the narrative to render it improbable that there existed also an impacted extra-capsular fracture of the neck. I have also myself reported one example of this fracture as having come under my own observation, 1 but of which I wish now to speak somewhat less confidently. The patient, James Red wick, a travelling showman, set. £3, fell, in August, 1848, from a high wagon, striking upon his left hip. When he got upon his feet, he found himself unable to walk, and was carried to his room. Dr. Wilcox, of this city, was called to see him, and applied a long straight splint. Fourteen days after the accident I saw the patient with Dr. Wilcox. The thigh was not appreciably shortened, nor was there either eversion or inversion; but the epiphysis of the trochanter major was carried upwards toward the crest of the ilium half an inch, and slightly sent in. No crepitus could be detected. The splint was continued live weeks; and about a month after, I found the fragment in the same place, but he was able to walk with only a slight halt. I think this also may have been an extra-capsular impacted fracture. With the small amount of positive information which we possess in relation to this fracture, we might venture a few conjectures as to what would constitute its symptoms, or as to the probable results and the Fig. 120. Sir Astley Cooper's mode of treating fractures of the trochanter major. (From A. Cooper.) most suitable treatment; but we prefer to occupy ourselves with a simple statement of the facts, so far as they are known, leaving all mere speculative inferences to those who choose to make them. § 4. Fractuees of the Shaft of the Femur. Etiology. —Unless the fracture has taken place just above the condyles, or immediately below the trochanter minor, in a very large proportion of cases it has been produced by a direct blow, such as the passage of a loaded vehicle across the thigh, or the fall of a piece of timber directly upon it. An analysis of twenty-one cases, taken indiscriminately, presents three fractures immediately above the condyles, and these were all produced by falls upon the feet; but of the remaining eighteen, all of which occurred higher in the limb, only 1 Hamilton, Trans. Amer. Med. Assoc., op. cit., vol. x. p. 254. 380 FRACTURES OF THE FEMUR. two were the result of falls upon the feet or of indirect blows, and one of these was a fracture just below the trochanter minor. Pathology. —It has already been remarked that this bone is most frequently broken in its middle third, and usually at a point somewhat above the middle of the shaft. I have made the same observation in an examination of specimens belonging to Dr. Mutter. In his cabinet, of twenty-four fractures of the shaft, three belonged to the upper third, two to the lower, and nineteen to the middle third. In the adult, these fractures are, with only an exceedingly rare exception, oblique; and the obliquity is generally greater than in the case of other bones. This fact, which it is very difficult to determine, in most cases, upon the living subject, I have established by a considerable number of observations made upon cabinet specimens. A transverse fracture is found only twice in Dr. Mussey's collection, containing thirty examples of fracture of the shaft; and in Dr. Mutter's collection, specimen B 71 is an adult femur, broken nearly transversely through its middle third; and it is united with a shortening of about one inch. Indeed, it is more common to find a transverse fracture in the middle third than at any other point of the bone; but in the upper third the obliquity is extreme and almost constant. At whatever point of the shaft the bone is broken, the degree of obliquity is generally such that the fragments cannot support each other when placed in apposition; unless indeed the fracture is near the condyles, where the greater breadth of the bone creates an additional support; but even here, the cabinet specimens still present a striking obliquity with more or less overlapping. I believe that in each of the three specimens of fracture at this point found in the collection belonging to the Albany Medical College, the obliquity is such that the fragments were not supported, and an overlapping has taken place. In specimen 719 the fracture extends into the joint; and although it is united by bone, a shortening of about one inch has occurred. In the case of children, and especially of infants, the rule is reversed; the bone is either broken transversely or nearly transversely, or it is serrated or denticulated, so that complete lateral displacement is much less frequent. The same remark is probably true of some fractures occurring in extreme old age; but as the shaft of the femur is not often broken in very old persons, owing to the readiness with which the neck yields to violence, I have not had an opportunity to verify this opinion. The direction of the obliquity varies exceedingly, especially in the middle and upper thirds; in the middle third, however, it is generally downwards and inwards; but in the lower third, its direction is, with only rare exceptions, downwards and forwards, and the superior fragment is found lying in front of the inferior. In one instance I have found both femurs broken at the same point, and in the same manner. Mr. L. Brittin, aged about fifty-five years, while employed upon a building, fell from a fourth story window upon the stone pavement below, striking upon his feet. In addition to several other fractures, I found both femurs broken obliquely down- FRACTURES OF THE SHAFT OF THE FEMUR. 381 wards and forwards, just above the condyles. Yery little inflammation ensued, and although it was found impossible to employ extension, union occurred readily, and with only a moderate overlapping. In the left limb, however, the upper fragment pressed down sufficiently to interfere somewhat with the patella, and the patient is unable now, after the lapse of several months, to straighten the knee completely. The motions of the right knee are unimpaired. I have only once met with a fracture at this point in which the line of separation was downwards and backwards. As the case presents several points of interest, it will be proper to narrate the facts somewhat at length. George Taylor Aiken, of Lockport, N. Y., aat. 7. May 18, 1854, in jumping down a bank of about three feet in height, he broke the right thigh obliquely, just above the kneejoint. Direction of the fracture obliquely downwards and backwards. Dr. G., an accomplished surgeon, residing in Lockport, was called. The limb was not then much swollen. He applied side splints, rollers, &c., carefully, and then laid the limb over a double-inclined plane. The knee was elevated about six or eight inches. Before applying the splints, suitable extension had been made, and after completing the dressings, the two limbs seemed to be of the same length. Fig. 121. Fracture at base of condyles. On the second or third day, Dr. G. noticed that the toes looked unnaturally white, and were cold. Counsel was now called at the request of Dr. G., when it was determined to abandon all dressings, and direct their efforts solely to saving the limb. The result was that slowly a considerable portion of his foot died and sloughed away, leaving only the tarsal bones. The fracture united, but with considerable overlapping and deformity. Feb. 26, 1856, the boy was brought to me by his father. On examining the fracture I noticed that the anterior line of the femur seemed nearly straight, and this appearance was owing in some degree to the muscles, which covered and concealed the bone, and in some degree, also, to the manner in which the fragments rested upon each other: the pointed superior end of the lower fragment resting snugly upon the front of the upper fragment, so that no abrupt angle existed in front. On the back of the limb, however, the lower end of the upper fragment, quite sharp, projected freely downwards and backwards into the popliteal space, so that its extreme point was only about half an inch above the line of the articulation. The limb had shortened one inch, and this enabled us to determine accurately that the lower point or the commencement of the fracture was one 382 FRACTURES OF THE FEMUR. inch, and a half above the articulation, while the point where the line of fracture terminated in front, was probably quite three inches and a half above the joint. The motions of the knee-joint were pretty free. The leg was extremely wasted, and the anterior half of the foot having sloughed off", the sores had now completely healed over. He was able to walk tolerably well without either crutch or cane. Subsequently, Dr. G. found it necessary to sue the father of the child for the amount of his services, when Mr. Aikin put in a plea of malpractice, and that consequently the services were without value. The case was tried in the March term of the Niagara circuit of 1856, at Lockport, N. Y., the Hon. Benj. F. Greene presiding. On the part of the defence it was claimed that the death of the foot was in consequence of the bandages being too tight. They failed, however, to show that they were extraordinarily or unduly tight. While on the part of Dr. G., the prosecutor, it was shown that the death of the toes was preceded by a total loss of color, and that it was not accompanied with either venous or arterial congestion. The medical gentlemen examined as witnesses, declared that this circumstance furnished the most positive evidence which could be desired, that the death of the toes was not due to the tightness of the bandages, but that its cause must be looked for in an arrest of the arterial or nervous currents supplying the limb, or in both. They believed, also, that the projection of the superior fragment into the popliteal space was sufficient to cause this arrest. They also believed that overlapping and consequent projection could not have been prevented in this case, and that, therefore, the treatment was not responsible for this unfortunate result: indeed, they regarded the treatment as correct, and the result as a triumph of skill, in that any portion of the limb was saved; the leg and foot now remaining being far more useful than any artificial leg and foot could be. The Hon. Judge, in a speech remarkable for its clearness and liberality, sought to impress upon the jury the value of the medical testimony. The jury returned a verdict for Dr. G., allowing the amount of his claim for services, with the costs of suit. Specimen 121, in Dr. March's collection at Albany, presents a similar disposition of the fragments. The fracture is oblique, from above downwards and backwards, and the upper portion lies behind the lower. It is firmly united by bone, but with an overlapping of from two and a half to three inches. The young gentleman who showed me the specimen remarked that it had been found impossible, owing to an ulcer upon the heel, and to other causes, to employ in the treatment any degree of extension. These two are the only examples which have come under my observation in which a fracture at this point has taken this direction. Sir Astley Cooper does not seem to have recognized this form of fracture and displacement. Amesbury, has, however, recorded one case, which came under his own observation, where, although the bloodvessels and nerves escaped, the bone projected through the skin 383 FRACTURES OF THE SHAFT OF THE FEMUR. in the ham, and finally exfoliated. 1 And he thinks the point of bone may sometimes so penetrate the artery and injure the nerves as to render amputation necessary, in order to save the life of the patient. M. Coural also has related a case in which an epiphysary disjunction, occurring in a child twelve years old, was attended with a displacement of the upper fragment backwards, and amputation became necessary. 2 I know of no other cases of this rare accident which have been reported. Lonsdale refers to it as "the rarest direction for a fracture to take;" and thinks that in case of its occurrence, the vessels in the popliteal space will stand a chance of being wounded; but he mentions no example. The popliteal artery hugs the bone so closely at this point, that a displacement of the upper fragment in a direction downwards and backwards must always greatly endanger its integrity. Indeed, it is here that the artery and vein are in the closest contact with each other, and with the bone; an anatomical fact, which has been used by Richerand and others to explain the greater frequency of aneurisms in the ham. The direction of the displacement, however, in fractures of the shaft of the femur, does not always depend upon the direction of the line of fracture. In fractures of the upper third, whatever may be the direction of the line of fracture, the lower end of the upper fragment inclines forwards and outwards, and the upper end of the lower fragment inwards ; unless, indeed, this inclination is controlled by actual entanglement of the broken ends with each other. In the middle third the fragments also generally take the same relative position, whatever may be the direction of the fracture; but when the fracture takes place at or near the condyles, where the diameter of the bone is much greater, the direction of the obliquity determines pretty uniformly the direction of the displacement. Symptoms. —The symptoms which characterize a fracture of the shaft of the femur are those which are common to all fractures, namely, mobility, crepitus, displacement of the fragments, pain, and swelling, to which are added generally a shortening of the limb, with eversion of the foot and leg. Owing to the great amount of muscle covering the thigh, and sometimes to the swelling which immediately follows the injury, it is often very difficult to determine at what precise point the fracture has occurred, and still more difficult to say whether the fracture is oblique or transverse; indeed, this latter question is sometimes decided approximately by a reference to the age of the patient rather than by the examination of the limb. The immediate shortening varies from half an inch to an inch and a half, or even more; and it will average about one inch in the case of healthy adults. Prognosis. —Whatever may have been the general opinion of experienced surgeons as to the question of shortening in other fractures, 1 Remarks on Fractures, &c, by Joseph Amesbury, vol. i. p. 293. London, 1831. 2 Archiv. Gen. de Med., torn. ix. p. 267. 384 FRACTURES OF THE FEMUR. very few certainly have ever claimed that in fractures of the femur a complete restoration of the bone to its original length was generally to be expected. There seems, however, to have existed only certain vague and indefinite notions as to the proportion and amount of this shortening, and which have had for their basis nothing better than a few imperfectly analyzed observations. Says Scultetus (quoting first from Hippocrates): "'For the bones of the thigh, though you do draw them out by force of extension, cannot be held so by any hands; but when the first intention slacks, they will run together again; for here the thick and strong flesh are above binding, and binding cannot keep them down.'— Hippocrates de fract. Which Celsus seems to confirm, Lib. 8, cap. 10, where he writes as follows of the cure of legs and thighs: 'For we must not be ignorant that if the thigh be broken, that it will be made shorter, because it never returns to its former state.' And Avicenna, Lib. 4, Fen. 5, saith 'that it is a rare thing for the thigh once broken, to be perfectly cured again." "These words admonish us," continues Scultetus, "that we should never promise a perfect cure of the thigh; but rather, using all diligence, we should foretell that it is doubtful that the patient will be always lame; but when this shall happen from the nature of the fracture, or which most frequently falls out, from the impatience of the sick person, it may be imputed to our mistake; and instead of a reward, bring us a disgrace." 1 Says Chelius: " Fracture of the thigh-bone is always a severe accident, as the broken ends are retained in proper contact with great difficulty. The cure takes place most commonly with deformity and shortening of the limb, especially in oblique fractures, and those which occur in the upper and lower third of the thigh-bone. Compound fractures are so much more difficult to treat." 2 Maclise, while commenting somewhat indefinitely upon certain plans of treatment, takes occasion to say: "Out of every six fractures of either clavicle or thigh-bone, I believe that as the result of our treatment by the present forms of mechanical contrivances, there would not be found three cases of coaptation of the broken ends of the bone so complete as to do credit to the surgeon." 3 Says John Bell: "The machine is not yet invented by which a fractured thigh-bone can be perfectly secured." And Benjamin Bell declares that " an effectual method of securing oblique fractures in the bones of the extremities, and especially of the thigh-bone, is perhaps one of the greatest desiderata in modern surgery." " In all ages," he adds, " the difficulty of this has been confessedly great; and frequent lameness produced by shortened limbs arising from this cause, evidently shows that we are still deficient in this branch of practice." 4 1 The Chirurgeon's Store-house, by Johannes Scultetus, a Famous Physician, and Chirurgeon of Ulme in Suevia. London, 1674. 2 System of Surgery, by J. M. Chelius, translated, &c, by South. First Amer. ed., vol. i. p. 627,1847. See also p. 625, paragraph 679. 3 Surgical Anatomy, by Joseph Maclise, Surgeon. First Amer. ed. Part I. p. 36,1851. * System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. 385 FRACTURES OF THE SHAFT OF THE FEMUR. Colles observes, that " although three or four methods of treatment are practised, the pieces at the conclusion are often found overlapped." 1 One reason for which, in his opinion, is a too blind adherence to the principles recommended by Pott. Velpeau says, that " after fractures of the femur, there is no limping unless the shortening exceeds three-quarters of an inch; and the same is true if the shortening occurs in the tibia." The reason is, that the pelvis inclines toward the shorter limb, and thus compensates for the deficiency in length. In speaking of the various contrivances for dressing the fractured femur, he remarks that, "most of them fail to obviate the shortening, and produce eschars, anchylosis, or troublesome arrests of the circulation. This is the price that is usually paid for the employment of these complicated machines, and a shortening of a quarter to three-quarters of an inch is not avoided after all. The simplest apparatus that will maintain the adjustment of the fractured femur, so that union may take place with shortening of only half an inch, is the best." 2 Nelaton holds the following language:— " A fracture of the body of the femur, with an adult, is always a grave accident, inasmuch as it demands so long a confinement to the bed, and especially on account of the shortening of the limb, which it is almost impossible wholly to prevent; accordingly, Boyer recommends to the surgeon, from the first day, to announce to the parents of the patient the possibility of this accident. "With infants, on the contrary, it is almost always easy to avoid the shortening." 3 While Malgaigne declares his opinion on this subject thus, at length:— " When we do not succeed in drawing back the misplaced fragments, end to end, so that they may oppose themselves to the action of the muscles, it is impossible to preserve to the member its normal length, whatever may be the appareil or method employed. Surgeons are not sufficiently agreed upon this question. " Hippocrates gives us to understand, that we can always correct the shortening; Celsus, falling into the opposite error, declared, that a broken thigh always remains shorter than the other. At a period quite recent, Desault pretended to cure all fractures without shortening, and his journal contains several examples. In imitation of Desault, various practitioners have modified, corrected, and improved the apparatus for permanent extension, and they claim to have themselves obtained as complete success. I ought then to declare here in the most positive manner, that I have never obtained like results, either in the use of my own apparatus, or with that of others, nor indeed where in pursuance of my invitation, several inventors have applied their apparatus in my wards. I have examined, more than once, per- 1 Lectures on the Theory and Practice of Surgery, by Abraham Colles (Dublin), p. 321. Philadelphia ed., 1845. 2 Peninsular Journ. of Med., vol. iii. p. 384; also Memphis Med. Journ., vol. iv. p. 254, 1856. 3 Elemens de Pathologie Chirurgicale, par A. Nelaton, torn, prem., p. 752. Paris, 1844. 386 FRACTURES OF THE FEMUR. sons declared cured without shortening, and yet, upon measurement, the shortening was always manifest. The misfortune of all those who believe that they have obtained those miraculous cures, is that they have not even thought of instituting a comparative measurement of the two limbs; I will say even more, that they are most generally ignorant of the conditions of a good and faithful measurement. Sometimes, also, they have been deceived in another way; in falling upon fractures which were not displaced, especially with young persons, and they have believed that they have cured with their apparatus a shortening which had never existed. In short, when the fragments are not displaced, or even when they are brought again into a contact maintained by their reciprocal denticulations, it is easy to cure the fracture of the femur without shortening; aside of those two conditions, the thing is simply impossible. " Several distinguished surgeons of our day have acknowledged this impossibility, and have renounced, in consequence, permanent extension. They allege, moreover, that an overriding of even three centimetres is of little importance, and occasions no limping. I cannot agree with this opinion. I have seen persons walk very well with a shortening of one centimetre; beyond this limit, either they limp, or they have lifted the heel of the shoe, or, in short, the limping is only concealed by a lateral deviation of the spine. 1 We thus are made to comprehend how a fracture with overlapping is always serious, and how cautious we ought to be in our prognosis." 2 That the foregoing remarks are intended by the author to be equally applicable to other fractures of the shaft of the femur than to those of the middle third, is made evident by what he has said before, when speaking of fractures of the upper third. "The prognosis is sufficiently favorable when the fragments are denticulated (engrene'es): when they ride, on the contrary, we must look for a shortening as almost inevitable."— Ibid., p. 718. In our own country several of the most distinguished surgeons have testified to the constant difficulty, if not impossibility, of curing fractures of this bone without a shortening. In a suit instituted against a surgeon in New York city, for alleged malpractice in the treatment of an oblique, comminuted, and otherwise complicated fracture of the femur near its condyles, Dr. Mott is reported to have testified that "more or less shortening of the limb is uniformly the result after fractured thigh, even in the most favorable circumstances." 3 In a very interesting communication made to the author by Jonathan Knight of New Haven, late President of the American Medical Association, occurs the following passage :— " I have seen but few fractures of the femur in the adult, unless of 1 Dr. Buck, of New York, thinks that with a shortening of one inch, or even one inch and a half, the patient may have " a useful limb, with little or no halting in his gait." N. Y. Journ. of Med., vol. xvi. p. 294. 2 Traite des Fractures et des Luxations, par J. M. Malgaigne, torn, prem., pp. 723, 724. Paris, 1847. 3 Boston Med. and Surg. Journ., vol. xxxiv. p. 450. See also opinions of Drs. Reese, Post, Parker, Cheeseman, Wood, &c, in relation to the prognosis in this particular case. 387 FRACTURES OF THE SHAFT OF THE FEMUR. the most simple kind, in which there was not some remaining deformity ; often slight, so as not to impair the usefulness of the limb, and in others considerable and apparently unavoidable." Dr. Knight adds, however: " In the greater proportion of the fractures in children, the recovery has been so nearly perfect that no marked deformity or lameness has followed." Says Dr. Gibson: " Had the surgeon no other difficulties to encounter than such as present themselves after simple transverse fracture of the shaft of the thigh-bone, he would have little reason to complain of the defectiveness of art, or of the power of nature in promoting a cure. So different, however, from this is the result of an oblique fracture of the body of the bone, or of a transverse fracture of its neck, that it is hardly possible in any case to calculate with certainty upon reunion without more or less shortening and deformity of the limb." 1 Dr. Detmold, in his remarks made before the New York Academy of Medicine, at its meeting in March, 1855, declared his belief that a shortening of the femur always occurs after fracture, and that " but one inch of shortening in an average of twenty cases is a good result." 2 Dr. J. Mason Warren, of Boston, writes to me as follows: "As you are making observations on fractures, I would state that, after a long and very careful observation, I have never yet seen, either in Boston or elsewhere, an oblique fracture of the thigh, in a patient over seventeen years of age, in which there was not some shortening. I have had cases shown to me in which it was averred that the limb was not shortened, but on measuring myself I have found the fact otherwise. In children, I believe that union without shortening may be accomplished." In a paper published by Dr. Lente in the number of the New York Journal of Medicine for September, 1851, he states that he believes the average shortening after treatment in the New York City Hospital to be three-quarters of an inch; but subsequently Dr. Buck, one of the hospital surgeons, has furnished Dr. Lente with more exact statistics. Says Dr. Buck:— "After carefully scrutinizing over one hundred cases of fracture of the femur, taken from the register of the N. Y. Hospital, and eliminating such as involved the cervix, or condyles, or belonged to the class of compound fractures, there remained an aggregate of seventyfour cases, of both sexes, and of all ages from 3 to 63, in which the shaft of the femur alone was fractured. In all these cases, the difference in the length of the fractured limb resulting from the treatment was ascertained by careful measurement with a graduated tape, and the following deductions were drawn from the analysis:— " Of the 74 cases of all ages, 19 resulted without any shortening, a proportion of about one-fourth. The average shortening of the remaining 55 cases was a fraction less than f of an inch. "Seventeen cases in the above aggregate were under 12 years of age, 1 Institutes and Practice of Surgery, by Wm. Gibson, 8th ed., vol. i. p. 297. Philadelphia, 1841. 2 New York Journ. of Med., second series, vol. xvi. p. 261. 388 FRACTURES OF THE FEMUR. of which six resulted without any shortening, a proportion of about one-third. The average shortening in the remaining 11 cases, was a fraction less than one-half an inch. " Of the 57 cases over 12 years of age, 13 resulted without any shortening, a proportion of about one-fourth; and the average shortening in the remaining 44 cases was a fraction over f of an inch." 1 It is not to be denied, however, that a few surgeons in all parts of the world have claimed, and still continue to claim, in their own practice, or from the adoption of their own peculiar plans of treatment, much better success. Indeed, some of them do not hesitate to affirm that, as a general rule, any degree of shortening is quite unnecessary. Mr. Amesbury declares, that when the fracture is in the " middle or lower third," under a "judiciously managed" application of his own splint, "consolidation of the bone takes place without the occurrence of shortening of the limb, or any other deformity deserving of particular notice." 2 Mr. South, in a note commenting upon an opposite sentiment expressed by Chelius, and already quoted, remarks: " In simple fractures of the thigh-bone, except with great obliquity, I have rarely found difficulty in retaining broken ends in place, and in effecting the union without deformity, and with very little, and sometimes without any shortening. For the contrary results the medical attendant is mostly to be blamed, as they are usually consequent upon his carelessness or ignorance." 3 Mr. Hunt, of the Queen's Hospital, at Birmingham, who treats all fractures with the apparatus immobile of Seutin, has published the results of his observations; and of the simple fractures of the femur only one presented, after the cure, any degree of shortening; and he adds, that all other fractures which he has treated by this method were followed by " equally good results." 4 In relation to which statements, Mr. Glamgee exclaims: " This is conservative surgery. What other mode of treatment would have given such results ? And those cases are not exceptional. Mr. Hunt tells us he has selected them from amongst many others equally successful. They accord with the experience recorded in my little treatise on this subject; and the works of Seutin, Burggraave, Crocq, Velpeau, and Salvagnoli Marchetti, record numerous cases no less remarkable and demonstratively conclusive. 4 Desault, also, according to the passage from Malgaigne, which I have already quoted, " pretended to cure all fractures without shortening." I do not find, however, any other authority for this statement, as here made; neither in his Treatise on Fractures and Luxations, edited by Bichat, nor elsewhere. Bichat even says positively, 1 Buffalo Med. Journ., vol. xv. p. 22, June, 1859. 2 Practical Remarks on Fractures, by Joseph Amesbury, vol. i. p. 334. London ed., 1831. 3 Op. cit., vol. i. p. 627. 4 Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson Gamgee. London ed., pp. 159, 160. * Op. cit., p. 167. 389 FRACTURES OF THE SHAFT OF THE FEMUR. that " Desault himself did not always prevent the shortening of the limb." 1 He declares, however, that " Desault has cured, at the Hotel Dieu, a vast number of fractures of the os femoris, without the least remaining deformity." 2 Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault, as modified by Physick and Hutchinson (Fig. 122), was equally successful 3 Fig. 122. Physick's Spijnt.—The splint is intended to reach to the axilla, but the counter-extension is made by a perineal band. Physick employed a second, long, inside splint. Dr. Scott, of Montreal, Prof, of Clinical Surgery in the McGill College, and Physician to the Montreal General Hospital, has reported 19 cases of fractures of the long bones, taken promiscuously and without selection, from his hospital service, of which 3 belonged to the clavicle, 7 to the femur, 8 to the tibia and fibula, and 1 to the condyles of the humerus. All of which recovered without any degree of shortening or deformity; except the case of fracture of the condyles of the humerus, which resulted in death. 4 It is never a pleasant duty to call in question the accuracy of another's statements, as to what he has himself alone seen and experienced. The circumstances which would justify such an expression of scepticism, where the witnesses, as in this case, are presumed to be intelligent and honest men, must be extraordinary. Such, however, I conceive to be the circumstances in this instance. It is certainly very extraordinary that a few gentlemen of acknowledged skill, but whose means and appliances are concealed from no one, are able to do what nearly the whole world besides, with the same means, acknowledges itself unable to accomplish. Such is the fact nevertheless; and our lack of faith in their testimony is only a necessary result of our experience, and of the experience of the vast majority of practical surgeons, as opposed to theirs. I might properly enough dismiss this subject with no further argument than may be found in the overwhelming testimony of practical surgeons, that broken femurs do in their experience rarely unite without more or less shortening; but I cannot avoid calling attention to the evidence of the falsity of the opposite opinion, which is furnished by the testimony of the very persons who themselves claim to have obtained such fortunate results. It is not, as might have been supposed, one particular form of dressing, which, in itself peculiar, and more perfect than all others, has fur- 1 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. Bichat. Amer. ed., p. 251. 1805. 2 Op. cit., p. 223. s Elements of Surgery, by John Syng Dorsey, vol. i. p. 163. Philadelphia, 1813. 4 " Medical Chronicle" of Montreal, vol. i. No. 7, 1853. 390 FRACTURES OF THE FEMUR. nished these results. On the contrary, the plans of treatment have been constantly unlike, and sometimes quite opposite. Thus: Desault used a straight splint, with extension and counter-extension, and he refused to adopt the flexed position recommended by Pott, because his experience, and the experience of other French surgeons, had taught him its inutility. 1 Adopting the straight position, he made perfect limbs; with the flexed position, he found it impossible to do so. Dorsey used the splint of Desault, as modified by Physick and Hutchinson. South, whose success seems to have been equal to that of Desault or Dorsey, adopts also the straight position; but he makes no permanent extension, except what may be accomplished through the medium of four long side splints applied after "gentle" extension has been made by the assistants. Mr. Amesbury, on the other hand, made perfect limbs only with his own double inclined plane; and speaking in general of the various plans hitherto contrived, not excepting that invented by Desault, or the method practised by South, which had already been recommended by several surgeons, he declares that " they are seldom able to prevent the riding of the bone, and preserve the natural figure of the limb. Indeed, so commonly does retraction of the limb occur under the use of the different contrivances usually employed, that I have heard a celebrated lecturer (now retired) in this town, publicly assert, that he never saw a fractured thigh-bone that had united, without riding of the fractured ends!" 2 And in his "General Inferences," he uses the following emphatic language: " The contrivances which are commonly used in the treatment of these fractures do not sufficiently resist the operation of the forces above mentioned, but suffer their influence to be exerted upon the bone, in all cases more or less injuriously, and at the same time often assist in producing displacement of the fractured ends; so that deformity, differing in kind and degree in different cases, is almost the constant result of fractures of the femur treated by these means." 3 While Mr. Gamgee, a writer of much talent and industry, thus broadly contradicts the statements of Desault, South, Dorsey, and Amesbury, and administers a severe rebuke even upon the illustrious Liston: " Pott's plan, the long splint, M'Intyre, and their modifications, as a rule entail sensible deformity, which in many cases is very considerable. It is a significant fact, that, though the example established in University College Hospital by the late Mr. Liston, of treating fractures of the thigh by the long splint (Fig. 123), and of the leg by the modified Mclntyre, which are admitted equal, if not superior, to other splints, was rigidly followed in that institution, the patients admitted with broken thighs or legs were frequently discharged with manifest deformity." 4 1 Works of Desault. Op. cit., p. 225. 0 Amesbury on Fractures, &c, vol. i. p. 310. 3 Op. cit., vol. i. p. 384. 4 Advantages of the Starched Apparatus, by Joseph Sampson Oamgee. London, 1853, pp. 54, 55. 391 FRACTURES OF THE SHAFT OF THE FEMUR. With how much force his own remarks as to the experience of the University College Hospital will apply to the starched bandages used by himself, the reader will be able to determine when referred to the opinion of Yelpeau, already quoted, who claims no result better than an average shortening of half an inch. It is true, however, that M. Yelpeau prefers and advocates the starched bandage, but it is not true that he claims to be able to prevent a shortening of the bone. Fig. 123. Listen's method, recommended by Samuel Cooper, Fergussou, Pirrie, and others. " What other modes of treatment would have given such results ?" This question, propounded, no doubt honestly, by Mr. Gamgee, has here its fair and satisfactory answer. Almost any of the various modes named; for if we must receive his testimony, we are equally bound to receive the testimony of Desault, South, Dorsey, Amesbury, and Scott. If we give credit to Mr. Gamgee, so far as to doubt the statements of these latter as to the degree of success claimed by them, by the same rule we must doubt his own statements also, as to the degree of success claimed by himself. This I say with all sincerity and kindness, fully believing that these gentlemen are mistaken, and not that they intentionally misrepresent the facts. By a reference to my " Eeport on Deformities after Fractures," it will be seen that the average shortening in fractures of the upper third of the femur, in the cases examined by me, was about four-fifths of an inch; in the lower third it was a fraction over three-quarters, and in the middle third, a fraction less than three-quarters of an inch; and the average of the whole number was almost exactly three-quarters of an inch (three-quarters and These analyses were made upon simple fractures, and were exclusive of those in which no shortening at all occurred. An analysis which included also those which had not shortened, reduced the average shortening to half an inch and about one-tenth. An examination of cabinet specimens does not present a result so favorable even as this. Of nineteen fractures of the shaft of the femur contained in Dr. Mutter's cabinet, not one seems to have been shortened less than one inch. Specimen B 63, a fracture of the middle third, is united with a shortening of two inches and a quarter; and specimen B 130, imperfectly united after a fracture through the middle third, is overlapped three and a half or four inches. In conclusion, I wish to say briefly, that in view of all the testimony which is now before me, I am convinced— First. That in the case of an oblique fracture of the shaft of the 392 FRACTURES OF THE FEMUR. femur occurring in an adult, whose muscles are not paralyzed, but which offer the ordinary resistance to extension and counter-extension, and where the ends of the broken bone have once been completely displaced, no means have yet been devised by which an overlapping and consequent shortening of the bone can be prevented. Second. That in a similar fracture occurring in children or in persons under fifteen or eighteen years of age, the bone may sometimes be made to unite with so little shortening that it cannot be detected by measurement; but whether in such case there is in fact no shortening, since with children especially it is exceedingly difficult to measure very accurately, I cannot say. Third. That in transverse fractures, or oblique and denticulated, occurring in adults, and in which the broken fragments have become completely displaced, it will generally be found equally impossible to prevent shortening; because it will be found generally impossible to bring the broken ends again into such apposition as that they will rest upon and support each other. Fourth. That in all fractures, whether occurring in adults or in children, where the fragments have never been completely or at all displaced, constituting only a very small proportion of the whole number of these fractures, a union without shortening may always be expected. Fifth. That when, in consequence of displacement, an overlapping occurs, the average shortening in simple fractures, where the best appliances and the utmost skill have been employed, is about threequarters of an inch. If we consider the muscles alone as the cause of the displacement in the direction of the long axis of the shaft, the shortening of the limb, other things being equal, must be proportioned to the number and power of the muscles which draw upwards the lower fragment. This will vary in different portions of the limb, but nowhere will this cause cease to operate, nor will its variations essentially change the prognosis. I have not intended to say that other causes do not operate occasionally in the production of shortening, but only that muscular contraction is the cause by which this result is chiefly determined, and that its power will be ordinarily the measure of the shortening. Treatment. —All the early surgeons, so far as we know, adopted the straight position in the treatment of fractures of this bone; either with simple lateral splints, or with long splints, with or without extension, or with only rollers and compresses, or with extension alone. Such was the unanimous opinion and practice of surgeons until about the middle of the last century, at which time Percival Pott wrote his remarkable treatise on fractures; a work distinguished for the originality and boldness of its sentiments, and which was destined soon to revolutionize the old notions as to the treatment of fractures, and to establish in their stead, at least for a time, what has been called, not inappropriately, the " physiological doctrine;" the peculiarity of which doctrine consisted in its assumption that the resistance of those muscles which tend to produce shortening can generally be sufficiently over- 393 FRACTURES OF THE SHAFT OF THE FEMUR. come by posture, without the aid of extension, and that for this purpose, for example, in the case of a broken femur, it was only necessary to flex the leg upon the thigh, and the thigh upon the body, laying the limb afterwards quietly on its outside upon the bed. Very few surgeons, even of his own day, ever gave in their full adhesion to the exclusive physiological system as taught and practised by Pott himself, but multitudes, especially among the English, adopted in general his views, only choosing to place the patients upon their backs rather than upon their sides, and laying the limbs flexed over a double inclined plane. (Fig. 124.) To the support of this system of Fig. 124. Double inclined plane employed in Middlesex Hospital, London. Pott's, thus modified, Sir Astley Cooper, C. Bell, John Bell, Earle, "White, Sharp, and Amesbury (Figs. 125, 126), lent the influence of their great names, and its triumphs, so far as the judgment of British surgeons was concerned, soon became complete. Fig. 125. Auiesbury's splint. Fig. 126. Amesbury's splint applied. In France, and upon the continent generally, the reception of this system was more slow and reluctant; but Dupuytren now for once 26 394 FRACTURES OF THE FEMUR. taking ground with his great rival, Sir Astley, adopted almost without qualification these novel views. The decision of Dupuytren determined the opinions of a large portion of the continental surgeons; and had it not been for the early and decisive opposition of Desault and Boyer (Fig. 127), the great surgeon of St. Bartholomew might have continued for a long time to have enjoyed a triumph upon the continent, and perhaps throughout the world, equal to that which had already been decreed to him in Great Britain. Fig. 127. Boyer's splint. On this side of the Atlantic, the practice of Pott, at least in so far as it applied to the treatment of fractures of the thigh, never gained a distinguished advocate; and but few ever adopted the practice as modified by White, Amesbury, Bell, A. Cooper, &c. But whatever may have been the early success of these doctrines, either here or elsewhere, it is certain that a strong reaction has taken place, and that gradually, in all parts of the world, the opinions of practical surgeons have been settling back into their old channel. It would be difficult to find to-day, in France, a dozen distinguished surgeons who adopt universally the flexed position in the treatment of fractures of the femur; and in England the reaction is, if possible, even more complete. In my tour of 1844, during which I visited very many of the hospitals of great Britain and upon the continent of Europe, I do not remember to have seen the flexed position once employed in the treatment of a broken thigh; and I shall presently show that the straight position is at the present moment very generally adopted by the best American surgeons. There have been, then, three grand epochs in the history of the treatment of fractures of the thigh. First. That in which the straight position was universally adopted, and which reaches from the earliest periods to the period of the writings of Pott, or to about the middle of the last century. Second. The epoch of the flexed position, which, inaugurated by Pott, had already begun to decline at the beginning of the present century, and which may be said to have been completed within less than one hundred years from the date of its first announcement. Third. The epoch of the renaissance, or that in which surgeons, by the vote of an overwhelming majority, have declared again in favor of the straight position. This is the epoch of our own day. Although American surgeons have generally adopted the straight splint in the treatment of fractures of the thigh, yet the form and construction of the splint have been greatly varied. The simple long 395 FRACTURES OF THE SHAFT OF THE FEMUR. splint of Desault and the more complicated apparatus of Boyer (Fig. 127), have each their advocates; but it is seldom that we meet with these, or with any of the other forms of apparatus originally employed in foreign countries, without noticing that they have been subjected to considerable modifications; indeed, most of the straight splints as well as double inclined planes in use at present among American surgeons, may fairly be regarded as original inventions. Nathan Smith, of New Haven; 1 Nathan R. Smith, of Baltimore 2 (Fig. 128); Nott, of Mobile 3 (Fig. 129); McNaughton, of Albany, 4 Fig. 128. Nathan R. Smith's suspending apparatus, or double inclined plane. and Valentine Mott, of New York, are the only American surgeons of distinguished reputation, and with whose practice I am familiar, Fig. 129. Josiah C. •Norr's Double Inclined Plane. In this apparatus the limb is secured to the splint by vertical pins and leather straps; the upper surface of the thigh splint is carved out a little, to fit the thigh ; the two portions are articulated by a joint like that of a carpenter's rule, and this joint may be steadied by a horizontal bar underneath. For the rest, the drawing sufficiently explains itself. 1 Amer. Med. Rev. Published at Philadelphia, 1825, vol. ii. p. 355 ; also Medical and Surgical Memoirs of Nathan Smith. Published at Baltimore, pp. 129-141. 2 Med. and Surg. Memoirs, pp. 143-162. See also Geddings, Baltimore Med. and Surg. Journ., vol. i. 1833 ; and Sargent's Minor Surgery, p. 171. 3 Amer. Journ. Med. Sciences, vol. xxiii. p. 21. * Trans. Amer. Med. Assoc., vol. x. p. 317. Rep. on Defor. after Frac. 396 FRACTTJKES OF THE FEMUR. who recommend exclusively the double-inclined plane; and perhaps we have a right to infer from the following paragraphs, copied from a letter addressed to the author a few years since, that the opinions of Dr. Mott have undergone some modification in view of the improvements recently made in the construction of straight splints, and in the means of extension and counter-extension. "Many years since I introduced into the New York Hospital Boyer's long splint, and continued to use it there and in private practice for a long time. I found, however, in many cases, that I had more or less trouble at the foot and groin from the points of extension and counter-extension. I then gradually laid it aside, and for some years have again taken up the double inclined plane. " From the abundance which I have seen, I am. free to say that, if I had my own femur broken, I would be treated upon the double inclined plane. " The Drs. Burges, Brothers, Court St., Brooklyn, Long Island, have made an improvement upon the extended principle (Figs. 132, 133). Their apparatus is now complete, and is in use at the Bellevue Hospital, where I advised, some time since, that it should be tried. It has succeeded admirably in two cases." Dr. Nathan R. Smith has introduced another modification of the double inclined plane in what is known as his " anterior splint," and which is intended also as a suspending apparatus. I have seen it employed lately a good deal in the treatment of gunshot fractures of the thigh and leg in our various military hospitals, and it has often seemed to me better adapted to the purposes for which it was employed than any other apparatus. The gentlemen who were using it have also constantly testified in its favor. It is my opinion, however, that it is more universally applicable to gunshot fractures of the leg than of the thigh. The splint, if splint it can be properly called, is simply a frame composed of stout wire and covered with cloth (Fig. 130), which being Fig. 130. N. R. Smith's anterior splint. suspended above the limb, allows the limb to be suspended in turn to it by rollers; the rollers passing around both limb and splint from the foot to the groin. Wire of the size of No. 10 bougie is usually employed. The length of the splint should be sufficient to extend from above the anterior superior spinous process of the ilium to a point beyond the toes, the lateral bars being separated about three inches at the top and one-quarter of an inch less at the lower extremity. In the case of a broken thigh, the upper hook, to which the cord for suspension is to be fastened, ought to be nearly over the seat of 397 FRACTURES OF THE SHAFT OF THE FEMUR. fracture, and the lower hook should be placed a little above the mid die of the leg. (Fig. 131). Fig. 131. N. R. Smith's anterior splint, applied for a fracture of the thigh. While, on the other hand, among the advocates of the straight splint are found the names of Physick, 1 Dorsey, 2 Gibson, 3 Horner, 4 J. Hartshorne, 3 H. H. Smith, 0 Neill, 7 R. Coates, 8 H. Hartshorne, 9 Norris, 10 Gross. 11 Says Dr. Gross: "Many years ago, before I had much experience in this class of injuries, I occasionally employed the flexed position, but I soon found that it was objectionable, on account of the great difficulty in maintaining so accurate apposition to the ends of the fragments. Of late years I have confined myself entirely to the use of the straight position, and I have never had any cause to regret it. In the adult, I sometimes employ the apparatus of Desault, as modified by Physick, but much more frequently one of my own construction, somewhat upon the principle of that of Dr. Neill, described in the Philadelphia Medical Examiner for 1855. I have used it for nearly twenty years, and it has generally answered the purpose most admirably in my hands. It consists simply of a box for the thigh and leg, with a footpiece, and two crutches, one for the axilla and the other for the perineum, to make the requisite extension and counter-extension. With such an apparatus, an oblique fracture of the thigh* can be treated with great comfort to the patient, and with the assurance of a good limb. 1 Elements of Surgery, by John Syng Dorsey. Philadelphia, 1813, p. 175. 2 Ibid. 3 Institutes and Practice of Surgery, by Wm. Gibson, 6th edit., vol. i. Phila. 4 Treatise on the Practice of Surgery, by Henry H. Smith. Phila., 1856. 5 Ibid. « Ibid. 7 Philadelphia Med. Examiner. October, 1855. 8 Amer. Journ. Med. Sciences, vol. xx. p. 18. 9 Trans. Amer. Med. Assoc., vol. v. Rep. on Def. after Frac. 18 Ibid. 11 Ibid. 398 FRACTURES OF THE FEMUR. Fig. 132. Bcrob's Apparatus. Fig. 133. Burge's Apparatus applied. "A. Thick mattress. B. Thin mattress. O. Wooden platform upon which the thin mattress is laid. This platform is made in two pieces and hinged together so as to fold upon itself for convenience of transportation, and when in use is merely hooked upon the central platform D. " D. Central or cushioned platform supported at either end by wooden strips marked E, which rest upon F, a second platform of same extent as D. This constitutes a shelf for the bed pan, which may be introduced below from either side. " G. Hair cushion, upon which the hips of the patient rest. This cushion, as well as the platform D, to which it is buttoned, has a semicircular opening at its lower margin for convenience of defecation. " H. A rectangular wooden slide, exactly corresponding to its fellow upon the opposite side of the pelvis. These slides are so arranged upon the platform D as to be separated or approximated at will, and, by a thumb-screw which passes through a fissure in the horizontal portion of each, they may be fixed at the desired point so as exactly to embrace the pelvis of any patient. There is also a fissure in the perpendicular portion of each rectangular slide, and a screw passing through the same. One of these is to secure the upper end of tho long splint J, and the other for the attachment of a short splint J, upon the side of the pelvis corresponding to the uninjured limb. Both of these splints are well padded upon one surface, and may be elevated or depressed at will, in order to bring them to the level of the limbs, and fixed at the proper attitudo by the screws already mentioned. They are also mutually transferable, thus adapting the apparatus to fractures of either thigh. " 8S. Counter-extending pads. These are attached by leather straps to the upper surface of the platform D, about twelve inches apart. Passing under the cushion O, and becoming well-rounded pads, they traverse the tuberosities of the ischia, pass between the thighs and thence perpendicularly to the horizontal iron rod or crossbar L. The crossbar L is supported at each end by a perpendicular bar extending upwards from the platform Z>. Attached by one extremity to the crossbar L, is a rod P, running parallel with and situated directly above the thigh. The other end of this rod P, is supported by an arched iron bar N, extending upwards from the outer side of the long splint J. The rod P is designed to afford special support to the injured limb whenever such support is deemed advisable. Two or three strips of cotton cloth, of suitable width, may be passed around the limb, either internally or externally to the splints of coaptation, and tied over the supporting rod P. Splints of coaptation are to be applied according to the exigencies of the case. " M. An inside splint covered by the bandages. Q. The screw by which extension is effected in the ordinary way, having at oue oxtremitya swivel and hook tied to a strip of wood in the loop of adhesive plaster below the foot." 399 FRACTURES OF THE SHAFT OF THE FEMUR. In children, I have effected some excellent cures simply by means of a sole-leather trough, well padded and provided with a foot-piece. " The great objection to the flexed position is the difficulty of keeping the ends of the broken bones in apposition; the upper one having a constant tendency to pass away from the inferior. Other objections might be urged against the flexed position, but this is quite sufficient to induce me to reject it." 1 Dr. Neill, of Philadelphia, has contrived a very ingenious mode of making both extension and counter-extension at the same moment, by means of a twisted rope which is fastened by its two ends respectively, to the perineal band above and the extending bands below (Fig. 134). Fig. 134. John Neill's Straight Thigh-Splint.—Extension and counter-extension made at the same moment. J. F. Flagg's thigh apparatus, as used in the Massachusetts General Hospital, by Warren, Bigelow and others (Figs. 135 to 143 inclusive). Fig. 135. Fig. 136. Pelvic belt, and perineal strap. (From drawings furnished by Dr. L. M. Sargent, Boston, Mass.) Foot-piece and screw. Fig. 137. Lateral viow of the apparatus, without the belt 1 Trans. Am. Med. Assoc., vol. x.; also System of Surg., by S. D. Gross, 1859, p. 221. 400 FRACTURES OF THE FEMUR. Fig. 138. Front view, with folded sheet laid across. Fig. 139. Apparatus applied. Fig. 140. Side view of apparatus applied. Fig. 141. Fig. 142. Figs. 141, 142. Mode of making extension with adhesive plaster. Fig. 143. Perineal band secured with a padlock. " The belt is made of strong webbing, having pockets on each side, to receive the long splint. It is also furnished with straps and buckles. The perineal strap (Fig. 143), corresponding to the injured side, is kept constantly buckled, while the other may be occasionally loosened, or left off, as its purpose is only to steady the apparatus. "Where the straps pass under the perineum, they are covered with wash-leather. Before applying the belt, a pillow-case or two may be passed around the waist. The padlock is only to be used in case the patient persists in unbuckling the straps. FRACTURES OF THE SHAFT OF THE FEMUR. 401 The splints being applied, with also short side splints, junks, containing bran or sand, &c, are to be secured more firmly to the limb by bands of webbing and buckles." The two Warrens, father and son, of Boston, Kimball, of Lowell, Sanborn, of Lowell, Mass., Mussey, of Cincinnati, Ohio, J. B. Flint, of Louisville, Ky., Armsby, of Albany, 1 also recommend some form of the straight splint. Says Dr. Mussey:— "For all fractures of the thigh-bone I employ the extended position of the limb. There are but few cases in which extending force is not necessary to prevent the degree of deformity or shortening which would occur without it. Of thirty specimens of fracture of the shaft, in my collection, only two are transverse. In fractures of the neck, especially with old subjects, I sometimes avoid the application of any kind of apparatus for permanent extension; but in all cases, whether of the neck or shaft, where such extension is attempted, I have found the straight position of the limb to be the most reliable." And Dr. Kimball, who employs generally Sanborn's splint (Fig. 144), uses the following emphatic language:— "If I should be asked under what circumstances I would use the double inclined plane in case of fracture of the femur, I would unhesitatingly answer, never! I have long since abjured the double inclined plane in every form of fracture of this bone, finding the straight splint fully adequate to all purposes for which any apparatus of this kind is required. In support of this statement, I could furnish a great number of cases showing that the locality of the fracture, the importance of which is so much dwelt upon in the books, constituted, in no case, a valid objection to its use." Extension in Sanborn's apparatus is effected by means of adhesive straps, and counter-extension by a perineal band; but the patient may at any moment relieve the pressure in the perineum by resting his axilla upon the head of the crutch. Daniell, of Savannah, Georgia, recommends the Fig. 144 Sanborn's Splint, a. The movable crutch, b. The screw which fixes the crutch, e. The cross-bar to which the ends of the strap are fastened, d. The moving screw. straight position, the limb being laid in a kind of long box, and the extension being made with a weight and pully. 8 Dugas, of Augusta, Georgia, employs the pully and weight also, but uses the long side 1 Trans. Am. Med. Assoc., vol. x. Report on Deformities after Fractures. 2 Amer. Journ. Med. Sciences, vol. iv. p. 330, 1829. 402 FRACTURES OF THE FEMUR. splint instead of the box. 1 Howe, of Boston, recommended a similar method in 1824. 2 Dr. Gurdon C. Buck, of the New York City Hospital, uses the pulley, "without the long side splint. His perineal band is composed of India rubber tubing, "of one inch calibre, two feet in length," stuffed with bran or cotton lampwick, and covered with canton flannel, which covering may be renewed as often as may be necessary. The extending bands or adhesive plasters, terminating below the foot in an elastic rubber cord. The weight necessary to make suitable extension will vary from five to twenty pounds. Fig. 145. Gurdon Buck's apparatus. Having myself witnessed the operation of this apparatus, especially in some of the U. S. General Hospitals, I am prepared to attest its excellence and efficiency. Joshua B. Flint, 'of Louisville, Ky., has sometimes, as will be seen by the following quotation from a letter addressed to the author, employed a similar apparatus with excellent results. "Of late years I have generally employed Liston's single long splint; having it thickly padded, and then applying a roller from the foot to the hip, in such a manner as to secure the limb firmly to the splint. This is about the only case in which I now wrap a fractured limb with a roller." * ***** * " I have repeatedly used, and with much satisfaction, extension by means of the pulley, having the co-operation only of short lateral splints at the place of the fracture. With a mattress slightly inclined toward the head, and moderate, but persistent traction made on the injured limb by a weight made fast to the foot by means of a cord passing over a pulley—the pulley being secured to the foot-board—I have conducted some tolerably oblique fractures to a satisfactory termination, and with much more comfort to the patients than attends any other equally effectual method of extension." Wm. E. Horner, of Philadelphia, employed a long outside splint (Fig. 146, a), extending into the axilla, and padded, so as to avoid the 1 Southern Med. and Surg. Journ. Feb. 1854. • Howe, New Eng. Med. Journ., July, 1824. 403 FRACTURES OF THE SHAFT OF THE FEMUR. necessity of junks; with fenestras, for extending and counter-extending bands; and also afoot-piece; and a short inside splint (J), made to extend from the perineum to the bottom of the foot. Across the ex- Fig. 146. W. E. Horner's thigh-splint. cavated upper end of this splint, a strip of leather is stretched to receive the pressure of the perineum, while the perineal band is made to pass through two firm leather loops on the outside of the splint. 1 Dr. Joseph E. Hartshorne, of Philadelphia, rejected the perineal band altogether, and sought to make the counter-extension by means of the internal long splint alone; and for this purpose, he cushioned the head of the inside splint, as will be seen in the accompanying drawing (Fig. 147). The head of the outside splint may also be cushioned, Fig. 147. Joseph Hartshorne's thigh-splint. but not for the purpose of employing it as a means of counter-extension. The outside splint is so adjusted to the foot-piece, that it may be removed, in case of a compound fracture, without disturbing either the extension or counter-extension. 2 Fig. 148. George F. Shrady's suspending apparatus. 1 Treatise on the Practice of Surgery, by Henry H. Smith. 2 Ibid. 404 FRACTURES OF THE FEMUR. George F, Shrady, of New York, act. Asst. Surgeon IT. S. Army, has lately devised a very simple and ingenious mode of suspending the thigh and leg. The apparatus is composed of strong iron bars bent as in the above drawing (Fig. 148, a.), through which are passed two horizontal, sliding rods, the rods supporting two pieces of canvas upon which the limb may be suspended. The perpendicular bars are furnished each with a clamp and thumb-screw, by means of which, the bars may be made fast to the side rails of an iron bedstead, or, in case of necessity, to the sides of a stretcher. The clamps enable the surgeon to suspend the limb at any height from the bed, and to give to the canvas bottom any degree of inclination desirable. The accompanying drawings (Fig. 149, 1, 2, 3, 4), represents a very simple and easily-constructed apparatus devised by Dr. Alonzo Chapin, of Massachusetts, which has many points of real excellence. 1 It will serve at least to instruct the reader how he may furnish himself extemporaneously with a complete apparatus when he is not otherwise pre* Fig. 149. Alonzo Chapin's thigh apparatus. pared. The iron screw and swivel for making extension can be made by any blacksmith in a few minutes. Dr. Chapin uses two of these screws, but one would ordinarily answer the purpose equally well. By having the tenons in the side splints instead of in the foot-piece, the apparatus may be opened laterally and made to fit the sides of the limb more or less closely. There are many, however, of our most distinguished surgeons, who retain the flexed position in certain fractures, such as an oblique downward and forward fracture, occurring just below the trochanter minor, and a similar fracture just above the condyles, or in certain cases of fractures in children, or in very old people, but who, nevertheless, give a decided preference to the straight splint in those oblique fractures of the shaft which constitute by far the greatest proportion of all these accidents. Among these, I will mention the names of Post, of New York, 2 De Lamater, of Cleveland, Ohio, 2 Pope, of St. Louis, Mo., a Knight, of New Haven, 2 and Eve, of Nashville, Tenn. 2 1 Amer. Journ. Med. Sci., April, 1859, p. 355. 2 Trans. Amer. Med. Assoc., vol. x.; Rep. on Def., etc. 405 FRACTURES OF THE SHAFT OF THE FEMUR. Dr. Pope has given us his views upon this subject very much at length:— "In the treatment of fractures of the femur, I employ neither the straight nor the flexed position exclusively, but the one or the other, according to the site of fracture. If the fracture involves either the upper (below the trochanter minor) or the lower third (above the condyles) of the femur, I make use of the double inclined plane of Sir Charles Bell. If, on the other hand, the seat of fracture be in the middle third of the thigh, I greatly prefer the straight, long splint of Mr. Liston. "My reasons are briefly the following: In fractures below the trochanter minor, the upper fragment is tilted forwards and upwards, by the unrestrained action of the psoas muscle, so that no extension in the straight direction will avail to draw down the upper in a line with the lower portion of the lever. "The same thing results in fractures of the lower third, but in opposite directions. Here the heel becomes the fixed point, and the gastrocnemii draw the lower fragment backwards and downwards, whilst the upper fragment projects in front. Eectilinear extension can no more correct the malposition of the lower fragment in this case, than it can in the former that of the upper. But in both (upper and lower third fractures), by placing the limb over a double inclined plane, these otherwise insuperable deviations of the fragments are prevented, and the whole bone is brought into proper line. " When, on the contrary, the fracture implicates the middle third or even the middle half of the femur, I invariably employ the straight splint, which I regard as by far the simplest, most effectual, and best means of treatment; and, indeed, but for the reasons assigned, I should only be too glad to use it exclusively in the management of all fractures of the thigh. "My cabinet presents several specimens of broken femurs, which illustrate the soundness of these views: in which the abnormal direction of the fragments alluded to as occurring in fractures of the upper and lower thirds, is very marked; the deformities having resulted from treatment in the straight position. So far as function and symmetry are concerned, the lower deformity is altogether the most serious. The unseemly projection above the knee, the unnatural exposure in front of the articular surfaces of the condyles, which are not set bluffly on those of the tibia, together with the altered site of the patella, and the diminished power of the quadriceps muscle, both weaken and deform the joint. " With regard to the management of fractures below the trochanter minor, or at other points of the femur, by means of the double inclined plane, I am well aware of the difficulty of properly confining the pelvis, but this objection I am far from considering as insuperable. So, too, the outward tendency of the upper fragment, caused by the gluteus, may be humored by carrying the limb off at an oblique angle to the axis of the body. " It is, perhaps, needless to add, that in fractures of the condyles, of the inter-trochanteric portion, as well as of the neck of the femur (when 406 FRACTURES OF THE FEMUR. osseous union is attempted), whether within or without the capsule, I likewise give preference to the straight position." The practice of Dr. Pancoast, of Philadelphia, is peculiar, and will be best described by himself. " I treat all thighs, fractured in their middle part, by the long splint, and in the straight position. In fractures occurring at either end of the bone, I resort at first to the angular splint and the flexed position, and thus place the muscles more at rest; in which position, also, there is less tendency to angular displacement and shortening. After the lapse of a few days, when the disturbed muscles have lost their tendency to spasm, and the hardened cellular tissue about the fracture has formed a sort of bond between the ends of the broken bone, I gently bring the limb down to the straight position, and apply the long splint." 1 The practice of treating fractures of the thigh, as well as all other fractures of the long bones, with the roller alone, and without either lateral splints or extending apparatus, first suggested by Eadley, has found in this country but one distinguished advocate, Dr. Dudley, of Lexington, Ky. 2 Nor, with all my respect for that venerable and truly great surgeon, can I persuade myself that the practice is able to accomplish, in a majority of cases, the indications proposed, nor indeed that it is, at least in the hands of inexperienced surgeons, wholly safe. Dr. D., of Aberdeen, Miss., has reported to me one example in which, after the application of this bandage, by a pupil of Dr. Dudley's, to a negro slave, who had a fracture of the femur, death of the limb ensued, and amputation became necessary. The negro was sixteen years old, and healthy; the fracture was caused by the fall of a tree or of a branch, and was simple. The bandage was applied from the toes upwards to the groin, and was not opened for several days, at which time the whole limb was found to be in a state of dry gangrene, with the exception of the upper two-thirds of the thigh, which was swollen enormously, and partially gangrenous as high up as the groin. Dr. D. says: " Having heard the history of the case carefully stated, observing the leg and the lower part of the thigh to be in a state of dry gangrene, and seeing the marks of the bandage visibly impressed on the surface, my opinion was made up at the time that the gangrene had resulted from pressure of the bandage. The femoral artery at the groin was in a sound and natural state, and if I mistake not, after the limb was removed, it was traced to the point of obliteration where the gangrene commenced, and where the impression of the bandage was observed; thus far, I think, it was of natural size and calibre. Hence the conclusion is inevitable, that the death of the limb resulted from the pressure of the bandage, and not of one of the fragments. It was a curious specimen of dry mortification, and I regret that I did not use the means of preserving it. I was then engaged in a very laborious practice, thirty miles from home, on horseback, and conse- 1 Trans. Amer. Med. Assoc., vol. x. Rep. on Def., etc. 1 Amer. Journ. of the Med. Sci., vol. xix. p. 270 ; Transylvania Journal, April, 1836; Boston Med. and Surg. Journ., vol. xxxiv. p. 35. 407 FRACTURES OF THE SHAFT OF THE FEMUR. quently could not conveniently spare the time to attend to it as an object of surgical curiosity. Dr. H. and myself cut into the leg in various places in order to examine the muscles, arteries, nerves, etc., but found the integuments so hard that it was really difficult to penetrate them with a knife; the resistance to the knife was more like that of dry hickory wood than anything else." 1 In relation to other plans of treatment, I shall content myself by declaring my belief that the starched bandage of Seutin, Yelpeau, Gamgee, and others, cannot be regarded as a safe or effectual apparatus; and that extension alone, without either side splints or long splints, which I have seen practised by Jobert, of Paris, and other French surgeons occasionally, is inefficient. Nor can I look any more favorably upon the ingenious plan devised and practised by my talented countryman, Dr. Swinburne, of Albany, N. Y., and by which he also proposes to dispense with lateral splints altogether. 2 My remarks hereafter will therefore be confined to a more full declaration of the principles involved in, and the proper mode of using, the long splint. Without limiting ourselves to the consideration of any one of the special forms of apparatus, we may say that the following ought to be regarded as essential elements in the construction of the long straight splint (Fig. 156): Length sufficient to extend at least several inches above the ala of the pelvis, and the same distance below the foot; such thickness as that it shall be firm and unyielding; width sufficient to make it serve as one of the lateral splints, since over all the more properly called lateral splints it possesses this advantage, that it can never become displaced downwards or upwards; its width ought seldom to be less than three and half inches, nor should its width diminish as it descends toward the foot, as, in consequence of this construction, the roller, which is intended to secure the limb to the splint, has a constant tendency to slide in the same direction. A foot-piece, or transverse block to which the foot may be attached for the purpose of making extension as nearly as possible in the axis of the limb. If this foot-piece is movable, it will serve only the single purpose above mentioned, and no rule need govern its width. But in this case there must be another block attached to the bottom of the long splint, at a right angle with the shaft, and of the same width as the splint; the object of which will be to support and steady the side splint, and to prevent its rolling inwards or outwards. Where this is neglected, frequent disturbance of the broken fragments, and a deformity from inclination of the foot outwards or inwards, are apt to ensue. If the foot-piece is not movable, then it may be of the same width as the side splint, and serve both to steady the side splint and as a means of extension. The length of the foot-piece ought not to be such as to interfere with a long inner splint, in case its use should de deemed advisable. With two fenestras placed at the upper part of the splint, for the reception of the counter-extending band, the long outside splint is now complete. 1 For a more complete account of this interesting case, see Buffalo Med. Journal, vol. xiv. p. 193, Sept. 1858. 2 Swinburne, Amer. Med. Times, vol. ii. p. 134, Feb. 1861; also p. 143. 408 FRACTURES OF THE FEMUR. These are, so to speak, its simple elements, and compose the splint in its rudest form, without which no splint can be perfect, yet upon which many real improvements may be based. Thus, it must be regarded as an improvement to have the splint so constructed as that it may be readily lengthened or made shorter, to accommodate itself to the size of the patient; or that the foot-piece should be furnished with a screw, for the purpose of making the extension more uniformly; or that the same mode of operating should apply also to the counterextension. The adhesive plaster bands are beyond all comparison the best means of making permanent extension which are at present known to surgeons. Hitherto, one of the most serious difficulties in the way of extension, and the objection which has been most effectively urged against its adoption, has been the excoriations, ulcerations, and even sloughing, which so often occurred from the use of the various extending bands about the ankle. This, together with the injuries occasionally inflicted by the perineal band, has been regarded by other surgeons than Dr. Mott, whose opinion we have already quoted, as a sufficient reason for preferring the flexed position. But no one who has employed the adhesive plaster extending bands will doubt that, so far as injuries to the foot .and ankle are concerned, this objection is now entirely disposed of. It is adopted in many, perhaps most of the American hospitals, and in no case where it has been employed have I known the slightest excoriations to have been produced. I regard this simple invention, therefore, as one of the most important improvements in the treatment of fractures of the thigh, and it is not surprising that several claimants have appeared for the original suggestion. By Dr. Brinton it has been claimed for Dr. Ellerslie Wallace, of Philadelphia ; x by Dr. Sargent for Dr. Gross, of the same city ; 2 and by others for Dr. Swift, of Easton, Pa. ; 3 but however this may be, to Dr. Josiah Crosby, of New Hampshire, is certainly due the credit of having brought it into notice. 4 The mode of using adhesive plaster for extension is briefly as follows:— A single band, long enough to extend from a point just below the knee to twelve or sixteen inches beyond the foot, and about three inches wide, is to be applied along each side of the leg. Instead of one band on each side, two may be employed; which shall traverse each other somewhat obliquely, so that one band shall fall a little in front of the malleolus and one a little behind. Having wrapped the whole circumference of the ankle, including the malleoli and heel, in a heavy pledget of cotton, laid underneath the adhesive bands, a roller is now to be applied from the toes upwards as far as the knee, and secured with a little flour paste or starch. Before fastening the bands • Note to first American edition of Erichsen's Surgery, p 212. 2 Note to 3d American edition of Miller's Practice of Surgery, p. 653. See also N. Y. Med. Gaz., vol. iv. p. 87. ' North Amer. Med.-Chir. Rev., vol. iv. p. 584. * See case reported in N. H. Journ. of Med., for 1851; also N. Y. Journ. of Med., vol. vi. 2d series, p. 137. See, also, Trans. Amer. Med. Assoc., vol. iii. p. 382. FRACTURES OF THE SHAFT OF THE FEMUR. 409 to the foot-block, each band should be twisted into a rope below the foot; and to prevent any degree of lateral pressure upon the sides of the ankle and foot, already tolerably protected by the cotton, a piece of thin board, larger than the width of the ankle, and notched at each extremity, should be placed between the bands below the bottom of the foot. The attempt to use the adhesive plaster also as a perineal band, for the purpose of making counter-extension, does not seem to have been equally successful, unless I except the experience of that very excellent surgeon, Dr. David Gilbert, of Philadelphia, and of one or two other gentlemen mentioned by him, whose practice I will presently describe more particularly. For my own part I never could succeed to any purpose with these bands in the perineum, or at least no better than with the ordinary perineal bands; and I very much fear that, notwithstanding the ingenious contrivances of my friend Dr. Gilbert, we have still to incur the risk of ulcerations, &c, from this portion of our dressings; fortunately, however, the perineal band never completely ligates the limb, and it has rarely, therefore, been found so mischievous as the ordinary extending bands at the ankle. 1 In the fracture apparatus lately invented by the Burges, the peculiar mode of action of the perineal band, avoiding, as it does, pressure upon the front of the groin, diminishes still further this danger; and in the construction of my own splint, I have long had regard to the importance of this principle by attaching the anterior portion of the perineal band to an upright crutch-head, which is made to rise more or less from the top of the splint, according to the size or obesity of the patient. In Burges' and Lente's apparatus this principle is, however, most fully recognized, and the indication is most completely accomplished. Dr. John H. Packard, of Philadelphia, calls attention to the value of India-rubber as a means of permanent extension, to be employed in connection with the adhesive straps. Dr. Buck recommends the same. 2 I will take this occasion to mention that with large fat people, I have sometimes found it necessary to dispense with the perineal band altogether, and in such cases I have succeeded very well in making counter-extension by lifting the foot of the bed one or two feet, and trusting alone to the weight of the body. Dr. Gilbert, as I have already stated, believes also that the adhesive plaster may be employed as successfully in making counterextension as in extension. He published his first case of treatment by this method in the American Journal of Medical Sciences for 1851, and since then he has used it in every case of fracture, not only of the thigh, but of the leg, as he affirms, with the happiest results. Drs. Kerr, Kenderdine, and Hunt, of Pennsylvania, who have also adopted Dr. Gilbert's method, speak of it in terms of commendation. In the first of the accompanying wood-cuts (Fig. 150) nothing is intended to 1 For cases of sloughing, &c, from perineal band, see N. Y. Journ. of Med., vol. xvi., 2d. ser., p. 261, March, 1856; also same journal, Jan. 1840, p. 239. 1 Packard, Amer. Journ. Med. Sci., July, 1862. 27 410 FRACTURES OF THE FEMUR. be shown but the long splint and the adhesive straps employed in extension and counter extension. It will be seen also that Dr. Gilbert employs the ordinary tourniquet of Petit for the purpose of making the extension. The " pelvic band " is a broad strip of adhesive plaster, and serves to bind down the perineal bands more closely to the skin. If necessary, additional strips of adhesive plaster may be applied, and in order to increase their strength they may be doubled.' Fig. 150. D. Gilbert's mode of making Counter-extension, and Extension. 1 Anterior and posterior counter-extending adhesive bands, two and a half inches wide, crossing each other before they pass through the mortise holes. 2. The same crossing at the upper part of thigh and perineum. 3. Horizontal pelvic band, which may be three inches wide. 4. Extending bands, receiving strap of tourniquet in the hollow of the foot. 5. Tourniquet. Fig. 151. Gilbert's Apparatus applied in a Case of Fracture of both Thighs. 1, 1. Anterior adhesive counter-extending strips. 2. Distal extremity of posterior adhesive strip of left side. 3. Adhesive strip surrounding pelvis, binding the anterior and posterior strips to pelvis. 4. Inner extremity of the extending adhesive strip, forming stirrup under the foot to receive the strap of the tourniquet. 5. Cicatrix of left thigh. 7, 7. Petit's tourniquet, by which the power was applied. H. L. Hodge, of Philadelphia, adopting the same measures of counterextension, namely, the adhesive straps, has modified the idea of Gilbert by securing the strips of plaster to the sides of the body instead of the perineum, and attaching them to an iron rod which is made to project from the top of the splint beyond the shoulder. 2 Lente, of Cold Spring, N. Y., has also occupied himself with the invention of an apparatus by which he hopes, in some measure at least, to obviate the usual inconveniences of the perineal band. The 1 Gilbert, Amer. Journ. Med. Sci., April, 1859, pp. 410-424. 2 Hodge, Amer. Journ. Med. Sci., April, 1860. 411 FRACTURES OF THE SHAFT OF THE FEMUR. apparatus described by him possesses also many other peculiarities, and such as demand for it especial attention. I shall, therefore, per- Fig. 152. H. L. Hodgo's method of counter-extension in fracture of the femur. mit him to explain to the reader its several parts in his own language. Speaking of the different forms of the straight splint, he remarks :— "The pressure of the counter extending band upon the groin has always been the stumbling block of this apparatus. Desault saw the advantage of making the tuberosity of the ischium the point oVappui, but failed, as we have seen, in his attempt to do so; and various surgeons have since contrived as many different plans for effectually carrying out his idea, but without complete success. No one, however, has approached this nearer than the Burges. However, the fact seems to be that neither the groin nor the tuberosity is fitted to bear alone the pressure of the counter-extension in cases of considerable shortening, and therefore of great tension in the application of the extending power. "It is therefore my object, in the further modification of the New York Hospital apparatus, to distribute the pressure on these two points; and further, in order to render the pressure on the groin safer and more comfortable, and also to remove all pressure from the muscles, vessels, nerves, &c., of the thigh in front, I propose to add an iron brace (A, Fig. 153), extending, in a curved form, from the upper end of the external splint directly across the body to the median line, and cushioned on its inner surface as represented in the engraving. Sliding on this, and furnished with a binding screw to fix it at any required point, is a plate, P, to the lower part of which is attached a buckle for securing the anterior extremity of the perineal band. By this arrangement, I am enabled to make the direction of the counterextending force of this portion of the band correspond to the axis of the limb, instead of oblique; and, furthermore, it allows me to dispense with all that portion of the outer splint between the crest of the ilium and the axilla; thus reducing it to the original length of Desault, obviating the constriction of the chest by the body-band, and producing a less irksome confinement of the upper part of the body. In lieu of the body-band, there is a pelvic strap extending from the 412 FRACTURES OF THE FEMUR. end of the iron brace, to the movable plate of which it is secured by buckles, around the back to the top of the splint, thus binding the apparatus firmly to the pelvis, if found necessary. It should be mentioned that the brace is so attached to the splint, through the ingenuity of Mr. Tiemann, surgical instrument maker, of New York, as to allow of its being shifted to either side, according as the fracture is on the right or left, or of being removed for packing. He has also made the long splint in two portions sliding on each other so as to shorten or lengthen it according to the size of the patient, and to facilitate its package and transportation. Desault attached the posterior as well as the anterior extremity of the perineal band to the long splint; but it will be found that, by so doing, he does not grasp with it, as he intended, the tuberosity; on the contrary, when extension is applied, it slips under it or above it, and is thus almost totally ineffectual in relieving the groin. To be effective, it should be attached to the splint at a point considerably lower down; and it is necessary that the medium of attachment should be movable, in order that, when the upper end of the splint is placed opposite the christa ilii, it may be shifted, if necessary, a trifle upwards or downwards, that the band may exactly grasp the tuberosity. I therefore provide a button (B, Fig. 153), secured by a thumb-screw, and several holes at different contiguous points in the splint, to which it may be shifted with facility. The Fig. 153. posterior end of the perineal band is either passed under the outer splint and buttoned, as shown at B, Fig. 153, or carried between the cushion and splint, over the top of the latter to the button, as indicated at Fig. E, 154. The latter arrangement is applicable especially to fat and muscular subjects, particularly females, who have an abundance of fat and other tissues covering the tuberosity, which might allow the band to slip by the bone unless attached in this manner. I propose, also, to attach both the extending and counter-extending bands to the apparatus through the medium of elastics. Upon suggesting this to Mr. Tiemann, I found that some one had anticipated me with regard to the extending band; and Mr. T. has arranged a strong spiral spring in the ferule of the screw, which supplies the place of the elastic at that point. It is absolutely necessary that the elastics attached to the perineal band, which may be of India-rubber, should be very short, an inch or so, and very strong; otherwise, they FRACTURES OF THE SHAFT OF THE FEMUR. 413 Fig. 154. will give too much to the extending force, and had better be dispensed with entirely. These elastics are intended to fulfil two indications; first, to render the pressure more tolerable to the patient, as elastics always do; secondly, to keep up an equable and uninterrupted traction on the muscles of the thigh, thus tending still further to diminish the shortening, and to counteract the effect of any stretching or yielding in any part of the apparatus. In order to render the pressure of the perineal band still less unpleasant, and less likely to cause excoriation of the groin, it might be of service to apply several coatings of a mixture of collodion 25 parts, castor oil 1 part, which has been found to form, in other parts of the body, and might form here a smooth and enduring cuticle. " My remaining modification of the splint is a foot-piece (D, Fig. 153), attached by a slide and thumb-screw to the mortise in the external splint, and capable of removal at pleasure. * * * In Fig. 154 this arrangement is dispensed with, and its place supplied by a foot-piece (C), which also obviates the necessity for the block for preserving the parallelism of the adhesive bands, since these bands pass from the leg, on either side, around this piece, binding firmly to the sole of the foot. The cords connecting it with the screw are so arranged as to draw uniformly on this, so as not to tilt it against the ' ball' of the foot. By resting below the heel on the mattress, it serves to support the weight of the clothes, and also prevents eversion of the foot. This contrivance is in imitation of Boyer's, and may, by some surgeons, be preferred; although it is, in my opinion, not so efficient 414 FRACTURES OF THE FEMUR. as the foot-piece (D, Fig. 153). (F) is a wedge-shaped cushion, veryuseful in maintaining the whole apparatus in a level position, and taking off the pressure from the heel and tendo Achillis. An inside splint, extending from the perineum to the inner malleolus, and a guttered splint for the upper and lower surfaces of the thigh respectively, with suitable cushions for the splints, complete this apparatus." Following the suggestion made by Dr. Neill, 1 who uses for this purpose a Spanish windlass, I have had the foot-block of my own splint (Fig. 155) so constructed as that counter-extension may be made at the same moment with the extension. The principle is the same as that employed in the ancient "glossocomon," described by most of the early surgical writers. The advantages of this method are that the counterextension, as well as the extension, can be made slowly, steadily, and firmly; the patient cannot, if disposed to interfere with the dressings, loosen or disturb them; the limb is acted upon equally in each direction, and the rollers which secure the limb to the splint do not become drawn obliquely and disarranged by the daily attempts to increase or continue the extension. The only danger is, that, in the hands of inexperienced surgeons, too much force will be applied, and perineal ulcerations ensue. In constructing the perineal band, I now usually adopt the suggestion made to me some time since by Dr. Boardman, of Buffalo. A sheet of foolscap, or the half of a newspaper is folded into a ribbon of about one inch and a half in width; this is intended to give firmness to the perineal band, and to prevent its corrugation. The surface which is to be laid against the skin is then covered with cotton wadding, and the whole enveloped in a long, narrow strip of cotton cloth, and neatly stitched. The strip of cotton cloth must be much longer than the padded portion of the band, in order to tie through the fenestras. Before securing the band in place, a strip of patent lint should be laid in the perineum with its soft side against the skin. This may be occasionally renewed. With children I often employ only the simple splint figured in Fig. 156, yet if the little patient is restless and disposed to throw himself about the bed, I prefer the double splint shown in Fig. 157, to which is attached a screw of peculiar construction, called the "endless screw," (Figs. 158,159,160,161), the pattern for which was sent to me by some gentleman in Boston, whose name, I regret to say, I cannot now recall. It will be found necessary, generally, to confine both limbs to the long side splints with rollers, over junks, the rollers being carefully applied from the foot to the groin. In this way alone can children be prevented from constantly disturbing the dressings. When thus secured, these patients become completely manageable, and can be readily moved at any time from the bed to a lounge or even into the open air. In all cases one should prefer to use side splints, carefully fitted; the whole, both side and long splints, being applied to the limb over neatly-made cotton pads or junks, of which there ought to be laid 1 Philadelphia Med. Exam., vol. xi. p. 579. FRACTURES OF THE SHAFT OF THE FEMUR. 415 upon every part of the leg and thigh as many as may be necessary to prevent unequal pressure. Fig. 155. The Author's Single Straight Thigh-Splint, tor Children or Adults.—a. Crutch-head, with two rings for the passage of the perineal band, b, b. Upper sliding portion of the splint, c Ratchet to secure the upper portion of the splint when drawn out. d, d. Lower sliding portion of the splint, to which is attached the foot-block, e. Foot-block, which, with the lower sliding portion of the splint, d, is moved upwards or downwards by the screw,/, g. Brass ring fastened to the outer end of the fuot-block. The periueal band having passed through the rings in the crutch-head, is made fast to this ring; so that when the foot-block descends, extension and counter-extension are made at the same moment, h. Crosspiece, to steady the long splint. Fig. 156. The Author's Single Straight Thigh-Splint, for Children, or the straight splint in its simplest and elementary form. Fig. 157. The Author's Double Straight Thigh-Splint, for Children or Adults.—Both of the long splints are laid outside of the two thighs. Fig. 158. Fig. 159. Fig. 160. Fig. 161. SCALE ONE-FOURTH OF FULL SIZE, Endless Screw, used by the Author for making Extension in the Double Straight Splint.—Fig. 188. Front view. Fig. 159. Side view. Fig. 160. End view ; a is a screw working in a toothed wheel, b. Fig. 161. Front removed, showing the plane part of toothed wheel for extension strap, c, e. Two small screws to fasten extension strap. I am especially careful to place a thick but soft pad underneath the knee, since if this is not done the forced extension into which the hamstrings are thrown soon becomes irksome and even painful. A 416 FRACTURES OF THE FEMUR. thick compress ought also to be placed under the back of the leg, just above the heel, to prevent the weight of the limb from producing ulceration. To this general plan of treatment now recommended for fractures of the femur the writer makes no exceptions, unless it be in the case of a fracture of the neck of the femur occurring in very old persons, or in fractures just above the condyles, where the direction of the fracture is obliquely downwards and forwards; in the former of which often no rule can be adopted, except that the patient should be placed in that position which may be found most comfortable; and in the latter of which the flexed position seems indeed the most rational, yet, according to the evidence furnished by Malgaigne, its advantages over the straight position are far from being established. In fractures occurring just below the trochanter minor, my own experience agrees with that of the distinguished author just quoted, that the straight position is still the best; an experience which seems to me also to admit of a satisfactory explanation. It is not directly upwards, but rather outwards and upwards (Fig. 162), that the lower end of the proximal fragment is thrown by the action of the psoas magnus and iliacus internus, so that in order to meet the supposed indication it will be necessary to carry the lower part of the limb outwards also, a position which would certainly be found very inconvenient, if not actually impracticable, in the majority of cases. Nor can the tendency of the upper fragment to rise, and consequently to separate from the lower, be effectually met by posture alone, unless the thigh is completely flexed upon the body; a position, again, which will be found inconvenient, if not impossible. Fig. 162. It is apparent, therefore, that by posture alone we can only very imperfectly accomplish an approximation of the fragments; while, in adopting the flexed position, we have almost entirely, whatever may be said to the contrary, deprived ourselves of the means of extension and counter-extension. On the other hand, admitting that by the straight position we have momentarily provoked a resistance which flexion of the limb might have prevented, we shall be able, slowly but effectually, to overcome this resistance by steady and continued extension. In the one case we have made a present gain, but a final loss; and in the other a present loss results in our final gain. So it is that experience has shown in more than one case which has come under our observation, that although for a few moments, or perhaps for several hours, after the straight position has been assumed in these FRACTURES OF THE SHAFT OF THE FEMUR. 417 fractures, the upper fragment will rise spasmodically, after a time, longer or shorter, and especially after the application of the side splints and bandages, this tendency will cease altogether. My convictions upon this subject are clear, but since they do not correspond with the convictions of a pretty large proportion of practical surgeons, I am compelled to regard the question of posture in this particular fracture as still open. I will take the liberty to suggest, however, that it is by the results of carefully recorded experience alone that it can be ever determined, and not by any reference to physiological or anatomical arguments, which I suspect have had hitherto much more influence with surgeons in respect to this question than personal observation. In hospitals, and in private practice whenever the circumstances of the patient will warrant the expense, a bed constructed with especial view to fractures of the thigh ought to be regarded as an essential part of the apparatus; always contributing to the comfort of the patient, if it is not absolutely necessary to the attainment of the most complete success. Indeed, where some form of fracture-bed cannot be procured, and the patient is compelled to lie upon a common cot bed instead, or a common post bedstead, or upon the floor, I cannot think the surgeon ought to be held in any degree responsible for the result. Fig. 163. Jenks's fracture-bed From Gibson. The fracture-beds in use among American surgeons are exceedingly various, among which I will mention, as being especially ingenious, the beds invented by Jenks, Daniels, the Burges, Addinell Hewson, of Philadelphia, 1 J. Khea Barton, and B. H. Coates, of the same city. 8 ' Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101. 2 Eclectic Repertory, 5th and 9th vols. 418 FRACTURES OF THE FEMUR. Of these several contrivances, Jenks's bed (Fig. 163) has been for the longest period in use among American surgeons, and its excellencies most thoroughly tested. It is composed of "two upright posts about six feet high, supported each by a pedestal; of two horizontal bars at the top, somewhat longer than a common bedstead; of a windlass of the same length placed six inches below the upper bar; of a cog-wheel and handle; of linen belts, from six to twelve inches wide; of straps secured at one end to the windlass, and at the other having hooks attached to corresponding eyes in the linen belts; of a head-piece made of netting; of a piece of sheet-iron twelve inches long, and hollowed out to fit and surround the thigh; of a bed-pan, box and cushion to support it, and of some other minor parts. " The patient lying on this mattress, and his limb surrounded by the apparatus of Desault, Hagedorn, or any other that may be preferred, the surgeon, or any common attendant, will only find it requisite to pass the linen belts beneath his body [attaching them to the hooks on the ends of the straps, and adjusting the whole at the proper distance and length, so as to balance the body exactly], and raise it from the mattress by turning the handle of the windlass. While the patient is thus suspended, the bed can be made up, and the feces and urine evacuated. To lower the patient again, and replace him on the mattress, the windlass must be reversed. The linen belts may then be removed, and the body brought in contact with the sheets." 1 But in my own experience no bed has proved so complete and universally applicable as the fracture-bed invented more recently by Daniels (Figs. 164,165,166); and which may be used either as a double inclined plane or as a single horizontal plane suitable for the support of the patient when his limb is dressed with the straight splint. Sometimes I have had constructed a simple frame, covered with a stout canvas sacking, having a hole at a point corresponding with the position of the nates, and this I have laid directly upon a common four- Fig. lb'4. E. Daniels' Fracture-Bed. 1 Gibson's Surgery, vol. i. p. 320. 419 FRACTURES OF THE SHAFT OF THE FEMUR. Fig. 165. Fig. 166. E. Daniels' Fracture-Bbd. "A, represents a platform of a suitable length and width, and supported by four legs, a. To the upper surface of the platform, .4, there is attached a cross-piece, b, at a short distance from the centre, and directly through the centre of the platform there is made a circular hole or aperture, c (in dotted lines), said hole or aperture having a semicircular cut or recess in the cross-piece b. To the straight edge of the cross-piece b thore is attached, by hinges, d, a board, B, termed the body plane, the width of which may correspond with that of the platform A, and when depressed its outer edge maybe even with the edge of the platform. The sides of the body plane may be elevated, or raised so as to be slightly concave on its outer surface. To (lie opposite side or edge of the cross-piece b, and at each side of the semicircular cut or recess formed by the hole or aperture c, there are attached by hinges, e, cast-iron plates, 0 C, which are provided with grooves or ways at their sides, in or between which plates D D work. The plates O G, D D (one on each side) are thigh plan.es. and their edges are provided with ease or projections,/, in which a shaft, g, works, one on each plate 0 On each shaft g there is placed a pinion, which gears into a rack attached to the under surface of the plates D D. At one end of the shafts g there are attached ratchets g\ in which pawls,,/, catch, said pawls being attached to the sides of the plates C C. To the outer edges of the plates DD there are attached by hinges, Jc, boards, E E ; these boards are leg planes, and are slightly raised at their inner ends, where they are connected to the plates D, in order to form depressions to correspond to the shape of the legs. To the under surface of each leg plane there is attached a metal guide, I, in which a rack, m, works ; the outer ends of the racks have bars, n, projecting from them at right angles. To each leg plane there is attached a shaft, o, having a pinion, p, and ratchet q, thereon, and pawls, r, which catch into the ratchets q, the pawls being attached to the outer sides of the leg planes. The pinions gear into the racks m. The body plane, and also the thigh and leg planes, 420 FRACTURES OF THE FEMUR. are covered by a suitable mattress, E. with a hole made through it to correspond with the hole or aperture c in the platform A, and the mattress is slit or cut to cover properly the thigh and leg planes without interfering with their movements. To the under side of the platform A there is attached by hinges a flap, F, having a stuffed pad or cushion, t, upon it, which, when the flap Fis secured upwards against the platform A, fits in the hole or aperture c in the platform and mattress. The flap is secured against the platform by a button, u." post bedstead. A mattress and one or two quilts must be placed upon the boards of the bedstead underneath the sacking, and a sheet or two above the sacking, upon which last the patient is to be laid. In arranging the linen underneath the patient, the most convenient plan is, instead of using only one sheet, which will require that a hole shall be made in it corresponding to the hole in the sacking, to employ two sheets, and, doubling them separately, to bring the folded margin of each from above and from below to the centre of the opening. When the patient has occasion to use the bed-pan it is only necessary that two or four persons should lift this frame, and place under each corner a block about one foot in height, or it may be raised by a pulley and ropes suspended from the ceiling. We may also floor over a common bedstead, having previously, in case it is an adult whom we have to treat, removed the foot-board, so that we may extend the floor two or three feet beyond the usual length of the bedstead. In the centre of this floor we may make an opening, so arranged as to be closed by a board slid underneath, or by a door fastened with a couple of leathern hinges, and closed by a spring catch. A very comfortable bed, especially for children, can sometimes be made from a cot. But it will be necessary, always, to nail a piece of board firmly across the top and bottom of the bedstead when the sacking is at its utmost tension, in order to prevent the side rails from falling together. The top board must be nailed on vertically like an ordinary head board, so as to prevent the pillows from falling off) but the bottom piece should be at least one foot wide, and laid horizontally to support and steady the apparatus as it extends beyond the foot. Having had occasion to assist the late Dr. Treat, in the management of a fracture of the thigh, in the case of a little girl not quite three years old, I was struck with the simplicity and completeness of an arrangement which he had made to prevent the bed and the dressings from becoming soiled with the urine. It was only to leave directly underneath the nates a complete opening through to the floor for the escape of the urine, and to protect the margins of the sacking and sheets, which came nearly together at the opening, with pieces of oiled cloth folded upon themselves. It was found that not only the bed was in this way kept dry, but the dressings also; it being now observed that the dressings had become wet heretofore by soaking up the moisture from the bed rather than by the direct fall of the urine upon them. Having prepared the bed for the reception of the patient, we may proceed as follows in the case of a simple fracture. Lay the perineal band in its place, and four pieces of bandage transversely where the broken thigh is to repose; over the four transverse 421 FRACTURES OF THE SHAFT OF THE FEMUR. bands lay a firm splint, long enough to reach from the tuberosity of the ischium to the lower margin of the ham, and nearly as wide as the diameter of the thigh. This may be made of a board covered with cotton cloth, and carefully stuffed, so as to fit all the inequalities of the several portions of the limb. It can be fitted with sufficient accuracy by comparing and trying it upon the sound limb. Of all the side splints this is the most important, and the greatest care ought to be exercised in its construction. The patient, having been previously stripped and washed with warm water and soap, is laid upon the bed with his thigh reposing upon the back splint; the head and trunk being at first moderately raised to prevent any strain upon the muscles of the front of the thigh. An assistant seizes the knee firmly with both hands and makes moderate traction so as to steady the limb, and at the same time prevent the fragments from penetrating the flesh; while the surgeon lays his long strips of adhesive plaster upon each side of the leg in the manner which has already been described, protecting the ankles with small pads made of cotton batting. Elevating the foot a little more, he proceeds to apply a roller from the toes up to the ham. Everything is now ready for the long splint, which, in case only one is used, is laid outside the broken limb, and the perineal band adjusted and tied temporarily in a bow knot: one long junk is pressed between the splint and the limb, reaching from the hip to the heel, and immediately the surgeon fastens the extending bands to the foot-piece or to the extending screw, and tightens it moderately so that the assistant may release his hold upon the knee. The whole limb is now steadied and at rest, and the patient seldom fails to declare himself relieved; after which, the surgeon may proceed more at leisure to complete his dressings. A padded splint should next be laid upon the inside of the thigh, extending from the groin to immediately below the knee, but it must not be allowed to press much upon the knee, as it would be likely to become painful, and perhaps, vesicate the skin over the projecting bones. Another splint in front, extending from the groin to within one inch of the knee, completes the inclosure of the limb; and the whole are to be retained in place by tying the four transverse bands, previously laid under the limb, around the three short lateral splints, and the long outside splint. In some cases I prefer to secure the short lateral splints to the limb independently of the long splint, and then it is necessary to lay a fourth short splint upon the outside of the limb, between it and the long splint, otherwise the transverse bands will cut into the flesh. The perineal band ought now to be made permanently fast, and the extension carried to the point of utmost tolerance on the part of the patient, while the surgeon proceeds to apply a roller from the instep to the groin, enveloping at the same time the splint and the limb in its successive turns; but as he progresses upwards, he should lay between the limb and the splint and underneath the limb as many soft, cotton pads as may be needed to fill up all the inequalities; these pads it will be found necessary to extend from the malleolus externus 422 FRACTURES OF THE FEMUR. to near the middle of the leg, and to lay them under the tendo-Achillis and knee, outside of the knee, above the trochanter major, &c. Before the surgeon leaves he should ascertain whether the extension is too violent, or whether it is quite painful, and in either case it must be a little slackened. If the patient is a child, or an intractable adult, the double splint ought to be preferred, and the unbroken limb be secured to the opposite long splint in the same manner as the broken, only that no perineal band or extending straps are needed for the sound limb. The rules which have now been laid down in relation to the order and manner of dressing, are the results of my own personal experience as to what method is generally the most convenient and useful; but circumstances must occasionally require that they should be somewhat varied or modified; and when other forms of apparatus are employed than those for which I have already indicated my preference, the rules of procedure must be determined by the peculiarities of the apparatus. In short, much must always be left to the discretion of the surgeon, only that he never can be at liberty to dress a broken thigh in a hasty or slovenly manner. During the first two or three weeks the limb ought to be seen daily, and at each visit a careful examination of every portion of the apparel should be made, so far as this can be done without opening or removing the dressings; and whenever anything is disarranged, or has become too tight or too loose, so far as may be necessary to correct these faults, the bandages should be removed and readjusted. Generally they can be tightened by over-stitching or by additional bandages. If the patient complains of pain at any point where a splint presses, his complaints should receive prompt attention, and the cause should be ascertained and removed if possible. Especially ought the surgeon to look to the condition of the perineum; and generally no harm comes of slackening or removing the band whenever this part is to be inspected, since the weight of the body alone is sufficient, during the few minutes it is to be removed, to prevent any shortening of the limb. During the first week the extension should be increased, according to the ability of the patient to endure it, each day; and after that, steadily maintained until union has taken place. In the case of an adult, we ought never to encourage a hope that he can be released from his splints in less than eight weeks, although we may find it safe to remove them as early as the end of the sixth week; but the patient seldom wears the splints too long, while they are often removed too soon. Eemember that the fragments are in nine cases out of ten uniting side by side and not end to end; the muscles which act upon them are powerful, and the weight of the limb is great, so that the time within which the limb can be safely trusted alone is never short. The extension may, however, be relaxed as soon, generally, as the twenty-eighth day, and the leg may be lifted daily after this, and the knee and ankle very gently flexed and rubbed, but never so early as this period can the short side splints be abandoned safely. Still more FRACTURES OF THE CONDYLES. 423 important do I regard the continuance of the long side splint—no longer now as a means of extension, but only of retention—lest the weight of the limb should turn the foot gradually out, or occasion some other deformity. It is true that in some cases, where patients are remarkably careful and everything has gone along well, I have, at the end of four weeks, applied a paste bandage from the toes to the groin, and permitted them to get up upon crutches; but I would not dare to recommend this practice to the inexperienced surgeon or to the incautious patient. It has often done well, but sometimes it has proved disastrous. It is an extra hazard which the surgeon should be reluctant to incur. When at length the patient is permitted to leave his bed, a pair, of crutches becomes indispensable, and during the following two months but little weight should be borne upon the limb; and in rising from the bed care must be taken lest the limb should be so situated as that its weight would make it bend. § 5. Fractures of the Condyles. (a.) Fractures of the External Condyle. Dr. Alph. B. Crosby, 1 of New Hampshire, has published an account of a case of simple fracture of the external condyle, in a young man twenty-one years of age, and which happened from a sudden twist of the limb, while he was undressing himself to bathe. He was "standing on a shelving bank, with the right leg flexed over the left in order to remove his pantaloons: he lost his balance, partially twisted the leg, and fell to the ground." Six months after, the fragment was removed by Dr. Crosby, through an incision below the con-; dyle. The recovery of the young man has been complete. The accompanying drawing represents the specimen as seen from its lower or cartilaginous surface, and of its actual size. Dr. T. S. Kirkbride has also reported an example of simple fracture of this condyle, which was produced by the kick of a horse, the blow having been received upon the inside of the knee. When this patient entered the Pennsylvania Fig. 167. Dr. Crosby's specimen of fracture of the external condyle. Hospital, Dec. 1834, the knee was much swollen and crepitus was plainly felt, but the fragment was not displaced; the muscles upon the outer side, however, were so strongly contracted as to abduct the leg and produce considerable angular deformity. The limb could be easily made straight, but it returned to its former position of abduction, as soon as it was released. When fully extended, slight bending 1 Crosby, New Hampshire Journ. of Med. 1857. 424 FRACTURES OF THE FEMUR. of the joint did not give severe pain, but when in any degree flexed, Fig. 3 68. Sir Astley Cooper's ease of fracture of the external condyle. all motion was very painful. The limb was placed in a long straight fracture box, and cold applications were made; great swelling followed. It was kept extended in this manner, or in the long splint of Desault twenty-eight days; at which time union seemed to have taken place, but the motions at the joint were very limited and productive of great pain. From this period the limb was laid in a splint so constructed as that the angle at the knee could be changed daily. At the end of about six weeks he began to walk on crutches, and he could then flex the leg to a right angle. 1 Sir Astley has related a case of compound fracture of the same condyle, produced by falling from a curb-stone upon the knees. The man died on the 24th day. On examination after death the external condyle was found to be broken off, and also a considerable fragment was detached from the shaft higher up. 2 (b.) Fractures of the Internal Condyle Dr. Thomas "Wells, of Columbia, S. C, has reported an example of fracture of the internal condyle, accompanied with a dislocation of the head of the tibia outwards and backwards. The man was about forty years old, and intemperate. Dr. Wells was not called until two days after the injury was received, when he found the limb greatly swollen and gangrenous. The man's account of himself was that while walking in the back yard he fell, and thus dislocated his knee, and that he was then brought into the house, being unable to stand upon his feet. It does not appear that any attempt was made to reduce the limb, probably because his general condition indicated that speedy death was inevitable. On the fourth day he died. The autopsy disclosed, in addition to the dislocation of the tibia, that a thick scale of bone was broken from the inner part of the inner condyle, but it remained attached to the ligaments. 3 A case reported to me by Dr. Lewis Riggs, a very intelligent surgeon, practising in Homer, Oneida Co., N. Y., was more successful. A lad, aet. 15, was kicked by a horse, the blow being received upon the right knee. Dr. Riggs saw him within three hours after the accident, and found the internal condyle of the right femur broken off, carrying away more than half the articulating surface of the joint; the tibia and fibula were at the same time dislocated inwards and 1 Kirkbride, Amer. Journ. Med. Sci., May, 1835, vol. xvi. p. 32. 2 Sir Astley Cooper, On Disloc, &c, op. cit., p. 239. 3 Wells, Amer. Journ. Med. Soi., May, 1832, vol. x. p. 25. 425 FRACTURES OF THE CONDYLES. upwards, carrying with them the broken condyle and the patella. The displacement upwards was about two inches, and the sharp point of the inner fragment had nearly penetrated the skin. There was no external wound. The knee presented a very extraordinary appearance, and the lad was suffering greatly. Being at a distance from town, and the doctor having no chloroform or pulleys with him, he was obliged to depend solely upon the aid of five men who were present. The first attempt at reduction was unsuccessful, but in the second attempt, when the men were nearly exhausted in their efforts at extension and counter-extension, and while the doctor was pressing forcibly with both hands upon the two condyles, the bones suddenly came into position, except that the breadth of the knee seemed to be slightly greater than the other, a circumstance which was probably due to the irregularities of the broken surfaces, which prevented perfect coaptation. Neither splints nor bandages were required to maintain the bones in place; but anticipating the probable occurrence of anchylosis, and with a view to making the limb as useful as possible in this condition, the doctor placed him upon " a double inclined plane," which being supplied with lateral supports, would also prevent any deflection in either direction, in case the limb was disposed to such displacement. The subsequent treatment consisted in the use of cold water dressings. Very little inflammation followed. A portion of the integument sloughed, but the bone was not exposed, and it healed rapidly. On the twenty-fourth day Dr. Riggs gave to the joint passive motion, and this was repeated at intervals until, at the end of three months, he was able to walk with a cane. At the end of a year Dr. Riggs examined the leg, and found the knee a very little larger than the other, and he could not flex it quite as completely. In all other respects it was perfect, and the boy himself declared it was as good as the other. Treatment of Fractures of either Condyle. —The few cases of these accidents which have been reported have been, with one or two exceptions, treated in the straight position. In Kirkbride's case any degree of flexion was painful, although there was little or no displacement of the fragment; and we think we can see, in the relative position of the articular surfaces of the tibia and femur, a sufficient reason why the straight or nearly straight position must generally be preferred. Whichever condyle is broken, the remaining condyle will be sufficient to prevent a dislocation and consequent shortening of the limb, unless, indeed, the dislocation has already occurred as an immediate consequence of the injury. It is very certain that it would not take place from the action of the muscles when the limb was straight. In the flexed position I can conceive that it might take place, but yet not easily. It is not a dislocation of the limb, then, that we seek chiefly to avoid, but a deflection of the leg to the right or to the left, according as one or the other of the condyles has been broken. It will be readily seen that, in order to resist this tendency, nothing but the straight position will answer, and that for this purpose it will be necessary to lay a long splint upon one or both sides of the limb, and to secure the 28 426 FRACTURES OF THE FEMUR. whole length of both thigh and leg to this splint. The long fracture box used by Kirkbride, if well cushioned on all sides, seems to me at once to answer most completely this important indication, rendering it even unnecessary to employ a bandage, since the opposite sides of the box will compel the limb to adopt the proper position. As to the remainder of the treatment, it must consist essentially in the active employment of such means as are calculated to prevent and allay inflammation; especially ought the surgeon not to omit to avail himself of so valuable an antiphlogistic agent as cool water lotions. As soon as the union is consummated the joint surfaces should be submitted to passive motion in order to prevent anchylosis; and it would be better to commence this so early as to hazard somewhat a displacement of the fragment than to wait too long. It may not, in some cases, be improper as early as the fourteenth day, and in nearly all cases it should be practised as early as the twenty-eighth. (c.) Fractures between the Condyles and across the Base. Etiology. —A fracture of this character may be produced by a blow received upon the side of the limb or upon the lower extremity of the femur; sometimes the blow has been received directly upon the patella when the knee was bent, and Bichat mentions a case in which it was produced by a fall upon the feet. Symptoms. —This fracture is easily distinguished from the preceding by the much greater mobility of the fragments and by the palpable shortening of the limb, since an overlapping of the broken end is here almost inevitable. Bach fragment may be felt to move separately, and the motion will be accompanied with crepitus. Prognosis. —The danger of violent inflammation in the joint is imminent, and anchylosis of the knee is to be anticipated as the most favorable result, since the joint surfaces are likely to be rendered immovable by fibrinous deposits in their immediate vicinity, and also by the adhesion of the muscles to one another and to the bone higher up, where the fracture of the shaft has occurred. More fortunate results than these may, indeed, be hoped for, inasmuch as they have occasionally been noticed, but they cannot fairly be expected. In a majority of cases, such accidents have demanded, either immediately or at a later period, amputation. If recovery takes place, a shortening of the thigh is inevitable. Mr. Canton, of London, has twice performed successfully resection of the joint end of the bone in such accidents. 1 Treatment. —Malgaigne saw a patient who had been treated by Guerbois with the aid of extension and counter-extension, who was confined to his bed five months, and who had at the end of eight years very little motion in the joint, and he seems disposed to charge in some measure these unfortunate consequences to the position in which the limb was placed, namely, the straight position. But in my opinion, it is much more reasonable to suppose, that if the treatment was at > Lancet, Aug. 28, 1858. Trans. London Path. Soc, 1860. FRACTURES OF THE CONDYLES. 427 all responsible for the results, the error consisted in too long and unnecessary confinement, and in too much extension. I suspect that the mere matter of position had nothing to do with the anchylosis. Malgaigne does not, however, himself recommend anything more than a very slight amount of flexion at the knee; and to this practice I am prepared to give my assent; since it will give to the limb the best position in case anchylosis does occur, and it is not inconsistent with the employment of the moderate amount of extension which alone is justifiable after this accident. If the young surgeon should differ with me in opinion as to the necessity or propriety of using great force to retain the fragments in place and prevent overlapping, I beg him to consider that this accident never happens except from the application of an extraordinary force, and that consequently intense inflammation and swelling are almost certain to ensue; and that in some cases, the very fact that immediately after the accident, or for some hours succeeding, no swelling occurs, or muscular contraction, and that replacement of the fragments is easily accomplished, is evidence only of the great severity of the injury, and that the whole system is lying under the shock: to which, if the patient does not succumb, sooner or later reaction will ensue, and the fragments will be gradually drawn up with a resistless power. The surgeon ought to remember also that to make extension in this case, he is obliged to pull upon those very ligaments and tendons about the joint which, having been torn or bruised, must soon become exquisitely sensitive. The long straight box, already recommended when speaking of fracture of one condyle, is equally applicable here; only that it needs a foot-board, or some sort of foot-piece to which an extending apparatus may be secured, and that a pillow should be placed under the knee to give the limb the proper flexion. Case. —A man was admitted into St. Thomas's Hospital, London, Sept. 17,1816, with a fracture between the condyles, accompanied also with a fracture through the shaft higher up, occasioned by beingcaught in the wheels of a carriage while in motion. There was a small wound opposite the point of fracture, and the external condyle was displaced outwards. The limb was laid in a fracture box, and in a position of semiflexion. On the 18th of Nov., the external condyle, having protruded through the skin, and being dead, was removed with the forceps, bringing with it a portion of the articular surface. On the 6th of Dec. he was discharged from the hospital, and in February following he was walking without any support, and with the free use of the joint. 1 Case. —While I am writing, a gentleman living about eighty miles from town has been thrown from his carriage, breaking the left femur just above the condyles into many fragments, so that when I saw him, on the following day, the attending physician showed me about four or five inches of the entire thickness of the shaft which he had 1 A. Cooper on Disloe., &c, op. cit., p. 239. 428 fractures' of the patella. removed. The external condyle was completely separated from the internal, and was quite movable. In this case the attempt to save the limb resulted in the loss of the patient's life on the sixth or seventh day. CHAPTER XXIX. FRACTURES OF THE PATELLA. Causes. —Of seventeen fractures of the patella which have come under my observation, sixteen were the result of direct blows, or of falls upon the knee. In the remaining example the fracture was due solely to muscular action: A sailor, aged about thirty years, had caught the heel of his boot in a knot-hole in the floor, which threw him backwards, and in the effort to sustain himself the patella was broken transversely. Dr. Kirkbride has reported a case in which both patellae were broken in a similar manner but at different periods. The patient was a girl, set. 29, who was admitted into the Pennsylvania Hospital, Oct. 16, 1833. "In falling backwards, and making an effort to save herself," the right patella had been fractured. She was dismissed cured on the second of Dec, and on the 20th of April following she was readmitted, with a fracture of the left patella, produced in the same manner as before; but in her effort to save the right limb, the left received all the strain and the patella gave way. 1 Dr. Kirkbride ¦records another instance of fracture from muscular exertion in a man set. 32, who attempted to jump into a cart, by raising his body with his hands resting upon the bottom of the vehicle;' and Dr. Hayward, of Boston, saw a case in the Mass. Gen. Hospital, in a man set. 67, which occurred in consequence of a false step in descending a flight of stairs. 8 Pathology. —All the fractures produced by muscular action have been found to be transverse, and the same is true generally of fractures Fig. 169. Fig. 170. produced by direct blows; occasionally, however, we meet with Ion gitudinal fractures, or with fractures more or less oblique and com 1 Kirkbride, Amer. Journ. Med. Sci., Aug. 1835, vol. xvi. p. 330. 2 Hayward, Am. Journ. Med. Sci., vol. xxx., from New Eng. Quart. Journ., July, 1842. 429 FRACTURES OF THE PATELLA. minuted. Thirteen of the fractures seen by me were simple and transverse; one was simple and oblique, and one was comminuted. The oblique fracture was in the person of a child five years old, who fell on his left knee, Jan. 31,1848, breaking off a small fragment from the upper and inner margin of the patella. It did not separate from the main fragment except when the knee was flexed, and it was then thrown directly forwards, presenting to the finger a sharp point. Dr. Flint, who was with myself in attendance, kept the leg extended and had the knee constantly moistened with cool lotions. Six months after, I could not discover any traces of the accident. There is a specimen, illustrating a similar fracture, but not united, in the collection at St. Thomas's Hospital, London. 1 Dupuytren, A. Cooper and others have also mentioned cases of longitudinal fracture. I have seen a double transverse fracture, or a fracture of both patellae in a man set. 22, who fell from a third story window, striking, he says, upon his knees. He was taken to the Hospital of the Sisters of Charity, in Buffalo, and, after a few weeks, made an excellent recovery. . Fig. 171. Symptoms. —The symptoms which characterize a transverse fracture of the patella are sufficiently diagnostic. The fragments are separated from each other, the superior fragment being drawn upwards more or less, according to the power and activity of the muscles, or the degree to which the ligamentous covering of the patella has been torn. In some cases, also, the violent flexion of the knee, Fig. 172, has completed the separation which otherwise might have been only partial. By passing the finger along the anterior surface of the limb with a moderate degree of firmness, the depression between the fragments will be made manifest. No crepitus can be expected unless the fragments remain in contact, a condition which is very unusual. The patient is unable to stand, and especially is the power of extending the leg upon the thigh completely lost. Usually a good deal of swell- Fig. 172. Fragments separated by flexion of the knee 1 A. Cooper, On Disloc, &c, op. cit., p. 232, 430 FRACTURES OF THE PATELLA. ing immediately succeeds the accident, and after a time the skin becomes more or less discolored from effusions of blood. If the fracture is longitudinal or oblique, a slight separation is usually present, but not always very easily detected. Prognosis. —One of my patients, who had a comminuted fracture, with other serious injuries, died, but not as a consequence of the fracture. In the following case the fragments appear never to have united, although the patient recovered. John Sharkie, set. 24, a soldier in the British service, while serving in the East Indies, was struck on the right knee while he was in a sitting posture, with his leg bent under him. He was immediately placed under the charge of the surgeon of the 89th regiment of infantry. During the first eleven days no splints or bandages were applied, on account of the severe inflammation and swelling. A compress was then placed over both fragments, and they were bound together by rollers, &c. The whole limb was suspended on an inclined plane, the foot being made fast to a foot-board. This treatment was continued four months. When the bandages were removed the limb was badly swollen; and immediately the upper fragment was drawn up toward the body. Eighteen months elapsed before he could walk, even with the aid of a cane. March 27, 1855, twenty-nine years after the injury was received, he was an inmate of the Buffalo Hospital, and I was permitted to examine his knee carefully. The lower fragment is not displaced, but when the leg is straight upon the thigh the upper fragment lies two and a half inches from the lower, and when it is flexed upon the thigh the upper fragment is removed five inches from the lower. Fig. 173. There is no ligament or other bond of union, so far as I can discover. He walks with very little or no halt, but he cannot walk fast. In every other instance which has come under my notice union has taken place at periods varying from twenty-four to fifty-eight days, the average being thirty-eight days. Eleven cases have united by a ligament varying in length from one-quarter to one-half an inch. These measurements, made upon the living subject, may not be mathematically accurate, but they cannot be far from the truth. In one instance, the case of a man set. 40, the fracture having been treated by another surgeon, the ligamentous union, at first complete, seems to have subsequently given way in part. He called upon me for advice nine weeks after the fracture had occurred. The patella was surrounded with bony callus, so that it was considerably wider than the other. The fragments seemed to be united by a short ligament, except on the inner side, where there was a separation or rupture of the ligament to the extent of one-quarter of an inch. The 431 FRACTURES OF THE PATELLA. patient explained this by saying that the splint was removed at the end of four weeks, and that after a week more he began to walk, but that he almost immediately felt it tear or give way on the inner side. Dr. Kirkbride has reported a case of ligamentous union of the patella, in which the ligament was two and a half inches long, and was attached only to the inner margins of the fracture. " He was able to walk as rapidly as ever, and without perceptible limping." 1 A similar case is reported by Dr. "Watson, of New York, in which the fragments became separated three and a half inches. 2 In both instances the fragments were supposed to have united by a short ligament, which had become lengthened by premature use of the limb; in the case reported by Kirkbride, the ligament seemed to have partly torn, as in the case reported by myself. D. Coale presented to the Boston Society for Medical Improvement, at its April meeting in 1856, a specimen of a fractured patella taken from a man sixty-five years old, the fracture having occurred ten years before. The fragments were at first so closely united that no division between them could be discovered, but subsequently they became separated at their outer edges one inch, and at their inner edges one-eighth of an inch. 3 Twice, I believe, I have seen a bony union of the patella. The first instance is that to which I have already referred as an oblique or longitudinal fracture across one corner of the patella; and in the other example the action of the muscles upon the upper fragment was prevented by the occurrence of a fracture of the shaft of the femur at the same time, which permitted the thigh to shorten upon itself. The man was about twenty-five years old, and in a fall from a scaffold had broken his left femur, and also the patella. The patella was broken transversely, near its middle, and also longitudinally near its inner margin. The fragments were all distinctly made out. Drs. Lewis and Dayton, of Buffalo, were in attendance, and on the fifth day I was called in consultation. We dressed the limb with a long straight splint, employing moderate extension and counter-extension. The patella was covered with strips of adhesive plaster. On the fiftyeighth day I found the fragments of the patella united. June 3, 1854, five months after the accident, I examined the limb carefully. The femur was shortened half an inch, and, although the two main fragments of the patella were separated half an inch, the bond of union seemed to be bone. It was hard, and allowed of no motion in the upper fragment separate from the lower. The lateral fragment was also apparently united by bone and in place. He had but little motion in the knee-joint, yet he walked very well, and was able to pursue his trade, as a carpenter, without much inconvenience. Sir Astley Cooper succeeded in obtaining a bony union in some longitudinal fractures, but in a majority of cases it failed, owing to the want of apposition in the fragments. It might seem that it would be easy to accomplish apposition in all longitudinal fractures, but expe- 1 Kirkbride, Amer. Journ. of Med. Sciences, vol. xvi. p. 32. 2 Watson, N. Y. Journ. of Med. and Surgery, vol. iii., first series, p. 366. ' Coale, Boston Med. and Surg. Journal, vol. liv. p. 402. 432 FRACTURES OF THE PATELLA. rience has shown that it is not always, the fragments being kept asunder partly by the action of the oblique fibres of the vasti and partly by the pressure of the condyles of the femur, especially when the leg is slightly flexed. "Whether the fracture is transverse or longitudinal, a bony union may occasionally be obtained when the fragments are retained in absolute contact for a sufficient length of time; but the failure to procure a bony union is not a matter of consequence, since a short ligament is equally useful. Post, of New York, has reported three cases of compound fracture of the patella extending into the knee-joint, brought to a successful termination. 1 In a case mentioned by Eve, of Augusta, occasioned by the kick of a horse, and in which amputation became necessary on the tenth day, "the knee-joint was found filled with dark grumous blood; a portion of the cartilage of the internal condyle of the os femoris was chipped off, and the patella broken into a number of fragments." 2 Lewitt, of Michigan, has related a case of fracture in a lad set. 16, produced by striking his knee against a piece of timber, which resulted in suppuration of the knee-joint, but from which he finally recovered with the perfect use of the limb. The fracture of the patella was oblique, traversing only its upper and outer margin, and it was never much displaced. 3 Dr. Levergood, of Pa., has reported a similar case in which it became necessary to open the joint freely, yet it was followed by an excellent recovery, only a slight anchylosis remaining at the kneejoint 4 Treatment. —Sanborn, of Lowell, Mass., has contrived a method of treating transverse fractures of the patella, Figs. 174, 175, and also cases of rupture of the ligamentum patellae, which I shall take the liberty of describing in his own language. " While repairing one of the public buildings in this city, two men, masons by trade, were precipitated, by the breaking of a staging, a distance of twenty-five feet on to a plank floor. One of the men received a fracture of the base of the skull, and died in consequence; the other escaped with a rupture of the ligamentum patellae. The man was conveyed home, and a neighboring physician applied the usual dressing of a ' figure-of-eight' bandage, with a splint behind the joint. In the course of the following night, the pain in the knee became intolerable from the swelling and consequent tightness of the bandage, and all dressings were removed. The following day the case was transferred to my care by the attending physician. I found the knee a good deal swollen and inflamed, and there was evidence of extensive extravasation of blood into the joint and surrounding tissue. The patella was drawn up the thigh for a distance of four inches; and, although it could be brought down nearly to its proper situation by 1 Post, New York Journ. of Med., vol. ii., first series, p. 367. 2 Eve, Southern Med. and Surg. Journ., 1848 ; also Bost. Med. Journ., vol. xxxvii. p. 427. 3 Lewitt, Medical Independent, Sept. 1856. • Levergood Amer. Journ. Med. Sci., Jan. 1860. 433 FRACTURES OF THE PATELLA. the hand, a bandage sufficiently tight to keep it there could not be borne. The object to be accomplished, then, was to bring a sufficient force to bear on the patella, without making pressure on the joint or impeding the circulation of the limb. And it was accomplished in this manner: A strip of ordinary adhesive plaster, four feet long and two and a half inches wide, was applied to the limb from the upper portion of the thigh to the middle of the leg, leaving at the knee a free loop. A roller bandage was then applied above and below the knee, for the purpose of securing the plaster and controlliug the circulation and muscular contraction. A small stick, six or eight inches in length, then being put through the lodp over the knee, the plaster was twisted until the patella was brought nearly down to its proper situation. Before applying the twist, a hard compress was placed above the edge of the patella in such a manner as to bring the force to bear directly upon that bone. * * •* * Leeches and fomentations were applied to the joint, and, as the inflammation subsided, the plaster was tightened, until (at about the sixth day) the bone was brought fully down to its normal situation. It was there held, without the slightest uneasiness to the patient, until union took place. In Fig. 174. E K. Sanborn's mode of dressing a fractured patella. Represents the limb covered with a broad band of adhesive plaster lifted into a loop over the knee. Fig. 175. Same apparatus; dressing complete. Represents the band of adhesive plaster secured in place by a roller, while the loop is being drawn together by torsion. Underneath the plaster, and just above the upper fragment of the patella, a compress is placed to aid the adjustment. three weeks the man was able to walk alone, with the plaster still applied, and the recovery was ultimately perfect. There is now no perceptible halt in the gait. " Within the last two years several cases of transverse fracture of the patella have been treated by this method, both by myself and others in this vicinity, and with perfect success." 1 1 Boston Med. and Surg. Journ., vol. liv. p. 174. 434 FRACTURES OF THE PATELLA. The dressing which I have usually employed in the treatment of this fracture, consists of a single inclined plane, of sufficient length to support the thigh and leg, and about six inches wider than the limb at the knee. This plane rises from a horizontal floor of the same length and breadth, and is supported at its distal end by an upright piece of board, which serves both to lift the plane and to support and steady the foot. The distal end of the inclined plane may be elevated from six to eighteen inches, according to the length of the limb and other circumstances. Upon either side, about four inches below the knee, is cut a deep notch. The foot-piece stands at right angles with the inclined plane, and not *at right angles with the horizontal floor; it may be perforated with holes for the passage of tapes or bandages to secure the foot. Having covered the apparatus with a thick and soft cushion carefully adapted to all the irregularities of the thigh and leg, especial care being taken to fill completely the space under the knee, the whole limb is now laid upon it, and the foot gently secured to the foot-board, between which and the foot another cushion is placed. The body of the patient should also be flexed upon the thigh, so as the more effectually to relax the quadriceps femoris muscle. Fig. 176. The Author's Mode of Dressing a Fractured Patella. a. Bed b. Floor of apparatus, c. Foot-piece, furnished with fenestra? through which straps may be passed to secure the foot, and with pins on each margin, Single inclined plane fastened to the footpiece at any height, by means of a hook dropped over the pins, e, e. Cushion : thicker under the knee than at either end / Holler to secure leg and thigh to the inclined plane ; not completely applied, g. Adhesive plasters laid over a compress and crossed under the splint. Those from above pass through a notch in the splint below the knee, h, h. Ends of the compresses, seen from under the adhesive plasters. A compress made of folded cotton cloth, wide enough to cover the whole breadth of the knee, and long enough to extend from a point four inches above the patella to the tuberosity of the tibia, and onequarter of an inch thick, is now placed on the front of, and above the knee. While an assistant presses down the upper fragment of the patella, the surgeon proceeds to secure it in place with bands of adhesive plaster. Each band should be two or two and a half inches wide, and sufficiently long to inclose the limb and splint obliquely. 435 FRACTURES OF THE PATELLA. The centre of the first band is laid upon the compress partly above and partly upon the upper fragment, and its extremities are brought down so as to pass through the two notches on the side of the splint and close upon each other underneath. The second band, imbricating the first, descends a little lower upon the patella and is secured below in the same manner. The third, and so on successively until the whole extent of the compress and knee is covered, is carried more nearly at right angles around the leg and splint; the last bands passing obliquely from below the ligamentum patellae upwards and backwards. The dressing is now completed by passing a cotton roller around the whole length of the limb and splint, commencing at the toes and ending at the groin. This is to be applied lightly, as its object is only to support and steady the limb upon the splint. The great advantage which this mode of dressing possesses is, that it does not ligate the leg or thigh completely, since, on either side, between the broad margins of the splint and the points where the straps and bandages touch the limb, there is a space, more or less considerable, against which no pressure is made, and through which the circulation may go on without impediment; so that, however firmly the bands are drawn across the knee, no swelling occurs in the foot. As to its the best testimony which can be presented is the simple fact that of six cases treated by this method, four have united by a ligament of only one-quarter of an inch in length, and two by a ligament of half an inch. The following example of a fracture of both patellae will illustrate the general advantages of this dressing:— John Dundas, aet. 22, fell, October 22, 1852, in the night while asleep, from a window in the third story of a dwelling-house, striking with his knees upon the stone side-walk. On the tenth day I took charge of him at the Buffalo Hospital of the Sisters of Charity. I found both limbs in Gibson's modification of Hagedorn's splint for fractured thighs, with a figure-of-8 bandage loosely applied. The fragments were very much displaced. I immediately proceeded to inclose each leg, from the toes upwards as far as the knee, with a paste bandage, and then, having properly cushioned the limbs and laid them over two separate inclined planes, I secured the fragments in place with adhesive plaster; subsequently the limbs and planes were made fast together by successive turns of a roller. The knees were examined frequently, and the dressings occasionally renewed. November 28, 1852, thirty-seven days after the fractures had occurred, the splints and bandages were finally removed. Both patellae had united by ligamentous tissue, the length of which was about onequarter of an inch. In a few weeks more he left the hospital, walking with only a slight impairment of the motions of the joints. The plan adopted by M. Gama, of Val de Grace,' is similar to that 1 Malgaigne, Traite des Fractures, etc., op. cit., p. 764. 436 FRACTURES OF THE PATELLA. which I have now described, but the splint upon which the limb reposes is not so wide, while width is an essential point in the attainment of the objects which I propose. Dr. Neill, of Philadelphia, uses also the adhesive plaster straps, but they are not placed outside of the splint. 1 Such, also, I understand to be Mr. Alcock's method of using the adhesive plaster. 2 The dressing and apparatus employed by Wood, of King's College Hospital, is very similar to my own, but, as will be seen by the accompanying drawing (Fig. 177), the splint is only five or six inches wide. Dr. Wood has substituted hooks for the notches. 3 Fig. 177. Wood's apparatus. Dr. Dorsey, of Philadelphia, employed a very simple apparatus, Fig. 178, which will serve to illustrate the general plan adopted by many surgeons, both at home and abroad. It is liable, however, to the objec- Fig. 178. John Syng Dorsey's patella splint. tion already stated—namely, that it interrupts too much the circulation of the limb. His apparatus consists of a piece of wood half an inch thick and two or three inches wide, and long enough to extend from the buttock to the heel; near the middle of this splint, and six inches apart, two bands of strong doubled muslin, a yard long, are nailed. The splint is then cushioned, and the limb being laid upon it, a roller being first applied from the ankle to the groin, encompassing the knee 1 Philadelphia Med. Examiner, vol. x. p. 1. 2 Practical Observations on Fractures of the Patella and of the Olecranon, by Thomas Alcock, p. 296. 8 Fergusson's Surgery, p. 307. 437 FRACTURES OF THE PATELLA. in the form of the figure-of-8 ; after which the two muslin bands are secured across the knee in such a manner as that the lower one shall draw down the upper fragment, and the upper one elevate the lower fragment. A single instance will explain the danger of ligation to which I have alluded, and which, although it may be greater in case a starch or dextrine bandage is used, exists in some degree, whatever material for bandaging is employed, if it is applied to the whole circumference of the limb, and constant attention is not paid to the progress of the swelling. "A vine-dresser, set. 40, of a good constitution, fell and received a simple transverse fracture of the patella on the 15th of January. The medical officer called upon to attend him applied first a bandage for the purpose of drawing together the fragments, and afterwards a starched bandage extending from the toes to the upper part of the thigh; the limb was then put upon an inclined plane. The patient was visited a few times, but, as he scarcely suffered, the apparatus was in no way disturbed. On the first of March (sixteenth day) the attendant returned to remove the bandage, when the odor arising from the limb led him to believe that gangrene had taken place, and Dr. Defer was sent for. Dr. Defer found the limb in the following state: The toes which were not covered by the bandage were completely insensible and mummified. The bandage being removed, the gangrene was perceived to extend within seven inches of the knee, and was arrested in its progress. The foot was cold, and was totally insensible ; the epidermis was raised up, and was beginning to be separated from the skin. The articulation of the ankle was exposed, and the ligaments destroyed. The bones of the leg were also exposed in their lower third, and the tendons were in a sloughy state. Amputation was performed, and the patient recovered." 1 Very little better than the starch bandage, and exposing the patient in a still greater degree to the dangers of ligation and strangulation, are either of the methods recommended by Sir Astley Cooper, Figs. 179, 180. Fig. 179. Sir A. Cooper's method by circular tapes. Mr. Lonsdale's instrument, Fig. 181, is ingenious, but too complicated and expensive. It is also liable to the serious objection that it forbids almost entirely the use of bandages, which, while they are 1 Amer. Journ. Med. Sci., vol. xxiv. p. 462, from Gazette Medicale, No. 28. 438 FRACTURES OF THE PATELLA. Fig. 180. Sir A. Cooper's method by a leather counter-strap. capable of doing great mischief when they bind the limb too closely, are capable also of proving eminently serviceable when they press upon certain portions of the limb, and not with too much force. Malgaigne's hooks or clamps I regard as liable to more serious objections, and notwithstanding considerable testimony in their favor, I should be reluctant to recommend them. Fig. 181. Lonsdale's Apparatus for Fractured Patella.—A B. Two vertical iron bars, each supporting a horizontal one ; these horizontal arms slide upon the vertical bars, but can be secured at any point by the screws C D. To the horizontal beams are attached other vertical rods, which are movable, and yet fixable by screws, as at E Finally, to each of these last upright pieces is fixed an iron plate, F F, by means of a hinge point, which keeps the patella in place. The foot-piece is movable up and down upon the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to limbs of different length. In case the fracture is oblique or longitudinal, it will only be necessary to lay the limb in a straight position, so as to prevent that lateral displacement of the fragments which has been shown to occur when the limb is flexed. It will not be necessary to employ a splint, unless the patient is unmanageable and demands restraint, nor to elevate the foot. After the swelling has subsided, a slight amount of lateral pressure, accomplished by a few turns of a roller, with or without compresses, as the circumstances may seem to demand, will complete the mechanical part of the treatment. I have not mentioned the rapid and sometimes intense inflammation to which the knee-joint is liable after a fracture of the patella; and which is often greatly aggravated by the injudicious application of bandages. In no instance ought the bandages to be applied very tightly at the first dressing, and during the first five or six days the patient ought to be seen once or twice daily, and the most prompt attention given to any complaints of pain or soreness about the knee. 439 FRACTURES OF THE TIBIA. From the beginning, cloths moistened in cool water should be constantly laid over the dressing; but in case adhesive plaster is used, we must be careful not to soak the straps sufficiently to loosen them. If the swelling and inflammation increase rapidly, it would be far better to remove the straps or bandages altogether for a few days, than to take the risks consequent upon their continuance. The anchylosis which usually follows the recovery of the patient, and which is often almost complete, is to be overcome by long continued passive motion; but great care must be taken not to rupture the ligament, as we have already seen happen in some cases. Dr. Alfred C. Post, of the New York Hospital, has excised the knee-joint in a case of anchylosis of long standing; the limb being so much flexed in consequence of a comminuted fracture of the patella, as to be not merely useless, but an intolerable incumbrance. The patient was a laboring man of about forty years of age. This operation was made in preference to amputation, at the request of the man himself. 1 CHAPTER XXX. FRACTURES OF THE TIBIA. Etiology. —Fractures of the tibia alone are, in a large majority of cases, produced by direct blows, such as the kick of a horse, or a blow from a stick of wood ; in one instance I have seen it broken by a kick from a Dutchman's boot. It is occasionally broken by a fall upon the foot, the force of the impulse being expended before the fibula gives way, but almost always the fibula breaks at the same moment, or immediately after the fracture has taken place in the tibia. Dr. Proudfoot, of New York, has reported an example of fracture of the tibia in utero, produced in the sixth month of pregnancy, by violent pressure upon the abdomen. 2 Pathology, Division, &c. —In an analysis of twenty-five fractures of the tibia, five were found to have occurred in the upper third, nineteen in the middle third, and seven in the lower third; of which latter, one was a fracture of the malleolus. Five of the twenty-five are known to have been transverse or only slightly oblique. It is probable, also, that several of the remainder were transverse. In this respect, therefore, fractures of the tibia alone will be found to differ materially from fractures of the tibia and fibula; but it is only in accordance with the general observation that indirect blows produce almost constantly oblique fractures, and direct blows, somewhat more frequently, transverse. 1 Post, New York Med. Gazette, vol. i. p. 309, Nov. 1850. * Proudfoot, Bost. Med. and Surg. Journ., vol. xxxv. p. 268, 1846; from New York Journ. Med. 440 FRACTURES OF THE TIBIA. Many examples of fractures of the tibia extending into the kneejoint are recorded by surgeons, most of which were compound, or otherwise seriously complicated so as to render amputation necessary, and the consideration of which scarcely belongs properly to a treatise upon fractures. Prognosis. —No shortening can occur in this fracture unless one or both ends of the fibula are displaced, a complication which I have noticed in two instances; but in neither case did the shortening exceed one-quarter of an inch. Occasionally the upper fragment has been slightly displaced forwards. With these exceptions, and one other of delayed union which I shall presently mention, this bone in my experience has been found to unite promptly and without any appreciable deformity. Other surgeons have noticed occasionally that the upper end of the lower fragment has become displaced toward the fibula. Dr. Donne, of Louisville, has reported an example of delayed union in a simple, transverse fracture of the upper end of the tibia. The man was intemperate. Ten weeks after the accident no union had occurred, and Dr. Donne introduced a seton, and in about six weeks the fragments were firm. 1 If the fracture extends into either the knee or ankle-joint, the danger of anchylosis is imminent, yet experience has shown that it may sometimes be avoided. When the malleolus is broken off) it generally becomes slightly displaced downwards, and in this position a complete bony or ligamentous union takes place. Treatment. —The tendency to displacement, in a fracture of the tibia, is so slight, if it exists at all, that simple dressings, light splints of felt or binder's board, with rest in the horizontal posture upon a pillow, fulfil nearly all the indications which are usually present. The following cases will illustrate the usual course of these accidents. Mrs. W., of Buffalo, fell, Oct. 19, 1848, striking on her right knee, breaking the tibia transversely just below the tuberosity. The fall was the result of a misstep on level ground, and was attended with only slight bruising of the soft parts. She says that on attempting to rise she discovered what had happened, the bone projecting very distinctly, and she pushed and pulled it into place with her own hands. I dressed the limb by laying it upon a pillow outside of which were placed two broad deal splints, tying the whole snugly together with several strips of bandage. At a later period the leg and thigh were laid over a double inclined plane. At the end of six weeks all dressings were removed, and the fragments were found to have united firmly, and so perfectly as that the point of fracture could not be traced. Peter Hamil, of Buffalo, set. 29, was admitted into the hospital Aug. 31, 1849, with an injury to his left leg, which had occurred two days 1 Donne, Amer. Journ. Med., vol. xxviii. p. 524; from Western Journ. Med. and Surg., Aug. 1841. 441 FRACTURES OF THE TIBIA. before. A young surgeon had examined the limb, and thought the femur was broken just above the joint. He had applied a roller from the toes to the thigh; and to the thigh were applied lateral splints. These dressings were on the limb at the time of his admission, and were not removed until the next day. I could not then discover any fracture or displacement, and the dressings were discontinued, the limb being merely laid upon pillows. Oct. 4, when examining the limb, I detected a slipping sensation, like that produced in a false joint, through the upper end of the tibia, and I now easily understood what had been mistaken for a fracture of the femur. It was a transverse fracture through the upper end of the tibia, and without displacement. No splints were afterwards applied, and on the 25th of Nov., three months after admission, he was dismissed, the motion between the fragments having ceased, but the knee still remaining quite stiff'. The presence of inflammation, with other complications, may, however, occasionally render the treatment more difficult and the results less satisfactory. John Mahan, ast. 39. Admitted to the Buffalo Hospital, Feb. 16, 1853, with a compound fracture of the right tibia, near the middle of the leg. The bone was broken by the kick of a Dutchman. I found the limb much swollen and very painful, and I laid it carefully over a double inclined plane, and directed cold water irrigations; I also directed morphine in full doses. The inflammation for several days threatened the complete loss of his limb. On the tenth day, the distal end of the upper fragment was projecting in front of the lower, and I depressed the angle of the splint and made moderate pressure upon the upper fragment. On the twentieth day, the fragments were bent backwards, and I placed a compress behind. On the thirty-seventh day, we took the limb from the inclined plane and trusted alone to side splints. On the forty-fifth day, we removed all dressings. The fragments had not united. The limb was then laid upon a pillow, and six days later a firm gutta-percha splint was applied for the purpose of steadying the bone, but the splint was removed daily in order that the leg might be bathed and rubbed. He was allowed to sit up. On the fifty-ninth day, motion could still be perceived between the fragments, and he was directed to use crutches. On the ninety-third day, the union was found to be firm, the upper fragment remaining slightly displaced forwards. In case the fracture extends into the knee-joint, it is best to lay the limb upon pillows or in a nicely-cushioned box, and nearly straight. No extension or counter-extension is necessary here any more than in other fractures of the tibia alone, nor are lateral splints or rollers necessary or proper at first, as a general rule; but especial attention ought constantly be given to the prevention of inflammation, and of subsequent anchylosis. The omission to employ splints in a case of this kind was charged against a surgeon in Vermont as evidence of malpractice. I am happy to say, however, that, in this particular case, he was sustained by the testimony of the medical men and by the verdict of the jury; but the attempt which the reporter has made to 29 442 FRACTURES OF THE FIBULA. defend this as a universal practice in fractures of the legs, or of the tibia alone, is unfortunate, and evinces a lack of practical experience. 1 Whatever position is adopted, and whatever means of support or retention are employed, if bandages and splints are applied tightly or injudiciously, great suffering and irreparable mischief to the knee-joint may be the consequence. A man, ast. 23, entered the Pennsylvania Hospital July 18, 1839, with an oblique fracture through the head of the tibia. A physician had applied a bandage and splint to the leg, and sent him twenty miles to the city, and on examination after his arrival, the whole limb as high as the groin was much swollen, red, and excessively painful. The knee-joint was distended and very tender. All dressings were immediately removed and the limb laid in a long fracture-box, slightly elevated at the foot; cool lotions were applied, and the patient was freely bled, both from the arm and by the application of leeches. The limb was kept in this position about six weeks, and, at the end of two or three weeks more he was dismissed cured. Dr. Norris, who was the hospital surgeon in attendance, has, in his report of the case, very properly taken this occasion to warn surgeons of the danger of excessive bandaging and splinting in this kind of fracture, as well as in all other fractures of the lower extremities. 2 Fractures of the malleolus demand only that the limb should be laid upon its outer, or fibular side, with the foot so supported as that it shall incline inwards towards the tibia. In this simple disposition of the limb we have done all that can be done by any mechanical contrivance toward approaching the lower fragment to the shaft from which it has been broken. CHAPTER XXXI. FRACTURES OF THE FIBULA. Causes. —In a record of thirty-two cases I have been able to ascertain the cause satisfactorily in eighteen, of which number three were the results of falls directly upon the bottom of the foot, four of a slip of the foot in walking on level ground, or on ground only slightly irregular, and twelve of direct blows. Pathology. —In all of the fractures which have been produced by falls upon the bottom of the foot, and in all, except one, produced by a slip of the foot, the accident was accompanied with a dislocation of the ankle; the foot being turned outwards. In the one exceptional case mentioned, the dislocation may also have occurred, but the fact is not known. 1 Boston Med. Journ., vol. liv. p. 1, March, 1856. 1 JSorris, Amer. Journ. of Med. Sci., vol. xxiii. p 291. 443 FRACTURES OF THE FIBULA. Both Malgaigne and Dupuytren have noticed a dislocation in the opposite direction, or a turning of the foot inwards, more often than a turning outwards. I cannot think their observations were carefully made. Moreover, in at least seven of the twelve fractures produced by direct blows the tibia has been thrown more or less inwards, and consequently the foot has turned out. In twenty four examples the fracture of the fibula has taken place within from two to five inches of the lower end of the bone. Twice I have found the external malleolus broken off, and seven times the internal malleolus. Four of the fractures occurring in consequence of direct blows were compound, and one was also comminuted. Prognosis. —In a majority of cases, where the fibula has been broken from two to five inches above the lower end, the fragments have united inclined toward or resting against the tibia; occasionally I have seen them displaced backwards. Once the fibula refused to unite altogether. The malleoli have generally united nearly or quite in place, but in two instances the external malleolus has been found displaced very much downwards. Of the compound fractures, two required amputation, one was treated by resection of the lower end of the tibia, and one died without any operation. Douglas has reported a case of compound dislocation with fracture of the fibula, which being reduced, he was able to save the limb, but not without much difficulty, and the Fig. 182. Fracture of fibula near lower end. ankle remained stiff. 1 Other surgeons have met with similar success, but I shall refer to this subject again under the head of compound dislocations. Of those which recovered, twenty-eight in number, ten have been found to have more or less unnatural prominence of the internal malleolus, and in two of these the malleolus, or lower end of the tibia, projects very much. In nearly all of these examples the foot appears somewhat inclined outwards. Generally the ankle-joint has remained stiff for some time after the bandages have been removed; and probably in all cases in which the accident was accompanied with a dislocation of the tibia. But this stiffness has usually disappeared after a few weeks or months. Twice I have noticed considerable stiffness after about six months; three times after one year; in one case after two years, and in one case after twenty years the ankle would occasionally swell and become quite stiff. In one case it remained almost immovable after twenty years; and in a still more remarkable instance, I examined the limb thirty years after the accident, when the man was sixty-three years old, and although there existed no swelling or deformity, yet this leg was not as muscu- 1 Boston Med. and Surg. Journ., vol. xxxiv. p. 336, from Southern Journ. of Med. 444 FRACTURES OF THE FIBULA. lar as the other, and he declared that up to this time the ankle remained quite tender to the touch, and that occasionally it became painful. When I come to speak of dislocation of the ankle, I shall adopt the usual nomenclature, and shall name all those dislocations in which the tibia projects inwards from the foot, " inward dislocations of the tibia," yet I have some doubts as to the propriety of this appellation. This accident seems to me to have been in general rather a lateral rotation of the foot, or of the astragalus, upon the lower articulating surfaces of the tibia and fibula. Of all the ginglymoid joints, the ankle approaches most nearly in form to a ball and socket joint, in consequence especially of the marked prolongations of the malleolus internus and externus. In other ginglymoid articulations lateral displacements are not unfrequent, but lateral rotation can scarcely by any accident occur. Here, however, the reverse holds true; lateral displacement is difficult, while lateral rotation is comparatively easy of accomplishment. The majority of cases which occur, involving a disturbance of the relative position of the ankle-joint surfaces, are, I am satisfied, of this latter character, viz., lateral rotations within the capsule, rather than true dislocations; and although the restoration of the joint surfaces to position is, in general, easily accomplished; yet, in consequence of either a fracture of the fibula, or malleolus internus, or of a rupture of the internal lateral ligaments, it will almost always happen that some deformity will remain. The fragments of the fibula will fall inwards towards the tibia, and the foot, unsupported by either its fibula or its internal ligaments, will incline perceptibly outwards. Nor can this be prevented, usually, by any mechanical contrivance. Indeed, it would be easy to demonstrate, as I have often done to my pupils, that even Hupuytren's splint, usually employed in this accident, must fail of success in a great majority of cases; since the subsequent deformity is due, less to the fracture of the fibula and its consequent displacement, than to the loss of the internal ligaments, which loss nature can seldom fully repair. The whole apparatus of the joint has suffered greatly, and its form and functions, therefore, are not likely to be completely restored, whether the fibula has participated in the injury or not. As further evidence of the correctness of this view, I will state that in three of the examples in which I have found the fractured fibula united and resting against the tibia, the motions of the anklejoint have been completely recovered. If, however, it were true that a fracture and displacement of the fibula is the sole or essential cause of the subsequent deformity, it would still be found often impracticable to avoid the maiming, since it would still remain impossible to lift the broken ends from the tibia, against which, or in the direction toward which, they are so prone to fall. Inversion of the foot does not accomplish it, nor have I ever been able to make anything but the most trivial impression upon the upper end of the lower fragment by pressure upon the lower extremity of the fibula. I think too much confidence has been placed in the efficiency of 445 FRACTURES OF THE FIBULA. " Dupuytren's splint." I believe, indeed, that this splint ought generally to be preferred as a means of support and retention after this accident, and I have myself usually employed it; but I doubt whether it is able to accomplish more than a moiety of all that its illustrious inventor proposed. Treatment. —I have already expressed my preference for Dupuytren's mode of dressing as a general practice, and especially would I give the preference whenever the accident has been accompanied with an outward luxation of the foot, and a consequent rupture of the internal lateral ligaments, or a fracture of the internal malleolus. This mode of dressing is essentially as follows:— A pad, or long junk, made of a piece of cotton cloth, stuffed with cotton batting, is constructed of sufficient length to extend from the condyles of the femur to a point just above the malleolus internus. This pad must be about five or six inches in width, and thicker by one or two inches at its lower than its upper end. This is to be laid Fig. 183. Dupuytreu's splint modified upon the inside of the leg, with its base or thickest portion resting against the tibia just above the internal malleolus. Over this pad is to be placed a long firm splint, extending also from above the knee to three inches beyond the bottom of the foot. With a few turns of a roller the upper end of the splint will now be made fast to the knee, and with a second roller the lower end must be secured to the foot. The application of this last bandage requires, however, some care in its adjustment. Its purpose is simply to rotate the foot inwards, while at the same time the tibia is pressed outwards; and to this end it must be applied in the form of a figure-of-8 over both splint and foot, embracing alternately the heel and the instep. In order to be effectual, it must be drawn pretty firmly, and no portion of the bandage must pass higher than the malleolus externus. In some surgical books I have seen this apparatus represented with a roller embracing the whole length of the leg; and in others it is represented as encircling the limb two or three inches above the malleolus (Fig. 184), but it is evident that these modes of dressing must defeat the great object which Dupuytren had in view, namely, the throwing out of the upper end of the lower fragment. Fig. 184. Dupuytren's splint incorrectly applied. When the limb is thus dressed, the knee may be flexed and the leg laid upon its outside, supported by a pillow, or upon its inside, as in the accompanying engraving. (Fig. 185.) 446 FRACTURES OF THE TIBIA AND FIBULA. If it is only a fracture of the external malleolus, or if the fracture has occurred in the middle or upper third of the bone, this treatment Fig. 185. Dupuytren's splint as originally applied by himself. is no longer appropriate, and it will generally be found sufficient to place the limb at rest for a few days upon a suitable cushion or upon a pillow. It is scarcely necessary to say that, since after this accident anchylosis is so frequent, early and unremitting attention should be given to the establishment of passive motion in the joint. Indeed, I cannot but think that a desire to accomplish the indications recognized and urged by Dupuytren has led to the neglect of the indication which ought to have been regarded as of equal, if not of the greatest, importance, namely, the prevention of contractions and adhesions around and between the joint surfaces. As a general rule, the dressings ought to be wholly laid aside by the end of the third or fourth week; and although it may be well for a somewhat longer time to keep the foot turned in, by having it properly supported as it lies upon the pillow, yet after this date I regard the use of splints and bandages as only pernicious. CHAPTER XXXII. FRACTURES OF THE TIBIA AND FIBULA. Causes. —Probably four-fifths of these fractures are the results ot direct blows or of crushing accidents, such as the kick of a horse, the passage of a loaded vehicle across the limb, the fall of heavy stones or timbers, &c. In an analysis of ninety-eight cases, I find the bones broken in the upper third from a direct cause four times, and from an indirect cause once. In the middle third thirty-six have been referred to a direct cause, and one to an indirect; and in the lower third thirty-three to a direct cause, and sixteen to an indirect. An observation which does not sustain the remark of Malgaigne, based upon his analysis of sixtyseven cases, that fractures of the upper third are produced by direct causes alone, those of the middle third much more frequently by indirect causes, and that those of the lower third are especially due to 447 FRACTURES OF THE TIBIA AND FIBULA. indirect causes. Direct causes produce a large majority of the fractures of the lower third, but the proportion is smaller than in the middle third. Of the indirect causes, falls upon the feet from a considerable height —as from a scaffolding, or from the top of a building—are by far the most common. Four times I have found the bones broken by muscular action alone, as in the following example:— Mrs. W., of Buffalo, aged about twenty-five years, and weighing at this time nearly two hundred pounds, was descending her door-steps with an infant in her arms, when, the step being covered with ice, she slipped and fell, breaking her right leg just above the ankle. Mrs. W. says she felt and heard the bones snap before she touched the steps. Of this she is certain. We found the tibia broken obliquely, the fragments being quite movable, but not much, if at all, displaced. The limb was dressed with a carefully moulded and well-padded gutta-percha splint, and then laid in a pillow upon the bed. Mrs. W. experienced unusual pain from the fracture for several days, for the relief of which we were compelled at times to permit her to inhale chloroform. She was of a nervous temperament, and had frequently resorted to chloroform before to relieve neuralgic pains. The limb became very much swollen, and remained so for a week or two. No extension was ever employed. Within the usual time, the bones united in perfect apposition, and in about four months she was able to walk without any halt. Pathology, Symptoms, Sc. —We have seen that fractures of both bones through some part of the lower third are most frequent. Thus, of one hundred and forty-two fractures, eleven belonged to the upper third, forty to the middle, and eighty-five to the lower. In six cases the two bones were broken in different divisions. It is probable that in this analysis some errors have occurred, and that in a larger proportion than here stated the two bones have given way at opposite extremities, since it is often difficult, and sometimes quite impossible, to determine precisely where the fibula is broken; but the analysis is sufficiently correct to illustrate the much greater frequency of fractures of the lower third, and also the fact that the two bones generally break nearly on the same level; usually the point of fracture in the tibia is between two and three inches above the joint, where the bone is the weakest. In an examination of twenty museum specimens I have found both bones broken at the same point, or within two or three inches of the same point, sixteen times, and at extreme points four times; and in these last examples the tibia has always been broken in the lower third, while the fibula has been broken in the upper third. In fifteen of the fractures mentioned as belonging to the lower third only the malleolus of the tibia was broken, while the fibula was broken two or three inches above its lower end. Some of these were, perhaps, examples of dislocation of the ankle. I have seldom seen a transverse fracture of the tibia except in its lower or upper extremity, in the expanded portions of the bone, and 448 FRACTURES OF THE TIBIA AND FIBULA. even in those examples which we are accustomed to call transverse, because they are sufficiently so to prevent any sliding or overlapping of the fragments, there has existed, generally, a marked inclination of the line of fracture in one direction or another. The examples of fracture produced by muscular action have, without an exception, occurred in adults. Three of them were in the lower third of the leg, and one in the middle third. I think they were, all of them, nearly transverse, since they never became much, if at all displaced. Most of the fractures of the tibia produced by falls upon the feet are very oblique, and the direction of the fracture is generally downwards, forwards, and inwards; but I have found almost every conceivable variation from this general rule. The fracture in the fibula is even more constantly oblique than the fracture in the tibia ; but this is a point of very little practical consequence, and one which we can seldom determine positively, unless one of the fractured ends protrudes through the flesh. Compound and comminuted fractures are more frequent here than in any other of the bones of the body. My tables, which have rejected all fractures demanding immediate amputation, most of which are compound, do not for this reason give a j ust idea of their proportion to simple fractures; yet even in these tables, of one hundred and fifty-nine fractures, fifty-nine were compound, and also, generally, more or less comminuted. Of eighty cases reported by W. W. Morland, of Boston, from the Massachusetts General Hospital, and in which the character of the accident is recorded, thirty-nine were compound 1 The symptoms indicating a fracture of both bones of the leg are the same which are usually present in other fractures, namely, mobility, crepitus, shortening of the limb, distortion, swelling, &c. Generally Fig. 186. Compound and commiuuted fracture of the leg. the lower end of the upper fragment projects in front, and can be seen or felt; but in some instances the swelling follows so rapidly that it is impossible to feel distinctly the point of fracture, and its existence can ' Transac. of Mass. Med. Soc. for 1840; Fractures, by A. L. Pierson. 449 FRACTURES OF THE TIBIA AND FIBULA. only be determined by the crepitus, mobility, and shortening of the limb, or, perhaps, by the marked deformity or deviation from the natural axis. The shortening, where it exists at all, varies at the first from a line or two, to a half or three-quarters of an inch. Generally, it is about half an inch. Prognosis. —The average period of perfect union in twenty-nine cases, including those in which union was delayed by extraordinary causes beyond the usual time, was forty days. The general average under ordinary circumstances may be stated at about thirty days. Union has been delayed in six cases, four of which were simple fractures, and two were compound. The longest period was seventeen weeks. F. C. T., of Erie Co., N. Y., set. 35, had an oblique, simple fracture of both bones, in the upper third, caused by jumping from a buggy, in June, 1852. The limb was dressed with lateral splints, compresses and bandages, and laid upon a pillow. Eight weeks after the fracture had occurred, the gentlemen in attendance wished me to see the limb with them. I found Mr. T. still in bed, and the fragments not at all united. Mr. T. had enjoyed average health heretofore, but he was never very robust. When I was called to see him he looked pale; his skin was cold and moist, pulse 120, and appetite poor. The broken leg and foot were greatly swollen. The swelling was cedematous. Considerable excoriations existed on the back of the leg. The fragments were quite movable, and were overlapped three-quarters of an inch. We agreed that the patient ought, as soon as possible, to be got out of bed, so as to enable him to recover his strength, which had sadly declined. To this end, a gutta-percha splint was made to fit accurately the whole length of the leg; and, having attached a large number of tapes, it was to be secured upon the limb. Several times each day it was to be removed, and the limb bathed with brandy and water. Gradually, also, the limb was to be brought down to the floor, and the patient be made to sit up, and, as soon as possible, he was to walk with crutches, or to ride. Nov. 4, 1852, Mr. T. visited me at my house. The directions had been followed implicitly. About two weeks after my visit, he rode out, and in about nine weeks, or seventeen weeks from the time of the fracture, the bones were found united. His health and strength were quite restored, and the limb was no longer cedematous. It was found to be straight, or with only a slight projection of the upper fragment in front of the lower, and shortened three-quarters of an inch. A gentleman, aet. 33, from Bergen, N. Y., was struck by a billet of wood on the 3d of August, 1856, breaking his left leg nearly transversely, three and a half inches above the joint. The fracture was simple. A surgeon was called immediately, who applied bandages and side splints, and then laid the limb over a double inclined plane. At the end of six weeks the dressings were removed, but the bones had 450 FRACTURES OF THE TIBIA AND FIBULA. not united. Four years after the accident, this gentleman consulted me. I found him in good health, but no union had yet taken place. This is the only example, except where amputation or death interposed, in which the union has been so long delayed as to entitle it to be considered as a case of non-union. My own observation would, therefore, incline me to think that, while non-union is a rare event in fractures of the leg, delayed union is more frequent than in most other fractures. It has once occurred to me to see a complete non-union of the fibula after a period of several years, while the tibia had united well. This circumstance occasioned no inconvenience to the patient, and was not known to him until I had made the discovery. A little more than one-half of those cases in which an accurate note of the result has been made, have been found to be more or less shortened by overlapping, namely, sixty-one cases out of one hundred and ten. The greatest amount of shortening in any one case has been one inch and a half; and the average shortening of the sixty-one caseshas been half an inch and a fraction over. This analysis includes both simple and compound fractures; but a pretty large proportion of the simple fractures have also been found shortened, as in the following extreme illustration. John Granger, of Hungerford, England, ast. 43, was tripped by a stone while walking, breaking his right leg through its lower third. Fracture simple and oblique. It was treated by Richard Barker, surgeon, of Hungerford, England. He employed only side splints. Two years after, I found the leg shortened one inch, the upper fragment riding upon the front and inner side of the lower. Generally, when a shortening has occurred, I have found the upper fragment in front of the lower, and oftener a little upon the inner than upon the outer side. The deviation from the natural axis of the limb has been noticed by me in a good many instances. Seven times the lower part of the limb has fallen backwards, and five times it has, in a degree much less marked, inclined inwards. Once I have seen it inclined outwards, and twice forwards. Ulcers upon the back of the heel, seen by me five times, as a result of undue pressure upon this part, have, however, been presented but once in a case of simple fracture. It is not very unusual to find, also, over the exact point of fracture, and after the lapse of several months, or even years, an ulcer, or sinus, which is due sometimes to the presence of a small fragment of bone which has remained in the wound from the time of the accident, or to a thin scale which has subsequently exfoliated. In other cases it is due to the prominence of the salient angle when the lower part of the limb inclines considerably backwards, and in still other cases, no doubt, to the general dyscrasy of the system, and to the same causes which produce chronic ulcers in the lower extremities where only the skin has been originally injured. I have reported elsewhere examples of this complication existing after five months, two, and FRACTURES OF THE TIBIA AND FIBULA. 451 three years, 1 and in the remarkable case which I shall now briefly relate, an ulcer existed at the end of twenty-three years. Thurstone Carpenter, when four years old, received an injury, breaking both bones of one of his legs near its middle. The fracture was compound. It was dressed and treated by an excellent surgeon, then residing in Buffalo, but long since dead. Twenty-three years after the accident, Mr. Carpenter called upon me on account of a paralysis of his lower extremities, which had recently occurred. He stated that from the time of the fracture until within about one year, an open ulcer had existed over the seat of fracture, and that soon after it had closed over completely he began to lose the use of his limbs. During the time it was open, small scales of bone have frequently been thrown off. The limb is half an inch shorter than the other, but straight. Two years since, I amputated the leg of a gentleman residing in Quincy, Chautauque Co., N. Y., which had been broken a little above the ankle in 1844. The accident was produced by the wheel of a carriage, and the skin was considerably lacerated. The wounds, however, healed kindly, and the broken bones united in the usual time without any apparent deformity, but the limb continued swollen and painful, until finally suppuration took place. After twelve years of great suffering, I amputated the leg near its middle, from which time he made a speedy recovery. I found the lower end of the tibia inflamed, softened, and expanded, and containing in its interior about three ounces of pus, but no sequestrum. Anchylosis of the knee or ankle-joint may follow as a result of the accident or of improper treatment; and at one or both of these joints I have found more or less anchylosis at the end of nine months, one year, six years, twenty-five, thirty, and forty years. Generally, however, it disappears in a few weeks, and seldom remains, to any considerable extent in the knee-joint after the dressings have been removed two or three weeks; but an Irishman called upon me in 1853 whose leg had been broken about three inches below the kneejoint six years before. It was a simple fracture. A surgeon in Ireland had treated the case. I found the limb shortened one inch and a half, the fragments being overlapped and displaced backwards at the point of fracture. The knee was also partly anchylosed. I could not learn what the treatment had been. In other cases, where no permanent anchylosis has followed, the ankle-joint has been occasionally painful, and subject to swellings, after the lapse of many years. After all that has been said as to the occasionally serious nature of the consequences of these accidents, as shown in the shortening of the limbs, in their deviations from their natural axes, in the stiff ankles, ulcers and abscesses, it must be still admitted that in another point of view these results are not extraordinary, and may hereafter continue to be fairly anticipated in a certain proportion of cases, even under the best management; since it must be understood that more fractures 1 Trans. Amer. Med. Assoc. Report on Deformities after Fractures. 452 FRACTURES OF THE TIBIA AND FIBULA. of the leg are attended with serious complications than of any other limb; and that while many produce death rapidly from the severity of the shock, and very many are condemned at once to amputation, a large number of those which are saved have been in that condition which has rendered the application of bandages or splints impossible for many days. Indeed, not a few of these crooked limbs may still be presented as real triumphs of the art of surgery, inasmuch as by consummate skill alone have they been saved. Treatment. —Without being able, in a case which presents so many forms and complications, to establish any rule of universal application, I nevertheless do not hesitate, after considerable experience, in declaring a plan of treatment which in my opinion ought to be adopted with only occasional exceptions, that is, I mean to say, in simple fractures. The plan to which we choose to give so general a preference is well known as that recommended and practised by Pott, the distinguished surgeon of St. Bartholomew's Hospital; and with only slight modifications, it will be found applicable to probably ninetenths of all the simple fractures of the leg, and to some of the compound fractures. The apparatus will consist of two splints with pads and bandages. First we are to construct a splint (Fig. 187), made of a thin piece of board, long enough to extend from a little above the knee, to a point two inches beyond the sole of the foot, about seven inches in width, and reaching forwards at the lower end, so as to support the foot. This splint is to be covered heavily with cotton batting in order that it may fit all the inequalities of the outer side of the leg and foot, taking, however, especial care that there should be a depression at a point corresponding to the external malleolus, so deep as that even when the limb is bound down to the splint the malleolus shall not touch. The splint with its padding must then be covered with cotton cloth neatly sewed on. The remaining splint may be made of binder's board, felt, or gutta percha; but in either case it need not extend higher than the bend of Fig. 187. Long splint for treatment of a fracture of the leg in Pott's position. the knee or lower than the upper margin of the malleolus internus, unless the fracture should be near one of these extremities; and in 453 FRACTURES OF THE TIBIA AND FIBULA. case it does extend lower, the same precautions must be taken to protect the malleolus internus from pressure. Whichever also of the materials is employed, the splint never ought to be applied directly to the skin, but a thin pad made of a few layers of cotton sheeting covered with cotton cloth must be laid underneath. It is seldom that I have found it necessary or useful to apply any bandages directly to the skin; but in certain cases of compound fractures where dressings have been applied which needed support and protection, a bandage has been of service. The roller, unless the patient is a child, whose limb can be easily lifted and managed, is always objectionable; but the many-tailed bandage, made of narrow strips of cloth, laid upon each other as we have already described in our general remarks upon bandages, &c, is much to be preferred. Having made these preparations, we proceed to flex the leg to a right angle with the thigh, and, by the hands, make extension and counter-extension as much as the patient will bear, or as much as may be necessary to restore the fragments to place. If the fracture is compound, and the point of bone protrudes through the skin, it is often difficult to replace it. That is, we are unable to overcome the action of the muscles sufficiently to make the limb of its natural length, and for this reason, mainly, we are unable to get the point of bone beneath the skin. If we cannot then " set" the bone, or bring the ends into apposition, and this will be the fact pretty often, we still have no apology generally for leaving the bone outside of the skin. First, an attempt must be made to accomplish this reduction by pulling aside the skin with the fingers, or with a blunt hook. This simple procedure has often succeeded with me in a moment, when others have been trying in vain to accomplish the same end by pulling upon the limb. If this fails, then the skin should be cut sufficiently to allow the bone to retire, or if the point is sharp, and especially if it is stripped of its periosteum, it may be sawn off. Resecting thus the end of an oblique fragment does not generally affect in any degree the length of the limb, or interfere with a prompt and perfect cure, but on the contrary it often is advantageous in every point of view. Having restored the fragments to their places as well as we may, the limb is laid carefully on its outside upon the long wooden splint. We shall now find it necessary generally to add two or three thin pads, in order to supply vacancies which we have not perfectly provided for in the preparation of the splint. Generally we shall also see the necessity of placing a pretty thick pad under the outer margin of the foot or toes, so as to bring the great toe in line with the inner edge of the patella, and spine of the tibia. The other side splint is now laid along the inner or tibial side of the limb and with successive turns of a roller, or with a number of narrow and separate strips of cloth, the whole are bound together, and the limb is left to repose upon its outer side. The patient may, if necessary, lie upon his back, but it is better that he should be turned a little toward the side of the broken limb. The danger of twisting the fragments upon each other is lessened by lying upon the same side with the broken limb, but I have frequently 454 FRACTURES OF THE TIBIA AND FIBULA. permitted patients to lie upon their backs and found no such result. If the long under splint extends a little way upon the thigh and is well fastened to the thigh, the twist cannot very well occur. By adopting this general plan of treatment we avoid all chances of gangrene or swelling of the foot from excessive ligation, and it is to these accidents, especially, that the remarks of Dr. Norris, already quoted, are applicable. The large size, and irregular form, of the bones of the leg, the small amount of muscular tissue covering them, especially near the articulations, the severity of the injuries to which they are liable, with their remoteness from the centre of circulation— these circumstances, altogether, render them exceedingly exposed to injury from the too great or unequal pressure of splints or of bandages; and it has often occurred to myself, as it has to Dr. Norris, to find the skin vesicated, or even ulcerated and sloughing, when the patients are first admitted to the hospital; a condition which, in nine cases out of ten, is due to the mal-adjustment of the splints, or to the tightness of the bandages. If bandages are used under the splints, and next to the skin, they must be applied very moderately tight, and loosened or cut as the swelling augments; and from the first day of the treatment to the last, the surgeon must be careful to loosen or tighten the dressings when the swelling increases or subsides, just as the prudent boatman trims his sails to the rising and falling breeze. The following case, which has been communicated to me by Dr. Fuller, of Wyoming, N. Y., with permission to make such use of it as I choose, is sufficiently pertinent for the instruction of others, and deserves a public record. A man, ast. 71, fell from a tree, striking upon his foot, Aug. 27,1855, producing a backward dislocation of both the tibia and fibula upon the os calcis, and also a fracture of both bones of the leg a few inches above the ankle. An empiric took charge of this unfortunate man, and immediately applied lateral splints and a firm roller from the toes to the knee. Notwithstanding the remonstrances and prayers of the patient to have the bandage loosened, it was kept on until the ninth day, when the doctor cut the bandage upon the top of the foot, and it was found vesicated. Ignorant, however, as to the cause of this vesication, and of the danger which it threatened,.he omitted to loosen the remainder of the bandages, and the limb was left in this condition until the twenty-third day, when Dr. Fuller being called and having removed all the dressings, found the integuments covering the whole foot dead and dried down to the bones. The dislocations had not been reduced. Soon after this the limb became cedematous, and on the twenty-seventh of October the leg was amputated by Dr. Barrett, of Le Roy; from which time the patient recovered rapidly. But it is to the advantages of the posture recommended by Pott that I wish especially to direct attention. The position hitherto generally preferred by surgeons has been that in which the limb rests upon its back, either in a box or upon a double inclined plane; but all of the five examples of ulcers upon the heel which I have seen have been 455 FRACTURES OF THE TIBIA AND FIBULA. after treatment in this position. Indeed, it is almost impossible for this accident to happen in any other way, and it has therefore never occurred to me to see it in cases treated by Pott's method. It is true that, with great care, such a result might generally be prevented while the leg is resting upon its calf, yet experience shows that it is by no means easy to avoid it always. And if, in our anxiety to obviate this evil, we place pads underneath the tendo Achillis, above the heel, we incur the risk of pressing the fragments forwards, and of compelling them to unite with the whole lower part of the leg inclined backwards. I have mentioned already that this has happened in cases that have subsequently come under my observation no less than seven times, while an attempt to correct this fault by placing the support under the heel has either produced ulcers of the heel, or driven the lower part of the limb in the opposite direction. The same thing—that is, a deviation backwards or forwards—might happen in any posture, but I am sure it is much less liable to in Pott's position than in any other. Then, again, a twist or rotation of the lower fragment is more liable to take place when the toes point upwards, and the limb rests upon the calf and heel, than when the limb reposes upon its side. In the one case it is resting upon a narrow surface, with the whole weight of the foot disposing it to either eversion or inversion, while in the other it lies upon a broad surface, with the foot entirely at rest, and demanding no extraordinary support. In short, Pott's position is less irksome to the patient, and vastly less troublesome to the surgeon. Ugly and crooked limbs are sometimes inevitable, and they are often the consequences of unskilful management, or of inattention on the part of the surgeon; but, other things being equal, the best legs have, in my experience, come out of Pott's position, and the worst out of the double inclined plane and the box. As to the tendency of the upper fragment to rise at the point of fracture, it depends, no doubt, upon the usual direction of the fracture, and the action of the muscles both in front and behind; so far as the former circumstance is the cause—that is, the direction of the line of fracture—no position is sufficient to remedy it, and in relation to the action of the muscles, the indications are as easily and naturally fulfilled with the limb upon its side as upon its back. Generally the leg needs to be flexed upon the thigh; but if the fracture is high up, and its direction is obliquely downwards and forwards, it must be made nearly or quite straight, so as to overcome the action of the anterior muscles of the thigh, acting, through the ligamentum patellae, upon the upper fragment. The simple rule which I recommend and adopt is, to flex or . extend the limb more or less until it is ascertained in what position the apposition of the fragments is most complete. In such few cases as demand or warrant a resort to extension and counter-extension, a double inclined plane furnishes the most convenient mode for its accomplishment; but it is only occasionally that, in fractures of the leg, permanent extension and counter-extension can be employed, an assertion which, however much it may excite surprise, 456 FRACTURES OF THE TIBIA AND FIBULA. experience will prove true. If the fracture is near the middle of the leg, quite remote from the points upon which the appliances for extension, &c, are to be made fast, and the inflammation is moderate, something may be done in this way; but when the point of fracture approaches the ankle-joint, as it actually does in a great majority of cases, a gaiter, made of any material whatever, if it has sufficient firmness to overcome completely the action of the muscles, will inevitably cause congestion and swelling, accompanied sooner or later with great pain and with ulcerations, and simply because the extension is made directly upon parts already tender and inflamed from the accident itself; and when we add to this complete and violent ligation of the limb near the seat of fracture, a similar ligation of the limb just below the knee, for the purpose of making counter-extension, as is done in what is known among American surgeons as "Hutchinson's splint" 1 (Fig. 188), we are prepared to understand how the worst consequences may ensue. I have once seen, when this abominable apparatus had been used, a complete ring of ulceration below the knee, and another as complete around the foot and ankle. The limb was twice girdled, and yet the surgeon thought he was performing a duty for the omission of which he would scarcely have been regarded as excusable. Fig. 188. James Hutchinson's splint for extension, etc., in fractures of the leg. (From Gibson.) Jarvis's adjuster, a still more mischievous, inasmuch as it is a more powerful instrument, operating in a similar manner, has been productive of like consequences; but Jarvis's adjuster is liable to the additional objection that by its great weight it drags off the limb, turning the toes outwards, an objection which no care or diligence can generally overcome. I could wish that neither of these appliances would ever again be impressed into the service of broken legs. Neill, of Philadelphia, Crandall, of New York, and Daniels, of Broome Co., N. Y., have each sought to overcome some of the difficulties in the way of making extension in fractures of the legs, by 1 Elements of Surgery, by John Syng Dorsey, vol. i. p. 181. Philadelphia, 1813. 457 FRACTURES OF THE TIBIA AND FIBULA. substituting adhesive plaster for the usual extending or counterextending bands. Says Dr. Neill: " For simple fractures of both bones of the leg, attended with shortening and deformity not easily overcome, the limb should be placed in a long fracture-box (Fig. 189), with sides extending as high as the middle of the thigh, and a pillow should be used for compresses. Fig. 189. John Neill's apparatus for fractures of the leg, requiring extension and counter-extension. "The counter-extension is made by strips of adhesive plaster, one inch and a half in breadth, secured on each side of the leg below the knee, and above the seat of fracture, by narrower strips of plaster applied circularly. The end of the counter-extending strips may then be secured to holes in the upper end of the sides of the fracture-box, by which the line of the counter-extension is rendered nearly parallel with the limb. " The extension is also to be made by adhesive strips, in a mode which is now well known and understood. The ends of the extending bands may be fastened to the foot-board of the box.'" Dr. Neill further remarks: " In compound fractures of the leg, shortening and deformity are often difficult to overcome, as is well known to experienced surgeons. In such cases we may wish to dress the wounded soft parts, and, at the same time, maintain a certain amount of extension and counter-extension. " This can be readily accomplished by having the sides of the fracture-box (Fig. 190) sawed in two parts at the knee, so that the sides Fig. 190. John Neill's apparatus for compound of the leg. of the box above the knee, from the upper ends of which the counterextension is made, need not be disturbed during the dressing, while that portion of the side of the box, corresponding to the leg, may be ' Philadelphia Med. Exam., vol. xi. p. 580, 1855. 30 458 FRACTURES OF THE TIBIA AND FIBULA. opened at pleasure, without diminishing the tension of the extending or counter-extending bands." In compound fractures of the leg, Dr. Gilbert recommends a modification of the common fracture box (Fig. 191). In this apparatus the foot-board is omitted, and a block for the reception of the frame of the tourniquet is substituted. Each side of the box consists of three separate segments. Of these the upper and lower are permanently screwed to the bottom-board, and the central one is attached by hinges. By this arrangement there is full access to the wound, which may be dressed from day to day without disturbing the extension and counterextension, maintained by the permanently attached upper and lower segments. Fig. 191. Gilbert's Box for Compound Fractures of the Ler. 1. The four counter-extending adhesive strips, as if encircling the knee and upper part of leg. 2. The two extending adhesive strips crossing at the bottom of the foot, ready to be applied to the foot. 3. Tourniquet. The following wood-cuts (Figs. 192,193,194) are intended to illustrate the apparatus invented by R. O. Crandall, for the purpose of Fig. 192. Section of Crandall's apparatus, applied to the limb; showing adhesive plaster counter-extending band, gaiter for extension, &c. Fig. 193. Posterior view of the lower portion of Crandall's apparatus. FRACTURES OF THE TIBIA AND FIBULA. 459 Fig. 194. Crandall's apparatus complete. The counter-extending straps are passed over a block of wood supported above the knee, to prevent their pressure upon the sides of the knee. making permanent extension. The extension is represented as being made by a gaiter, but Dr. Crandall leaves it to the choice of the surgeon whether he shall employ the gaiter or adhesive straps. 1 Without intending to deny to these contrivances much ingenuity and considerable practical value, I am far from conceding that they will be found capable of overcoming altogether the action of the muscles where the ends of the fragments do not support each other. Their mode of action is such that they can scarcely do more than to steady the limb, and if they operate upon the fragments at all in the direction of their axes, it must be only in the most inconsiderable degree. The adhesive plasters are substituted for the circular knee bands and the gaiters with a view to avoid the ligation; but in order to do this they must not encircle the limb, but only be laid parallel to its long axis. The leg of an adult or that portion to which the adhesive plasters can be applied, supposing the fracture to be exactly at the centre, may be sixteen inches, that is, eight inches for extension and eight for counter-extension; but when we employ the same means for extension in fractures of the thigh, we find it necessary to apply the straps over the whole of these sixteen inches, the entire length of the leg, or they will not hold. It will be apparent also that we cannot use even the eight inches which we have, for the purpose of argument, allowed these gentlemen in fractures of the leg. There must be at least a space of eight inches between the ends of the two opposing straps in order that they may operate at all upon the fragments; indeed I do not believe that even then their influence would reach beyond the skin to which they were directly applied; but if a space of eight inches is left, only four remain for the straps at either end; and this is an amount of surface wholly insufficient for our purpose. What then shall we do when the fracture is near one of the extremities of the bone? These gentlemen seem to have forgotten, moreover, that the whole leg is tender and that the skin easily vesicates. In short, they have not seen the many points of difference between the application of these means in fractures of the thigh and leg, and which, while they allow us to accomplish all that we could desire with the one, are of little or no use in the other. We shall then always come to the same conclusion ; whatever means we may employ to make permanent extension in fractures of the leg, we must either fail to acccomplish all that we 1 Crandall, Phil. Med. Journ., vol. iv. p. 193, Jan. 1856; also Transac. of Med. Assoc. of Southern and Central New York, 1855, pp. 81, 82. 460 FRACTURES OF THE TIBIA AND FIBULA. desire or incur the hazards incident to complete and firm ligation of the limb; and if the preference is given to any form of apparatus to accomplish these ends, it must be to some form of the double inclined plane, by which we may at least avoid ligation in the upper part of the limb, the counter-extension being made against the under surface of the thigh while it is resting upon the thigh piece; or to one of the long straight thigh splints which will enable us to make the counterextension from the thigh and perineum. The paste, starch, or dextrine bandage (Fig. 195), I have used in a few cases of simple fracture of the leg within a day or two after Fig. 195. "Immovable" apparatus applied to the leg. (From Fergusson ) the accident, but not unless I felt certain from the nature of the injury that no swelling was to occur. It is only in those fractures in which the bones do not become displaced, or only very slightly, that I would recommend its employment at a period so early. But as soon as the fragments have united, in almost any form of fracture of the leg, it will not be improper to put on the paste bandage and allow the patient to go about carefully upon crutches; or if, indeed, the fragments have not united, but the swelling has completely subsided and the wounds have healed, it cannot be regarded as unsafe to adopt this practice. The young surgeon cannot, however, be too much impressed with the danger of this mode of treatment, as a universal or general plan, employed without discrimination. Its most devoted ad- vocates, Seutin, Velpeau, Gamgee, and others, will not deny the necessity of caution in its use; and the numerous accounts of crooked limbs, ulcerations, and even of gangrene which have been attributed fairly, I think, to one or another of the forms of the immovable dressing, ought to be sufficient to place us fully upon our guard. 1 The majority of such cases as in my judgment may be safely intrusted to a paste bandage, will also do well enough in almost any form of dressing; and not a few of the examples of simple fracture of the leg without much if any displacement, which have come under my notice, I have treated by simply inclosing the leg neatly in a pillow, tied against the limb with tapes, only that I have taken care that the pillow shall be so fastened around the foot and leg as to keep the limb steady. At other times I have laid outside of the pillow 1 Accidents resulting from the use of the immovable apparatus. Amer. Journ. Med. Sci., vol. xxv. p. 460, Feb. 1840; from Gazette des HOpitaux. 461 FRACTURES OF THE TIBIA AND FIBULA. thus arranged, two broad side splints, and bound these against the limb, with the pillow interposed; or I have in the summer used splints made of rolls of straw inclosed in pieces of cloth—"straw junks." In all these cases I have laid the leg upon its back, and I cannot say but that the limbs have done well. If a double inclined plane is used, I prefer either a plain apparatus, such as we have already described as in use for fractures of the thigh, constructed of boards, joined together by hinges opposite the knee, and with an upright foot-board, upon which a carefully arranged and thick cushion has been placed, or the more elegant double inclined plane of Liston (Fig. 196). Fig. 19(3. LUton's double inclined plane ; applied to the leg in a case of compound fracture. (From Miller.) In using Liston's apparatus, it must not be inferred that the knee is always to be bent. The apparatus is designed to be used occasionally as a straight splint; and there will be found many case of fractures of the legs in which the straight position will be most suitable: this is especially true of such fractures as, occurring just below the knee- Fig. 197. Louis Bauer's wire splints for the leg. 1 joint, have the line of fracture directed obliquely downwards and forwards. But there are many compound fractures which demand the 1 Bauer, Buffalo Medical Journal, April, 1857, vol. xii. 462 FRACTURES OF THE TIBIA AND FIBULA. same extended position; and in nearly all cases where this form of apparatus is used as a double inclined plane, the lower end of the splint should be elevated so that the heel shall not be much below the level of the knee. Bauer's wire splints, used also for side splints (Fig. 197), when they are formed to fit the limb accurately, possess some advantages which must recommend them to the attention of surgeons; but neither these Fig. 198. Swing box or "cradle." (From Skey.) splints nor any others, however accurately fitted, ought to be applied directly to the naked skin. They require always the interposition of a well-padded lining. Fig. 199. Salter's cradle. (From Fergusson.) Boxes are rarely useful except in certain compound fractures. They are heavy and awkward machines, which prevent the patient from moving readily in bed; or which being fixed, if he does move, allow 463 FRACTURES OF THE TIBIA AND FIBULA. the upper fragment only to descend, or to move upon the lower as a fixed point. If used at all, they ought generally to be suspended (Fig. 198), or made to move on a suspended railway (Fig. 199). But, however they are arranged, the limb is a great part of the time concealed from sight, and the surgeon is prevented from making use of such means to rectify deviations in the line of the bone, as he would probably have otherwise employed. The swing invented by James Salter, of London (Fig. 199), is constructed so as to allow not only a lateral motion, but also a more complete motion in the direction of the axis of the limb, by which the danger of pushing the fragments upon each other is obviated. This is accomplished by the rolling of two pulley-wheels upon a horizontal bar. The case in which the leg rests may be made of metal or of wood, and the frame of iron for the sake of lightness and strength. These boxes are sometimes filled with bran, the bran being closely packed upon all sides so as to support the limb uniformly and gently. This method of treating compound fractures of the leg was first sug- gested by J. Rhea Barton, of Philadelphia 1 and has been much used in the Pennsylvania Hospital. It possesses the advantage of affording a perfect protection against flies in the summer season, and of absorbing the matter as it escapes. Whenever any portion of it becomes soiled by blood or pus it may be dipped out with a spoon, and its place supplied with fresh bran. The support which it gives to the limb is also uniform Fig. 200. Fracture box, with movable sides. without being at any time excessive, and Dr. Coates states that the escape of blood in rapid hemorrhages has been known to increase the bulk of the bran sufficiently to arrest the bleeding by its accumulated pressure. In whatever position the leg is placed, and with many of the forms of apparatus which we have enumerated, it will be found necessary to protect the limb from the weight of the bed-clothes by some contrivance similar to that figured in the accompanying drawing (Fig. 201). Malgaigne, who declares that the whole world knows how impossible it is, in an immense majority of cases, to overcome the projection of the superior fragment when the limb Fig. 201. Wire rack for fracture of leg. is placed in the extended position (over a double inclined plane), and who affirms that neither Pott's position, nor Dupuytren's modification of it, will do much, if any better, nor, indeed, that Laugier's plan of cutting the tendo Achillis possesses in this respect any real advantage, concludes at last to resort to a new and really ingenious method, the 1 Barton, Amer. Journ. of Med. Sci., vol. xvi. p. 31, and vol. xix. p. 515. 464 FRACTURES OF THE TIBIA AND FIBULA. value of which, also, he claims to have already fully demonstrated. His apparatus (Fig. 202) consists simply of a steel band of sufficient Fig. 202. Malgaigne's apparatus for oblique fractures of the leg. (From Malgaigne.) size to encircle three-fourths of the limb, at the two extremities of which are two horizontal mortises through which a band is passed, and which may be buckled upon itself behind. The centre of the metallic arch, in front, is penetrated with a firm, metallic screw, terminating in a very sharp point, and which is moved by a flat thumbpiece. The limb being laid over a double inclined plane, and the pads being carefully adjusted, as we have already directed when speaking of other forms of apparatus, and the limb properly extended, the apparatus of Malgaigne is placed over the limb, with the sharp point of the screw resting upon the upper fragment, a few lines above the point of fracture; and at the same moment that this point is pressed firmly down to the bone, the fragments being held together by an assistant, the strap is buckled as tightly as possible under the splint. A few turns of the screw will now make its point penetrate more deeply into the bone, and insure the most complete apposition of the broken extremities. " This is accomplished," says Malgaigne, " with very little pain to the patient;" and, as will be seen (Fig. 203), the steel arch effectually prevents any ligation of the limb. Fig. 203. Malgaigne's apparatus applied. (From Malgaigne.) In some cases of extreme deformity of the legs consequent upon badly united fractures, resection of the bones has been practised with more or less success. , ~D I * 465 FRACTURES OF THE TIBIA AND FIBULA. The first case of which I have seen any mention made where the bones were actually resected, is reported by Charles Parry, of Indianapolis, Ind. A young man, aet. 15, having broken his leg near its middle, the fragments united, from some cause, nearly at right angles with each other. Some years afterwards, on the 15th day of January, 1838, Dr. Parry operated, by removing a wedge-shaped portion from both the tibia and fibula. The recovery was tedious, but satisfactory. 1 Mr. Key, of London, made an operation of this kind upon a gentleman who had suffered a fracture of the right tibia from a musket ball. The limb was nearly useless, since he could only bring his toes to the ground. Mr. Key operated in Oct. 1838, and when the report of the case was made five months subsequently, the patient was doing well. 9 In Sept. 1840, Dr. Mutter, of Philadelphia, made a similar operation upon a patient whose leg was shortened three inches and a half and very much deformed, by which operation, when the recovery was complete, the shortening was considerably reduced. 3 Cases may occur which will justify a resort to these extreme measures, or in which they may be preferred to an amputation; but an examination of the several examples reported will show that these operations are not unattended with danger to the life of the patient; indeed, in this respect, amputation has greatly the advantage. If, moreover, the surgeon expects by this method to lengthen a limb, where it is merely overlapped and shortened, he is, I am certain, destined to disappointment, at least in all cases where sufficient time has elapsed for the bones to have become firmly united. I have never myself refractured a bone, but I have several times met with cases of old fractures newly broken, and I have constantly observed that I could never extend the limb one line more than it was before the last fracture. The muscles had contracted to that point, and their contraction would not be overcome. In the case reported by Mutter, he believed that he stretched the muscles two inches. With all deference for the skill and honesty of this gentleman, I think that he was mistaken. If, however, the object of the operation is to straighten the limb, then no doubt it may be sometimes accomplished; and in some degree also by the straightening of the limb, the shortening may be overcome; but in our opinion, such procedures ought to be reserved for extraordinary circumstances. An instructive case of refracture is reported by Dr. Horner, of Philadelphia, in the Medical Examiner. The limb had been broken eight weeks and was quite crooked, but was not very firmly united, and Dr. Horner having refractured it, was able at once to restore it to a nearly straight line. 4 1 Parry, Amer. Journ. Med. Sci., Aug. 1839, p. 334. 1 Key, Amer. Journ. Med. Sci., Aug. 1839, p. 339, from Guy's Hospital Reports, April, 1839. 3 Mutter, Amer. Journ. Med. Sci., April, 1842, p. 359 Three similar cases may also be found in the Oct. No. for 1841, and the April No. for 1842 of the same journal, in which the operations were made by Portal, of Palermo. Malgaigne mentions two other examples. 4 Horner, New York Journ. Med., May, 1851, p. 432. 466 FRACTURES OF THE TARSAL BONES. CHAPTER XXXIII. FRACTURES OF THE TARSAL BONES. Causes. —The astragalus is generally broken by a fall from a height, the patient having struck upon the bottom of the foot. Monahan, in an analysis of ten cases, found it had been broken by a fall upon the foot nine times, 1 and only once by a crushing accident. The calcaneum is also occasionally broken by violent lateral pressure, but much more often by a fall upon the foot, or rather upon the heel. In some instances both heel bones have been broken at the same moment; but Malgaigne has collected eight cases of fracture of this bone by muscular action, as in jumping upon the toes; the posterior portion of the bone being thus violently acted upon by the tendo Achillis. South, in his Notes to Chelius, has mentioned two other cases, one of which was seen by Lawrence, and has been reported in the second volume of the Lancet. This person had received the injury by jumping off a stage coach. The fragment was found to be drawn upwards slightly, but not so far as to prevent crepitus when the muscles on the back of the leg were relaxed. The other example mentioned by South, is a cabinet specimen contained in the museum of St. Bartholomew's Hospital. The fracture had taken place just below the attachment of the tendo Achillis, but the upper fragment was not displaced. 2 Mr. Cooper mentions two other cases, both produced by violent efforts on the part of the patients to sustain themselves when falling. In one of these the fragment was immediately drawn up three inches. 3 The other bones of the tarsus are generally broken by crushing accidents, such as the fall of heavy weights upon them, by the passage of loaded vehicles, &c. Pathology. —The astragalus often, indeed generally, escapes without injury in those crushing accidents which break many or most of the other bones of the foot, and, as we have seen, it is seldom broken except when the patient has fallen upon the bottom of his foot; but at the same moment, the foot being turned forcibly out or in, a dislocation of the tibia takes place, and the fibula is broken. In nine of the cases collected by Monahan, one or the other of these forms of dislocation had occurred, in eight of which the dislocation was compound. The direction of the fracture is found to vary greatly; thus, it has been found broken in its length, antero-posteriorly, in its 1 Fracture of the astragalus, with an analysis of the recorded cases of this injury. An inaugural thesis, presented to the Faculty of the Buffalo Med. Col., March, 1858, by Bernard Monahan, M. D. 2 South, Notes to Chelius's Surgery, vol. i. p. 639, Amer. ed. 3 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 467 FRACTURES OF THE TARSAL BONES. breadth or transversely, and in one instance it has been divided nearly horizontally, so as to separate the upper face completely from the lower. Sometimes it suffers a species of impaction, the fragments being actually driven into each other; at other times, as in one case related by Amesbury, the bone may be split without the occurrence of any displacement. The calcaneum also may be broken in any direction, and it is equally with the astragalus liable to impaction, by which its vertical diameter is sensibly diminished, while its transverse diameter is increased. If the fracture is a consequence of muscular action, the line of fracture is always posterior to the astragalus, and in some cases only that portion is broken off to which the tendo Achillis has its attachment. It may be broken also vertically, directly underneath the astragalus, in which case the lateral and interosseous ligaments will prevent anything more than a slight displacement of the posterior fragment. When the fracture takes place posterior to the lateral ligaments, the detached fragment is liable to be drawn very far from the body of bone, even to the extent of four or five inches, and possibly further when the leg is extended upon the thigh and the foot flexed upon the leg. Constance relates a case in which the tuberosity, having been broken off by a direct blow, was drawn up five inches. 1 Fractures of the calcaneum produced by contraction of the sural muscles are generally simple, but those which result from a crushing of the bone are more often compound. The same remark is applicable also to the other bones of the tarsus, the fractures of which, being only produced by direct blows, are generally complicated with external wounds. Symptoms. —All fractures of the bones of the tarsus demand especial care in their diagnosis, since only a few of the usual signs of fracture are in a majority of the cases presented. The explanation of this fact will be found in the number, size, and strength of the bones of the tarsus, and in their close and firm union by ligaments, by which they give to each other a mutual support, so that the fracture of a single bone does not necessarily or usually result in displacement or deformity, and even crepitus is with difficulty detected; and when we consider, moreover, that the fracture is generally produced by great violence, directly applied, in consequence of which the foot in most cases becomes rapidly and enormously swollen, we shall understand the true nature of the difficulties which are usually presented in the way of an accurate diagnosis. Of all the usual signs of fracture, crepitus alone is pretty generally present, but even this often fails to tell us which bone is broken, and still more often does it fail to inform us as to the direction and extent of the bony lesions. If the whole or a portion of the tuberosity of the calcaneum is separated by the action of the muscles, and the fragment is drawn upwards, it may be discovered in its new position, and the heel will be 1 Constance, Amer. Journ. Med. Sci , vol. v. p. 222. Nov. 1829, from the Midland Med. and Surg. Reporter. 468 FRACTURES OF THE TARSAL BONES. flattened or shortened, but no crepitus can be felt unless the fragments are again brought in contact. Treatment. —Not any of the fractures of the tarsal bones in themselves demand the use of splints, and it is only when complicated with a dislocation of the ankle and fracture of the fibula that it is proper to employ apparatus of this sort; certainly the exceptions to this rule must be very rare; so that our practice in these cases will be confined chiefly to the prevention and reduction of inflammation. The limb must be placed in the most easy position, and cool water lotions assiduously applied. This will be the sum of the treatment demanded during the first few days after the receipt of the injury in probably all cases of simple fracture, and in many cases of compound fracture. If single bones, or fragments of single bones, are displaced to any considerable extent, and there is an external wound communicating with the fracture, I have no doubt it would be best in all cases to remove at once by dissection the projecting bone, even although it were possible, or perhaps easy, to force it back again to its place, as has been done successfully by Ashhurst, of Philadelphia. 1 The same rule I would apply to examples of fracture uncomplicated with any external wound, if the fragments were very much displaced, and could not by the application of moderate force be replaced, since the bone left to project would prevent the patient from ever wearing a boot with comfort, and would entail as much weakness upon the limb as would be likely to follow from its complete separation. But such cases as I have last supposed are exceedingly rare; indeed, I have never met with a simple fracture of a tarsal bone accompanied with displacement. Norris has, however, reported a case of fracture of the astragalus accompanied with displacement of about one-half of the bone, but without any lesion of the soft parts. This was in the person of a man Eet. 30, who was admitted into the Pennsylvania Hospital on the 26th of Sept. 1831. "An hour previous to admission, while descending a ladder, he slipped and fell in such a manner as to throw the entire weight of his body upon the outer part of his left foot. Upon examination, the foot was found to be turned inwards and nearly immovable. A slight depression existed immediately below the lower end of the tibia, and there was a considerable hard and rounded projection on the outer part of the foot, a little below and in front of the extremity of the fibula. The skin covering this projection was reddened, but not excoriated. There was no fracture of either bones of the leg." These appearances led Drs. Norris and Barton, under whose care the patient was placed, to regard the accident as a simple luxation of the astragalus forwards and outwards; and a short time after admission efforts were made to reduce it. " This was done after relaxing in as great a degree as possible, the muscles of the leg, by fixing the knee and having assistants to keep up extension, by seizing the heel and front part of the foot; at the same time the bone being pushed inwards and toward the joint by the surgeon. These efforts were continued 1 Ashhurst, Amer. Journ. Med. Sci., April, 18C2. 469 FRACTURES OF THE TARSAL BONES. for a considerable time, but had no effect in changing the position of the bone. " Six hours afterwards, Drs. Huston and Harris saw the patient in consultation, when efforts were again made at reduction, which not proving more effectual than in the first trial, the excision of the bone was determined on. " The patient being properly placed, an incision was made through the integuments, parallel with the course of the tendons, commencing a short distance above the projection on the foot, and extending dowa far enough to expose fairly the astragalus and its torn ligaments. The bone was then seized with forceps and easily removed after the division of a few ligamentous fibres, that continued to connect it to the adjoining parts. " Very little hemorrhage occurred, two small vessels only requiring the ligature. " After removal, it was discovered that about one-half of the surface which plays in the lower end of the tibia had been fractured, and remained firmly attached to the extremity of that bone, and as it was judged that the efforts to remove this would be likely to produce more injury to the joint than would arise from allowing it to remain, no attempt was made to extract it. " The joint being carefully sponged out, the sides of the incision were brought accurately together by means of sutures and adhesive straps, after which simple dressings and a roller were applied, and the foot, restored to its natural situation, placed in a fracture box." Subsequently that portion of the astragalus which was permitted to remain, having become carious and loosened, was removed also. The case continued to do badly; all the bones of the tarsus and even the lower ends of the tibia and fibula becoming eventually carious; and on the 27th of March, 1853, more than a year and a half after the receipt of the injury, the leg was amputated; but no healthy action ensued, and the patient soon died. 1 The result of this case can scarcely be regarded as having settled in reference to the value of the procedure which I have recommended. For reasons which seemed satisfactory to the surgeons who made the operation, only one-half of the broken bone was removed; whether the result would have been different if the whole had been at once taken away, we cannot now determine. I have related it, however, as the only example of a simple fracture with displacement which I have been able to find upon record; and in this case, several surgeons of merited distinction concurred in the opinion that the protruding fragment ought to be removed. A fracture of the posterior portion of the calcaneum, especially when it has been produced by muscular action, constitues an exception to fractures of the tarsal bones generally, and demands usually that apparatus of some kind should be employed in its treatment. In order to replace the posterior fragment when displaced, or to maintain it in apposition until a bony union is accomplished, it will 1 Norris, Amer. Journ. Med. Sci., vol. xx. p. 379. 470 FRACTURES OF THE TARSAL BONES. be necessary to shorten the gastrocnemii by flexing the leg upon the thigh and extending the foot upon the leg. But to retain the limb in this position it will be expedient always to employ apparatus. A very simple contrivance, however, will generally answer all the indications. A bandage, padded strap, or a stuffed collar, may be fastened Fig. 204. Apparatus for fracture of the tube rosity of the calcaueum. about the thigh just above the knee, and made fast to the heel of a slipper by a tape (Fig. 204). The apparatus is the same which has been recommended for a rupture of the tendo Achillis. In addition to this, the limb ought to be covered from the foot upwards as far as the knee with a snug roller, underneath which, on each side of and above the detached fragment, ought to be placed suitable compresses, the object of the roller being to diminish muscular contraction, and the compresses being intended to retain the detached piece in contact with the main body of the bone. Some surgeons have not found it necessary to flex the leg upon the thigh, and they have contented themselves with extending the foot upon the leg, and confining it in this position by a splint of wood or gutta percha laid along the front of the leg, ankle, and foot. In still other cases, the fragment has shown so little disposition to become displaced as to render no precautions of any kind necessary, except to impose upon the patient complete quiet, with the limb resting upon its outside and flexed, as in Pott's fracture of the fibula. As soon as the inflammation has sufficiently subsided, passive motion must be given to the ankle in order to prevent, as far as possible, the anchylosis which is an almost constant result of these accidents. Indeed, the patient is fortunate who recovers a tolerable use of his foot after the lapse of many months, nor can he be assured that the inflammation will leave these bones and their dense fibrous envelops for a long period, and that it may not result in caries of more or less of the tarsal bones, demanding finally amputation of the whole foot. We have not intended to speak in this place of those severer accidents, accompanied with comminution and extensive laceration, which forbid the hope of saving the foot, and for which immediate amputation is the only proper resource, but which constitute, in fact, the great majority of all the fractures of the tarsal bones. 471 FRACTURES OF THE METATARSAL BONES. CHAPTER XXXIV. FRACTURES OF THE METATARSAL BONES. These bones can scarcely be broken except by direct blows, and the great majority of their fractures are the results of severe crushing accidents, such as render amputation sooner or later necessary. Of those which do not demand amputation, by far the largest proportion are compound fractures; of which class the following example will serve as an illustration. A man in the employ of one of the railroads which connect with this city was run over by a loaded car on the 14th of June, 1856, crushing his right arm so as to render its immediate amputation necessary. I found also a compound comminuted fracture of the fourth metatarsal bone of the right foot. Considerable hemorrhage occurred from the wound, but this ceased spontaneously. Cool water dressings were diligently applied, without splints or bandages, and although some inflammation and suppuration ensued, the parts finally healed over and the fragments united, with only a slight backward displacement at the seat of fracture. When only one bone is broken, the displacement is usually very trivial; but when several are broken, it may be considerable. Malgaigne relates an example of this latter accident in which, the three middle bones being broken by the wheel of a carriage, and the integuments being badly torn and bruised, it was found impossible to retain the fragments in place. The patient recovered, and was able to place the foot well to the ground, but the proximal fragments continued to project upwards upon the top of the foot to such a degree as to require a special shoe. In a majority of cases, the direction of the displacement is backwards or upwards, especially when the middle metatarsal bones are the subjects of the fracture. I have in my cabinet a second metatarsal bone broken obliquely near its middle, with only a very slight displacement of the lower fragment backwards; and also a cast of a bone which has united with an enormous backward projection. In one instance I have seen the metacarpal bone of the little toe cut in two with an axe, and the fragments united in about thirty days, but with the lower fragment slightly displaced outwards. Delamotte relates a case also in which the first four metatarsal bones were cut off, and complete union was accomplished on the fortieth day: at the end of two months the patient walked without lameness. If the fragments are not displaced, nothing is required except that the foot shall be kept at rest, and the inflammation controlled by suitable means. 472 FRACTURES OF THE PHALANGES OF THE TOES. In case, however, a displacement exists, it ought to be remedied, if possible, since, if only very slight, it may become the source of a serious annoyance. If the fragments project upwards they interfere with the wearing of a boot, and if they sink toward the sole, the skin beneath is liable to remain constantly tender, and the patient may thus be seriously maimed for life. In case the displacement is not due to the action of the muscles, but only to the nature and direction of the force producing the fracture or to entanglement of the broken ends, and it is likely to cause any of the inconveniences which I have mentioned if permitted to remain, it will be advisable at once to employ considerable force in the way of pressure, or to elevate the fragments through an opening previously made upon the dorsum of the foot, calling to our aid even the saw or the bone cutters, if necessary. After which the fragments may be retained in place by carefully applied pasteboard splints and compresses. CHAPTER XXXV. FRACTURES OF THE PHALANGES OF THE TOES. If fractures of the other bones of the foot are generally of such a character as to require immediate amputation, these fractures demand this extreme resort still more often. Our experience, therefore, in the treatment of fractures of the phalanges of the toes is extremely limited. Lonsdale observes that it is not uncommon to find great irritation arise after fracture of the great toe; an inflammation extending along the absorbents on the inside of the leg to the groin, causing abscesses to form in different parts of the limb, and producing sometimes great constitutional disturbance. An illustrative case has come under my own observation at the Buffalo Hospital of the Sisters of Charity. The patient, Morgan McMann, aet. 18, was admitted Dec. 28, 1853, having several days before received an injury upon the great toe which contused the flesh severely and broke the first phalanx. He was then suffering from severe pain in the foot and leg, and the absorbents were inflamed quite to the groin. Poultices being applied to the foot and cool lotions to the limb, the inflammation soon subsided, but not until a portion of the toe had sloughed away. Eventually also it became necessary to remove some portion of the phalanx, which had died; after which the wounds healed kindly. When any of the smaller toes are broken, it will be found easier to support the fragments by a broad and long splint which shall cover the whole sole of the foot and all the toes at the same time, than to attempt to apply a splint to the broken toe alone. If, however, we prefer this latter mode, a thin piece of gutta percha will be found altogether the most convenient material for the purpose. If the great toe is broken, its great breadth may prevent any displacement, and a well-moulded gutta-percha splint will generally secure a perfect and rapid union. PART II. DISLOCATIONS. SI DISLOCATIONS. CHAPTER I. GENERAL CONSIDERATIONS. § 1. General Division and Nomenclature. A dislocation is the displacement of one bone from another at its place of natural articulation. Dislocations may be divided into accidental or traumatic, spontaneous or pathologic, and congenital. Our remarks upon the etiology, pathology, symptomatology, prognosis and treatment of these injuries must be considered as applicable only to accidental or traumatic dislocations, unless the fact is in any case otherwise stated. Accidental dislocations are those in which the bones have suffered displacement in consequence of the application of a sudden force; and surgeons have divided these accidents into Complete and Partial, Simple, Compound, and Complicated, Recent and Ancient, Primitive and Consecutive. A complete dislocation is one in which no portions of the articular surfaces remain in contact. A partial dislocation is one in which the articular surfaces are not completely removed from each other. A simple dislocation is that form of the accident in which the bone has only slid from its articulation, and is accompanied with the least or only an average amount of injury to the soft parts or to the bones adjacent to the joint. A compound dislocation implies that the articulating surface of the bone has been thrust through the flesh and skin, or that in some other way a wound has been made which communicates with the joint. Complicated dislocation is a term employed by some writers to designate a condition wholly differing from a compound dislocation, or, in some cases, a condition of extra complication. Thus, a simple dislocation may be complicated with a fracture, or with the laceration of an important bloodvessel, &c.; and a compound dislocation may be 476 GENERAL CONSIDERATIONS. complicated in the same way, and with the addition, perhaps, of extensive laceration and destruction of integument, muscles, nerves, &c. A recent luxation has taken place within a period of a few days, or, at most, of a few weeks; and an ancient luxation has existed during a longer period; the exact point of time at which a dislocation shall be called recent or ancient not being fully determined by surgeons, and the application of these terms is therefore always somewhat arbitrary. By primitive luxation we mean that the bone remains nearly or precisely in the position into which it was at first thrown; while by secondary or consecutive luxation we understand that it has subsequently, in consequence of the action of the muscles, or from unsuccessful efforts at reduction, or from some other cause, changed its position sufficiently to entitle it to a new designation. Thus a primitive dislocation upon the ischiatic notch may become a secondary dislocation upon the dorsum ilii, or the reverse. § 2. General Predisposing Causes. Age. —According to Malgaigne, whose conclusions are based upon an analysis of six hundred and forty-three cases, dislocations are very rare in infancy, only one having occurred under five years; but the frequency increases gradually up to the fifteenth year, from this period more rapidly up to the sixty-fifth year, and from this time onward again dislocations become more rare. He has mentioned none after the ninetieth year; and the period of greatest frequency is between the thirtieth and sixty-fifth year. To this middle period belong four hundred and seven of the whole number. The inference from this analysis may be thus briefly stated: age, as a predisposing cause, is most active in middle life, less active in advanced life, and least active of all in early life. It is proper, however, to observe that while such statistics may be relied upon as indicating the relative frequency of these accidents at different periods of life, they cannot be regarded as determining absolutely the value of age alone as a predisposing cause, since the direct or exciting causes may be more active at one period than another, and in some measure these latter causes may be, and doubtless are, responsible for such results. Constitution and Condition of the Muscles and Ligaments. —It may be stated as a general fact that persons of feeble constitutions, and whose muscular systems are much weakened, suffer dislocation from slighter causes than those who are in health, and whose muscular systems are firm and vigorous; and that a relaxation of the ligaments which surround a joint, however this may have been occasioned, predisposes to dislocation. Thus, a paralyzed and atrophied limb is predisposed to luxation; a joint in which the capsule has become stretched by effusions, or by violent extension, or weakened by laceration from a previous dislocation, or by ulceration, or if in any other way the articulation is deprived of these natural protections, we need scarcely say that it is thereby rendered more liable to luxation. 477 GENERAL SYMPTOMS. Ball and socket joints, other things being equal, are more liable to displacement than ginglymoid; but then much more depends upon the relative exposure of the joint than upon its anatomical structure, so that the elbow is much more frequently dislocated than the hip, the shoulder-joint, however, being, from its position and extent of motion, peculiarly exposed, and being also a ball and socket-joint, is, of all others, most liable to dislocation. § 3. Direct or Exciting Causes. These may be classed under two general heads, namely, external violence and muscular action. External violence operates either directly or indirectly. When a person falls upon the knee and dislocates the head of the femur, the force is said to have acted indirectly, and this is by far the most frequent mode of dislocation; but when the blow is received upon the upper end of the humerus, and its head is sent into the axilla, it is said to have been dislocated by direct violence. Muscular action produces a dislocation slowly, as in some cases of chronic rheumatism, and then it is called a spontaneous or pathologic dislocation; or suddenly, as in the violent spasmodic contractions which accompany convulsions; or sometimes by the mere voluntary effort of the muscles; and these latter are true accidental luxations. It is very probable that external force can seldom be regarded as the sole cause of a dislocation, but that, in a large majority of cases, muscular action consenting with the shock, performs an important role in the history of the accident. The limb being driven obliquely across its socket by the external violence, is seized by the stretched and excited muscles with such vigor as to contribute not a little to the unfortunate result. Thus it will be found that the same force which is adequate to the production of a dislocation in the living and healthy subject is wholly insufficient to accomplish the same in the dead; and a man who is fully intoxicated seldom suffers a dislocation. § 4. General Symptoms. As fractures are characterized by preternatural mobility and crepitus, to which may be generally added the circumstance that, when reduced, the fragments will not remain in place without external support, so, on the other hand, dislocations are characterized by preternatural rigidity, an absence of crepitus, and by the fact that, when reduced, the bone does not generally require support to maintain it in position. These three are the usual, and they may be termed the common, signs of distinction between fractures and dislocations, but no one of them can be alone depended upon as positively diagnostic. Generally, when a bone has been dislocated, we shall find the limb in a certain position, which is uniform for all dislocations of the same character, and almost immovably fixed; but when the ligaments and muscles about the joint have been extensively torn, or the whole body is still 478 GENERAL CONSIDERATIONS. suffering under the shock, or in any other circumstances where the power of the muscles is weakened, this rigidity may give place to extreme mobility. True crepitus does not exist without a fracture, but is not always present in fractures, and there is often a sensation produced in the rubbing and chafing of dislocated bones which very much resembles certain kinds of crepitus, and by the inexperienced has been often mistaken for it. I allude to the subdued rasping sound or sensation which is found generally on the second or third day, and sometimes earlier, and which is the result of fibrinous effusions, or, perhaps, in some instances, of the mere rubbing of firmly compressed ligamentous and cartilaginous surfaces upon each other. The crepitus of a recent fracture can be scarcely confounded with this obscure sensation, unless it is in some cases of incomplete fracture, or of a fracture situated remote from the surface, as in the case of the hip; but a fracture which is a few days old, whose surface has become softened by inflammation and more or less covered with lymph, and, when the rigidity is great, may sometimes deceive the most experienced surgeon, so exactly will it be found to imitate the sensations produced by the chafing of an inflamed joint, or of closely approximated fibrous surfaces. I have said that a true crepitus does not exist without a fracture; but then a very minute fracture, such as the detachment of a scale of bone by the tearing away of a tendon or of a ligament, may produce crepitus; or even the separation of a piece of cartilage may sufficiently expose the bone to determine the presence of this phenomenon. These are, however, no longer examples of simple dislocation. Nor are the two inverse propositions, in relation to the retention of the bones in place, invariable in their application. A broken bone, well reduced, does not always manifest .a tendency to displacement, nor does a dislocated limb, when restored to its socket, in all cases maintain its position without support. The other general signs of dislocation are pain, swelling, and discoloration. The pain is generally more intense in dislocations than in fractures, the expanded end of the bone resting often upon one or more large nerves, which usually, with the arteries, approach very near the joints, this pressure being also greatly increased by the extreme tension of the muscles. Not unfrequently numbness and temporary paralysis of the whole limb are the consequences. In other cases the pain is due solely to the pressure upon the muscles or to the tension of the muscles, or, perhaps, to the tension of the untorn ligaments and capsule. Generally, the limb is shortened, but in a few cases it is found slightly lengthened, while the natural axis of the bone with its socket is always changed. If examined early, and before the supervention of swelling, the joint end of the displaced bone may be felt in its unnatural position, and a corresponding depression may be discovered in the situation of the articulation, especially if the bones are superficial. 479 PATHOLOGY. § 5. Pathology. The dissection of recent dislocations produced by external violence, shows the capsular ligament more or less torn, and also a rupture of some of the lateral and other short ligaments, with a complete rupture in most cases of some of the tendons which immediately surround the joint, or of those which are attached to the capsule: the muscles, nerves, arteries, &c., through which the bone in its passage has passed, or upon which it is found resting, being also contused, stretched, or torn asunder. This description, however, does not apply to dislocations produced by muscular action alone, in a majority of which cases the capsule is only stretched, and not torn, and no lesions of other structures are necessarily present. If the dislocation remains unreduced, the margins of the old socket, in the case of enarthrodial articulations, become gradually depressed, while the concavity of the socket is filling in with a fibrous or bony tissue, until at length the whole of this portion of the joint apparatus is nearly or entirely obliterated. This process is generally very slow, and may not be consummated until after the lapse of many years. ¦ At the same time, but with much greater rapidity, the head of the bone in its new position, and the soft or hard parts upon which it rests, are undergoing certain changes to adapt them to their new relations, and calculated in some measure to restore the limb to its normal functions. If the head of the bone rests upon muscle, the cellular and fibrous tissues which enter into the composition of the muscle become condensed and thickened, forming a shallow or elongated cup, whose margins are attached to the neck or shaft of the bone, and whose walls are lubricated with synovia. If it rests upon bone, by a process of interstitial absorption a true socket is formed, sometimes deep and sometimes shallow, whose edges, receiving additional ossific depositions, become lifted so as to form a rim. At the same time the head of the bone is undergoing corresponding changes, to adapt itself to the newly-formed socket; it is flattened or otherwise changed in form, and in the progress of this change its natural secreting and cartilaginous surfaces are gradually removed, a porcelaneous deposit taking its place. The same kind of hard, polished, ivory-like deposit is found also in those portions of the new socket which have been especially exposed to pressure and friction. Instead of the eburnation, an imperfect fibro-serous surface or synovial capsule may be formed. I have in my cabinet an example of ancient luxation of the hip-joint in which the head of the femur, having rested upon the dorsum ilii, has formed a nearly flat but smooth surface—a kind of elevated plateau; in other cases I have seen the margins of the new socket so elevated as to rest against the neck of the femur, and completely lock it in. Consenting with these changes, and in consequence partly of the disuse of the limb, the muscles, and even the bones sometimes, suffer a gradual atrophy. In some measure these alterations may be due also to the pressure of the dislocated bone upon arterial and nervous 480 GENERAL CONSIDERATIONS. trunks, by which their functions become partially or completely annihilated, and their structure even may be wholly obliterated. In consequence also of the inflammation which immediately results, we ought not to omit to notice that the large trunk of an artery sometimes becomes firmly adherent to the capsule or periosteum of a displaced bone, and its reduction is attended with imminent danger of laceration and of a fatal hemorrhage. Numerous instances of this grave accident, especially in attempts to reduce old dislocations of the shoulder-joint, are upon record. § 6. General Prognosis. We shall study the prognosis of these accidents to better advantage when we come to speak of the individual bones and their various forms of dislocation; but it is proper to state in this place, generally, that very few joints, having been once completely displaced from their sockets by external violence, are ever so completely restored as not to leave some traces of the accident for many years, if not for the whole of the subsequent life of the patient, either in the partial limitation of their motions, or in the diminished size and power of the muscles of the limbs, or in the presence of an occasional arthritic pain: the degree and permanence of these sequences depending upon the joint which is the subject of the displacement, the extent of the original injury, the length of time it has remained unreduced, the means employed in its reduction, the health and condition of the patient, with so many other contingent circumstances as to preclude the idea of a complete specification. If the bone is not reduced, a permanent maiming is inevitable; but it is surprising how much time and the intelligent processes of nature can eventually accomplish toward a restoration of the natural functions, especially when aided by a good constitution and judicious treatment. If the symmetry of form and grace of motion are never replaced, the value of the limb, for all the practical purposes of life, is not unfrequently completely re-established. § T. General Treatment. The first indication of treatment is to reduce the bon*e. Whatever delays may be proper or justifiable in certain cases of fracture, such delays are never to be argued in cases of dislocation. The sooner the reduction is accomplished, the better. For this purpose we resort at once to such manipulations or mechanical contrivances as the nature of the case demands; and if these fail, or if at the first they are deemed insufficient, we invoke the aid of constitutional means, or such as are calculated to diminish the power and antagonism of the muscles. Many dislocations may be reduced promptly by manipulation alone; which mode is always to be preferred when it will prove sufficient, for the reasons that it is generally the least painful to the patient, and the least apt to inflict additional injury upon the muscles and ligaments. 481 GENERAL TREATMENT. A person wholly unacquainted with anatomy or surgery, may occasionally succeed in reducing a dislocated limb; indeed, it frequently happens that the patient himself, by mere accident in getting up or in lying down, accomplishes the reduction; and even in a very large majority of cases force and perseverance will finally succeed by whomever they may be employed; but the observing student of surgery will soon discover the difference between accident and brute force on the one hand, and intelligent manipulation on the other. The charlatan bone-setter does not often allow himself to fail, unless the courage of his patient gives out, or he ignorantly supposes the reduction to be effected when it is not; but his success, achieved through great and unnecessary suffering, is often obtained, also, at the expense of the limb. "While the surgeon whose knowledge of anatomy enables him to understand in what direction the muscles are offering resistance, and through what ligaments the head of the bone must be guided, lifts the limb gently in his hands, and the bone seeks its socket promptly and without disturbance, as if it needed only the opportunity that it might demonstrate its willingness to return. We must understand not only what muscles and ligaments antagonize the reduction, if we would be most successful, but also what muscles, by being provoked to contraction, will themselves aid in the reduction. In short, to become expert bone-setters in the department of dislocations, one must possess a complete knowledge of the physiognomy or the external aspect of joints, acquired only by repeated and careful examinations, he must be familiar with the anatomy and functions of the muscles, he must understand thoroughly the ligaments, he must have experience, tact, and fertility of resource. Without these qualifications a man will do better never to undertake to treat dislocations, since he is constantly liable to mistake fractures for dislocations, and dislocations for fractures; he will submit a sprained wrist to violent extensions under the conviction that the joint is displaced; he will mistake natural projections for deformities, and fail to recognize the real deformity when it actually exists; he will leave bones unreduced, fully believing that they are reduced ; and he will all in all, within a few years, accomplish vastly more evil than he can ever do good. Let a man practice any other branch of surgery if he will, without experience or scientific knowledge, but he must not attempt to reduce dislocated bones. The most learned and the most skilful we shall find falling into error, embarrassed by the uncertainty of the diagnosis, or successfully resisted by the power of the opposing agents; what then can be expected of those who are both ignorant and inexperienced, but failures and disasters ? As a means of disarming the muscles, or of placing them oft' their guard, we often practise successfully the diversion of the mind of the patient. At the very moment that the limb is moved or extension is made, a question is addressed to him, or he may be suddenly surprised by some unexpected intelligence. Extension and counter-extension, made with our own hands or with the hands of assistants, constitute the second resort where manipulation alone has failed. The surgeon, seizing upon the limb firmly with 482 GENERAL CONSIDERATIONS. his hands, makes the extension, while the assistants make the counterextension ; or, instead of grasping the limb directly, the operator may Fig. 205. Clove hitch. (From Erichsen.) use for this purpose circular and longitudinal bandages, or the bandage or handkerchief tied in the form of the clove hitch (Fig. 205). Extension is thus applied in connection with manipulation, aided, perhaps, by direct pressure upon the head of the displaced bone. Failing in this, we employ some one of the various mechanical contrivances which, while they are capable of exerting much more power, possess also the important advantage of operating gradually and steadily, by which mode the resistance of the muscles is always more speedily and more completely overcome. For this purpose surgeons employ generally in the case of the large limbs the compound pulleys (Fig. 206), or the simple rope windlass, which is thus described by Dr. Gilbert, of Philadelphia: " Place the patient, and adjust the extending and counter-extending bands as for the pulleys ; then procure an ordinary bed-cord or a wash-line, tie the ends together and again double it upon itself, pass it through the extending tapes or towels, doubling the whole once more, and fasten the distal end, consisting of four loops of rope, to a window-sill, door-sill, or staple, so that the cords are drawn moderately tight; finally, pass a stick Fig. 206. Compound pulleys and ring to which one end of the pulley rope is fastened through the centre of the double rope, then by revolving the stick as an axis or double lever, the power is produced precisely as it should be in such cases, viz., slowly, steadily, and continuously." Jarvis's adjuster, although very complex, possesses some advantages over the pulleys, which may, perhaps, entitle it to the preference in a few cases. DOUBLE OR BILATERAL DISLOCATION. 483 Among the constitutional means, ether and chloroform occupy the first rank; indeed they are, at the present day, almost the only means of this class to which surgeons resort, and their value in this point of view can scarcely be over-estimated. Only when some unusual circumstance or condition of the patient forbade the use of an anaesthetic, would the surgeon return to the ancient practice of bleeding ad deliquium, of prostrating the system with antimony, or to the use of those vastly less efficient agents, opium and the warm bath. CHAPTER II. DISLOCATIONS OF THE LOWER JAW. There are two principal forms of this dislocation, namely, the double or bilateral dislocation, and the single and unilateral; in both of which the direction of the displacement is forwards. To these there has been added one example of an outward displacement accompanied with a fracture. 1 § 1. Double or Bilateral Dislocation. This form of dislocation of the lower jaw is much the most frequent, being met with in about two out of every three cases. It appears also to occur oftener in women than in men, and usually between the twentieth and thirtieth year of life. In infancy and extreme old age it is exceedingly rare; yet Sir Astley Cooper mentions a case in which " two boys" being at play, one had an apple thrust into his mouth, producing a double dislocation; and Nelaton saw the same accident in an old man of seventy-two years, who was toothless. This comparative immunity in youth and old age has been ascribed to certain peculiarities in the form of the jaw at these periods of life. Nelaton attributes its more frequent occurrence in middle life to the great length and strong anterior inclination of the coronoid process. In a majority of cases the direct or immediate cause has seemed to be muscular action alone. Malgaigne found this cause to prevail in twenty-five out of forty cases; and of the twenty-five cases fifteen were occasioned by gaping, five by convulsions, four by vomiting, and one by rage. Dr. Physick, of Philadelphia, found both condyles dislocated in a woman in consequence of the violent gesticulation of her jaw while scolding her husband. But in a more remarkable case still, this surgeon found the jaw dislocated after recovery from a profuse salivation, and of the cause of which, or the time of its occurrence, the patient, a young girl, could give no account. Dr. Physick made 1 Robert, Journal de Chir., 1844. 484 DISLOCATIONS OF THE LOWER JAW. several ineffectual attempts at reduction, and only succeeded at last after he had made her completely intoxicated with ardent spirits. 1 Dr. E. Andrews, of Michigan, found both condyles dislocated by a lobelia emetic. The patient had often taken these emetics before, and had frequently experienced a sensation "of catching" at the joint, but the jaw had always until this time resumed its position spontaneously. 2 Among the causes from outward violence, the introduction of some foreign body into the mouth, and the extraction of teeth, occupy the most important place. In fifteen cases, seven were from the former and six from the latter cause. My late pupil, A. W. Gilbert, has related a case which came under his own observation, produced by a similar cause. During his apprenticeship with Dr. Parsons, a dentist, he was requested to insert a set of teeth for a young man residing in Cattaraugus Co., N. Y., and while opening his mouth to take an impression of his gums, he dislocated " both condyles forwards, under the zygomatic arches;" but so perfectly were the muscles relaxed, that he immediately reduced them, without the least difficulty, by placing his thumbs as far back as possible upon the molar teeth, depressing the back part of the jaw, and at the same moment elevating the chin. 3 The late Prof. James Webster, of Eochester, N. Y., dislocated the jaw of a lady while attempting to pry out a root of one of the molars. Pathology. —In order that we may better understand the pathology of this accident, it will be proper to say a few words in relation to the anatomy of the temporo-maxillary articulation and the other parts concerned in the dislocation now under consideration. The articulation is formed by the condyloid process of the inferior maxilla and the glenoid fossa of the temporal bone, in front of which fossa, and at the root of the zygomatic arch, is a slight elevation, called the articular eminence. Between the joint surfaces, both of which are covered with a cartilage of incrustation, is placed an interarticular cartilage, which divides the joint into two cavities, one corresponding to the condyle of the inferior maxilla, and the other to the glenoid fossa, each of which is furnished with a distinct synovial membrane. Properly there is but one ligament—namely, the external lateral— which passes from the outer surface of the articular eminence to the corresponding surface of the neck of the condyle. What is called the internal lateral ligament arises from the apex of the spinous process of the sphenoid bone, and is inserted into the margin of the dental foramen, and has therefore no immediate connection with the articulation, although it tends to strengthen the joint. The same is true of the stylo-maxillary ligaments. The lower jaw is drawn upwards, or closed upon the upper jaw by the action of the temporal, masseter, and internal pterygoid muscles; it is drawn downwards by the action of the digastricus, mylo-hyoideus, and genio-hyoglossus muscles; forwards by a few fibres of the masseter 1 Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. 2 Andrews, Peninsular Journ. Med., vol. iii. p. 101. 1855. 3 Gilbert, Thesis, on Dislocation of the Inf. Max. University of Buffalo, 1858. DOUBLE OR BILATERAL DISLOCATION. 485 and by the external pterygoid muscles; and laterally by the alternate action of the external and internal pterygoid muscles. When the mouth is open to its utmost extent, the maxillary condyle rises upon the articular eminence until it rests upon its very summit. Indeed, it is probable that in most persons it advances rather in front of the centre of the eminence; so that in order to become actually dislocated it only needs that the capsule shall be somewhat relaxed, or that it shall actually give way in front, when the condyles slide forwards and occupy a position directly in front instead of behind this eminence. It is easy to comprehend how the combined action of the two external pterygoid muscles, with a portion of the fibres of the masseter, may alone produce the dislocation when the mouth is wide open, and especially when, in consequence of a slight blow upon the chin, the anterior portion of the capsule becomes lacerated; for it must be noticed that the ascending ramus, with its prolonged condyloid process, constitutes a lever of the first kind, in which the temporal muscle, attached to the coronoid process, the masseter, and even the mastoid process, constitute the fulcrum, the anterior portion of the capsule, the weight, and the force acting against the front of the chin, the power. In this position of the condyle, drawn upwards and forwards by the action of the pterygoid and temporal muscles, the chin descends toward the neck, and the Fig. 207. Double dislocation of the inferior maxilla. coronoid process rests against the back of the superior maxilla, or against the malar bone at the point of its junction with the upper maxillary. The temporal, masseter, and internal pterygoid muscles are very much upon the stretch, if not more or less lacerated. Symptoms. —The mouth is widely open and the jaw nearly immovable. It has been noticed generally that the chin may be slightly depressed, but that owing probably to the pressure of the coronoid process against the body of the upper maxilla, or against the malar bone, it is generally impossible to elevate the jaw in any degree whatever. The jaw is also slightly advanced; a depression, covering a considerable space, exists between the auditory canal and the posterior margin of the condyle. A slight fulness is observed in the temporal fossa and also upon the side of the cheek in the region of the masseter muscle. Ordinarily the patient suffers considerable pain, but not always, from the pressure of the condyles upon the branches of the temporal nerves. There is a constant flowing of the saliva from the mouth; the patient 486 DISLOCATIONS OF THE LOWER JAW. is unable to articulate, and even deglutition is performed with great difficulty. Prognosis. —"When the dislocation remains unreduced, the lower jaw gradually approximates the upper, and its anterior projection sensibly Fig. 208. Double dislocation of the inferior maxilla. diminishes, the saliva ceases to dribble from the mouth, deglutition and speech are restored, mastication is performed with considerable ease, and in short, the patient comes at length to experience no great inconvenience from the displacement. Robert Smith relates the case of a woman whose lower jaw was dislocated during an epileptic convulsion. She was at the time in one of the metropolitan hospitals, but the accident was not noticed by the surgeons, and it remained ever afterwards unreduced. At the end of a year she could close the lips perfectly, but was able to open the mouth only to a limited extent; the teeth of the lower jaw remained advanced, the involuntary flow of saliva had ceased, and the faculty of speech had been regained 1 In Professor Webster's case, to which I have before referred, although the jaw was immediately and easily reduced, after the lapse of several years when I saw the lady, she still complained that it hurt her whenever she eat, and that she often felt the condyles slip in their sockets. Reduction has been accomplished by Physick in the case already related after the lapse of several weeks; Sir Astley reduced a double dislocation after one month and five days, which had been overlooked by the surgeon in attendance; 2 and Donovan succeeded after ninetyeight days. 3 Treatment. —Reduction may generally be accomplished with ease in cases of recent luxation, in the following manner: The patient being seated upon the floor with his head between the knees of the operator, a couple of pieces of cork, gutta percha, or pine wood are placed as far back between the molars as possible, when the surgeon seizing upon the chin draws it steadily upwards, taking care not to draw it forwards at the same time, since by this movement he would resist the action of the muscles which naturally tend to restore it to place whenever the condyloid processes are lifted sufficiently from the zygomatic fossae. Many surgeons prefer to sit or stand in front of 1 Robert Smith, on Fractures and Dislocations. Dublin, 1854, p. 288. 2 Sir Astley Cooper, on Disloc. and Frac, Amer. ed., p. 316. 3 Donovan, Amer. Journ. Med. Sci., Oct. 1842, p. 470, from Dublin Med. Press, May 25,1842. 487 SINGLE, OR UNILATERAL DISLOCATIONS. the patient, and depress the condyles by means of the thumbs placed inside of the mouth and upon the tops of the molars. If the thumbs are used in this way, it would be well to protect them with a piece of leather, or to slip them off from the teeth suddenly when the condyles are gliding into their places, as the muscles sometimes close the mouth with sufficient violence to bruise severely anything which might at this moment be interposed between the teeth. The method practised by Ravaton, of simply lifting the chin gradually and forcibly toward the upper jaw, was essentially the same, but far less efficient; for although he placed nothing between the molars to serve as a fulcrum, the backmost teeth themselves must in some degree perform this service whenever the lower jaw being dislocated and drawn upwards, the chin is forcibly approximated toward the upper. In other cases it has been found necessary first to disengage the coronoid process, by depressing the chin gently, and then pressing backwards in the direction of the articulation; a method which would certainly deserve a trial in case of the failure of that first described. This was the method practised by Hippocrates. A more effectual expedient, however, consists in reducing one side at a time; taking good care always that the side first reduced is not reluxated while the attempt is being made to reduce the other, a thing which happened in one of the cases treated by Sir Astley Cooper, and has happened many times in the practice of other surgeons. Finally, if all other expedients fail, we ought not to hesitate to resort to anaesthetics, nor indeed could any objection exist to their employment at any period of the treatment, were it not that in a large majority of cases the reduction is effected so easily and promptly as to render their employment wholly unnecessary. After the reduction is accomplished, it will be a matter of wise precaution to sustain the jaw by a double-headed bandage passed under the chin, and secured upon the top of the head, so as to prevent the mouth from being accidentally opened too far, especially during sleep, since experience has shown that a tendency to a reproduction of the dislocation remains for some time. It will be prudent to continue these measures of protection for at least one week; after which the danger of anchylosis should be borne in mind, and the extent of passive motion should be gradually and cautiously increased. In illustration of this tendency to reluxation, Malgaigne refers to the case mentioned by Putegnat of a woman whose jaw for many years became luxated at least once a month; but she was always able to reduce it herself. § 2. Single, or Unilateral Dislocations. The causes of this accident are in general the same as those which produce double dislocations, and it occurs most often in middle life. Tartra has seen one exceptional example in a child only fifteen 488 DISLOCATIONS OF THE LOWER JAW. months old, and Levison saw a case in an old man who had lost all his teeth. 1 Symptoms. —The mouth is open, but not so widely as in double dislocation; the jaw is nearly immovable; the teeth are advanced; the condyloid process can be felt in front of the articular eminence, leaving a depression in its natural situation, and the coronoid process is more prominent than in the bilateral dislocation. It will be remembered that we have already pointed out an important diagnostic mark between a fracture of the neck of the vertical ramus and a dislocation of one condyle. In the latter the chin inclines to the opposite side, while in the former it falls toward the side upon which the accident has occurred. According to Hey, this lateral deviation of the chin is not always present in dislocations; and Robert Smith mentions one case in which the surgeon was misled by this circumstance so far as to attempt a reduction upon the left side when the dislocation was upon the right. Treatment. —The same rules of treatment which we have established for dislocations of both condyles will be applicable to the single dislocations, with only such modifications as will be naturally suggested to the surgeon. In the case mentioned by Levison, the dislocation was constantly recurring upon the left side; and it was especially liable to happen when just awakening from sleep. "He would then pull his jaw, press it backwards, when, after about half an hour's work, bang it seemed to go, and all was right again." This old gentleman was finally relieved of these annoyances by a band fastened under the chin. In such a case, an apparatus constructed after the same plan as my lower jaw fracture apparatus might perhaps serve a useful purpose. § 3. Conditions of the Jaw simulating Luxations. There is a condition of the temporo-maxillary articulation called by Sir Astley Cooper "subluxation of the jaw," in which it is assumed that the condyles slip before the anterior margins of the inter-articular cartilages, and thus for the time render the jaw immovable. No positive evidence, however, has ever been presented, either by Sir Astley or others, that any such derangement of the joint apparatus does actually take place, the opinion being based, not upon dissections, but only upon the symptoms which are known to accompany the accident. It is quite probable that this explanation of the phenomenon in question is the true one, yet it is not impossible that it has no relation whatever to the intra-articular cartilages, but that it indicates a true subluxation of the inferior maxilla upon the zygomatic eminences. It occurs mostly in young people, and in those of a feeble or scrofulous diathesis. Relaxation of the capsule, ligaments, and muscles about the joint may, therefore, be regarded as the principal predispos- 1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 38S, from London Lancet. 489 CONDITIONS OF THE JAW SIMULATING LUXATIONS. ing causes. The exciting causes are generally yawning, or biting upon some very hard substance. The symptoms are a sudden arrest of the motions of the jaw, with the mouth about half open, the arrest of motion being accompanied or preceded generally with a sensation of slipping in one of the articulations. The chin is slightly inclined to the opposite side. The condyle may be felt somewhat advanced in its socket, and while it remains in this position the patient experiences some pain. Frequently the condyle resumes its place spontaneously, or after a slight lateral motion of the jaw; but at other times it requires some little manual force to replace it. I have myself, during several years of my early life, while pursuing my studies at college, experienced this accident many times. It was peculiarly prone to occur in the morning, and it became necessary that I should eat with some care at my first meal. Sometimes the locking of the jaw was upon the right and sometimes upon the left side; it was always painful. Generally the condyle was made to fall into place by a voluntary lateral motion of the jaw, but occasionally I was obliged to press gently against the chin with my hand. I never adopted any measures to remove the predisposition, but as I became older the annoyance gradually ceased. Benevoli, in a dissertation published at Florence, Italy, in the year 1747, describes another condition very analogous to this which we have now described, but which evidently depended upon a contraction of the muscles. A priest having opened his mouth very widely in gaping, found himself unable to close it. A surgeon who was called diagnosticated a dislocation of the jaw, and attempted to reduce it, but failing, Benevoli was called, who, observing " that the jaw was not absolutely immovable, that the articulations were not separated, and that the chin did not incline outwards or toward the sternum," concluded that it was only a contraction of the depressing muscles. He therefore prescribed fomentations and oily unctions. The same night the temporal muscles had acquired the size of a couple of eggs, from contraction, but the next day the patient could shut his mouth, and by the following day the tumefaction of the temporal muscles had also disappeared, and the restoration of the functions of the mouth was complete. Malgaigne, to whom I am indebted for the above case, relates two others, one in the person of the surgeon Mothe, and the other in a young man who was suffering from paralysis and spasmodic contractions of the muscles. Mothe observes that it had occurred to him very often, and that it still continued to happen sometimes, that when he gaped pretty widely, the genio-hyoid and mylo-hyoid muscles contracted with so much force as to render it impossible for him to close his mouth; these muscles being thus in a state of cramp, their bellies became hard under the chin, and so painful that he was obliged immediately to press upwards against the under surface of the chin in order to oppose their action. This condition would last from one to three minutes, and was relieved, generally, by frictions made with the hand 32 490 DISLOCATIONS OF THE SPINE. over the contracted muscles. Sometimes he actually believed that the lower jaw was dislocated, although the result always convinced him that it was not. CHAPTER III. DISLOCATIONS OF THE SPINE. Delpech and Abernethy denied the possibility of a dislocation of the spine, either in the cervical, dorsal, or lumbar region, without the concurrence of a fracture. Says Sir Astley Cooper: "I have never witnessed a separation of one vertebra from another through the intervertebral substance, without fracture of the articular processes; or, if those processes remain unbroken, without a fracture through the bodies of the vertebrae." He would not, however, be understood to deny the possibility of a dislocation of the cervical vertebras, their articular processes beingplaced more obliquely than those of the other vertebrae. The accident is, no doubt, exceedingly rare, at least without the complication of a fracture, and it is not improbable that the actual number is smaller than the reported examples would indicate. Those who make autopsies do not always perform their duties with that exact fidelity which might be necessary to determine so nice a point as a fracture of an oblique process, and it is quite likely that the circumstance may have been overlooked in some cases; but a considerable number of well authenticated examples of simple dislocations of cervical vertebrae have accumulated within the last fifty years. The reported examples of simple dislocations of the other vertebrae are not so numerous, nor as well attested. The causes are in general the same with those which produce fractures of the vertebrae, such as falls upon the head, feet, or back, and violent flexions of the spine backwards or to the one side or the other. Several examples are recorded of " spontaneous" dislocations, the result of some morbid changes in the bones or in the ligaments of the spinal column; which accidents seem to belong more properly to general treatises upon surgery. The symptoms, also, partake of the same general character with fractures; the accident being accompanied with more or less complete paralysis of those portions of the body which receive their nervous supply from below the point at which the dislocation has occurred; the spinal column presenting at the seat of displacement an angular projection or some form of irregularity; and the distortion beingattended with pain, especially when an attempt is made to move the body. In very many cases the symptoms are so nearly like those presented in a case of fracture, that the diagnosis is rendered exceedingly difficult. 491 DISLOCATIONS OF THE LUMBAR VERTEBRAE. The presence or absence of crepitus may aid in the diagnosis, and yet it is well understood that this symptom is often absent in simple fractures, and that it may be present in all those examples of dislocation which are accompanied with a fracture of an oblique process, or of any other portion of the vertebrae, which class of examples constitutes a large majority of the whole number. There is usually present, however, in the dislocation, whether partial or complete, a peculiar fixedness or rigidity of the spine, which serves to "distinguish this accident from a fracture of the spine as plainly as the preternatural rigidity of the limb in dislocations of the long bones, serves to distinguish these accidents from fractures of the same bones. The head, or upper portion of the spinal column is bent forwards, or backwards, or more commonly to one side, and in this position it remains immovably fixed until the reduction is accomplished. Some-v times, also, the surgeon may feel distinctly the lateral deviation of the spinous process, and, in the neck, the transverse processes become an important guide in the diagnosis. After these few general remarks, I shall proceed to speak of dislocations of the spine in the same order in which I have treated of fractures of the spine. § 1. Dislocations op the Lumbar Vertebrae. Sir Astley Cooper, plainly intimates that he does not believe a dislocation can occur in either the dorsal or lumbar region without the concurrence of a fracture, and Boyer affirms positively that it is '' entirely impossible." Without wishing ourselves to insist upon the actual impossibility of these accidents, we are prepared to affirm that no well-authenticated case has yet been reported; at least of a complete dislocation, unaccompanied with a fracture of the articulating apophyses. We can even conceive it possible that a lumbar vertebra may be dislocated forwards or backwards, and that a dorsal vertebra may be dislocated laterally without a fracture; yet we hardly think either of these events probable. What we urge, however, is that no evidence appears to be furnished that such a dislocation has actually occurred. Cloquet mentions the case of a " tiler" who fell from the roof of a house backwards, and dislocated one of the lumbar vertebrae. This patient lived many years after the accident, and at the autopsy it was found that the second lumbar vertebra had been luxated to the right by a movement of rotation about the left articular process, the two oblique processes of the left side preserving their connection, while those of the right were separated quite half an inch. The right vertebral plate was broken, and the canal of the vertebra was thus thrown open and widened. 1 Dupuytren says that a man was crushed by the falling of a bank of earth upon his loins, when in the act of bending forwards. On the third day he was brought to Hotel Dieu, when it was observed that 1 Cloquet, Malgaigne, from Jouru. des Difformites de Maisonabe, torn. i. p. 453. 492 DISLOCATIONS OF THE SPINE. his lower extremities were completely paralyzed; and that there existed in the upper part of the lumbar region, a hard tumor, by pressure upon which a crepitus was manifest. A second tumor could be distinctly felt in front through the abdominal parietes, and the length of the spine was evidently diminished. This man died on the sixth day from a gradual asphyxia. When the body was examined it was found that the last dorsal and first lumbar vertebras had been pushed forwards more than one inch, lacerating the spinal marrow, breaking the transverse and oblique processes of the last dorsal and first two lumbar vertebras, and tearing off a small fragment of the body of one of the vertebras where the intervertebral substance adhered to it. 1 These are all the cases of dislocation of the lumbar vertebras of which I am able to find any record. Both were accompanied with fractures. In neither case was any attempt made to reduce the dislocations. In the second, it is scarcely probable that any means could have been employed which would have succeeded in restoring the bones to their places; nor is it probable that if the bones had been restored to place, the patient would have survived the accident a day longer, probably not so long. The cord was greatly lacerated, and the diaphragm torn up and displaced, rendering a recovery almost impossible. In the first example, where the dislocation was less complete, and the complications less grave, could reduction have offered any reasonable chance for relief? By extension, combined with a movement of rotation in a direction opposite to that in which the displacement had taken place, it is possible that a reduction might have been accomplished. The attempt certainly would have been justifiable; but since the man lived " many years" without the reduction, it is doubtful whether the result of a reduction would have been more fortunate. § 2. Dislocations of the Dorsal Vertebrae. Malgaigne enumerates twelve examples of dislocations of the dorsal vertebras. I have found reported by American surgeons, at dates too recent to have been included in his analysis, two other examples; but of this number only three are claimed to have been simple dislocations, unaccompanied with fracture. One of the fourteen was a dislocation of the fifth dorsal vertebra upon the sixth, one of the eighth, two of the ninth, five of the eleventh, and five of the twelfth. The relative frequency of their occurrence in the different vertebras corresponding with the observation of Weber, as to the points of the spinal marrow which allow of the greatest freedom of motion, and are consequently most liable to dislocations. The direction of the displacement in ten cases, was observed to be six times forwards, twice backwards, and twice to the one side. Two of those which were unaccompanied with fracture, occurring respectively in the tenth and sixth dorsal vertebras, were examples of a dislocation forwards, and the third, belonging to the ninth vertebra, 1 Dupuytren, Injuries and Dis. of Bones, Syd. ed., p. 340. 493 DISLOCATIONS OF THE DORSAL VERTEBRAE. was a dislocation backwards. A lateral luxation without fracture lias not been recorded. It is worthy of remark, also, that these three examples, being all which our science up to this moment possesses, have happened in the experience of the same surgeon. 1 A moment's consideration of the anatomy of these processes will render it apparent that even a partial luxation forwards without a fracture of the oblique apophyses is impossible, and that in the direction backwards, the luxation can only occur to the extent of about onequarter of an inch, constituting only a species of articular diastasis, without breaking off the articulating apophyses of the lower corresponding vertebra. The first two examples, therefore, notwithstanding they have been received without question by Malgaigne, I shall unhesitatingly reject. The third, which alone carries evidence of its having been correctly reported, and which was only a partial dislocation, is related as follows: " A mason having fallen from a height in such a manner as that the lower part of his back struck upon the angle of the upper step of a ladder, died on the following day. After death it was observed that the spinous processes of the dorsal vertebras were prominent down to the tenth; and that the tenth process with all of the processes below were depressed. It was also noticed that this depression, very marked when the trunk was thrown backwards, gradually diminished and finally disappeared altogether when the body was bent forwards. On removing the soft parts it was found that the ligaments were extensively torn asunder and detached, so as to permit the articulating apophyses of the tenth vertebra to be carried into contact with the back of the ninth. The spinal marrow had undergone no visible alteration. 2 Malgaigne thinks he has once observed the same thing on a living subject, and that by simply bending the body forwards he accomplished the reduction and effected a perfect cure, except that a slight curvature remained at the point of injury. Among the cases reported as having been complicated with fracture, the following example, reported by Dr. Graves, of New Hampshire, to Dr. Parker, of this city, possesses unusual interest. On the second day of Jan. 1852, a man, set. 25, was struck on the back while in a stooping posture by a falling mass of timber, causing a dislocation of the last dorsal upon the first lumbar vertebra. His lower extremities were completely paralyzed, and priapism continued for several hours. The surgeon determined to make an attempt at reduction, and for this purpose he placed the patient upon his face, and secured a folded sheet under his armpits and another around his hips, directing four strong men to make extension and counter-extension by these sheets. Chloroform was administered, and when the patient was completely under its influence, the extending and counter-extending forces were applied, and in a few minutes the vertebras glided into place with a distinct bony crepitus. The restoration of the line of the vertebral column was found to be nearly but not quite perfect. On the sixteenth day he began to have slight sensations in his feet, 1 Melchiori, Gaz. Medica, stati sardi, 1850. 2 Melchiori, loc. cit. 494 DISLOCATIONS OF THE SPINE. and at the end of six or eight weeks he was able to control the evacuations from the bladder and rectum. Several months later he had recovered so completely as to walk with only the aid of a cane. 1 I know of only one similar case. Rudiger has published an account of a dislocation obliquely backwards and to the right side, which occurred at the same point in the spinal column. The subject was a musketeer, who had been struck upon his back by a falling wall which he was endeavoring to pull down. Rudiger laid him upon his belly, and by the assistance of others he was able, but not without causing pain, to reduce the bones. Immediately, however, when the extension was discontinued, the action of the muscles caused the displacement to recur. The surgeon then directed four men to make extension, while another man retained the bones in place by pressing upon them with his hands. After several hours this method of pressure was replaced by a board underlaid with compresses and sustaining a weight of more than fifty livres. On the following day it was found sufficient to bind compresses over the projecting bone, and in this condition the patient remained fifteen days; during all of which time he lay upon his belly with his shoulders more elevated than his pelvis. On the twentieth day he could lie upon his back, and in about six weeks he was so completely restored as to be able to pursue his trade as before! 2 This is certainly a very extraordinary case, whether considered in reference to the means employed to restore the bones to place, or to its results: and if the statements are to be received at all, it must be with some hesitation and allowance. On the other hand, we are able to present at least one example in which, although no reduction has been accomplished, the patient has survived the accident many years; yet it must be admitted that his recovery is far from having been as complete as in the two cases just mentioned. Joseph Stocks, set. 11, in the spring of 1826, was crushed under the body of an ox-cart in such a manner as to produce a dislocation of the last dorsal from the first lumbar vertebra, causing immediately almost complete paralysis of all the parts below. This young man was seen by Dr. Swan, of Springfield, Mass., in the summer of 1834, at which time he was occupied as a portrait painter. His lower extremities remained paralyzed and of the same size as at the time of the receipt of the injury. He was unable-to sit erect owing to the mobility of the spine at the seat of dislocation, and he had therefore lain constantly upon his side. The upper portion of his body was well developed, and his intellectual faculties were of a high order. 3 It is not, however, with a life of perpetual deformity that the two examples of reduction already described are to be contrasted. A result so fortunate as this, where the bones remain unreduced, is unique; in all the other cases reported the patients died miserably after periods ranging from a few days to one year or a little more. 1 Graves, N. Y. Journ. Med., March, 1852, p. 190. 2 Rudiger, Journ. de Chir. de Desault, torn. iii. p. 59. 3 Swan, Bost. Med. and Surg. Journ., vol. xxii. p. 102, March, 1840. 495 DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAE. Charles Bell has related the case of an infant who was run over by a diligence, and who died thirteen months after the accident. On examination after death the last dorsal vertebra was found to be completely luxated backwards and to the left, upon the first lumbar vertebra. 1 With these facts before us, I think we cannot hesitate when the nature of the accident is fully made out, and especially when the dislocation has occurred in the lower dorsal vertebrae, to attempt the reduction by forcible extension, united with judicious lateral motion, or with a certain amount of direct pressure upon the projecting spines. § 3. Dislocations of the Six Lower Cervical Vertebra. It is much more common to meet with simple luxations of the vertebrae of the neck uncomplicated with fractures, than of either of the other vertebral divisions. This is doubtless owing to the greater extent of motion which their articulating surfaces enjoy. They may be dislocated forwards or backwards. The forward luxation may be complete or incomplete; with both sides equally advanced ("bilateral" of Malgaigne), or one of the articulating apophyses may be dislocated forwards, leaving the opposite apophysis in its place (" unilateral" of Malgaigne). Schranth 2 has collected twenty-four examples of luxation of the cervical vertebrae, of which four are recorded as dislocations forwards, two back, and six to the one side or the other. Three of this number were dislocations of the atlas; two were dislocations of the second vertebra; five of the fourth ; two of the fifth ; two of the sixth, and one of the seventh. In the other' cases the seat was not stated. Malgaigne has brought together forty-five examples; of which twenty-one were complete forward luxations, nine incomplete forward luxations, nine unilateral and forwards, and four were backward luxations. There were dislocations of the second vertebra upon the third, four were dislocations of the third vertebra, ten of the fourth, eleven of the fifth, fifteen of the sixth, and two of the seventh. The bilateral forward luxations are generally caused by a fall upon the top and back of the head, or upon the top of the head while the neck is very much flexed forwards. The unilateral is caused generally by a direct blow upon the back of the neck, the blow being probably directed somewhat to one side or the other. The number of backward luxations which have been reported are too few to enable us to indicate very accurately the general causes, but it seems probable that they are most often occasioned by a fall upon the fore and top part of the head, received while the neck is bent forcibly back. In dislocations of the cervical vertebrae forwards, the head is usually depressed toward the sternum; in dislocations backwards the head is thrown back, and in unilateral dislocations the head is turned over 1 Charles Bell, on Injuries of the Spine. 1824. 2 Schranth, Amer. Journ. Med. Sci., May, 1848, from Archiv. for Phys. Heilkunde. 496 DISLOCATIONS OF THE SPINE. one of the shoulders. Neither of these malpositions of the head is uniformly present in these several dislocations, and indeed not unfrequently, especially in case the system is greatly shocked by the accident, the head and neck assume a preternatural mobility, and may be turned easily in any direction. The spinous process, unless the patient is very fleshy or considerable swelling has supervened, can easily be felt, and its deviations to the right or to the left, forwards or backwards, furnish us with the most valuable and important sign of the dislocation. Even the transverse processes may be felt sometimes, especially in the upper part of the neck, with sufficient distinctness to render them useful in the diagnosis. To these circumstances we may add paralysis of the body below the seat of injury, with pain and swelling at the point of dislocation. In some cases also the patient has himself distinctly felt a cracking or sudden giving way in the neck at the moment of the accident. Prognosis. —The complete bilateral luxations, whether backwards or forwards, have in most cases terminated fatally within a short time, generally within forty-eight hours. Unilateral luxations are less speedy in their results, but when the dislocation remains unreduced, death generally takes place in a month or two. Lente, of this city, relates a case of incomplete dislocation of the fifth cervical vertebra backwards, unaccompanied with fracture, which accident the patient survived five days. 1 A patient of Eoux's lived eight days; but in the case of a second patient mentioned by Lente, with a complete luxation, without fracture, of the fifth vertebra, the patient survived the injury only two hours. 2 On the other hand, occasional examples are presented of partial or complete recovery with the luxation unreduced. Horner, of Philadelphia, presented to the class of medical students of the University of Pennsylvania in 1842, a lad set. 10, who had fallen a distance of twenty feet, alighting upon his head. He was found senseless and motionless, with his head bent under his body. He gradually recovered from the shock, but his neck was stiff* distorted, and motionless, his face being inclined downwards to the right side. Two days after, his " common and accurate perceptions returned, but he was affected for some time with tingling and numbness in his left arm." When presented to the class the transverse processes, from the fifth upwards, were about half an inch in front of those below, showing that the left oblique process of the fourth was dislocated forwards upon the fifth. The rotary motions of the neck could now be executed to some extent, but much more freely to the right than to the left. Professor Horner refused to make any attempt to reduce the dislocation. 3 Dr. Purple, of New York, has reported a case of what was called a dislocation of the fifth and sixth cervical vertebras, producing complete paralysis of the lower part of the body, in which the patient survived 1 Lente, New York Journ. Med., May, 1850, p. 284. 2 Lente, ibid., p. 397. 3 Horner, Ainer. Journ. Med. Sci., April, 1843, from Med. Exam. 497 DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA. the accident many years; but his lower extremities were so useless and cumbersome as to induce him, in the year 1851, six years after the injury had been received, to submit to the amputation of both at the hip-joint. In 1852, having become very intemperate, he died, but no autopsy was obtained, so that the exact character of the injury was never ascertained. 1 Sanson, of Paris, has reported also a case which came under his observation at Hotel-Dieu, of dislocation of the " third cervical vertebra backwards," from which, although unreduced, the patient partially recovered. The character of this accident was not much better determined; for, although he felt a severe and sharp pain at the moment of the injury, which was greatly aggravated by motion, and his head was bent forwards and to the left, "the chin being fixed on the upper part of the sternum," there was no paralysis of either the motor or sentient nerves. After the lapse of about four months he left the hospital, still unable to lift his chin more than four inches from the sternum; after which he resumed his usual occupations, suffering no further inconvenience than what was occasioned by the unnatural position of his head. 2 Notwithstanding the authoritative testimony of Sanson that this was a dislocation backwards, one cannot avoid the conclusion that it was either a unilateral subluxation, or perhaps a mere diastasis of the articulation, or else that it was an example of sprain of the muscles, and consequent contraction of one set, or paralysis of the opposing set of muscles. It is certain that it was not a complete luxation, nor, since there was no paralysis of the body below the point of injury, can it be properly made use of as an argument for non-interference where such paralysis does actually exist. Let us see now what encouragement an attempt at reduction may offer, in a case which presents so little ground of hope where the reduction is not accomplished. Dr. Spencer, of Ticonderoga, N. Y., relates that a man, set. 50, fell backwards from a board fence, striking upon the superior and anterior portion of his head, dislocating the second from the third vertebra of the neck. His head was thrown back so far as to prevent his seeing his own body, and all below the injury was completely paralyzed. Repeated attempts were made to reduce the dislocation, "but the transverse processes had become so interlocked that every effort proved abortive," and he died forty-eight hours after the injury was received. 3 Gaitskill also attempted reduction in a case of dislocation of the seventh cervical vertebra, but failed. 4 Boyer failed in two cases. It is related by Petit Radel, that a young patient at La Charite expired in the hands of the surgeons, upon such an attempt being made a few days after the accident ; 5 and Dupuytren says " the reduction of these dislocations is very dangerous, and we have often known an individual perish from the compression or elongation of the spinal marrow which always attends these attempts." 1 Purple, New York Journ. Med., May, 1853, p. 319. 2 Sanson, Amer. Journ. Med. Sci., Feb. 1836, p. 514 ; from Gaz. des Hopitaux. 3 Spencer, Boston Med. and Surg. Journ., vol. x. No. 11. 4 Gaitskill, London Repository, vol. xv. p. 282. * Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. 118. 498 DISLOCATIONS OF THE SPINE. Dr. Shuck, of Vienna, relates that a man, ast. 24, while engaged at his work on the fifth of Dec. 1838, twisted his head suddenly round, in consequence of one of his companions roaring into his ear, when he instantly felt something give way in his neck, and found it impossible to move his head. Next morning his head was turned to the right and bent down toward the shoulder. Every attempt to move his head caused great pain. He complained of weakness in his right arm, but all the other functions of his body were perfect. An attempt was immediately made to reduce the dislocation by lifting him by the head, but without success. On the 7th of Dec, the weakness and numbness of the right arm had increased, and the attempt to reduce the bones was renewed. The patient was laid horizontally upon a bed, and extension made from the chin and occiput while counter-extension was made from the shoulders. The force thus employed was gradually increased until the patient and assistant felt a snap as of two bones meeting, when it was found that the head was restored to its natural position, and the power of moving it had returned. The next day his arm was more powerless than before, and on the following day he had vertigo, but these symptoms soon yielded to copious bleedings, and he left the hospital cured on the 13th. 1 Dr. Hickerman, of Ohio, has reported also in the Ohio Medical Journal, a case of dislocation of one of the cervical vertebras, the original account of which I have not seen, but only an abridged statement published in the Buffalo Medical Journal. By exploring the pharynx a prominence was felt opposite the junction of the fourth and fifth cervical vertebras; and the action of the heart was barely perceptible. Seizing the patient's head under his left arm, Dr. Hickerman in this manner made traction, while, with the index finger of the right hand in the patient's throat, he made firm pressure obliquely upwards, backwards, and to the left; after continuing the pressure for about forty or fifty seconds, the part against which the finger was placed gradually, yet quickly, receded in the direction in which the pressure was made, and instantly, as quickly indeed as the act could be possibly executed, the patient opened her eyes, and natural respiration was established. She then also immediately became conscious of what was transpiring about her, and signified by signs, for she was yet unable to speak, that she had suffered pain in the epigastrium. Complete recovery took place. 2 Schranth received under his care a patient who had a luxation of the "right transverse apophysis" of the fourth cervical vertebra, without lesion of the spinal marrow, which he reduced on the seventh day. The first attempt was unsuccessful; but the second, made with great caution, by the aid of four assistants, three of whom pulled the head upwards while the fourth pressed with his whole weight upon the shoulders, was completely successful. During the time that the traction was being made, the head was occasionally rotated slightly and moved laterally, and at the same moment the surgeon pushed 1 Shuck, Amer. Journ. Med. Sci., July, 1841, p. 207. 2 Hickerman, Buf. Med. Journ., vol. x. p. 702, April, 1855. 499 DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAS. firmly against the displaced apophysis. The reduction was attended with " various distinct crackings in the neck," which were loud enough to be heard. After some days of repose he resumed his occupation, no stiffness-remaining in the movements of the neck. 1 Dr. Edward Maxson, of Geneva, N. Y., was called on the 28th of Oct. 1856, to see a child about nine years old, who had met with a similar accident about forty hours before, namely, a dislocation of the right articulating apophysis of the fifth or sixth cervical vertebra, occasioned by suddenly turning her head around while at play. She at first complained only of pain and inability to straighten the neck; but whenever moved she became faint and irritable. A short time before the surgeon was called the mother had, in attempting to move her in bed, turned the face a little more to the left, when a severe convulsion immediately ensued. On examining the neck Dr. Maxson discovered the displacement of the transverse process. Having advised the parents of the danger necessarily incident to an attempt at replacement, and of the probable consequences of its being permitted to remain as it was, they consented that the trial should be made. " I grasped the head," says Dr. M., "with both hands, and proceeded according to Desault's method, only I first carried or turned the face very gently a little further toward the left shoulder, to, if possible, disengage the process; then lifting or extending the head, I turned the face very gently toward the right shoulder, when the difficulty was at once overcome, and she exclaimed: ' I can move my eyes.' Her countenance soon acquired a more natural appearance; the faintness passed off; she rested quietly through the night; had no return of the difficulty, and needed only an emollient anodyne to soothe the irritation and slight swelling which remained at the point of injury." 3 Bust, 3 Wood, of this city, 4 and others, have seen and reported similar cases attended with like success. So far the cases of successful reduction which we have described are examples of dislocation of only one of the articulating apophyses, and they are sufficiently numerous to establish the value of the practice. We have now to relate a case in itself unique, namely, a successful reduction of a dislocation of the fifth cervical vertebra, in which both apophyses appear to have been thrown forwards. It occurred in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y., and will be best understood by a reproduction of his own published account of the case. " E. K., the subject of this accident, was a laboring man, thirty years of age, tall and muscular, but not fat, with a neck longer than the average among men of equal height. On the evening of the 2d of October he became intoxicated, was brought home insensible, and did not recover from the combined effects of the shock and his libations until the following morning, when he was supposed by his wife to be laboring under cold and a stiff neck. She made some domestic applica- 1 Schranth, Amer. Journ. Med. Sci., May, 1848. 2 Maxson, Buffalo Med. Journ., Jan. 1857, p. 479. 3 Rust, Chelius, note by Smith. 4 Wood, New York Journ. Med., Jan. 1857, p. 13. 500 DISLOCATIONS OF THE SPINE. tions to the affected part, and administered a dose of cathartic medicine. When it was thought sufficient time had elapsed without obtaining relief, he was seen by Dr. Potter, of this city, and afterwards by Dr. Cullen, both of whom recognized a condition which was not only very unusual, but one which they had never before observed. I was then requested to examine the case, which I did on the ninth day after the accident. With some assistance and great personal effort, he was able to get out of bed, moving very slowly and cautiously. Desiring to expectorate, he was obliged to get down on his hands and knees, which he accomplished with the same deliberation. When seated in a chair, the head was thrown back and permanently fixed; the face turned upward with an anxious expression. The anterior portion of the neck, bulging forwards, was strongly convex, rendering the larynx very prominent. The integuments of this region were exceedingly tense and intolerant of pressure. The posterior portion of the neck exhibited a sharp, sudden angle at the junction of the fifth and sixth cervical vertebras, around which the integuments lay in folds. It was difficult to reach the bottom of this angle even with strong pressure of the fingers, and of course the regular line formed by the projecting spinous processes was abruptly lost. He complained of intense and constant pain at this point, which was neither relieved nor aggravated by pressure. With difficulty he swallowed small quantities of liquid, pausing after each effort, and could not be induced to take solid food, since the first attempt to do so after the accident was followed by violent paroxysms of coughing and choking. His breathing was obstructed and somewhat labored, being unable fully to clear the bronchia of their secretion. This, however, seemed rather an effect of the tense condition of the soft parts of the neck, than the result of pressure upon the spinal cord, since he presented no evidence of paralysis, either of motion or sensation, in parts below the neck. The sterno-cleido-mastoid muscles of both sides were felt quite soft and relaxed. " But one conclusion could be formed upon this state of facts, to wit: that the oblique processes of both sides were completely dislocated. The marked rigidity of the head seemed to preclude the probability of fracture through the vertebral bodies, and although the cartilage might be separated anteriorly, yet, the body not pressing backwards sufficiently to produce paralysis of the cord, it was hoped that the posterior vertebral ligament remained uninjured; it was, therefore, determined to make an effort at reduction on the following day. In addition to those originally connected with the case, I am under obligations to Drs. Ingraham, Turner, Palmedo, G. D. Ayres, and a number of other medical gentlemen who were present by invitation, all of whom confirmed the diagnosis, and rendered efficient services. " The patient was placed upon a strong table in a recumbent position, with a pillow resting under the shoulders, the head being supported by the hand during the administration of chloroform, of which an ounce was given before anaesthesia ensued. Counter-extension being made by two folded sheets placed obliquely across the shoulders 501 DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA. and properly held, the head was grasped by one hand placed under the chin, the other over the occiput, and by steadily and firmly drawing the head directly backwards, and then upwards, an attempt was made at reduction, but failed for want of sufficient power. Dr. Ingraham was then requested to place his hands immediately over my own in the same position as before, and steady traction was again made in the same direction. Our united strength was required in drawing the head backwards and upwards, to dislodge the superior oblique processes from their abnormal position. When this was felt to be yielding by Dr. Cullen (who kept one hand constantly at the seat of dislocation), Dr. Potter was directed to place his hands under our own, still in position, and assist in bringing the head forwards; at the same time the chest was depressed toward the table. The bones were distinctly felt to slip into their places; the line of the spine was instantly restored, the head and neck assuming their natural position and aspect. As soon as the patient became conscious, he expressed himself ignorant of what had taken place, but free from pain, and, in his own language, 'all right.' A bandage was arranged to support the head and keep it bent forwards. He had an anodyne for two nights following, after which no further treatment was necessary, and at the end of one week he had complete control over the movements of the head and neck. Be- Fig. 209. Ayres' case of bilateral dislocation of the fifth cervical vertebra. yond the debility and emaciation immediately dependent upon protracted fasting and loss of rest, he has experienced no uneasiness since the operation. His appetite is now good, and all the functions perform their duty normally. In a subsequent inquiry, to determine if possible the cause of the accident, he states that he distinctly recollects going into a store in Atlantic Street, near the ferry, and there having angry words with an acquaintance; that he left the store and was proceeding up the street (which is here a rather steep ascent), when he was violently struck from behind, over the lower portion of the neck. He likewise remembers falling forwards and striking against some object, but does not know what it was, nor what took place until the following morning." 1 1 Ayres, New York Journ. Med., Jan. 1857, p. 9. 502 DISLOCATIONS OF THE SPINE. § 4. Dislocations op the Atlas. Surgeons have met with several forms of displacement between the atlas and axis. First, a forced inclination forwards of the atlas upon the axis; in consequence of which the body or anterior arch of the atlas is made to recede from the odontoid process, and the transverse ligament glides upwards without breaking, so that the extremity of the odontoid process comes to occupy a position underneath or behind the ligament, and thus presses upon the cord. It is apparent also that this form of displacement cannot occur without a rupture of the vertical ligament which binds the transverse ligament to the axis, nor without a separation of the atlas from the axis posteriorly and a rupture of the posterior atlo-axoidean ligament. Second, a similar inclination of the atlas, accompanied with a rupture of the transverse and superior vertical ligaments, in consequence of which also the odontoid process is allowed to fall upon the cord. Third, the atlas in the same position, with the odontoid process broken at its base. Fourth, the atlas displaced directly forwards or backwards; and fifth, a displacement of only one articular process in a direction forwards. We have already, when speaking of fractures of the atlas, or of the atlas and axis together, called attention to several examples of that form of the dislocation which is accompanied with a fracture of the odontoid process. The other forms of dislocation are characterized by so few symptoms peculiar to themselves, or which can be regarded as diagnostic and not already sufficiently studied in connection with other dislocations of the neck, that we shall not deem it necessary to do more than remind our readers that if permitted to remain unreduced a speedy and fatal issue is inevitable, and to point them to a couple of examples of recovery, after reduction has been fortunately accomplished, for both of which I am indebted to Malgaigne. These may alone suffice to show that Dupuytren was in error when he declared that such accidents were wholly beyond the resources of our art. An old man received upon his head a bundle of hay cast from the top of a wagon. He fell with his head bent forwards so that his chin touched the top of the sternum, and in this position it remained immovably fixed; all the other portions of his body preserved their natural functions. A surgeon, who was indeed the father of Malgaigne, being called, assured -the patient that unless he could give him relief he certainly would die; but that inasmuch as the attempt might itself prove fatal, he ought at once to put in order his affairs. Accordingly the man partook of the sacrament; then the surgeon seated him upon the ground, and placing himself at his back with his knees resting upon his shoulders for the purpose of making counter-extension, and with a towel brought over his own shoulders and under the chin of the patient for extension, he proceeded to act upon the neck in the direction of the axis of the spine. The efforts were long and painful, but at last, while the head was lifted as far as possible, it was suddenly drawn backwards, and immediately it resumed its natural direction. 503 DISLOCATIONS OF THE DEAD UPON THE ATLAS. Absolute quietude was enjoined, and the patient recovered in a short time and without any accident. This patient was seen two years after by the younger Malgaigne, at which time no trace of the accident remained, except an impossibility of turning the head to the right or to the left. The other example is related by Ehrlich, but in this case the dislocation was backwards. A young man, set. 16, while carrying a sack of flour up a ladder, fell backwards, and the sack falling over upon his face and head came to the ground before him. He was found lying with his head thrown back and to the right, the head resting upon the scapula of this side, but having so completely lost its " solidity" that by its own weight it would fall from one side to the other. On the front and left side of the neck there existed a prominence supposed to be formed by the atlas; the patient was unconscious; the pulse was scarcely perceptible, and the whole body was suffering under paralysis. Ehrlich directed the shoulders to be held by one assistant, and the head to be drawn upon by another, while he pressed with his own hands forcibly upon the displaced atlas from behind. After several fruitless attempts, the reduction took place, accompanied with a sound distinctly audible to all of the assistants; the head resumed its position firmly, and the arms began to move. The head was afterwards maintained in place by a bandage. The cure proceeded rapidly, and after a time no trace of the injury remained but a disagreeable tension in the nape of the neck whenever he moved his head briskly to the one side or the other. 1 § 5. Dislocations op the Head upon the Atlas, or Occipito-Atloidean Dislocations. Lassus, Palletta, and Bouisson 2 have each reported one example of this dislocation. In neither case was the dislocation complete, but death occurred speedily in every instance. Dariste exhibited to the Anatomical Society of Paris, in 1838, a specimen of incomplete luxation of the occipito-atloidean articulation, with stretching of the transverse ligament. The patient from whom the specimen was taken having lived more than a year after the accident, when he died from a tubercle in the brain. 3 1 Malgaigne, Ehrlich, Malgaigne, op. cit., torn. ii. p. 334. 2 Lassus, Palletta, Bouisson, Malgaigne, op. cit., p. 320. 3 Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Gen., May, 1838. 504 DISLOCATIONS OF THE RIBS. CHAPTER IV. DISLOCATIONS OF THE RIBS. The ribs may be dislocated from the sternum, from the vertebras, and from each other. Surgeons have also spoken of dislocations of the ribs from their cartilages, but these cases ought to be regarded as fractures of the cartilages, since there is no proper articulation at this point. § 1. Dislocations op the Ribs prom the Vertebrae. Examples of this dislocation have been mentioned by Ambrose Pare, Bransby Cooper, Alcock, Donne, Henkel, Kennedy, Buttet, and some others; but most of these reputed cases have not borne the test of a critical analysis, and while Vidal (de Cassis) is in doubt whether the claims of even one have been fully established, Boyer denies absolutely its possibility. We see no reason, however, to question the authenticity of several of these examples. The case mentioned by Bransby Cooper, although very briefly narrated, leaves no room for doubt as to its real character. " Mr. Webster, surgeon at St. Albans, when examining the body of a patient who had died of fever, found the head of the seventh rib thrown upon the front of the corresponding vertebra, and there anchylosed. Upon inquiry, Mr. Webster learned that this gentleman, several years before, had been thrown from his horse across a gate, for which accident he had been subjected to the treatment usually followed in fractures of the ribs, and there is every reason to believe that it was at this time that the dislocation occurred." 1 These accidents seem to have been generally occasioned by a fall or a blow upon the back, and the dislocation has been accompanied, usually, with a fracture of some other rib, or of the transverse or spinous processes of the corresponding vertebrae. The head of the rib has always been found to be displaced inwards. The lower ribs, including the false and floating, are those which have been most frequently displaced. It would be difficult, if not impossible, during the life of the patient, to make a positive diagnosis, since the symptoms resemble so closely those which accompany a fracture of the rib near its posterior extremity. The nature of the accident producing the dislocation, the depression, mobility, and pain, are equally indicative of a fracture; while the failure to detect crepitus might easily be explained by the thickness of the muscular walls at this point, or by the riding, or by other displacements of the broken fragments. 1 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. DISLOCATIONS OF THE RIBS FROM THE STERNUM. 505 Chelius speaks of a peculiar "rustling," perceived when the body and ribs are moved by the surgeon or by the patient himself, and which is different from the sensation produced by emphysema or fracture. The treatment ought to be the same which would be adopted in case the rib was broken. Replacement of the dislocated bone must be regarded as impossible; and it only remains that we insure quiet as far as possible in this portion of the chest, and combat the pain and inflammation by suitable remedies. The circular bandage, however, recommended in these cases by Sir Astley Cooper, could only be serviceable in dislocations of those ribs which have an attachment to the sternum; the floating ribs, which have been found dislocated quite as often as either of the others, could derive no support from circular pressure, or from any other mechanical contrivance. § 2. Dislocations of the Ribs from the Sternum. Charles Bell observes: " A young man playing the dumb bells and throwing his arms behind him, feels something give way on the chest; and one of the cartilages of the ribs has started and stand prominent. To reduce it, we make the patient draw a full inspiration, and with the fingers knead the projecting cartilage into its place. We apply a compress and bandage, but the luxation is with difficulty retained." Ravaton, Manzotti, and Monteggia, have each, according to Malgaigne, reported one example of traumatic dislocation; in all of which the cartilages were thrown forwards in advance of the sternum. By pressure alone they have generally been replaced, the cartilage resuming its position suddenly and with a sound. The reduction may, nevertheless, be facilitated by bending the trunk backwards or by directing the patient to make a full inspiration. To maintain the reduction has been found more difficult, and Sir Astley directs that "a long piece of wetted pasteboard should be placed in the course of three of the ribs and their cartilages, the injured rib being in the centre; this dries upon the chest, takes the exact form of the parts, prevents motion, and affords the same support as a splint upon a fractured limb. A flannel roller is to be applied over this splint, and a system of depletion pursued, to prevent inflammation of the thoracic viscera." Instead of the pasteboard, we might use either felt or gutta percha. The patients spoken of by Ravaton and Manzotti were both cured in about one month. Mr. Bransby Cooper says that a baker's boy applied for relief at Guy's Hospital, who was the subject of displacement of the cartilages of the fifth and sixth ribs from their junction with the sternum, produced partly by the constant action of the pectoral muscles in kneading bread, but principally by his defective constitution. Mr. Cooper stated to the boy the necessity of changing his occupation, and advised him to go into the country, but as he was unable to do so little hope was entertained of his recovery. 1 1 B. Cooper, ed. of Sir Astley Cooper, &c, op. cit., p. 447. 33 506 DISLOCATION'S OF THE CLAVICLE. § 3. Dislocation of one Cartilage upon Another. The cartilages of the sixth, seventh, and eighth ribs, at those points of their upper and lower margins which come in contact with each other, possess a true arthrodial articulation, being furnished with both ligaments and a synovial membrane. Sometimes, also, the same anatomical structure extends to the adjoining surfaces of the fifth and sixth ribs, as well as to the eighth and ninth. This displacement, of which Boyer, Martin, and Malgaigne, have each reported one example, may take place when one falls upon his back, striking upon some projecting body, so that the chest is suddenly thrown forwards; in consequence of which the upper margin of the lower cartilage is depressed and entangled behind the lower margin of the upper. The inferior cartilage is, therefore, the one which is displaced rather than the superior, although this latter being made prominent by the pressure of the other from behind, seems alone to be displaced. It is probable that the contraction of the pectoral and abdominal muscles has a chief agency in the production of these dislocations, and that they are not solely or directly due to the shock of the accident. The treatment consists in pressing firmly upwards and backwards against the inferior margin of the upper, or overlapping rib, so as to disengage it from the lower, when by its own elasticity it will resume its natural position. The reduction might also be aided by a lull inspiration. CHAPTER V. DISLOCATIONS OF THE CLAVICLE. Of 23 dislocations of the clavicle observed by me, 5 belonged to the sternal end and 18 to the acromial. Of those belonging to the .sternal end, 4 were dislocations forwards, and one was a dislocation upwards. I have never met with a dislocation backwards. Of the acromial dislocations, the whole number were dislocations upwards, or upwards and outwards. § 1. Dislocation Forwards at the Sternal End. Causes. —This accident is generally caused by a fall upon the point of the shoulder, in consequence of which the sternal end of the clavicle is driven forcibly inwards and forwards. It is probable, also, that the blow which produces the dislocation is received rather upon the anterior and outer face than exactly upon the extremity of the 507 DISLOCATION FORWARDS AT THE STERNAL END. shoulder. A sudden effort of the muscles, as in the attempt to balance a weight upon the head, or to throw the shoulders backwards, when under drill, has been known also to produce this dislocation. In one example it was occasioned by placing the knee against the spine and drawing the shoulders forcibly back. Various other accidents, the philosophy of whose agency is not so easily explained, are said to have produced the same result; but it is not improbable that in many of these cases, the precise manner in which the injury was received has not been correctly understood or reported. Mr. Fergusson has once seen this displacement in a newly-born infant, which had happened during birth. It could be replaced with ease, but immediately slipped out again when left to itself. " Nothing was done; a new joint formed, and the child afterwards possessed as much power in the one arm as in the other." 1 Symptoms. —The head of the bone, unless the person is exceedingly fat, or great swelling has supervened, can be distinctly felt and seen in front of the sternum; the corresponding shoulder falls a little back; the head inclining also sometimes to the same side; the movements of the arm are embarrassed, and accompanied almost always with an acute pain at the point of dislocation. The clavicular portion of the sternocleido-mastoid muscle presents anunusually sharp and projecting outline and a careful measurement indicates, if the dislocation is complete, a sensible approach of the acromion process toward the centre of the sternum. If now the surgeon places his knee against the spine, and draws the shoulders back, the projection of the clavicle in front diminishes or disappears; if he carries the shoulder up it descends; and if he depresses the shoulder, it ascends. The simplicity and uniformity of the symptoms which usually characterize this accident will generally prevent the possibility of a mistake; but Pinel mentions the case of a man who having presented himself at one of the Fig. 210. Dislocation of the sternal eud forwards. hospitals of Paris, suffering under this dislocation, the surgeon in chief thought it a tumor of the bone, and advised the application of a plaster; and, on the other hand, a patient presented himself to Velpeau, who had been treated for a dislocation, when the bone was only expanded by disease. I have myself also seen a fracture so near the sternal end of the bone as not to be easily distinguished from a dislocation. Pathology. —In complete anterior luxation of the clavicle, the capsular ligament suffers a complete disruption, and also the anterior with the posterior sterno-clavicular ligaments. The rhomboid and 1 Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 203. 508 DISLOCATIONS OF THE CLAVICLE. inter-articular ligaments suffer more or less according to the extent of the displacement. The inter-articular cartilage may retain its attachment to the sternum, or it may be carried forwards with the clavicle. The head of the bone lies immediately underneath the skin and in front of the sternum; and generally it is found to have descended a little upon its anterior surface. Eicherand saw a case in which the sternal extremity of the bone was placed three inches below the top of the sternum. Wherever the bone lies, it carries with it the clavicular fasciculus of the sterno-cleido-mastoid muscle. Treatment. —Not one of the five forward dislocations of the clavicle seen by me has been completely reduced, or if reduced they have not been retained in place. In the following example the reduction, although faithfully attempted, was never accomplished. Mr. H., of Buffalo, ast. 45, was thrown by a horse, suffering at the same moment a fracture of the leg and a forward dislocation of the left clavicle at its sternal end. Prof. James P. White, with whom I was in consultation, made several attempts to reduce the dislocation by placing the knee against the spine and pulling the shoulders forcibly back, and the same efforts were repeated by myself, but without accomplishing the reduction. We also endeavored to reduce it by pressing directly upon the projecting bone, and by placing a pad in the axilla, using the arm as a lever as recommended by Desault, and with no better result. This patient was tolerably muscular, but while we were manipulating he was very much enfeebled by the shock of the accident. Finding that it was impossible to reduce the dislocation by any moderate amount of force, and believing that if we were to succeed we could not retain the bone in place, and the more especially because his left side was so much bruised that he could not bear an axillary pad or bandages of any kind, we desisted from any further attempts. Two years later I examined the shoulder and found the clavicle still unreduced, and its position unchanged. When he carries the shoulder forwards or backwards, there is a corresponding motion at the sternal end of the clavicle. The arm is not quite as strong as the other, and its freedom of motion is slightly impaired. I have also in my museum the cast of a case of complete forward dislocation at this point; which accident occurred in a lad twelve years old, who had fallen into a cellar on the 20th of Aug. 1856. The late Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined the arm, and dressings had been applied with a view to maintain the reduction; but on the fifth day after the accident I found the bone displaced; nor do I think reduction was ever afterwards maintained. A lad was brought into the Buffalo Hospital of the Sisters of Charity, with a dislocation of the same character, on the 25th of Sept., 1858, who had been run over by a wagon on the same day. Dr. E. P. Smith, one of the surgeons of the hospital, attempted faithfully to reduce it, but was unable to do so. Five days after, I found the bone out and quite movable. All apparatus having been removed, we laid him upon his back in bed, and kept him in this position three weeks. DISLOCATION FORWARDS AT THE STERNAL END. 509 He was then dismissed, with no change in the appearance of the bone, but he could move the arm as well as before the accident. Other surgeons have not met with, or at least they have not mentioned any cases in which the reduction of this dislocation was attended with difficulty, nor am I prepared to explain the difficulty which was experienced in my own (Mr. H.), and in Dr. E. P. Smith's case. Probably they ought to be regarded as exceptions to the general rule. But most surgeons have testified to the difficulty of retaining it in place when reduction has been fairly accomplished. Chelius says, "there commonly remains more or less deformity," and Malgaigne says that "it is difficult and rare to cure it without deformity." Nevertheless Desault (or, rather, his pupil Bichat, who has published his lectures), who always speaks very confidently of his ability to retain either broken or dislocated bones in their places, says that he " almost always obtained complete success" with his apparatus. It is remarkable, however, that of the three examples furnished by Bichat to confirm this statement, all of which were treated by Desault "himself, one recovered after a long time with a "very perceptible protuberance in front of the sternum," one with a " very slight protuberance," and in the other the "swelling was almost gone" on the twentieth day, and we are left in doubt as to whether the reduction was any more corn- plete than in either of the other cases. 1 Bicherand and Guersant succeeded no better with Desault's dressings. 2 Other surgeons have made similar claims for their own forms of apparatus, but experience still continues to show that a complete retention of the dislocated bone is seldom to be expected. Sir Astley Cooper recommends an apparatus, the construction and application of which are illustrated by the accompanying sketch (Fig. 211), the object of which is to draw the shoulders back, and at the same time, by the aid of two pads or cushions in the axillae, to carry the shoulders outwards. The dressing is then completed by placing the arm in a sling. He advises, however, that in Fig. 211. Sir Astley Cooper's apparatus for dislocated clavicle. some way direct pressure should be made upon the projecting point of bone. 1 Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 53. 2 Malgaigne, op. cit., torn. ii. p. 417. 510 DISLOCATIONS OF THE CLAVICLE. Yelpeau objects to any plan which will draw the shoulders back ; but, on the contrary, he thinks that the shoulders should be kept slightly forwards so as to diminish the tendency of the sternal end of the clavicle to escape in this direction. Dr. Folts, of Boston, affirms that he has been able in one instance to maintain complete reduction with Bartlett's apparatus for broken clavicles. 1 Until farther observations have determined the relative value of these and of many other processes, it will be well to adopt no fixed rule of action; but, having reduced the bone by either placing the knee upon the spine and drawing the shoulders back, or by making use of the humerus as a lever, we recommend that the surgeon shall seek to maintain it in place by such means as the experiment shall prove are most successful. Among these means, direct pressure upon the sternal end of the clavicle, the sling and perfect quietude of the muscles of the arm through the aid of bandages, are no doubt of the greatest importance, and can seldom be omitted. If then we find that a position of the shoulders more or less forwards or backwards best maintains the apposition, this position, whatever it is, ought to be continued. In order to be successful, sufficient time must elapse for the torn ligaments to become firmly reunited, during which the reduction must be constant; since every time the bone escapes, the whole work of repair has to be recommenced as from the beginning. To this end at least four or six weeks are necessary, and sometimes the period must be lengthened far beyond these limits; so that it may often become a grave point of inquiry whether the long confinement of the limb will not entail more serious consequences than have ever been known to arise from leaving the bone displaced, which in no case yet reported has more than slightly impaired the functions of the arm. § 2. Dislocation of the Sternal End of the Clavicle Upwards. Malgaigne has collected four undoubted examples of this dislocation, and I have been unable to find a report of any other except the very extraordinary case described by Dr. Rochester, at the September meeting of the Buffalo Medical Association, and which case, through the courtesy of Dr. Rochester, I was permitted to see several times. 2 Jerry McAuliffe, set. 44, on the 28th of August, 1858, while seated upon a load of wood, was caught under the bar of a gateway and violently crushed, the right shoulder being forced downwards and a little backwards. Dr. Rochester saw him very soon after the accident. On examination it was found that the sternal extremity of the right clavicle was thrown upwards so far as to rest upon the front of the thyroid cartilage, occasioning considerable pain, difficulty of respiration and loss of speech. Reduction was easily effected, and a retentive apparatus was immediately applied, consisting of a gutta-percha splint, 1 Folts, Boston Med. and Surg. Journ., vol. liii. p. 260. 2 Rochester, Buffalo Med. Journ., vol. xiv. p. 262. 511 DISLOCATION OF STERNAL END OF CLAVICLE UPWARDS. moulded to the clavicle and ribs, and retained in place with adhesive plaster. Suitable bandages, a sling, &c, were also employed to maintain complete rest. Notwithstanding all the care employed, the bone again became displaced, and when, nearly four months after the accident, this man came before the class of medical students at the Hospital of the Sisters of Charity, we found the sternal end of the clavicle carried upwards half an inch, and across toward the opposite side also about half an inch, and projecting somewhat in front. It was fixed in this position by ligaments which allowed it to move much more freely than natural, but which would not permit any great displacement. The corresponding shoulder was slightly depressed. MoAuliffe said that he felt no inconvenience or abatement of strength in the arm except when he attempted to lift weights above his head. The accident seems to have been produced in all the cases, so far as can be ascertained, by a force operating upon the end and top of the shoulder; in consequence of which the head of the clavicle is pushed and at the same time lifted, as it were, from its socket, tearing not only its capsule with the ligaments which immediately invest the capsule, but also in some instances the costo-clavicular ligament with some fibres of the subclavian muscle. The sternal end of the clavicle is found riding upon the top of the sternum, its head being placed between the sternal fasciculus of the sterno-cleido-mastoid muscle on the one hand, and the sterno-hyoid muscle on the other. In one of the cases seen by Malgaigne the head had traversed in this direction completely the intra-clavicular space, and lay behind the sternal portion of the opposite sterno-cleido-mastoid muscle. The symptoms are, a depression of the shoulder, with an elevation of the sternal end of the clavicle so as to increase sensibly the space between it and the first rib. The clavicle also encroaches more or less upon the supra-sternal fossa, occasioning a corresponding diminution of the space between the end of the shoulder and the centre of the sternum. The sternal portion of one or both of the sterno-cleidomastoid muscles may also be seen raised and rendered tense by the pressure of the head of the bone from behind. Reduction has been found easy, but Malgaigne thinks a perfect retention impossible, at least it does not seem to have been accomplished in any of the cases reported, although in most or all of them the remaining deformity was only slight. In no case did this trifling displacement seriously impair the functions of the arm. The same apparatus to which we shall give the preference in cases of dislocation upwards of the acromial end of the clavicle, at least with only such slight modifications as the peculiarities of the case will naturally suggest, will be suitable for this accident. The shoulder must be lifted by a sling, while the sternal end of the clavicle is pressed downwards by a pad and bandages; and all the muscles of the arm and chest, so far as is consistent with respiration and comfort, must be maintained in a state of perfect rest until the ligaments have become reunited. 512 DISLOCATIONS OF THE CLAVICLE. § 3. Dislocation op the Sternal End or the Clavicle Backwards. The first case upon record of this kind of accident, caused by violence, was published by Pellieux in 1834, in the Revue Medicals; until which time its existence had been generally denied. In the London and Edinburgh Journal of Medical Science for October, 1841, several cases are mentioned. Two forms of the accident have been described, one in which the head of the clavicle is driven backwards and a little downwards; and another in which it is displaced directly backwards, or backwards and a little upwards. In both of these classes, the end of the bone falls inwards toward the opposite clavicle, and occupies a space in the cellular tissue back of the sterno-hyoid and sterno-thyroid muscles, and in front of the oesophagus; the trachea, if reached at all, being probably thrust to the opposite side. The examples in which it has been found below the top of the sternum are much the most numerous; indeed, it is probable that the other form is only a secondary displacement, occasioned by the action of the fibres of the sterno-cleido-mastoid muscle. Causes. —Of the eleven examples mentioned by Malgaigne, four were occasioned by direct blows, and most of the remainder by crushing accidents, as by powerful lateral compression of the shoulders. One of the cases produced by a direct blow, was accompanied with an external wound, and is the only instance of a compound dislocation of this kind upon record. The man was admitted into St. Thomas's Hospital in Sept. 1835, and, according to his own account, the sharp end of a pickaxe had been driven through the flesh against the bone, The sternal end of the clavicle was found to be displaced backwards, and, with the finger thrust into the wound on the front of the chest, it could be distinctly felt resting upon the side and front of the trachea, where it interfered somewhat with respiration and deglutition. He had a great desire to cough, with a sensation of pressure on his windpipe, which was greatly increased when his head was thrown back. There was also a slight emphysema in the region below the collar bone and over the top of the sternum. The shoulder having been brought back with straps attached to a back-board, the bone readily resumed its place. The elbow was then brought forwards and bound to the side, and the wound being closed with adhesive plaster, he was put to bed with the shoulders much raised. No unfavorable symptoms followed, and in three weeks he left his bed. Three weeks later he left the hospital with the sternal end of the bone still falling a little backwards, and rather more movable than natural. 1 The following example, related by Morel-Lavallee, will illustrate that class in which the dislocation results from an indirect blow, or from a crushing accident. Lemoine, seventeen years old, had his right shoulder violently pressed against a wall by a carriage. He experienced at the moment 1 South, note to Chelius's Surgery, Amer. ed., vol. ii. p. 218. 513 DISLOCATION OF ACROMIAL END OF CLAVICLE UPWARDS. some pain at the bottom of his neck, and a great sensation of suffocation, which lasted for more than a quarter of an hour. The dyspnoea gradually subsided, but the motion of the right arm not returning, he, on the eighth day after the accident, entered La Charite. On examination, the two shoulders were found to be on the same level, but the right one was nearer the median line. The internal extremity of the clavicle was half concealed behind the sternum. On depressing the shoulder, the inner end of the clavicle arose and disengaged itself from behind the sternum; but reduction was effected by elevating the shoulder, while at the same time it was carried outwards and backwards. Desault's bandage was then applied, but as it became loosened, Velpeau's was substituted, which kept the bone completely in position until the eighteenth day, when the patient was lost sight of. 1 Symptoms. —The most constant symptoms are, the absence of the head of the bone from its socket, and its complete or partial disappearance behind the sternum, an approach of the corresponding shoulder to the median line, an inclination of the head to the opposite side, elevation of the shoulder, pain at bottom of the neck, impairment of the motions of the arm, sometimes difficulty in respiration and in deglutition, partial arrest in the circulation of the arm from pressure upon the subclavian artery, and a slight projection of the acromial end of the clavicle, noticed twice by Morel-Lavallee. It has not generally been found difficult to reduce this dislocation, nor when reduced, is it so liable to again become displaced as are the dislocations forwards; yet in only a few instances has the restoration been so complete as not to leave some deformity. In order to the reduction, the shoulder must be carried generally upwards, outwards, and backwards, and it may then be best maintained in position by laying the patient on his back upon an elevated cushion, as practised by Tyrrell in the case related by South. To this may be added such other measures, differing but little from those employed in other dislocations of the clavicle, as are necessary to insure complete rest to the muscles. Of course, no pads or bands across the clavicle can be of any service in this case. As in the other cases of dislocation at this point, the patients have generally recovered nearly the full use of their arms, even in one or two instances in which the reduction has never been accomplished. § 4. Dislocation of the Acromial End of the Clavicle Upwards. Of all the dislocations of the clavicle, this form is most frequent. I have met with it either as a partial or complete luxation nineteen times. The youngest subject was seven years of age, and the oldest sixty-three. All but one were males. Causes. —It is produced generally by a fall upon the extremity of the shoulder. Twice the blow has been received rather upon the back than upon the extremity, and once it was occasioned by the fall of a board directly upon the top of the shoulder. 1 Morel-Lavallee, Amer. Journ. Med. Sci., vol. xxix. p. 229,1842; from Gaz. Med. 514 DISLOCATIONS OF THE CLAVICLE. Symptoms. —When the dislocation is complete, the clavicle not only is lifted from its articular facet to the extent of the breadth of the bone, but it is pushed more or less outwards over the top of the acromion process; generally less than half an inch, but I have once seen it riding the process to the extent of three-quarters of an inch. In this last example, the case of James Moran, a strong, healthy laboring man, the clavicle was easily reduced, and it always went into place with a sensible click; but although every possible care was taken to retain it in place by bandages, compresses, an axillary pad and a sling, yet it was not accomplished, and on the third day he removed all the dressings, and refused to have them reapplied. I have usually found the shoulder slightly depressed; and in one instance, where it is probable the deltoid muscle had suffered some injury, the elbow hung away from the body, and any attempts to lay it against the side produced an acute pain in the shoulder. 1 It has been noticed also, in most cases, that the clavicular portion of the trapezius muscle appeared lifted and tense, especially when the neck was straight. Inability to raise the arm to a right angle with the body is a general but not constant symptom. In two instances, where the displacement was only moderate, the patients were at first and for some time afterwards unable to lift the arm in any degree from the side. In one example, a lady sixty years of age had fallen upon her shoulder and produced a dislocation upwards, but she had not consulted a surgeon Fig. 2J2. Dislocation of the acromial end of the clavicle, upwards aud outwards. until she called upon me, five months after the accident. The clavicle was then raised from its socket about half an inch, but it could be easily pressed back to its place, the reduction being attended with a grating sensation, a circumstance which I have not noticed in any other instance. She was not even then able to raise her arm to her head, nor had she been able to do so since the accident occurred. In all the motions of the arm and shoulder, the clavicle is seen to move more freely than natural immediately under the skin, and these motions are usually attended with some pain at the point of dislocation. This accident has been sometimes mistaken for a dislocation of the humerus, but unless the shoulder is already greatly swollen, the error is not likely to happen. If the point of the acromion process can be made out, it will be easy to determine, by sliding the finger along its spine, whether the clavicle is displaced or not, and by these means 1 Report on Dislocations, by the author. Transac. of New York State Med. Soc, 1855, p. 19. 515 OF THE ACROMIAL END OF CLAVICLE UPWARDS. to settle the question of its complicity in the accident. The question as to whether the shoulder is dislocated or not may be more difficult of solution, as we shall hereafter have occasion again to observe. Pathology. —Generally there exists simply a rupture of the ligaments immediately investing the joint, so that the clavicle rises from its socket only about half an inch, more or less, according to its diameter, and is carried outwards just sufficiently far to allow it to rest upon the upper margin of the acromial articulation. In at least fourteen of the cases seen by me, this has been the position of the acromial end of the clavicle, and for its complete reduction nothing more has been required than to press with moderate force upon the upper and outer end of the bone. In three cases I have found the bone not only thus lifted in its socket, but also driven over upon the acromion process from half to three-quarters of an inch; and in one instance, that of a gentleman, Mr. B., who was injured in a railroad accident, the acromial end of the clavicle was displaced outwards half an inch and backwards three quarters of an inch, while the sternal end also was considerably lifted in its socket and slightly sent inwards. The shoulder fell forwards and the coracoid process was one inch nearer the sternum than the same process upon the opposite side. In such cases more or less of the fibres of the coraco-clavicular ligament must have suffered a disruption; indeed, without a rupture of its external fasciculus, which anatomists have called the trapezoid ligament, such a dislocation cannot take place. Prognosis. —It is impossible for me to say what has been the precise result in all the cases which I have seen, but my notes furnish only one case of perfect retention after a complete dislocation at this point. David Thomas, aged about twenty-five years, fell sideways upon the ground, striking upon the extremity, and, as he thinks, a little upon the top of the shoulder. I found the clavicle dislocated upwards and outwards, so that it overlapped the acromion process half an inch. It was easily replaced, and having applied my own apparatus for broken collar bones, with the addition of a band across the shoulder and under the elbow to keep the clavicle down, I found that I had succeeded in retaining the bone in place. This dressing was continued until the forty-second day, when, on being removed, the clavicle was seen to be closely confined upon its articulation; and after a lapse of two years it still retains its position so completely that no difference can be detected between the opposite articulations. In the case of Moran, already mentioned, whose clavicle overlapped the acromion process three-quarters of an inch, and who threw off' the dressings at the end of three days, the same degree of displacement existed at the end of two years; the scapular end of the clavicle moving freely in every direction under the skin according as the arm was moved. In lifting, he says, the strength of his arm is undiminished until he raises the weight nearly to a level with his shoulders, and from this point upwards he can lift but little. For a laboring man it amounts to a serious maiming. I have seen the same loss of power in the arm to raise bodies above the head in at least two or 516 DISLOCATIONS OF THE CLAVICLE. three of the examples of less complete luxation, continuing after the lapse of several years; but in the majority of cases, although the bone does not remain reduced, the patients have recovered eventually the complete use of the arm in whatever position it may be placed. Treatment. —When the bone simply rises upon its socket the reduction is always easily accomplished by pressing firmly upon its extremity with the fingers; but if, at the same time, it has been carried outward, or outwards and backwards, the reduction is only accomplished by pulling the shoulders backwards, or by placing a pad in the axilla, using the arm as a lever, or by lifting the arm by the elbow and at the same time pressing the clavicle down; and it will sometimes require the application of all or several of these procedures at the same moment. In some cases the complete reduction has only been effected when the patient has been brought under the influence of an anaesthetic. As to the maintenance of the bone in its socket for a length of time sufficient to insure a firm union of the broken tissues, this will be found always more difficult, and, in a great majority of cases, absolutely impossible. Nearly all surgeons who have written upon this subject have made the same observation; and if occasionally a new apparatus in the hands of a clever surgeon has seemed to promise better results, the same apparatus in the hands of other equally clever surgeons, and under circumstances equally favorable, has been found almost constantly to fail; and we have been compelled again to exercise anew our ingenuity, and to seek for new resources, or to abandon the effort in despair. Only very lately a surgeon, Dr. Folts, of Boston, believed that he had found in Bartlett's apparatus for broken clavicles modified by the application of a shoulder-strap, the infallible remedy for this one of the many sad defects in our art. The most important part of this dressing, according to Dr. Folts, is the compress placed upon the upper and outer end of the clavicle, and the bandage or strap passed over the compress and under the point of the elbow to maintain it in position. 1 Dr. Folts is no doubt correct in regarding this strap as an important if not the essential part of the apparatus; and it is surprising that by Sir Astley Cooper, as well as by many other experienced surgeons, its value should have been overlooked. The chief obstacle to the retention of the bone in place is the powerful action of the trapezius, which constantly tends to elevate the outer end of the bone. In some measure this may be resisted by elevating very forcibly the shoulder, or by inclining the head, but both of these positions are extremely fatiguing, and will not be long endured. The bandage or strap, adjusted in the manner which Dr. Folts has recommended, is the only means of counteracting the action of the trapezius, upon which any substantial reliance can be placed; but the principle has long been understood and practised upon. Brasdor's tourniquet, or Petit's, secured by a strap brought under the point of the elbow, Boyer's double shoulder straps and Desault's third bandage, all aimed at the accomplishment Folts, Bost. Med. and Surg. Journ., vol. liii. p. 259. 517 OF THE ACROMIAL END OF CLAVICLE UPWARDS. of the same purpose; yet Boyer and Desault found all these contrivances fail in a majority of cases. Mayor employed a dressing constructed with a strap to buckle over the dislocated clavicle (Fig. 213); but Nelaton has seen this apparatus fail, also, when applied in his own wards. The experience of Dr. Folts at the time of his report did not extend beyond three cases, and the apparatus had been completely successful in only two of the three. Our own experience is sufficient to show that it will be found occasionally, but by no means constantly, successful. We have already mentioned one case in which we succeeded perfectly by this mode, but in several others which seemed equally favorable we have met with partial or complete failures. The practical difficulties are, the sensibility and consequent inability sometimes of the point of the elbow to bear the requisite pressure, and the even greater Fig. 213. Mayor's apparatus for dislocated clavicle. (''Triangle cubito-bis-scapulaire.") sensibility of the skin over the top of the clavicle; the tendency of the bandage to slide off from the shoulder and also to become displaced from the end of the elbow; the gradual relaxation of the bandages, which, when existing even in the most inconsiderable degree, is sufficient sometimes to allow the bone to slip out from its shallow socket; the impossibility of fixing the scapula, upon whose immobility as well as upon the immobility of the clavicle the retention depends; and, finally, the great length of time requisite to unite firmly the ligaments, if indeed they ever again become actually united. The band can be prevented in some measure from sliding off from the clavicle by a counter-band attached to a collar upon the opposite shoulder, but not without causing some pain and giving rise to excoriations generally in the opposite axilla; and, in a degree, all the other difficulties may be met by patience and ingenuity, but unfortunately the smallest failure in any one of these numerous indications insures a defeat. The axillary pad employed as a fulcrum upon which extension may be made is equally as dangerous here as in fractures, and I do not think it ought ever to be used for this purpose, but only as a means of moderate support and retention; indeed it would be well, perhaps, if it were discarded altogether. The case of Mr. B., already quoted, with a dislocation outwards and backwards, affords not only an illustration of the inefficiency of either the shoulder strap or the axillary pad in certain cases, but also, it seems 518 DISLOCATIONS OF THE CLAVICLE. to me, of the mischief which may result from their too diligent application ; for I cannot persuade myself but that most of the maiming in this case was due to the apparatus rather than to the original accident. This gentleman was injured on the 10th of November, 1855. A sling with an axillary pad and bandages was immediately applied. I saw him on the seventeenth day. The displacement was then such as I have described, but I did not observe any paralysis or emaciation of the limb. Having noticed that the clavicle fell into its socket when he lay upon his back in bed, at my suggestion all the dressings except the sling were removed, and the patient was laid upon his back in bed, with instructions to continue in this position, if possible, until the cure was completed; but after a few days I received a communication from his physician, stating that, owing to a troublesome cough, he had found it impossible to maintain this position. His residence was forty or fifty miles from town, and I sent him one of my dressings for broken collar bones with instructions as to its use; directing especially that a shoulder-strap should be used to keep the clavicle down. The dressing was applied and continued six weeks, and on being removed, the elbow, wrist, and finger joints were found to be stiff. The whole arm was emaciated and almost powerless. One year later there was no improvement in the condition of the arm; every joint from the shoulder down was almost completely anchylosed, the muscles were greatly wasted, and the hand trembled constantly. These results, it seems to me, were due to too long and too tight bandaging of the arm, and especially to the pressure of the axillary pad. I do not state this positively, but this is my belief. Is it worth while, then, to incur the dangers of too long confinement and of excessive bandaging for the purpose of attaining the always uncertain result of maintaining the bone in its socket ? We certainly may be permitted to make the attempt within certain reasonable limits; and especially if the patient is a female and the avoidance of deformity is a point of serious consideration; but never without keeping constantly in mind the possibility of a permanent anchylosis and paralysis of the limb. § 5. Dislocation of the Acromial End of the Clavicle Downwards. This form of dislocation is exceedingly rare, only three wellauthenticated cases having been placed upon record, one of which was seen and dissected by Melle, 1765, the second was met with by Eleury, in 1816, and the third is described by Tournel. Cause. —So far as we can ascertain, it has been produced only by a force which has acted directly upon the top of the clavicle. In the case mentioned by Tournel, a horse had trod upon the shoulder, and in the example recorded by Melle, the accident occurred in a child six years old, from an attempt to support a great weight upon the top of the collar bone. In this last example the humerus was dislocated also, and both dislocations had remained unreduced many years when the patient was seen by Melle. 519 ACROMIAL END OF CLAVICLE UNDER CORACOID PROCESS. This force acting directly upon the top of the clavicle would fail to dislocate the bone, except by first breaking down the coracoid process, if it did not happen sometimes that at the same moment the lower angle of the scapula was thrown outwards, in such a manner as to depress slightly the coracoid, and thus to permit the outer end of the clavicle to fall below the level of the acromion process. Symptoms and Pathology. —This dislocation, whether it has been produced artificially upon the dead subject or accidentally upon the living, has always been found to be accompanied with a complete rupture of the acromio-clavicular ligaments not only, but also of the coracoacromial and coraco-clavicular ligaments; the outer extremity of the bone resting between the acromion process and the capsule of the shoulder-joint, and a little posterior to the articulating facet which originally received the clavicle. The superior angle of the scapula approaches the body slightly, and its inferior angle is thrown outwards. A marked depression exists at the point of dislocation, accompanied with a sharp pain, increased especially when an attempt is made to move the arm. The patient is unable to lift the arm voluntarily, but it can be moved pretty freely in the direction forwards and backwards by the hands of the surgeon: abduction is much more difficult. Treatment. —Reduction is easily accomplished, at least in the only two examples upon the living subject in which the attempt has been made, it was effected promptly by drawing the shoulders gently outwards and backwards; nor has it been found any more difficult to maintain it in position when once replaced. "When the scapula is restored to its natural position and its lower angle approaches again the side of the body, a reluxation becomes impossible; since the coracoid process now effectually prevents that descent of the clavicle upon which its displacement always depends. It is only necessary, therefore, to secure the scapula at its base and lower angle snugly to the body, by a broad band and compress, and all the indications of treatment are completely fulfilled. § 6. Dislocation op the Acromial End of the Clavicle under the Coracoid Process. Pinjou met with one example of this singular dislocation, 1 and Godemer, of Mayenne, has recorded five more, 2 and these constitute the whole number which are at this day known to science. Cause. —Age and a consequent relaxation of the ligaments seem to constitute a predisposing cause, since of the six recorded examples four were between the ages of sixty-seven and seventy-one, and the other two were adults. In all the cases, also, the dislocation was the result of a fall upon the shoulder. The symptoms which have been said to characterize this accident are pain and a very marked depression at the point of displacement, 1 Pinjou, Journ. de Med. de Lyon, Juillet, 1842, from Vidal (de Cassia). 2 Godemer, Recueil des travaux de la Soc. Med. d'Indie et Loire, 1843, from Vidal. 520 DISLOCATIONS OF THE SHOULDER. with a corresponding projection of the acromion and coracoid processes; a rapid inclination outwards and downwards of the line of the clavicle, its outer extremity being felt in the axilla; the corresponding shoulder depressed and inclined forwards; freedom of motion in all directions except inwards and upwards; the lower angle of the scapula thrown outwards and backwards ; to which Morel-Lavalle'e has added an actual increase of space between the acromion process and the sternum. Treatment. —Godemer reduced all the examples which came under his notice easily, by directing an assistant to pull the arm backwards and outwards while he himself seized upon the clavicle with his fingers and disengaged it from under the process; but Pinjou, after many efforts by the same method, failed completely, and the patient having left him, the clavicle was reduced the next day by an empiric. Vidal (de Cassis) recommends that instead of pulling the arm outwards, by which procedure the pectoralis major is made to antagonize the surgeon, the elbow shall be brought down to the side, and kept there by the left hand, while the right hand, placed in the axilla, shall pull the upper end of the humerus outwards, converting the arm into a lever of the third kind. This process, I confess, seems to be much the most rational. Finally, having given the history of these cases as they have been reported, we shall scarcely have performed our duty as a faithful writer if we do not state frankly that we entertain a suspicion that both the gentlemen who have reported these curious examples have entertained us with fabulous or imaginary stories; and especially do these suspicions rest upon the cases reported by Godemer, who in five years saw five cases, each presenting throughout the same class of symptoms, the same facility of reduction, accomplished by the same means, and always with the same perfect result. If to these singular coincidences we add the fact that only one other surgeon has ever claimed to have met with the accident, and if we notice the actual anatomical difficulties which stand in the way of its occurrence, such especially as the complete occlusion of the subcoracoidean space by the tendons and muscles which pass from its extremity toward the chest and arm, we shall find a fair apology for some degree of scepticism. CHAPTER VI. DISLOCATIONS OF THE SHOULDER (HUMERUS AT ITS UPPER EXTREMITY). Owing to the great exposure, and the peculiar anatomical structure of the shoulder-joint, its structure having reference mainly to freedom of motion rather than to firmness and security in the articulation, dislocations of the humerus are very common. 521 DISLOCATION OF THE SHOULDER DOWNWARDS. "Writers have not been agreed as to the precise anatomical relations of these dislocations, nor as to the nomenclature. Yelpeau, Malgaigne, Yidal (de Cassis), Skey, and Sir Astley Cooper, have each adopted explanations and classifications peculiar to themselves. With the arrangement established by this latter surgeon, English and American students are the most familiar; and believing that it is more simple, and quite as appropriate as either of the others, I shall adopt it as the basis of my own descriptions. I shall have occasion, however, to dissent from the opinions and teachings of this distinguished surgeon, as to the exact seat and relations of the head of the humerus in some of these dislocations. According to Sir Astley Cooper, there are three complete luxations of the shoulder, namely, downwards, forwards, and backwards. § 1. Dislocation of the Shoulder Downwards (Subglenoid). This is usually called a dislocation into the axilla; the head of the bone resting rather upon the inner side of the inferior border of the scapula, near the base of that triangular surface which is found below the glenoid fossa. Since in both the other complete dislocations of the shoulder, the head of the humerus, in order to escape from its socket, must be made to descend more or less downwards, we shall regard this dislocation as the type of all the others, and shall make it the subject of especial consideration as well as of reference when speaking of the other forms of dislocation. Causes. —The most frequent causes of this accident are a fall from a height, in which the patient strikes upon the top of the shoulder, or a direct blow upon the same point. I have found the arm dislocated into the axilla by one or the other of these causes eight times. Seven times it has been dislocated by a blow upon the outside of the arm near its upper end; three times by a fall upon the extended hand; once by a fall upon the elbow, and in this latter case the arm was probably carried away from the body at the moment of the receipt of the injury. In all the above examples, the shoulder has been dislocated by the simple force of the blow, or with only slight aid from muscular action; but in a considerable number of cases the bone is displaced almost wholly by the action of the muscles, the arm having been previously violently abducted; and perhaps in some cases the capsule being torn before the resistance of the overstrained muscles has accomplished the displacement. Thus, in three instances I have known the dislocation to result from holding on to the reins after being thrown from a carriage ; in two cases the patients have fallen through a hatchway and been caught and suspended under the arms; once a woman met with this accident by holding on to a pump handle when she had slipped and fallen upon the ice. A few years since I examined the arm of a Swiss woman, Maria Norregan, who was then sixty-five years old, and whose humerus had been dislocated into the axilla seventeen years before, where it still remained. Her own account of the accident was, 34 522 DISLOCATIONS OF THE SHOULDER. that she was returning from the Jura Mountains, near Neufohatel, with a load of hay upon her head. She had carried it a long way with her hands held upwards, without once stopping to rest, and when at length she threw down the load at her door, the right shoulder was dislocated. The arm became soon very painful, and swollen to the fingers' ends; but she was too remote from, and too poor, to employ a surgeon. A tailor, who used to do the minor surgery of the neighborhood, bled her three or four times, but the dislocation was not recognized until many months after. A Mrs. Hunn informed me that when she was twenty-two years old she had a convulsion, and that her attendants, in trying to hold her upon her bed, actually pulled the shoulder out of joint. After the first accident the dislocation was not repeated for four years, but since then it had occurred from very slight causes many times. She was in the habit of reducing it herself by placing a ball in the axilla and using the arm as a lever. Dr. Lehman reports the case of a sailor on board an American brig, who was subject to a dislocation into the axilla from very slight causes, and especially if he bent his body far over to raise anything. He could also, by pulling horizontally, remove the head of the bone from its socket. It was reduced easily, and he experienced no pain either in the reduction or dislocation, nor, indeed, during the displacement 1 Pathology. —In this accident the head of the bone is made to press against the capsule below and immediately in front of the long head Fig. 214. Dislocation of the shoulder downwards into the ilia. (Subglenoid.) of the triceps, until the capsule gives way, and continuing to descend in the same direction it is finally arrested by the triangular surface of the inferior edge of the scapula immediately below the glenoid fossa. Owing to the pressure of the tendon of the triceps behind, it occupies a position also a little in advance of the centre of this triangle, or rather upon its anterior edge, so that it rests more or less upon the belly of the subscapularis muscle. The capsule is generally torn quite extensively, especially below and in front; and, contrary to what has been affirmed by Sir Astley Cooper, the tendon of the long head of the biceps is often broken asunder or detached completely from its insertion; 1 Lehman, Amer. Journ. Med. Sci., vol. i. p. 242, 1828. 523 DISLOCATION OF THE SHOULDER DOWNWARDS. the supra-spinatus muscle is stretched or lacerated ; the infra-spinatus, subscapularis and coraco-brachialis are put upon the stretch; the subscapularis being also sometimes completely torn from its attachment to the head of the humerus, and in either case, whether torn or merely compressed and stretched, the circumflex nerve, which runs along its lower margin, is subject to severe injury; the deltoid muscle is also placed in a condition of extreme tension; while the teres major and minor in this respect are subjected to but little change. Symptoms. —A palpable depression immediately under the extremity of the acromion process, more distinct in children, in very old and in thin people, than in adults of middle life or than in fat or muscular people, but never absent completely, unless the shoulder is very much swollen; the elbow carried out from the body three or four inches, sometimes a little backwards, and the line of its axis directed toward the axilla; the outer surface of the arm presenting two planes inclined toward each other, and meeting at the point of insertion of the deltoid muscle; the head of the humerus felt in the axilla, particularly when the elbow is carried away from the body; numbness of the arm, accompanied generally with pain, especially when any attempt is made to press the elbow against the side; rigidity with inability to move the arm freely in any direction, but especially inwards; allow- Fig. 215. Dislocation of the shoulder downwards into the axilla. (Subglenoid.) ing, however, of pretty free passive motion, but not permitting the elbow to touch the body without great pain, which pain is occasioned mostly by the pressure of the humerus upon the axillary plexus; under no circumstances can the hand be placed upon the opposite shoulder while at the same moment the elbow touches the thorax; 524 DISLOCATIONS OF THE SHOULDER. the head of the patient, and sometimes the whole body, inclined toward the injured arm; the arm lengthened from half an inch to an inch; a chafing or friction sound is not unfrequently present, especially if the bone has been some days dislocated; but Mr. Lawrence mentions a case in which there was a distinct crepitus, yet there was no fracture —Dr. Hays saw a similar case in Wills' Hospital, Philadelphia, in a woman, sixty years old, whose arm had been dislocated forwards eight weeks. 1 Other surgeons have related like examples, but it is probable that in all these cases there has been an exposure of the bone at or near the edge of the glenoid fossa, by the partial detachment of its ligamentous margin, or some portion of the head has become divested of its cartilaginous covering. Decisive as these signs usually are of the true nature of the accident, cases will every now and then occur in which the diagnosis will be attended with great difficulty, and especially if a few hours have been permitted to elapse since the occurrence of the injury, so that considerable effusions of blood and of lymph may have taken place; while at a still later period, when the swelling had subsided, the diagnosis again becomes easy. " At this latter period," says Sir Astley Cooper, " it is that surgeons of the metropolis are usually consulted; and if we detect a dislocation which has been overlooked, it is our duty in candor to state to the patient that the difficulty of detecting the nature of the accident is exceedingly diminished by the cessation of inflammation, and the absence of tumefaction. It has never happened to me to have seen a case of dislocation into the axilla which was not easily recognized, nor have I met with any cases in the practice of other surgeons, but in my report to the New York State Medical Society, already referred to, I have related two cases which were not recognized by the patients themselves, and no surgeon was called until after several days or weeks, and three cases in which empirics having been employed they failed to detect the dislocation. Although, therefore, I am prepared to admit the justness of the observations made by Sir Astley Cooper, I think that if the case is seen within an hour or two after the accident, its nature may be generally determined promptly by the surgeon of ordinary experience; but upon this subject I have already spoken very fully in the chapter on fractures of the humerus; and from the examples and opinions which I have there presented it will be inferred that it is much more common to mistake a fracture for a dislocation, than a dislocation for a fracture, an observation which is equally as applicable to dislocations forwards as to the form of dislocation now under consideration. Prognosis. —If the force which displaced the bone was not great, or if the shoulder-joint has not suffered any injury from the accident itself beyond the mere rupture of the capsule and a moderate straining of the muscles, and if the dislocation has been early and easily reduced, the patient is immediately after the reduction able to move the arm freely in all directions; very little swelling follows, and in a 1 Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv. p. 236, May, 1839. 525 DISLOCATION OF THE SHOULDER DOWNWARDS. short time a perfect restoration of all the functions of the limb is accomplished. It cannot, however, always be inferred from the degree of violence employed in the production of the dislocation, nor from the absence or presence of swelling, how much injury the tendons, muscles, and nerves have suffered, since the same causes produce greater lesions in one person than in another, and the amount of swelling may depend upon the accidental rupture of an unimportant bloodvessel, or upon some peculiarity in the constitution of the patient predisposing to serous, fibrous, or sanguineous effusions. To whatever cause we may find occasion to attribute the result, it will nevertheless be observed that, in a great majority of cases, the limb is not restored to all its original strength and freedom of motion until after the lapse of some months; and the shoulder does not resume its perfect form and symmetry until a much later period; occasional pains, especially after exercise of the muscles, and in certain conditions of the weather, are present also at irregular intervals and for indefinite periods of time. Opposite and more favorable terminations must be regarded as exceptions to the rule. Where the reduction has been made within a few hours, I have found the shoulder affected with muscular anchylosis with more or less weakness of the arm after a lapse of from a few days to one or two years. A laborer, set. 41, had dislocated his right shoulder into Dr. H., an intelligent young surgeon, reduced the bone easily with his hands alone, while the patient was still unconscious from the shock of the injury. After six weeks he called upon me, accompanied by his surgeon, thinking that it was not properly reduced because the arm was still painful, and he could not move it freely. The bone was, however, well in its socket. One year later I examined this man, and found some anchylosis remaining in the shoulder-joint. James Rogers, set. 39, fell while running and struck upon his right shoulder. Dr. Eastman, Prof, of Anatomy in the Buffalo Medical College, reduced the dislocation four hours after the occurrence, in the following manner: The patient being seated in a chair, Dr. Eastman placed his knee in the axilla and manipulated, while one assistant supported the acromion process, and another pulled downwards upon the forearm. The time occupied in the reduction was about two minutes, and the bone finally resumed its position with a snap audible to all the persons in the room. For some months after, and at the period when I was invited to see him, the muscles about the shoulder were rigid, and the motions of the joint embarrassed; but at the end of two years, Dr. Eastman informed me that the joint had become free, and the arm as useful as before, except that he could not throw a stone. In another case, a gentleman residing in an adjoining county, set. 42, was thrown from his carriage, falling forwards upon his hands. The dislocation was reduced promptly, by placing the heel in the axilla, and within fifteen minutes after it had occurred. Three months after this the patient consulted me on account of the immobility of the shoulder-joint, and because several surgeons had expressed a doubt 526 DISLOCATIONS OF THE SHOULDER. whether it was properly reduced. The anchylosis was then so complete that the humerus could not be moved separately from the scapula, but there was no displacement. This gentleman again called upon me at the end of four years, and I then found the arm nearly restored to its original condition, but it was not quite so strong as before. He experienced also "curious" sensations in his arm and hand occasionally. The anchylosis had continued with very little improvement about two years, after which it had been gradually disappearing. I need scarcely say that in those examples in which the reduction of the bone has been delayed beyond a few hours, or for several days or weeks, the continuance of the anchylosis has been more persistent; but in no case which has come under my observation, unless the bone still remained unreduced, has the anchylosis been permanent. For this reason I am disposed to think that muscular, rather than fibrous or ligamentous anchylosis, is the cause, generally, of the immobility of the joint. I have certainly never in any instance met with a true bony anchylosis as a consequence of a shoulder dislocation. The anchylosis in question seems to be a result simply of laceration or more generally of a severe strain of the muscular fibres, resulting in inflammation and a contraction of these fibres; and its occurrence in any particular case may therefore be justly attributable either to the position of the bone when it is dislocated, to the force of the blow which has produced the dislocation, or to the violence applied in the attempts at reduction. Paralysis and wasting of the muscles of the arm, either with or without muscular contraction and rigidity, are also observed in a certain number of cases. Especially has it been noticed that the deltoid muscle is liable to atrophy; and in their attempts to explain the frequency of its occurrence in this latter muscle, surgeons have generally referred to a probable rupture of the circumflex nerve, a circumstance which the autopsies show does occasionally take place; or to a mere stretching of this nerve; yet it is quite as fair to presume that in many cases it is due solely to the greater injury which the deltoid muscle has sustained by the unnatural position of the head of the bone during the continuance of the dislocation, for, with the exception of the supraspinal s, it is placed more upon the stretch than any other. Nor is it improbable that in some cases it is due to the mere force of the blow which, having been received directly upon the top of the shoulder, has contused the muscle. In short, any of the causes which may determine in the deltoid inflammation and consequent rigidity, must finally result in desuetude and consequent atrophy. In quite a number of cases my attention has been called to a remarkable fulness just in front of the head of the bone, which has continued sometimes for many months and even years after the reduction has been effected, the patients having in several cases applied to me to know whether this did not indicate that the bone was not in its socket, especially as it has been usually attended with some stiffness in the joint. Not unfrequently I have been told that surgeons who had noticed this fulness, thought the bone was not reduced; and in one instance I am informed that a jury returned a verdict against the sur- DISLOCATION OF THE SHOULDER DOWNWARDS. 527 geon, where there was no other evidence of malpractice than this fulness with some anchylosis, but which, in the opinion of these gentlemen, was conclusive evidence that the bone was not properly set. The deception is also often the more complete from the fact that there may exist a corresponding depression underneath the acromion process, behind. It may be present where but little force has been used, either in the production of the dislocation, or in its reduction. I have seen it in a girl, only fourteen years of age, who had dislocated her left shoulder into the axilla, by a fall upon a slippery side-walk. I reduced the bone, assisted by Dr. George Bur well, of Buffalo, within half an hour after the accident. Dr. Burwell held upon the acromion process while I lifted the arm to a right angle with the body, and pulled gently, and the reduction was at once accomplished ; but we immediately noticed that the head of the bone seemed to press forwards in the socket so as to resemble what Sir Astley Cooper has described as a partial forward luxation. There was also a corresponding depression behind. Carrying the elbow back rendered the projection more decided, but bringing it forwards would not make it entirely disappear. In other instances much more difficulty has been experienced and more force has been employed in the reduction. A man weighing two hundred pounds, and forty-one years of age, residing at Bath, in Steuben Co., fell from a load of hay in May, 1853, striking upon the top and front of the left shoulder. It was immediately ascertained that he had dislocated his arm into the axilla, and broken his leg. A young surgeon attempted within a few minutes to reduce the dislocation, but failed; and about two hours later it was reduced by another surgeon, with the aid of chloroform and Jarvis's adjuster. Four years after the accident had occurred, this gentleman came to me accompanied by the surgeon who had made the reduction, in consequence of its having been intimated by some medical men that it was not properly reduced. The arm was not as strong as the other; some anchylosis existed at the shoulder-joint; but especially it was noticed that there still remained a remarkable fulness in front as if the head of the bone was pressed forwards. By no manipulation or position could this fulness be made to disappear, yet the bone was plainly enough in its socket. This phenomenon is probably due in some cases to a rupture of the supra-spinatus muscle, and the consequent preponderating action of the antagonizing muscles, or to the laceration of the capsule, but most often, I imagine, to a rupture or to a displacement of the long head of the biceps, a circumstance to which I shall more particularly allude under the subject of " partial dislocations." Among the results of this dislocation must be placed a tendency to reluxation, which, although it may not often be made manifest by its actual occurrence, owing perhaps to the prudence of the surgeon, yet it does take place in a sufficient number of cases to establish its peculiar liability. Indeed, we need only consider how imperfect is the protection against this accident, when once the capsule has been torn, to appreciate this observation. Examples of spontaneous luxa- 528 DISLOCATIONS OF THE SHOULDER. tion, or of luxation of the shoulder from very trivial causes, after it has once been luxated, may be found in the experience of almost every surgeon. I have myself met with several persons who have had a second or third luxation from a slight cause, and in some instances, where the patients were subject to epilepsy, the luxations have occurred whenever the convulsions returned. A gentleman residing in Toronto, Canada West, had a dislocation of the right shoulder into the axilla when he was quite a child, and the accident was renewed when twenty-nine years old by falling from a carriage head foremost, with his right arm extended and uplifted. Since then until he called upon me, a period of about six years, he has been constantly subject to the same dislocation; and he cannot raise his arm high above his shoulders without producing a sub-luxation, the head of the humerus resting upon the outer margin of the lower and anterior edge of the glenoid fossa, but by rotating the arm outwards it immediately resumes its place. I found the whole limb as fully developed, and he said it was quite as strong as the opposite limb. I have already mentioned the case of Mrs. Hunn, whose arm had been dislocated more than twenty times in the last five years; and I remember a lad, Pat. Dolan, aged nineteen years, whose left arm was dislocated by falling from the mast-head of a vessel and hanging by his hand. No attempt was made to reduce it until fourteen hours after the accident, at which time it was set by two German doctors, but not until they had pulled upon it three hours. Four months after it was again dislocated by the slipping of an oar while he was rowing a boat. A surgeon having failed this time to bring it into place, I succeeded readily and without the aid of an anaesthetic, by raising the arm directly upwards in the line of the body, while my foot was pressed upon the top of the scapula. We have referred more than once to the occasional difficulty of diagnosis in this as well as in many other shoulder accidents; and I have alluded to five cases in which the dislocation was not recognized, but none of them had been seen by a surgeon. Other writers have, however, mentioned many examples of unreduced dislocations of the shoulder, for which surgeons of skill and experience were responsible. In other cases the dislocation has been clearly made out, but the surgeon has been unable to reduce the bone. It has been my fortune to succeed in several instances where others have made a fair trial and have failed, but the following case leaves me no opportunity to boast the superiority of my own skill above that of my confreres. Mary Kanally, aet. 49, a large, fat, laboring woman, was admitted into the Buffalo Hospital of the Sisters of Charity, with a dislocation of the right humerus into the axilla, which had occurred twelve hours before. This is the same woman of whom I have before spoken as having produced the dislocation by a fall while holding upon the handle of a pump. Drs. Lockwood and Baker, of Buffalo, were first called, and attempted reduction. They made extension and counter-extension in every possible direction, and for a long time, but to no purpose. She was 529 DISLOCATION OF THE SHOULDER DOWNWARDS. then sent to the hospital. Without attempting to describe minutely the various modes of extension and manipulation which I employed, I will briefly state that having placed her completely under the influence of chloroform, the manipulations were made assiduously during one hour without success. On the following morning she was bled freely from the opposite arm, and chloroform again administered ; extension being made in the presence of Prof. Charles A. Lee and other gentlemen, with Jarvis's adjuster. After more than an hour the effort was again suspended. On the following day we made a third attempt; the patient being completely under the influence of chloroform, but with no better success. The chloroform produced a condition approaching apoplexy, and it was not again used. On the tenth day, assisted by Prof. James P. White and other surgeons, we applied the compound pulleys, moving the arm in various directions. Twice we thought the reduction was accomplished, but as often as we proceeded to examine it attentively we found it was not. If it did ever pass into the socket, it was immediately displaced. The woman after this refused to submit to any further attempts, and she soon left the hospital, nor have I seen or heard from her since. Sir Astley Cooper has thus described the appearances presented on dissection of a dislocation which had been long unreduced: " The head of the bone altered in its form; the surface toward the scapula being flattened. A complete capsular ligament surrounding the head of the os humeri. The glenoid cavity entirely filled by ligamentous matter, in which were suspended small portions of bone, which were of new formation, as no portion of the scapula or humerus was broken. A new cavity formed for the head of the os humeri on the inferior costa of the scapula (Fig. 216); but this was shallow, like that from which the bone had escaped." When the dislocation into the axilla remains unreduced, the consequences are always sufficiently grave, but they differ very much in degree, in character, and in persistence, according as the arm has remained a longer or shorter time unreduced, and according to the presence or absence of complications. These conditions will be. best illustrated by a reference to examples. Wm. S., a German, set. 51, fell down a flight of steps while intoxicated, producing a dislocation of the left arm into the axilla. Eleven hours after the accident, he was received into the Fig. 216. New socket, in an ancient luxation of the shoulder downwards. (From Sir A. Cooper.) Buffalo Hospital of the Sisters of Charity. No attempt had been made to reduce the bone. The reduction was effected by myself with tolerable ease, by extending the arm perpendicularly above the head, while my foot pressed upon the top of the scapula. The head of the hume- 530 DISLOCATIONS OF THE SHOULDER. rus could be plainly felt in the axilla approaching the socket, until it seemed to be directly over it, when, on lowering the arm, it was found to be reduced. After the reduction, the patient could not raise the arm more than eight inches from the body. The fingers, hand, and forearm were almost paralyzed. Three weeks later, when he left the hospital, his arm had improved, but he could not flex his fingers. Mrs. G., set. 70, fell down a flight of steps and dislocated her arm into the axilla. She did not suspect the nature of the injury, and no surgeon was called. I was consulted one week after the accident, at which time she was suffering great pain from the pressure of the head of the bone upon the axillary nerves. We first attempted to reduce the bone by resting the knee in the axilla while she was sitting, but without success. We then placed her in bed, and with my knee in the axilla, the acromion process being supported by the hands of an assistant, we restored the bone after a few moments, of pretty firm extension downwards and outwards. After the reduction she could not raise her arm, but the pain was much abated. One month later, the arm remained very weak. She could not raise it more than six inches toward her head, but I could raise it to a right angle with the body without causing pain. The whole hand felt numb, and was occasionally painful. The deltoid muscle was slightly atrophied. There was also a slight flatness under the acromion process behind, and on the outer side, with a corresponding fulness in front. Mary Ann Hasler, set. 47, was admitted to the hospital with a dislocation of the right humerus into the axilla. The arm had been dislocated three weeks in consequence of a fall upon the upper and outer part of the shoulder. An empiric, who saw it fifteen minutes after the fall, and when the arm was not swollen, said it was not dislocated. On the fifth day, a Catholic clergyman discovered that it was out, and attempted to reduce it, but was not successful. When she came under my notice, the arm was lengthened about one-quarter or one-half of an inch, and hung out from the body in a condition of almost complete paralysis. There was very little swelling about the shoulder or arm, and the head of the bone could be distinctly felt in the axilla. The patient being rendered partially insensible by chloroform, I placed my heel in the axilla, and by pulling moderately about thirty seconds in a direction slightly outwards from the line of the body, the bone was reduced. Seven days after the reduction, she left the hospital, the arm being yet quite useless, though not greatly swollen. There was also a striking fulness in front of the head of the bone. Wm. Gardner, of Painted Post, N. Y., aet. 75. dislocated the right humerus into the axilla twenty years before I saw him, by falling upon his hands with his arms extended. I found the arm weak and atrophied, so that he could raise it but slightly outwards from his side; he was unable to move it forwards much beyond the line of his body, but he could carry it back quite freely. The whole hand was in a condition of partial insensibility. I have before mentioned the case of Maria Norrigan, the Swiss woman, whose arm had been dislocated downwards seventeen years. 531 DISLOCATION OF THE SHOULDER DOWNWARDS. The deltoid muscle has become greatly wasted; the head of the bone can be felt obscurely in the axilla; the arm is shortened perceptibly; the elbow hangs freely against the side; the little and ring fingers are numb, and also one-half of the forearm; the whole hand and arm are weak and atrophied; she complains also occasionally of a troublesome sensation of formication over the arm and hand; she cannot straighten her fingers perfectly; the elbow may be raised from the side to a right angle with the body, but she cannot raise it herself more than one foot; she carries it back a little more freely than forwards. In compound dislocations, the prognosis must always be regarded as exceedingly grave. In the only example which has come under my notice, the circumstances attending which I shall hereafter mention in the general chapter devoted to compound dislocations, the patient died from sloughing of the axillary artery. Mr. Scott has, however, reported a case, in a boy fourteen years of age, who recovered rapidly after the reduction was effected, and in thirteen months his arm was nearly as useful as before. 1 Treatment. —The principles of treatment in this dislocation are very simple and easy to be comprehended. I speak now of recent uncomplicated cases of dislocation into the axilla; and, notwithstanding the various and sometimes almost contradictory views which surgeons have entertained as to the best and most rational modes of procedure, I continue to affirm that the laws which are to govern the reduction in a great majority of cases are established and indisputable. Observe now the obvious anatomical facts, and then consider the inevitable inferences. The capsule is torn, generally extensively, along the inner and lower margins of the socket. The head of the bone is lodged below and slightly in advance of its natural position, in consequence of which the points of origin and insertion of the deltoid muscle and the supra-spinatus are separated somewhat and their fibres rendered tense, insomuch that the arm is abducted and actually lengthened. At first, and in the most simple cases, these are the only muscles which are in a state of extreme tension, but after the lapse of a few hours, or of a few days, nearly all the other muscles about the joint, most of which were originally only in a condition of moderate extension, and some of which were rather relaxed than extended, sympathize with those which are suffering the most, and a general contraction and rigidity ensue, increased also at the last by the supervention of inflammation and its consequences. What, from these simple premises, must be the obvious practical deductions ? That in the simplest forms of the dislocation the most rational mode of reduction will be to elevate the arm sufficiently to relax the overstrained deltoid and supra-spinatus muscles, which bind the head of the bone in its new position, and to pull gently in the same direction, in order to overcome the moderate resistance offered by several other muscles, but whose tension cannot be relieved by the same manoeuvre. 1 Scott, Amer. Journ. of Med. Sci., vol. xx. p. 515, Aug. 1837, from the London Lancet for March 4, 1837. 532 DISLOCATIONS OF THE SHOULDER. Failing in this, that we shall increase the relaxation of the first named muscles, by pulling at a right angle with the body, or even directly upwards; and meanwhile, as we carry the arm more and more upwards, we shall operate more powerfully against the resistance of the other muscles. If in all these modifications of the same procedure, we keep the arm a little .back of the axis of the body, we shall accomplish the indications the most perfectly. Such are the conclusions which must be drawn from the anatomical, or, as Mr. Pott would call it, the " physiological" argument; and which assumes as its basis that the muscles constitute the sole or the main obstacle to the return of the bone to its socket. If any surgeon maintains that the premise is unsound, and that the restoration of the head of the bone is opposed by the untorn fibres of the capsule or by any other important circumstance than the action of the muscles (we speak of ordinary cases), we shall content ourselves by referring him again to the extensive laceration which this capsule generally suffers, and to the constrained and almost uniform position of the arm, as a sufficient reply to his objection. It must not be forgotten that in all these modes of extension, for with nearly all of them some slight degree of extension is found necessary, there must be afforded some point of resistance beyond the bone; and this it is really which has constituted one of the greatest impediments to reduction. It is not that the muscles are in such an extraordinary state of extension or rigidity that they must be operated against with great force ; it is not that the margin of the glenoid fossa is an elevated barrier, like the margin of the acetabulum, over which the bone must be lifted before it can fall into its socket; but the explanation of the difficulty so often experienced in producing effective extension and counter-extension is to be sought for mainly in the fact that the scapula, upon which the humerus rests, is movable, being held to the body by little else than muscles, which, in fact, bind the scapula much less firmly to the body than the muscles of the shoulder now bind the scapula to the arm; while at the same time the scapula itself presents very few points against which a counter-extending force can be properly and efficiently applied. Occasionally it will be only necessary to elevate the arm to an acute angle, or to a right angle with the the resistance of the deltoid and supra-spinatus being overcome, the bone will at once resume its place. In several instances which have come under my notice nothing more has been necessary; and where it can be done, the least possible pain and injury are inflicted. It is the method, therefore, which in all recent cases I have first tried and would wish to recommend. By it I have more than once succeeded when other and more violent efforts had failed. At other times it will be necessary to add to this simple manipulation only a moderate degree of extension, such as the hands of the surgeon can make, without the application of direct counter-extension except what is effected by the weight and resistance of the body. If, however, the bone refuses to move, we shall then be obliged to 533 DISLOCATION OF THE HUMERUS DOWNWARDS. consider upon what point, and by what means we can best apply a counter-extending force. Ample experience has taught me that the extremity of the acromion process is the only available point when we are making the extension in a line below a right angle, or in a line downwards more or less approaching the axis of the body. It has been supposed that the counter extension could be made in the axilla against the inferior margin of the scapula; but several obstacles are presented to the successful application of force at this point. The axillary space is narrow and deep, so that even with the ingenious contrivance of placing first a ball of yarn in the axilla, and upon this the heel of the operator, it will be found exceedingly difficult to enter the axilla without at the same time pressing with considerable force against its muscular margins; but to press upon the pectoralis major and latissimus dorsi is to neutralize our own efforts. If,, however, the heel or the ball does press fairly into the axilla, it will not find the scapula readily, but it must impinge first upon the head of the humerus, which is always a little to the inner side of the scapula. If it ever is made to reach actually the inferior border of the scapula, and I do not think it is, the effect must be still only to tilt the scapula upon itself by throwing back its lower angle, and not to separate the glenoid cavity or its upper and anterior margin from the head of the humerus. Whatever success, therefore, may have attended this mode of practice, either in my own hands or in the hands of other surgeons, must be ascribed not to the counter-extension thus effected, but simply to the operation of the heel as a wedge, which, by insinuating itself between the body and the head of the bone, has thrust it outwards and upwards into its socket; or to its having acted as a fulcrum upon which the humerus has operated as a lever. It is to the extremity of the acromion process, then, that we must apply our counter-extension when we are employing this mode of extension. The fingers or hands of a faithful assistant may answer the purpose, or having removed his boot, the operator may often press successfully with the ball of his foot, and the more he carries the arm outwards the more secure will be his seat upon the process; or we may adopt some of the contrivances for securing the process which have been suggested by other surgeons; such as a band crossing the shoulder, and made fast to a counter-band, which passes through the armpit and against the side of the body. Dr. Physick, of Philadelphia, reduced a dislocation in this way as early as the year 1790, in the case of a patient admitted to St. George's Hospital, in London, while he was a student of medicine, and he subsequently taught the same in his lectures. Physick directed that an assistant should press firmly against the process with the palm of his hand. Dorsey and Hays approve of the same method, 1 and perhaps a majority of American surgeons regard it favorably. If we pull directly outwards, at a right angle with the body, we ' Physick, Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorsey's Elements of Surgery, vol. i. p. 214. Philadelphia, 1813. 534 DISLOCATIONS OF THE SHOULDER. may still continue to press upon the acromion process with the foot; or we may perhaps trust to the method of making counter-extension first suggested by Nathan Smith, of New Haven. Dr. Smith exclaims: " What surgeon of experience has not encountered the difficulty which almost always occurs in fixing the scapula ?" and then proceeds to explain how difficult it has been found to hold securely even upon the acromion process by either the fingers of an assistant or the split band, and concludes by stating what seems to him the most effectual mode of rendering the scapula immobile, namely, to make the counter-extension from the opposite wrist. By this method the trapezii are provoked to contraction, and the scapula of the injured side is drawn firmly toward the spine and the opposite scapula. In illustration of the value of this procedure he relates the case of a gentleman who had suffered a dislocation of his left shoulder, and upon whom an unsuccessful attempt at reduction had already been made by a respectable surgeon. Dr. Smith being called, proceeded as follows : Two gentlemen made counter-extension from the Fig. 217. N. K. Smith's method. opposite wrist, while Dr. Smith and Dr. Knapp made extension from the wrist of the injured side, at first pulling it downwards, but gradually raising it to the horizontal direction, and then gently depressing the wrist. On the effort being steadily continued for two or three 535 DISLOCATION OF THE HUMERUS DOWNWARDS. minutes, the bone was observed to slip easily into its place. This gentleman subsequently informed Dr. Smith that this procedure gave him much less pain than that adopted by the first surgeon. 1 The same method has been practised and recommended by the son of Nathan Smith, Prof. Nathan R. Smith, of Baltimore. 2 But no position places the scapula so completely under our control as that in which the arm is carried almost directly upwards and the foot is placed upon the top of the scapula. By this method we may succeed generally when every other expedient has failed, yet it is painful, and I cannot but think that it increases the laceration of the capsule, and does sometimes serious injury to the muscles about the joint. La Mothe was the first to recommend this method, 3 but as early as the year 1764, Charles White, of Manchester, made fast a set of pulleys in the ceiling, and, placing a band around the wrist of the dislocated arm, he drew the patient up until the whole body was suspended. No pressure, however, was made upon the scapula from above, which is no doubt the most essential part of the process. 4 By La Mothe's plan, Jobert succeeded after twenty-three days when all the usual methods had failed. 5 Sometimes this procedure is modified by placing the hand of the operator against the top of the scapula, as is shown in the accompanying drawing. Fig. 218. La Mothe's method, modified. A gentle movement backwards or forwards, a slight rotation of the limb, or suddenly dropping the arm toward the body, diverting the attention of the patient, are little tricks of the operator, which now and then prove successful. Sir Astley Cooper thus describes his method of applying the heel to the axilla (Fig. 219) :— 1 Nathan Smith, Med. and Surg. Memoirs, 1831, p. 337. 2 Nathan R. Smith, Amer. Journ. Med. Sci., July, 1861. 3 La Mothe, Am. Journ. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges de Med. et Chir., Paris, 1812. 1 C. White, Ibid., from Med. Obs. and Inquiries, vol. ii. p. 273, London, 1764. 5 Ibid., vol. xxiii. p. 237, Nov. 1838. 536 DISLOCATIONS OF THE SHOULDER. " The patient should he placed in the recumbent posture upon a table or sofa, near to the edge of which he is to be brought; the surgeon then binds a wetted roller round the arm immediately above the elbow, upon which he ties a handkerchief; then he separates the Fig. 219. Sir Astley Cooper's method of applying extension with the heel in the axilla, patient's elbow from his side, and, with one foot resting upon the floor, he places the heel of his other foot in the axilla, receiving the head of the os humeri upon it, whilst he is himself in the sitting Fig. 220. Sir Astley Cooper's method of operating with the knee in the axilla. posture by the patient's side. He then draws the arm by means of the handkerchief, steadily, for three or four minutes, when, under common circumstances, the head of the bone is easily replaced; but if more force be required, the handkerchief may be changed for a long towel, by which several persons may pull, the surgeon's heel still remaining in the axilla. I generally bend the forearm nearly at right angles with the os humeri, because it relaxes the biceps, and consequently diminishes its resistance." He was also accustomed in some cases to reduce the dislocation by substituting the knee for the heel. (Fig. 220.) Placing the patient upon a low chair, the axilla is laid over the knee of the operator, and while one hand steadies the acromion process and scapula, the other presses downwards upon the lower end of the humerus. If some hours or days have elapsed since the occurrence of the 537 DISLOCATION OF THE HUMERUS DOWNWARDS. dislocation, it will be necessary to resort to chloroform or ether for the purpose of paralyzing the muscles, as well as with the view of preventing pain, and it may be necessary, in addition, to resort to pulleys, or to some similar permanent mode of extension. The same measures also sometimes become necessary in very recent cases, especially in muscular subjects. In employing the pulleys we generally operate not exactly in a line with the axis of the body, nor above a right angle, but between an angle of 45° and a right angle. Mr. Skey has suggested a plan by which we may combine the principle of the heel in the axilla with the pulleys, but which plan would, in my judgment, be very much improved by a counterextending force applied to the acromion process. I ought to say, however, that Mr. Skey prefers that the scapula should not be fixed, believing that the reduction is much more easily effected when the glenoid cavity is drawn downwards in the act of making the extension. With all respect for the opinion of this distinguished surgeon, we cannot precisely agree with him, and while we would be disposed to recommend in some cases a trial of his method of applying the pulleys, we would at the same time, or certainly in the event of its failure, add the acromial support, and especially would we advise that the arm should be more abducted. The following is Mr. Skey's method, as described by himself:— "There is no reason why, in very muscular subjects, or in old dislocations, the same principle may not be applied conjointly with the use of pulleys. For the purpose of retaining this admirable, because most efficient principle, I employ a well-padded iron knob, which may represent the heel, from which there extend laterally two Fig. 221. Iron knob employed by Skey, instead of the heel. strong straight branches of the same metal, each ending in a bulb or ring of about four inches in length, the office of which is designed to keep the margins of the axilla as free from pressure as possible." The iron knob is to be pressed well up into the axilla and attached to cords fastened to a staple; the patient lying upon his back or inclined a little to the opposite side. The arm is then to be drawn downwards bv the pulleys, "as nearly as possible parallel to, and in contact with the body." 1 In this way Mr. Skey says that he has succeeded in reducing a great many dislocations, whether occurring in very muscular men, or after some days', or weeks', or even months' duration; and he thinks 1 Skey, Operative Surgery, Amer. ed., p. 93. 35 538 DISLOCATIONS OF THE SHOULDER the plan especially applicable to cases which require long and per sistent extension. Fig. 222. Skey's method of making extension and counter-extension with pulleys. Mr. Skey and many other surgeons prefer to make the extension from the hand. I have succeeded as well, and it has seemed to be less painful to my patients, when I have followed the practice of Sir Astley, and made the extension from the arm. Sir Astley always made the extension more or less out from the line of the body, and generally almost at a right angle when using the pulleys, the scapula being made fast by " a girt buckled on the top of the acromion," or by a split cloth, as in the accompanying drawing. Fig. 223. Sir Astley Cooper's mode of making extension with pulleys. The instrument invented by Dr. Jarvis, of Portland, Conn., called the adjuster, useless and even mischievous as we have found it in its application to the treatment of fractures, possesses considerable merit as an apparatus for reducing old dislocations, especially of the shoulder. The 539 DISLOCATION OF THE HUMERUS DOWNWARDS. principal advantage which may be claimed for it is, that while the forces are being applied the limb may be moved pretty freely in all directions ; thus enabling us to employ rotation at the same time that the extension is made. "We may also lift or depress, adduct or abduct the limb without relaxing the extension. In the hands of American surgeons it has occasionally been successful when other means have failed. Dr. Jarvis has related a case presented at the Marine Hospital, at Mobile, Tenn., of forty-two days' standing, which he reduced on the second attempt, after other means had failed, 1 and Dr. May, of Washington, reduced a similar dislocation at the end of six weeks, by the same apparatus, without, however, having previously resorted to any other means. 3 I have myself used the apparatus occasionally, both in my hospital and private practice, and can speak favorably of its operation. I must not omit to mention the practice adopted by Prof. H. H. Smith, of Philadelphia, according to whom nearly all dislocations of the shoulder, of a recent date, may be promptly and easily reduced by manipulation alone. His method consists first, in flexing the forearm upon the arm, while, at the same moment, the elbow is lifted from the body; second, in rotating the humerus upwards and outwards, employing the forearm as a lever; and third, in reversing this last movement, that is—rotating the humerus downwards and inwards, while at the same moment the elbow is carried again to the side. 3 When the dislocation is into the axilla this manoeuvre will generally succeed; but if the head of the humerus has slipped forwards, even only sufficient to engage itself slightly under the tendons of the coraco brachialis and biceps, the outward rotation of the humerus will inevitably thrust the head farther forward, and fasten it more certainly underneath these tendons; while the rotation of the humerus in the opposite direction will alone often be sufficient to carry the head directly into the socket. Ancient Luxations. —Finally, I ought to speak somewhat more in detail of the manner of procedure, and of the principles involved in the reduction of old dislocations, or of dislocations requiring the interposition of mechanical appliances; especially with a view to the more complete exposition of my own practice in these cases. If the dislocation is recent, but reduction is found impossible without the aid of mechanical apparatus, the difficulty will be understood to consist mainly, if not altogether, in the resistance offered by the muscles. If, in a few exceptional cases, the capsule, or an untorn tendon, or the margin of the glenoid fossa, present themselves as obstacles, they must still be considered as unusual and extraordinary impediments, the existence of which may be regarded rather as possible than probable. Almost our sole purpose, then, it will be understood, in all recent cases requiring mechanical appliances, and in some ancient cases, is to overcome the contraction of the muscles. 1 Boston Med. and Surg. Journ., vol. xxxix. p. 215. 2 Boston Med. and Surg. Journ., vol. xxxv. p. 454. 3 H. H; Smith, Gross's Surg., ed. of 1863, p. 152. 540 DISLOCATIONS OF THE SHOULDER. "We prefer always to place the patient upon a mattress laid upon the floor; two silk handkerchiefs, or two pieces of a cotton roller, are then laid along the radial and ulnar sides of the humerus, and over the middle of these, immediately above the condyles, a wetted roller is applied, its end being made fast with a needle and thread rather than with a pin. The upper ends of the longitudinal strips, or of the handkerchiefs, are now turned down and tied to the opposite ends, thus converting them both into lateral loops. For the purpose of making counter-extension, a sheet is passed around the body under the axilla, and made fast to a staple; while an intelligent assistant is to manage the scapula with his naked hands, either by pulling with his fingers placed under the process, or by pushing with the palm of his hand and ball of his thumb. The pulleys, secured to a staple exactly opposite to that which holds the counter-extending band, are made ready, but not for the present attached to the arm. As soon as the patient is placed completely under the influence of an anaesthetic, the operator is ready to proceed with the reduction. It is my maxim never to attempt to accomplish by complicated and violent measures, what may be done as well by more simple and gentle means, I think it proper, therefore, to make several attempts at reduction by manipulation alone, aided now by the anaesthetic, the extending and counter-extending bands, &c, before resorting to the pulleys. Seating himself upon the mattress, with his boots drawn, the surgeon should bend the forearm to a right angle with the arm, and planting one heel in the axilla, with one hand he should seize upon the loops at the elbow, and with the other steady the hand and forearm of the patient, while he proceeds to make firm traction for a few seconds in the line of the body, or only a little out from this line. Failing in this, he may direct the assistant to seize upon the scapula, and make counter-extension; still not succeeding, he may change his foot from the axilla to the acromion process and pull directly outwards at a right angle with the body, or' he may swing himself gradually around until he comes to be above the head of the patient, and the foot presses firmly upon the top of the scapula; now descending again in the same direction, he will very probably find the limb reduced, or capable of being reduced easily, by operating upon it as a lever by laying it across the body while at the same moment it is rotated slightly outwards. If still the reduction is not accomplished, the pulleys must at once be put in requisition. The sheet passed around the chest and fastened to a staple, is only a means of supporting the body and rendering it more steady; as a means of counter-extension its value is inconsiderable. To make fast the scapula we must still rely mainly upon the naked hands of strong men or upon a strap drawn firmly across the process and held in place by an assistant. It must be constantly borne in mind that we intend to conquer the muscles by fatiguing them, and that this cannot be done by a force suddenly applied, however great it may be, but only by gentle, steady, and long-continued extension. The muscles, when attacked openly and vigorously, resist, and will suffer laceration rather than yield, DISLOCATION OF THE HUMERUS DOWNWARDS. 541 while on the other hand, an insidious but persevering approach seldom fails to end in their defeat. The forearm is again flexed, and the arm carried out to a right angle with the body, the pulleys secured to the loops, and the assistant takes hold upon the process, while the surgeon draws gently upon the rope attached to the pulleys; as soon as everything is moderately tense, he is to desist for a few moments. Again the rope is drawn upon gently, and again the progress of the extension is suspended. In this way the operator is to proceed during half an hour, or two hours, as the nature of the case may demand; occasionally rotating the humerus, and occasionally lifting its head toward the socket. Meanwhile, it is understood that the principal counterextension is made by the assistants, who must relieve each other at the acromion process. The sheet in the axilla, or rather against the side of the chest, has some value in this respect when the arm is at a right angle with the body, but in itself it cannot control the scapula, only as it holds the body to which the scapula is attached. Much, therefore, as we may regret the inconvenience of making counterextension by hands alone, experience and anatomy alike must teach that here it is the only mode. If these dislocations are reduced often by other methods, as no doubt they are, then it is only an evidence that in these examples, little or no counter-extension was necessary. Sometimes the dislocation is not reduced when the extension is given up, but if then a resort is promptly made to some one of the simple methods already described, while the muscles are still exhausted, it very often happens that the reduction is easily accomplished. It will be prudent in all cases, in order to prevent a reluxation, whether the dislocation is recent or ancient, as soon as its reduction is effected, to place the arm in a sling and secure the elbow to the side by a few turns of a roller. I do not think the axillary pad necessary, and I am afraid it has sometimes done as much mischief as the dislocation itself. The following examples will illustrate the variety of expedients to which we are obliged sometimes to resort before our efforts prove successful:— Thomas Leeding, of Niagara Co., N. Y., set. 52, a laborer and a muscular man, dislocated his right arm into the axilla by jumping from the cars when they were in full motion. The blow was received upon the shoulder. An intelligent country surgeon, assisted by several other persons, attempted reduction within an hour after the accident, but failed, and as the patient had some distance to travel, he was not brought under my notice until eighteen hours had elapsed. "We first administered chloroform, and then, while an assistant held firmly upon the acromion process, I pulled in the line of the body, then outwards, and finally upwards, but to no purpose. Having then applied Jarvis's " adjuster," and after the arm had been kept extended at a right angle with the body fifteen minutes, we removed the apparatus and found the bone in its place. John Harrington, set. 50, a very large and powerful man, fell while intoxicated, and dislocated his left humerus into the axilla. No surgeon was called until the tenth day, when he first consulted Dr. 542 DISLOCATIONS OF THE SHOULDER. Dudley, who at once brought him to me. Without delay we applied the pulleys, and placing the arm at a right angle with the body we made extension fifteen minutes; occasionally also rotating the arm. We then removed the pulleys, and while an assistant held upon the acromion process, with my heel in the axilla I made extension in the line of the axis of the body, then outwards, and finally upwards with my foot upon the top of the scapula. I next seated my patient in a chair, and drew his arm and axilla forcibly over my knee. The bone was not yet reduced; I therefore bled him twenty-four ounces, or until partial syncope was induced, and proceeded to repeat most of these processes, but with no better result. At this moment I determined to use sulphuric ether, which had just been introduced as an anaesthetic, and while he was completely under its influence the pulleys were again applied and the extension continued for some time, and until the rope broke. He was then again placed in a chair, and the axilla brought over my knee, when in a moment the reduction was accomplished. John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably muscular, but spare. Bowles fell down a flight of stairs, and dislocated his left humerus into the axilla. The shoulder became much swollen, and was very painful, but he did not suspect a dislocation, and did not consult a surgeon. Eight weeks after the accident he applied to me. There were present the usual signs of this dislocation, but the arm was by careful measurement one inch and a half longer than the other. The reduction was accomplished on the same day, in presence of Drs. Lee, Webster, Coventry, Ford, and Jewett. The time occupied in the reduction was about two hours. An attempt was first made with the heel in the axilla and with violent rotation and extension. The same plan was repeated with the aid of ether, which was administered freely. Jarvis's adjuster was now applied, with no result, except that either in consequence of the force employed by the adjuster, or in consequence of the free use of ether, or of both, he became convulsed violently, which was accompanied by frothing at the mouth, and other grave symptoms. The adjuster was removed, and the exhibition of ether discontinued. As soon as the convulsions ceased, and before consciousness had returned, extension, rotation, &c, were again made by hands. Finally, after all extension was relinquished, placing my knee in the axilla I reduced the bone by a very slight rotary action upon the arm. The bone was at once plainly in its socket, but the unusual length of the limb continued, being one inch and a half longer, though it could be shortened to the same length as the other by lifting the elbow. A pad was placed in the axilla, and the arm secured with a sling and roller. The next day the arm remained in place, but it was now only one inch longer than the other. At the end of a fortnight it was only three-quarters of an inch longer, and could be reduced to the same length by lifting; the pain and swelling about the shoulder, which never were great, were subsiding, and the patient was dismissed. However skilfully our efforts may be directed, they will be found DISLOCATION OF THE HUMERUS DOWNWARDS. 543 occasionally to fail; either owing to adhesions which have taken place, between the head of the bone, or rather its capsule, and the adjacent tendons, muscles, etc., to some extraordinary position of the head and neck of the bone in its relation to ligamentous or tendinous structures, to a filling up of the glenoid fossa, or to some other cause not fully explained. Such failures have happened not only in the hands of ignorant and unskilful surgeons destitute of appliances, but also in the hands of those who are the most expert, and who are the most completely provided with all the necessary apparatus. Indeed, if the truth were known, it would probably be found that the number of failures has been greater than the successes. The records of surgery, however, furnish a great many examples of ancient dislocations of the humerus reduced after periods ranging from one month to six, or even longer. Dieffenbaeh has been able to accomplish the reduction of a forward dislocation after two years, but not until he had cut the tendons of the pectoralis major, latissimus dorsi, teres major, and teres minor, and had divided the ligaments surrounding the new joint. 1 It would be unjust to the young surgeon not to call especial attention to the numerous examples of serious and even fatal accidents which have followed upon the attempts to reduce ancient luxations at this joint. My friend, George C. Blackman, of Cincinnati, a distinguished surgeon, having recently met with one of these unfortunate accidents in his own practice, has had the candor to make a public statement of the case and of the circumstances which attended it. In a letter to the editor of the Western Lancet, published in the November number for 1856, he writes as follows :— "About the 10th ult., aided by yourself, I succeeded in reducing by manipulation, without the pulleys, a dislocation into the axilla, of eighty days' standing. The reduction was accomplished in a very few minutes, under the influence of chloroform and ether, and the next morning the patient left for the country, in a comfortable condition. Since that I have received no tidings from him. Encouraged by the result in this case, another patient, himself a physician, a tall athletic man, and about fifty years of age, decided to submit to the same manipulation, although his arm had been dislocated for about sixteen weeks. The dislocation was downwards and inwards, and about the tenth week an unsuccessful attempt, by another surgeon, had been made with the pulleys, to which the force of six men was applied for two and a half hours. The patient being under the influence of chloroform and ether, aided by yourself, Drs. Fries, Cary, Graham, and Kauffman, I commenced my manipulations, adducting, rotating, abducting, and elevating the arm. These efforts had been made for about ten minutes, and the least possible violence employed, when a tumefaction appeared in the pectoral region, which in a few minutes attained a considerable size. Supposing that the axillary artery was ruptured, as no pulse could be felt at the wrist, a ligature was immediately applied to the vessel at the upper part of its course. The operation was performed about 10 o'clock A. M., and compression of the pectoral region made by means 1 Dieffenbaeh, Bost. Med. and Surg. Journ., vol. xxii. p. 382, from Medicin. Zeitung. 544 DISLOCATIONS OF THE SHOULDER. of a sponge and broad roller. On removing this the next morning, the tumefaction had nearly disappeared. The patient continued comfortable, and about nine days after the application of the ligature, I was compelled to leave the city on a professional visit to Indiana. I left on Friday afternoon and returned on Monday morning, at which time I learned that my patient had died on Sunday morning, from hemorrhage at the seat of ligature. Two physicians, his most intimate friends, lodged in the same house with him, but before they reached his bedside the quantity of blood lost was so great that he sank exhausted in about two hours from the first and only attack of hemorrhage. Previous to my departure for Indiana, I had suggested to the physicians in charge, the importance of having compressed sponge at hand, to be used in any emergency of the kind, but this was not used by the attendant; instead of applying pressure instantaneously, he went in search of the physicians, who, at that early hour in the morning were in bed. The time thus lost unquestionably led to the fatal catastrophe. " I might refer you to numerous instances of success in the reduction of old dislocations —from two to six months' standing—which have occurred since the days of Wiseman, but I propose to notice only the accidents by which some of these attempts have occasionally been followed. One of the earliest recorded, so far as we have been able to learn, is the case reported by Desault. 1 " During the effort of this surgeon to reduce an old dislocation, suddenly a considerable 'tumeur aeriennd appeared below the clavicle, which Desault attributed to the 'degagement de Vair amasse entre les cellules rompues du tissu cellulaire /' In a few days this tumor entirely subsided under the influence of 'astringents et une compression methodique 1 Whether it was the result of a disengagement of air from the lacerated cells of the cellular membrane, as supposed by Desault, or of a rupture of bloodvessels, we leave the reader to determine. "It is somewhat singular that Desault should have met with two cases of this extraordinary phenomenon. Pelletan's explanation, in our opinion, throws some light on this subject. In an attempt to reduce a luxation of four months' standing, the same kind of ' tumeur aerienne' appeared. It was opened, and the hemorrhage from the torn artery was fatal. 2 " Malgaigne states that he is acquainted with but a single instance of an ' emphyseme veritable' following- a reduction, and that is the one reported by Flaubert, in his Mem. sur plusieurs cas de luxations dans lesquels les efforts pour la reduction ont ete suivis a"accidents graves, which appeared in the Repertoire d'Anat. et de Phys., 1827. The patient, a female, aet. 70, screamed violently during the operation, and Malgaigne is disposed to believe that the emphysema was independent of the luxation, or the reduction. " Malgaigne, himself, attempted reduction in a case of sixty-eight days' standing, but was forced to discontinue his efforts in consequence of the sudden appearance of a tumefaction in the axilla, and on the 1 Desault, Journ. de Chir., t. iv. p. 301. * Pelletan, Chir. Clin., t. ii. p. 951. DISLOCATION OF THE HUMERUS DOWNWARDS. 545 shoulder. Ice was applied, and in the course of a few hours the swelling was arrested, and by the twenty-second day, the blood which he thinks came from ruptured muscular branches, was completely absorbed. 1 " A case occurred to Flaubert, in which, besides the tumefaction, the pulse could not be felt at the wrist. The hand was cold, insensible, and immovable. The next day, however, the pulse returned to the wrist, and in the course of twenty-six days the effused blood was absorbed. Froriep lost a patient from a rupture of the axillary vein, which proved fatal in an hour and a half after the operation. The reader may find in the comprehensive treatise of Malgaigne, details of cases in which the axillary artery was ruptured. We pass over those observed by Yerduc, Petit, Platner, Delpech, and that referred to by Sir Charles Bell, in his Operative Surgery. The late Dr. John C. Warren tied the subclavian to arrest the progress of an enormous aneurismal tumor in the axilla, the result of the reduction of a recent dislocation, and of supposed pressure of the operator's boot. In this instance the coats of the artery were so contused that sloughing took place during a fit of coughing, five days after the accident. 2 In 1824, M. Leudet lost a patient at the hospital at Rouen. The dislocation was of only eleven days' standing, and was complicated with a fracture of the margin of the glenoid cavity, as in the two fatal cases which occurred in the practice of Prof. Gibson, of Philadelphia. The latter cases are too familiar to every surgical student to require particular mention in this place. Prof. Gibson, in connection with the report of the above cases, gives briefly the details of a fatal operation by David, of Rouen. The luxation had existed several months, and great force was employed in the reduction. This resulted in an inflammation, mortification, and death. Some years since, Lisfranc attempted the reduction in a case of four months' standing. He succeeded; but on visiting the patient an hour afterwards he was found dead. His death was attributed to cerebral congestion, as the autopsy showed the axillary artery, veins, and nerves uninjured. 3 In the same volume, MM. Lenoir and Larrey refer to cases in which, they have met with lesion of the brachial plexus, giving rise to paralysis, and yet these were recent cases, and the reduction was most readily accomplished. But I will not multiply cases of this kind; those already related will suffice, in the minds of many, to answer the question—At what period of time after a dislocation of the shoulder, is an attempt at reduction justifiable? When Prof. Gibson lost his first patient, he wrote that 'should a case, similar in external appearance to that of James Scofield again occur, I shall feel justified in adopting a similar course.' 4 When he Jiad lost his second patient (John Langton), he expressed his views as follows: ' The conclusions which I am now prepared to draw are directly the reverse of what I have stated in some of the foregoing pages; I am now disposed to condemn, in the most unqualified terms, 1 Malgaigne, op. cit., p. 150. 2 Warren, Amer. Journ. Med. Sci., vol. xi., N. S., 1846. 8 Lisfranc, Bui. de la Soc. Chir., t. i. p. 718. * Gibson, Elements of Surg., vol. i. p. 824, 4th ed. 546 DISLOCATIONS OF THE SHOULDER. all attempts at the restoration of ancient luxations of the humerus and other bones—except in cases where the patient is remarkably thin and debilitated, and where there has been little or no inflammation at the time of, or subsequent to the displacement.' At a meeting of the Societe de Chirurgie of Paris, July 3, 1850, M. Maisonneuve reported a case in which, after M. Yelpeau had failed, he succeeded in reducing a luxation of the shoulder of twelve weeks' standing, and elated with this triumph over the veteran of La Charite*, he asserts there are but few cases in which, with the aid of chloroform, we may not succeed. ' Quelles resistances y a-t-il a vaincre id, en effetV he asks. ' 11 riy a presque pas d 1 engrenage; les muscles sont neutralises par le chloroforme; il ne reste done que des adherences fibreuses: Von pourra presque toujour's les surmonter, ou les romprej 1 But these fibrous adhesions are not the only obstacles to overcome: where the tissues surrounding the head have become consolidated by inflammation, the axillary vessels and nerves must be in danger of laceration. Perhaps, however, as M. Maisonneuve suggests, this accident may be avoided by ' extensions preparatoires, 1 as in the attempts to restore contracted limbs to their natural shape." Norris has reported three cases of ancient dislocation into the axilla, treated at the Pennsylvania Hospital; one, of four weeks' standing, was reduced in thirty seconds by the aid of the pulleys; the second, which had existed seven weeks, was reduced by the same means in about one hour; and the third, dislocated ten weeks, was left unre- duced after extension and counter-extension had been made for an hour. In the second case, however, suppuration occurred in or about the joint, and, on the tenth day, the abscess was opened, giving exit to a large amount of pus. He left the hospital with the parts about the shoulder still much hardened and stiff. 2 Dislocation, with Fracture of the Humerus near its Upper End. We have thus far omitted to speak of the treatment of dislocations of the humerus accompanied with fracture near its upper end. The older writers, almost without an exception, agreed in declaring the reduction of these dislocations impossible, until the fracture had united. And, so late as the year 1828, we have the report of a case treated in this manner by a surgeon in Massachusetts. Br. Warren, of Boston, himself reduced the dislocation at the end of four weeks, when the fracture was found to have united. 3 But, whatever difficulty surgeons may have experienced before the introduction of anaesthetics, it is quite certain that at the present day such delay is no longer necessary, at least in a great majority of cases. In order to the reduction, even extension and counter-extension»are rendered unnecessary, provided the muscular system is thoroughly relaxed, for, by simply pressing firmly the head of the bone toward the socket, the reduction has often been speedily accomplished. 1 Maisonneuve, Bui. de la Soc. Chir., t. i. p. 718. 2 Norris, Amer. Journ. Med. Sd., vol. xxxi. p. 24. 3 Boston Med. and Surg. Journ., No. i., 1828; also, Amer. Journ. Med. Soi., vol. ii. p. 233. DISLOCATION OF THE HUMERUS FORWARDS. 547 Richet reports an example of this kind in a man sixty-eight years of age, in whom the dislocation was complicated with a fracture of the neck of the humerus. The attempt was not made until the fourth day, when it proved successful without extension. The fracture was afterwards adjusted and consolidated so that he recovered the complete use of his arm. 1 At a meeting of the New York Academy of Medicine in May, 1855, Dr. Watson reported a case of fracture of the humerus near its head, complicated with a dislocation into the axilla. The patient was a robust man, past the middle age, and had received the injury by a blow on the shoulder from a steam engine. He was very much prostrated at the time of being admitted into the hospital, and the examination was not made until the following morning. The arm was then found lying close to the side, but in other respects it presented the usual signs of a dislocation. Ether was immediately administered; and while extension and counter-extension were applied, and a sweeping motion given to the arm, drawing it from the body, firm pressure with the fingers was made in the axilla, forcing the head toward the socket, and the bone slipped into its position. 2 In the Transactions of the American Medical Association, I have reported of supposed dislocation accompanied with a fracture, which I succeeded in reducing on the eighth clay. 3 Many other examples have been recorded by other surgeons in which the reduction has been accomplished immediately, and without much difficulty, by simple pressure upon the head of the bone, while the patient was under the influence of an anaesthetic, and without the aid of extension; indeed, it is quite doubtful whether extension in these cases is of any service. If, however, the surgeon were to fail by pressure alone, it would be proper to employ extension and manipulation ; 4 in the event of a failure by these means, the case ought to be treated as a fracture, and the earliest period after the union of the fragments should be seized upon to accomplish the reduction of the dislocation. The frequent success of the older surgeons by this method is sufficient to warrant the attempt. The treatment of compound dislocations of this joint will be considered in a separate chapter devoted to the general consideration of compound dislocations of all the joints connected with the long bones. § 2. Dislocation op the Humerus Forwards. (Subcoracoid and Subclavicular.) Causes. —The causes of this dislocation are the same with those which produce dislocation downwards into the axilla, except that it is more likely to occur in a fall upon the elbow or upon the hand when the line of the axis of the arm and forearm is thrown behind the 1 Richet, Amer. Journ. Med. Sci., vol. xii., newser., p. 293, from Bulletin de Th£rap. 2 Watson, Amer. Journ. Med. Sci., vol. xvi., new ser., p. 383. 3 Op. cit., vol. ix. p. 93. 4 Hartshorne, Case reduced by Manipulation, Amer. Journ. Med. Sci., Jan. 1855, pp. 273—4, from Med. Examiner. 548 DISLOCATIONS OF THE SHOULDER. body. If it is the result of a direct blow, the impulse has usually been received rather upon the back than upon the outer side of the head of the humerus; or the upper end of the bone having been orignally thrown directly downwards upon the inferior edge of the scapula, may have been made to assume the position forwards, beneath the pectoral muscle, in consequence of the peculiar action of the muscles, or of the position of the arm in an attempt to rise. By this latter mode of explanation the dislocation forwards is consecutive only upon a dislocation downwards. In several instances which have come under my notice the dislocation has been due to muscular action alone. In one example the dislocation occurred frequently in consequence of epileptic convulsions. This was in the person of a lad, aet. 18, of a slender frame and feeble muscles. When the dislocation had taken place, he was frequently able to reduce it himself; sometimes he was obliged to call upon a surgeon, and at other times he left it out a day or two, or until it became reduced spontaneously. This spontaneous reduction generally took place at night, during sleep. At the time he called upon me the bone had been out two days, and he could not reduce it. I administered chloroform, and then made repeated and prolonged efforts to reduce it, adopting all the usual modes of manipulation, but without resorting to mechanical appliances. The father now refused to allow me to proceed, and he was taken home with the bone unreduced. The following day he called at my office, to say that during the night, while asleep, and, he thinks, while turning over in bed, the bone suddenly resumed its place. Pathology. —Omitting for the present to speak of partial luxations, the existence of which, as a form of traumatic dislocation, we are pre- Fig. 224. Subcoracoid dislocation. scapular muscle. pared to question, we shall proceed at once to describe the anatomical relations and the various lesions which generally accompany a complete luxation forwards. Of these we shall observe two principal varieties, differing mainly in the degree or extent of the displacement. Thus we may find the head of the humerus resting beneath the coracoid process (Fig. 224), having the conjoined tendon of the short head of the biceps and of the coraco-branchialis lying upon its anterior surface, while its posterior and outer surface rests upon the venter of the scapula in front of the glenoid fossa; in which position it has usually thrust up, to a greater or less extent, the belly of the sub- Sir Astley Cooper, Fergusson, and others, when mentioning this form of dislocation, call it a "dislocation into the axilla;" by Boyer it is called a " primary luxation forwards." Dr. Wood, of New York, has reported an example, accompanied with a fracture of the neck of the humerus, which he has named "dislocation under the subscapularis muscle." The drawing which accompanied the report, made from the 549 DISLOCATION OF THE HUMERUS FORWARDS. autopsy, sufficiently shows that it was a dislocation of the same character which we are now describing. 1 And Dr. Parker, of the same city, has called attention to a similar case, an account of which was first given in Reese's edition of Cooper's Surgical Dictionary. The head of the humerus reposed in the "subscapular fossa." 2 By Malgaigne, Vidal (de Cassis), and others, this is called a subcoracoid dislocation, a term which, as being more distinctive and appropriate than either of the others, I shall choose to adopt. In the second variety (Fig. 225), the head, having escaped from underneath the coracoid process, is made to approach nearer to the sternum, so as to apply itself more or less closely to the inferior edge of the clavicle. In which case the head and neck will be placed behind both the pectoralis major and minor, and also behind the short head of the biceps and coraco-brachi- Fig. 225. Subclavicular dislocation alis; or between these several muscles on the one hand, and the serratus magnus, covering the second and third ribs, on the other hand. It is in this latter position that the head of the humerus is usually found, and upon the appearances which accompany this more advanced form of dislocation writers have generally based their descriptions, diagnosis, treatment, &c, of forward luxations. In either form of the accident, the deltoid, with the supra, and infraspinatus, is greatly stretched, and the two latter sometimes torn; the subscapularis is displaced upwards and backwards, while its tendon is in some instances completely wrenched from the head of the humerus. Mr. Erichsen has seen the lesser tubercle itself completely broken off in two examples of this accident which he has been permitted to examine after death. 3 Occasionally the axillary nerves are carried forwards with the head of the bone; and in this case the pain produced by their being thus pressed upon is even greater than in dislocations into the axilla. In this accident, as in dislocation downwards, the long head of the biceps is sometimes broken; the circumflex nerve may be contused or ruptured, and the capsule is generally torn very extensively. Symptoms. —If the dislocation is subclavicular (Fig. 225), a depression exists under the outer end of the acromion process, extending also underneath its posterior margin; the elbow hangs away from the body, and a little backwards; the axis of the limb is much changed, being thrown inwards in the direction of the middle of the clavicle, the whole body inclining moderately to the same side; there is also more » Wood, New York Journ. of Med., May, 1850, p. 282. 2 Parker, New York Journ. of Med., March, 1852, p. 187. 3 Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250. 550 DISLOCATIONS OF THE SHOULDER. or less inability to move the arm, especially in a direction forwards or outwards; a fulness is seen underneath the clavicle, and to the sternal side of the coracoid process, occasioned by the head of the humerus; the head moving with the shaft. To these we may add the common sign of all dislocations of the humerus, mentioned by Dugas, viz: the impossibility of placing the hand upon the opposite shoulder while at the same moment the elbow is made to touch the front of the chest. If the dislocation is forwards, but subcoracoid (Fig. 226), the head of the bone will be found below this process and deep in the anterior Fig. 226. Subcoracoid luxation. margin of the axillary fossa. It cannot, therefore, be so distinctly felt; but the other signs are the same as in the dislocation forwards under the clavicle. Prognosis. —While on the other hand experience has shown that the axillary nerves and artery are less liable to suffer serious and permanent injury than in dislocation downwards, and that the capsule, with the tendinous, and muscular tissues about the joint, are no more liable to laceration, on the other hand, the difficulty of reduction has been often increased, and consequently a larger number of examples, in proportion to the actual number which occur, have been left unreduced. Dr. Norris relates a case which the surgeon who was first called supposed to be a mere contusion, but which, on being admitted to the Pennsylvania Hospital, three months after the accident, was found to be a dislocation forwards under the clavicle. The arm was almost useless. Dr. Norris made extension and counter-extension with pul- 551 DISLOCATION OF THE HUMERUS FORWARDS. leys nearly an hour, but to no purpose; and finally, at the request of the patient, the attempt was given over. 1 Treatment. —The same rules of treatment which we have established in relation to dislocations into the axilla will be found to be applicable to this dislocation, with the exception that the extension will have to be made, generally at first, somewhat in a line backwards from the body, and that our efforts will frequently have to be continued with more perseverance, although with less fear of injury in consequence of supposed adhesions between the artery and the adjacent tissues. The extension also must always be made downwards and outwards, if the dislocation is subclavicular, until the head of the bone has escaped from beneath the coracoid process; we may then pull directly outwards or even upwards, while at the same moment pressure is made with the hand upon the head of the bone in the direction of the socket. If the dislocation is subcoracoid, our modes of procedure need scarcely vary in any respect from those which we have recommended for dislocations into the axilla. The plan adopted in the following case has been found sufficient in several examples of subcoracoid dislocation. Mr. McA., of Buffalo, set. 73, moderately muscular, fell through a trap-door, striking upon his right elbow and dislocating the humerus forwards. "Within two hours after the accident I found the head of the bone resting under the coracoid process, where it could be distinctly felt and seen. There was a marked depression under the acromion process, and the arm was carried out from the body and slightly back. He had not suffered much pain. The patient was seated in a chair, and while Dr. Lemon, who was at that time my pupil, supported the acromion process, I pushed the head of the humerus outwards toward the socket, with my left hand, while with my right I pulled gently upon the arm in the direction of the axis of the body. After about twenty seconds it slid suddenly into its place with an audible snap. Simple manipulation alone will also be found sufficient in many cases of subclavicular dislocation. A German, Simeon Grennas, set. 21, fell upon an icy side-walk and dislocated his right humerus under the'clavicle. We found him about an hour after the accident sitting with his head inclined to his right side, and supporting his elbow with his left hand. A marked depression existed under the outer end of the acromion process, and instead of the usual fulness there was a flatness under the process behind. The elbow was carried out from the body and very slightly backwards. While Dr. Boardman supported the acromion process I lifted the elbow from the side, carrying it first upwards and backwards, and then forwards, making thus a short detour with the arm, and when the manoeuvre was nearly completed the bone slid into its socket with a slight snap. No extension was used, and no more force was employed than 1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 279. 552 DISLOCATIONS OF THE SHOULDER. was sufficient to lift and rotate the arm. He was not at the time of the reduction faint, nor were his muscles relaxed from any other cause. More than once I have accomplished the reduction by extension made directly upwards, as in the following example. A gentleman, forty-five years of age, had his left shoulder dislocated forwards under the clavicle in a railroad collision on the 8th of October, 1858. A young surgeon had been making extension in various ways for half an hour, when, by placing my foot upon the top of the scapula and drawing the arm directly upwards, I accomplished the reduction immediately and without much effort. Six months after the accident, I found the deltoid muscle considerably wasted, and he was still unable to raise his arm to a right angle with the body. I have in this way also reduced a dislocation which had existed seventeen days, the nature of the accident having been misunderstood by the attending surgeon. The man was twenty-three years old, and quite muscular. The dislocation had been produced by a severe blow received directly upon the shoulder, and the arm was still considerably swollen and very tender. The reduction was accomplished in a few seconds while the patient was under the influence of chloroform, but by my hands alone, aided only by the pressure of the foot upon the top of the scapula. In December, 1857, Dr. White, of Buffalo, and myself reduced a subclavicular dislocation of the right shoulder, which had existed sixty days, in a man sixty-eight years of age. The surgeon who first saw the man thought it was only a sprain or a severe bruise. When he came to Buffalo, the whole limb was enormously swollen, and neither Dr. White nor myself had much expectation of accomplishing a reduction without a resort to pulleys and anaesthetics. He was, however, placed upon the floor, and after extension made for about half an hour, during which time we had pulled the arm in various directions, upwards, outwards, and downwards, I at last succeeded while my heel was placed in the axilla, and while the limb was undergoing a slight rotation. No anaesthetic was employed. These several cases are mentioned that the surgeon may understand how impossible it is always to establish absolute and invariable rules of procedure which shall be applicable to every accident of this character. The method which will succeed readily in one case may fail completely in another, although belonging to the same class, and not apparently differing in its anatomical relations. Before relinquishing the attempt, we ought to have put in requisition all the expedients which the experience of other surgeons has shown to be worthy of a trial. § 3. Dislocation of the Humerus Backwards. (Subspinous.) This form of dislocation has been seldom met with. Only two cases according to Sir Astley Cooper, occurred in Guy's Hospital in thirty-eight years; but in the last edition of Sir Astley Cooper's treatise on Fractures and Dislocations, edited by Bransby Cooper, nine 553 DISLOCATION OF THE HUMERUS BACKWARDS. cases are mentioned. 1 Sedillot,* Malgaigne, Desclaux, 3 Van Buren, 4 W. Parker, 3 Lepelletier, 6 Trowbridge, 7 Physick, Snyder, 8 and myself, have each seen one example. 9 Causes. —One of the patients mentioned in Mr. Cooper's book had his shoulder dislocated backwards in an epileptic convulsion; one had fallen upon his shoulder; another met with the accident while pushing a person violently with the arm elevated; and a fourth, seen by Mr. Coley, " was pulled down by a calf which he was driving, a cord having been tied to one of the calf's legs, and being held fast by the man's hand." My own patient, Frederick Kretner, had his arm caught in machinery on the 14th of Jan. 1860. The dislocation was discovered when I was preparing to amputate the arm soon after the accident occurred. Of the manner in which the other cases were produced no precise account is given. Desclaux's patient fell from a height with his arm in front of him. In the case seen by Dr. Parker, of New York, a woman, set. 60, had fallen forwards and struck upon the outside of her elbow, arm, and shoulder. No attempt was made to reduce it until the fourteenth day, she not having for some time called the attention of any surgeon to its condition. Trowbridge's patient was thrown from a horse, striking on the palm of his hand. Pathology. —Mr. Cooper has given us a careful account of the dissection in the case of Mr. Complin, already alluded to, whose arm had been dislocated by muscular spasm. This gentleman was fifty-two years of age, and had been subject to epileptic fits, in one of which the shoulder was dislocated. Many attempts were made to reduce it, but although it seemed to be easily drawn into its socket by extension merely, yet, as soon as the force ceased, the head of the bone slipped again upon the dorsum scapulae, and in this situation it was finally permitted to remain until his death, which did not take place until rive years after. In the mean time, he was able to move the limb but very slightly, so that his arm was almost useless. Mr. Cooper, to whom the arm was sent after death, found the head of the bone resting under the spine of the scapula, and against the posterior edge of the glenoid fossa, where it had formed a slight depression, and the head itself had become somewhat changed in form by absorption. The tendon of the subscapularis muscle and the internal portion of the capsular ligament were torn at the point where the muscle was inserted, but the greater portion of the capsule remained, having been pressed back by the head of the bone. The supra-spinatus was stretched, while the infra-spinatus and teres minor were relaxed. The long head of the biceps was elongated but not ruptured. The glenoid fossa was rough and irregular upon its surface, the cartilage being absorbed. 1 A. Cooper, op. cit., p. 352, etc. ' Sedillot, Amer. Journ. of Med. Sci., vol. xiii. p. 551, Feb. 1834. 3 Desclaux, New York Journ. of Med., Nov. 1851, p. 109, from Revue Medicale. 4 VanBuren, ibid., Nov. 1851, p. 110. 5 Parker, ibid., March, 1852, p. 186. 6 Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1834. 7 Trowbridge, Bost. Med. and Surg. Journ., vol. xxvii. p. 99. 8 Gibson's Surgery. 9 Examples have also been seen by Dupuytren, Arnolt, Best, Levacher, Berard, Fizeau, Velpeau, Fergusson and Kirkbride. New York Journ. Med., March, 1852, p. 193. 36 554 DISLOCATIONS OF THE SHOULDER. The fact that the bone would not remain in place when reduced, was explained by the rupture of the subscapulars, and the consequent loss of antagonism to the action of the infra spinatus and teres minor. 1 The accompanying drawing is a copy of that furnished by Mr. Cooper, to illustrate the position occupied by the bone. I ought to mention that this case has been regarded by Vidal (de Fig. 227. Subspinous dislocation. Cassis), Malgaigne, and others, as only subacromial, and as a variety of the dislocation backwards, differing from that in which the head of the bone occupies a position underneath the spine. But as I can see no difference except in the degree or extent of the displacement, I prefer not to regard the distinction made by these surgeons. Symptoms. —The signs of this accident are, a projection under the spine of the scapula, produced by the head of the bone, the head being obedient to the motions of the arm; a corresponding depression in front and under the outer extremity of the acromion process; a wide space between the head of the bone and the coracoid process, into which the fingers may be pushed deeply; the axis of the shaft of the humerus directed upwards and outwards toward a point posterior to the glenoid fossa; the forearm carried forwards across the chest; the humerus rotated inwards, unless the subscapularis muscle is torn; immobility, but the motions of the arm are not generally so much impaired as in either of the other dislocations; and finally, as in all other dislocations of the humerus, the hand cannot be laid upon the opposite shoulder while the elbow touches the side or front of the chest. In Parker's case the elbow was thrown outwards, although the arm was carried very much across the chest. Desclaux's patient held his hand upon his head, with his arm horizontally across his body. Usually the diagnosis will be easily made; in my own case the position of the head of the bone was easily recognized, but Sir Astley relates one case in which, on the morning following the accident, a surgeon was unable to discover the dislocation, and on the seventeenth day Bransby Cooper failed to make the diagnosis; nor, indeed, on the twenty-third day did Sir Astley himself determine that it was a dislocation, until he had unexpectedly reduced it while manipulating upon the arm. In a second example, Sir Astley at first believed it to be a fracture, but a more careful examination showed it to be a dislocation backwards. In this instance the limb could not be rotated outwards, as the subscapularis was not torn, and continued to offer resistance when the arm was moved in this direction; he was also suffering much more pain than did the other patients, owing, as Sir 1 Sir A. Cooper, op. cit., p. 354. 555 DISLOCATION OF THE HUMERUS BACKWARDS. Astley thinks, to pressure upon the articular nerves. In the case of Mr. Collinson, also mentioned by Mr. Cooper, a surgeon who saw the patient immediately after the accident, failed to discover the true nature of the injury; and Trowbridge's patient had suffered a dislocation several weeks before the nature of the accident was fully determined. Prognosis. —The reduction has always been sooner or later accomplished, except in one instance; in this case we have seen that the arm never recovered any considerable degree of usefulness. Mr. Collinson's arm, reduced on the second day, was restored to all of its functions within one month. Dr. Parker's patient had nearly recovered the complete use of her arm at the end of four weeks, although it was not reduced until it had been out fourteen days. Sedillot succeeded in reducing the dislocation in the case of his patient, at the end of one year and fifteen days. Lepelletier after forty-five days. Trowbridge after forty days, and in this latter case, we are informed that the arm was restored to usefulness. Treatment. —In the first case mentioned by Sir Astley Cooper, " the bandages were applied in the same manner as if the head of the humerus had been in the axilla, and the extension was made in the same direction as in that accident" (downwards and a little outwards). In less than five minutes the bone slipped into its socket with a loud snap. The second case was treated successfully in the same way. Mr. Dunn also having failed to reduce by pulling upwards, finally succeeded by pulling at the wrist downwards and forwards, while an assistant pushed the head of the bone toward the socket; the heel was not placed in the axilla, which Mr. Bransby Cooper thinks would have only retarded the reduction. Mr. Key also failed to accomplish reduction while carrying the arm upwards and backwards, but when the patient had become faint, by placing the heel in the axilla and pulling downwards a minute or two, the bone was reduced. Vidal (de Cassis) recommends the same plan, namely, that we shall pull in the direction in which we find the limb; Trowbridge employed the pulleys the extension being made downwards and forwards: while Dr. Parker succeeded equally well with his patient, by " pulling the arm outwards, downwards, and slightly forwards." Counter-extension was at the same time made by a sheet in the axilla, and the head of the humerus was pushed toward the socket by the hand. In Mr. Collinson's case, the scapula was supported by a towel, while " gradual extension of the limb was made directly outwards, and then the arm being moved slowly forwards, the head of the bone was distinctly heard to snap into its socket." The time occupied was not more than two or three minutes. Sir Astley, however, seems to give the preference to the method which succeeded so happily in the case of Mr. G., while he was still manipulating with a view to determine the character of the accident. " I readily reduced the bone," he remarks, "by raising the head and arm, and by turning the hand backwards behind the head." In one other instance, having failed to reduce it by slight extension outwards, he raised the arm perpendicularly, and at the same time forced it backwards behind the patient's head, and the reduction was promptly 556 DISLOCATIONS OF THE SHOULDER. effected. In the case of Kretner, I first attempted reduction by pressure directly upon the head of the humerus, but failing, I proceeded to carry the arm outwards and downwards, which manipulation was attended with immediate success. The patient was under the influence of chloroform. After the reduction, a compress should be placed against the head of the bone, and underneath the spine of the scapula, and this should be secured in its place by several turns of a roller. The forearm ought also to be placed in a sling, with the elbow thrown a little back of the centre of the body, so as to direct the head of the humerus forwards. * § 4. Partial Dislocations of the Humerus. Sir Astley Cooper has related in his treatise two cases of supposed incomplete luxation of the head of the humerus forwards; and in confirmation of his views he has added an account of the appearances presented on dissection in the body of a subject brought into the rooms of St. Thomas's Hospital. Bransby Cooper, in his edition of the same work, furnishes the report of a similar case which came under the observation of Mr. Douglass, of Glasgow. Hargrave and Dupuytren have each reported one example of this species of dislocation, in which its existence was said to be confirmed by dissection. Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and many others have admitted its possibility; Malgaigne, however, only admits its existence when the capsule remains entire. Without intending to examine very much at length the value of these opinions, I shall content myself with declaring that the existence of this, or of any other form of partial luxation of the shoulderjoint, as a traumatic accident, has not up to this moment been fairly established; and that the anatomical structure of the joint renders its occurrence exceedingly improbable, if not absolutely impossible. The only example mentioned by Sir Astley Cooper, in which a dissection was made, showed that the long head of the biceps had been ruptured, and that the capsule was torn, while the head of the humerus was resting under the coracoid process. We shall have no difficulty, therefore, in assigning it to its proper place as a complete, sub-coracoid dislocation. In Mr. Hargrave's case also, the tendon of the biceps was torn; while Dupuytren omits to mention what was the actual fact in relation to this tendon in the case seen by him, but it is distinctly stated that the head of the bone rested upon the ribs. Mr. Hargrave seems, therefore, to have described a case of rupture of the long head of the biceps, and it is probable that Dupuytren, who knew nothing of the previous history of the subject, has given us a faithful account of a pathological dislocation, a result of disease, and not of a direct injury. If the head of the humerus is driven from its socket by violence, and remains thus displaced, it is, we assume, a complete luxation; since it is only by having placed the semi-diameter of the head of the bone outside of the margin of the glenoid fossa that it can be made 557 PARTIAL DISLOCATIONS OF THE HUMERUS. for one moment to retain its abnormal position. To accomplish this amount of displacement upwards, or upwards and forwards, or directly forwards, the acromion or the coracoid process must be broken. While its occurrence in any other direction must involve at least a most extraordinary extension, if not an actual laceration of the capsule. If we admit, with Malgaigne, that occasionally the capsule has been found capable of such extraordinary extension without actual rupture, we still are unwilling to regard this as a fair example of a partial dislocation, since the head of the bone no longer moves in its socket, being at no point in actual contact with the articular surface of the glenoid fossa. It is essentially a complete dislocation, according to all the admitted definitions of this term. It is quite probable that a majority of these accidents were examples of rupture or of displacement of the tendon of the long head of the biceps, the effect of which, as Mr. John Gr. Smith, 1 and Mr. Soden 2 have shown by a number of dissections, is to allow the head of the humerus to be drawn upwards and forwards in its socket, until it is arrested by the two processes, and by the coraco-acromial ligament. Says Mr. Soden: " To enable the bone to maintain its equilibrium, it is necessary that the capsular muscles should exactly counterbalance each other; and as there is no muscle from the ribs to the humerus to antagonize the upper capsular muscles" (that is, to draw the head of the humerus downwards), "it is suggested that this office is performed by the sin- Fig. 228. Displacement of the long head of the biceps. gular course of the long tendon of the biceps, which by passing over the head of the bone, when the muscle is put in action, tends to throw the head downwards, and backwards; it follows, therefore, that the tendon being removed, the head of the bone would rise upwards and forwards." The drawing (Fig. 228) represents the case of displacement of the tendon of the biceps seen by Mr. Soden, and of which he had been permitted to make a dissection. 3 I have myself frequently observed, and I have before, when speaking of the prognosis or results of dislocations, called attention to the fact, that the head of the humerus sometimes remains for a long time after the reduction has been effected slightly advanced in its socket, so as to lead to a suspicion that it is not properly reduced. While I am writing, two additional illustrations have come under my notice, in 1 Amer. Journ. Med. Sci., vol. xvi. p. 219, May, 1835, from Lond. Med. Gaz. 2 Ibid., vol. xxix. p. 480, from Lond. Med. Gaz., July, 1841. 3 Pirrie's System of Surg., Amer. ed., p. 255 ; also, Sir Astley Cooper, edited by Bransby Cooper, Amer. ed., p. 363. 558 DISLOCATIONS OF THE SHOULDER. one of which the patient, a lad of about fourteen years of age, had been subjected to the pulleys during four consecutive hours to accomplish a more complete reduction. The same thing, also, has been noticed by me occasionally where the shoulder had been subjected to a violent wrench, but no actual dislocation had ever occurred. In either case the explanation is probably the same, the long head of the biceps has been broken or displaced. I mean to say that in this circumstance we may find a sufficient and perhaps the most frequent explanation; yet it is quite probable that in a considerable number of cases, the laceration of the capsule, and the action of the muscles, are alone concerned in the production of this phenomenon. I have seen one example, in the person of Mr. Craig, of Brooklyn, in which the tendon suddenly resumed its position after the lapse of several days, and the prominence of the head of the humerus at once disappeared. Alfred Mercer, of Syracuse, N. Y., in a very interesting paper on this same subject, relates several examples of forward displacement after injuries to the shoulder-joint, one of which, as being exceedingly pertinent, I shall take the liberty of quoting. "Mrs. B., a well developed woman, of full habit, aged fifty-six, seven years since was thrown from a carriage, dislocating her right shoulder, which was reduced a short time after the accident, but the shoulder was painful, and tender to the touch, and almost useless for months after. She could carry the arm forwards and backwards, but could not raise it from the side, or carry the hand behind her, or raise it to her head, for fourteen months. She has gradually gained better use of her arm, but now, July, 1858, she cannot raise the elbow from the side more than half way to a horizontal position without assistance, but with assistance, the arm may be carried into any position without pain or resistance. Measurement shows no appreciable difference in the size or length of the arm, or size of the shoulder; but the point of the shoulder is still tender to the touch, is prominent in front, and correspondingly flattened behind. The head of the humerus appears to rest against the outside of the coracoid process, but the fulness of habit obscures the diagnosis, compared with the. other cases. Several doctors, at different times, have examined the shoulder; some have said it was not properly reduced, and advised a suit for malpractice. "I examined the shoulder again in November last; it presented the same general appearance, although the patient was much thinner in flesh from recent sickness. Some six weeks previous to this examination, in a sudden and thoughtless effort to raise the arm above the head, the muscles unexpectedly obeyed the will; since which time she has had perfect use of it, though the deformity still remains. She thinks she felt or heard a snap when the arm went up, but it was followed by no pain, soreness, or swelling." 1 There can be no doubt, we think, that in this case at least, the deformity and maiming were due in a great measure to a displacement of the long head of the biceps. 2 1 Mercer, Buffalo Med. Journ., vol. xiv. p. 641, April, 1859. 1 Broointield'a Chirurg. Observ., vol. ii. p. 76. DISLOCATION OF HEAD OF RADIUS FORWARDS. 559 CHAPTER VII. DISLOCATIONS OF THE HEAD OF THE RADIUS. I have met with eighteen examples of dislocation of the head of the radius; of which fourteen were dislocated forwards and only four backwards: or, rejecting those cases which were complicated with fracture, I have recorded eight cases of simple forward luxation, and two of simple backward luxation. My experience, therefore, does not correspond with the experience of Boyer, Velpeau, Vidal (de Cassis), Chelius, B. Cooper, Guthrie, Gibson, and some others, who declare that the dislocation backwards is the more frequent of the two. Indeed, I ought to say of both of the examples of backward luxation of the radius which have come under my notice, and which I have marked as simple, that they were ancient luxations, and I am not entirely certain, therefore, that they had not been originally complicated with a fracture, although at the time of my examination they presented no such evidence. § 1. Dislocation of the Head of the Radius Forwards. Causes. —A fall upon the elbow, the blow being received directly upon the posterior face of the head of the radius; a fall upon the hand with the forearm extended and pronated; extreme pronation of the forearm; or, according to Denuce, a blow upon the inside of the elbow, which is equivalent to a violent adduction of the forearm. In children, and especially in those of a strumous habit, whose ligaments are feeble, a subluxation forwards, or even a complete luxation, is occasionally produced by being lifted suddenly from the floor by the hand or by an attempt to sustain the child when he is about to fall. I have seen several examples of this latter form of the accident produced in this way. Batchelder,' Sylvester, 2 Goyrand, 3 and many other surgeons have mentioned similar cases. Dr. Krackowitzer related to the New York Academy, in 1856, a case of complete dislocation forwards, produced, as was supposed, in the act of turning the child in delivery. The arm was ecchymosed, and the dislocation was very distinct. 4 1 New York Journ. Med., May, 1856, p. 333. 2 Amer. Journ. Med. Sci., vol. xxxi. p. 206, Jan. 1843. * Ibid., vol. xxxii. p. 228, July, 1843. 4 Krackowitzur, New York Journ. Med., March, 1857, p. 262. 560 DISLOCATIONS OF THE HEAD OF THE RADIUS. Pathological Anatomy. —The head of the radius is carried forwards upon the humerus, and sometimes a little inwards or outwards; the Fig. 229. Head of radius forwards. Anatomical relations. anterior and external lateral ligaments, with the annular, are generally more or less broken. Sometimes the anterior and external lateral are alone broken, the annular ligament being then sufficiently stretched to allow of the complete dislocation; or the anterior and annular having given way, the external lateral may remain intact. Symptoms. —The head of the radius can in general be distinctly felt in its new situation, rotating under the finger when the hand is pronated and supinated; we may sometimes also recognize a depression corresponding to its natural situation, behind and below the little head of the humerus. The external border of the forearm is slightly shortened, and the arm inclines unnaturally outwards. The tendon of the biceps is relaxed. The forearm is generally pronated, sometimes it is in a position mid- way between supination and pronation, but I have never seen it supinated. I have particularly noticed this fact in my report made to the New York State Medical Society in 1855, and Denuce*, who has also examined these cases carefully, affirms that it is seldom supinated, notwithstanding the general statements of surgeons to the contrary. The arm is usually a little flexed, and cannot be perfectly extended without causing pain; nor can it be flexed much, if at all, beyond a right angle, owing to the impediment offered by the humerus, against which the head of the radius now impinges. Prognosis. —Denuce says, " The reduction is often impossible, more frequently still, difficult to maintain." In proof of which he refers to the observations of Danyau and Robert. " In the case of recent luxation related by Robert, it was found impossible to maintain a reduction which he thought he had several times accomplished, and he believed that the difficulty consisted in a portion of the torn annular ligament having become entangled between the head of the radius and the condyle of the humerus. 1 Sir Astley Cooper was unable to accomplish the reduction in two recent cases; and of the six cases which came under his immediate observation, only two were ever reduced. In Bransby Cooper's edi- 1 Memoire sur les Luxations du Coude, par Paul Denuce. Paris, 1854. DISLOCATION OF HEAD OF RADIUS FORWARDS. 561 tion of Sir Astley's work, other similar examples of non-reduction are related. Malgaigne says that in a collection of twenty-five cases which he has made, the accident was unrecognized or neglected in six, and ineffectual efforts at reduction had been made in eleven; so that only eight of the whole number were reduced. I have myself met with five of these simple dislocations which were not reduced, two of which, however, had not been recognized, and no attempts at reduction had ever been made; one had been treated by an empiric, Sweet, a "natural bone-setter," but without success; one had been reduced, but it had become reluxated, and in the remaining example I was myself unable to reduce the dislocation on the seventh day. The following are brief notes of four of these cases:— A young man, get. 23, presented himself at my office, to whom the accident had occurred about one year before. The surgeon who was first called did not recognize the dislocation, and no attempt had ever been Fig. 230. Head of radius forwards. External appearance of limb. made to replace the bones. The forearm was forcibly pronated and could not be supinated, but he could extend it completely, and flex it somewhat beyond a right angle. It was strong, and nearly as useful as before. II. H. B., set. 6; dislocation produced by a fall upon the elbow. The surgeon who was called did not detect the nature of the injury. Eighteen years after, I found the head of the radius lying in front of the old socket, having formed a new socket in which it moved freely. From the elbow to the hand the arm inclined outwards, or to the radial side; pronation and supination were perfect. He could flex the arm to an acute angle, but not so completely as the other. The arm was as strong as the other, but it was frequently hurt by lifting. Ira E. Irish, aet. 12. " Sweet" was at first employed, but failed to reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years old, I examined the arm. He could not flex the forearm upon the arm beyond a right angle; and when the attempt was made, the radius struck against the humerus. Complete supination was impossible. The arm was as strong as the other except in raising a weight above his head. Occasionally he was annoyed with slight pains in this limb. Urias Lett, a colored barber of Buffalo, aged forty-eight years, was 562 DISLOCATIONS OF THE HEAD OF THE RADIUS. thrown from a carriage, producing a dislocation of the right radius, and severely bruising the elbow-joint. He drove a couple of spirited horses several miles after the accident, and did not see Dr. K., a highly accomplished young surgeon, until six hours had elapsed. The elbow was then much swollen, and exquisitely tender, and Lett would not permit much if any examination, to enable Dr. K. to determine his condition. The Dr. applied simple dressings, and the next day requested me to see him. The whole arm was then swollen and tender, and very little examination was admissible. The dressings were, therefore, not completely removed, but only laid open sufficiently to enable us to see the joint. We suspected a forward luxation of the head of the radius, but could not positively determine the point—the patient not permitting any kind or degree of manipulation. We decided, therefore, to wait a few days, until the inflammation had somewhat abated, and then, if the existence of a dislocation was ascertained, to attempt its reduction. On the seventh day the swelling had measurably subsided, and the diagnosis became satisfactory. We immediately placed him under the complete influence of chloroform, and made long continued and violent efforts at reduction, but without success. Severe inflammation again followed these efforts, and Lett would never consent to another trial. After four years, I find the bone still out. He can flex the forearm upon the arm almost as far as he can the opposite limb; he can carry it nearly to his mouth; the head of the radius sliding off upon the outer face of the humerus, and not resting plumply against it; indeed, the radius seems to have been gradually pushed outwards as well as forwards. The hand is forcibly pronated, and cannot be supinated. The attempt to supine produces a click in the neighborhood of the head of the radius, as if it struck against a bone. The arm is as strong as the other, and not wasted. He has constantly pursued his occupation as a barber, after only a few weeks' confinement. If the dislocation is accompanied with a fracture of the ulna, unless the fracture is transverse or incomplete, reduction is not generally accomplished. When speaking of fractures of the shaft of the ulna, I have related several examples illustrative of this remark. Norris has made the same observation. 1 I have, however, three times met with this accident thus complicated in children, in the treatment of which a much better result has been obtained. In the first example, a lad aged nine years had broken the ulna in its upper third and dislocated the radius forwards. Dr. White, of Buffalo, and myself were in immediate attendance. Both the fracture and dislocation were easily reduced, and in a few weeks the limb was sound and perfect, except that a slight fulness remained in front of the head of the radius, and this continued for several years. In the second example, a lad of the same age as the other, was treated by Dr. Austin Flint and myself. We reduced both the fracture and the dislocation by extending the arm from the wrist, while at the same moment pressure was made upon the head of the radius from before backwards. A right angled splint was applied and continued during a period of four weeks, being removed 1 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 21. 563 DISLOCATION OF HEAD OF RADIUS FORWARDS. daily for the purpose of giving to the joint gentle, passive motion, &c. After this the arm was permitted to straighten gradually, and at the end of a month more, the joint was moving freely, and with no degree of displacement at the point of fracture or dislocation. It is quite probable that in each of the above cases the separation was not complete, although crepitus was distinct, and the displacement of the broken ends was very marked'. In the following case the fracture was certainly incomplete:— Elizabeth Carmody, set. 4, was brought to me, August 6, 1851, with a fracture of the ulna, two inches below its upper end, the fragments being inclined backwards, while the radius was dislocated forwards. Both bones were easily replaced, and the functions of the arm were soon completely restored. 1 Where the restoration has been promptly effected and maintained steadily, the motions of the joint are soon restored; but in one case the head of the radius has. been found to play very freely and loosely after the lapse of two years, and in others it has remained slightly prominent in front, as if it was a little in advance of its socket. Treatment. —Extension and counter-extension should be made in the direction in which we already find the limb, namely, with the forearm slightly bent upon the arm, while at the same moment the surgeon should seize the elbow with his hands, and press the head of the radius back with his two thumbs. Other methods will often succeed; but by this we relax the biceps, and put the parts in the best position to accomplish the reduction easily and promptly. Sir Astley directed to supine the forearm while the extension was being made from the hand, but Denuce' prefers that the forearm should be in a position of pronation. After the reduction is effected it is never safe to straighten the arm completely at once, nor indeed for some weeks; not until the ligaments have been sufficiently restored to resist the action of the biceps. The arm must therefore be flexed and placed in a sling, or, if the radius is disposed to become reluxated, a right-angled splint ought to be placed upon the back of the arm and forearm, and, by the aid of a compress and roller, an attempt should be made to retain it in place. Nor will it be found safe at any period to compel the arm by force to resume the straight position, since this bone, when it has once been dislocated, will for a long time be liable to luxation. A boy, aged about four years, was presented at my clinic by his father, having a forward dislocation of the head of the radius. The dislocation still existed after several months. The father's purpose in bringing the child was to ascertain whether he could not claim damages for malpractice. The account which he gave was as follows : The surgeon called it a dislocation forwards, and pretended to reduce it. A right-angled splint was applied, with a roller. At the end of three weeks the father removed the splint, but did not discover anything out of place. Finding, however, that the elbow was stiff, he took measures 1 This case was erroneously reported to the N. Y. State Medical Society as an example of fracture of the radius, with dislocation. 564 DISLOCATIONS OF THE HEAD OF THE RADIUS. to straighten it forcibly. In a few days he discovered the head of the bone out of place, and so it has remained ever since. I explained to him that there was much reason to suppose that the surgeon had properly reduced the dislocation, and that he had himself reproduced the accident, by straightening the arm, through the action of the biceps upon the upper end of the radius. The father declined any further surgical interference, and no prosecution has followed. . Dr. Batchelder, of this city, in a very excellent paper on dislocations of the head of the radius, describes a method of reduction suggested to him first by Dr. Goodhue, of Chester, Vermont, and which he has himself found more successful than any other method; indeed, he says it never fails, yet he does not inform us in precisely how many cases he has made the trial. The plan suggested by Dr. Goodhue consists essentially in first making extension from the hand, and pressing at the same time downwards and backwards upon the head of the radius until it has descended to a level with the articulating surface of the humerus. As soon as this is accomplished, the forearm is to be suddenly flexed upon the arm in such a direction as that the hand shall pass outside of the shoulder; at the same moment, also, the pressure must be continued vigorously upon the head of the radius. 1 § 2. Dislocation of the Head of the Radius Backwards. Denuce* has collected fourteen examples of this luxation; but Malgaigne, who rejects a portion of these cases, and adds one or two more, admits only twelve. In addition to those mentioned by these two writers, I have found recorded, or incidentally noticed, one by May,* one by Bransby Cooper, 3 one by Lawrence, 4 one by Liston, 3 two by Case, 0 two by Gibson, 7 one by Parker, 8 three by Markoe, 9 and to these my own observations have added four more, in all twenty-eight supposed examples. Of the examples brought under my own notice I have already in the preceding section affirmed that two of them were accompanied with fracture, and I am not entirely certain but that they all were. Markoe, of New York, whom we have mentioned as having reported three cases, found in each case a fracture of the internal condyle of the humerus, and, after an examination of a number of the reported examples, he does not find any evidence that this dislocation ever occurs as a simple uncomplicated accident. I am unable to complete the critical analysis which Dr. Markoe has undertaken; yet I confess that, so far as I have been able to do so, the testimony strongly con- 1 Goodhue, New York Journ. of Med., May, 1856, p. 333. 2 May, Sir Astley Cooper on Dislocations, &c, by B. Cooper, op. cit., p. 403. 3 B. Cooper, ibid., p. 404. 4 Lawrence, Pirrie's System of Surgery, p. 259. . 5 Liston, Practical Surgery, p. 88. 6 Case, Amer. Journ. of Med. Sci., vol. vi. p. 254, from 11th No. of Provincial Med. Gazette. 7 Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379. 8 Parker, New York Jour, of Mod., Maroh,1852, p. 188. 9 Markoe, ibid., May, 1855, p. 382. 565 DISLOCATION OF HEAD OF RADIUS BACKWARDS. firms his conclusions. "While I am prepared to admit the possibility of the luxation without either a fracture of the lower end of the humerus or of the ulna, I have found no written account of any case, nor have I seen an example, which was absolutely conclusive. The example reported by Parker as having occurred in the practice of N. K. Freeman, of this city, is one of the few which seems to admit of but very little doubt. In July, 1850, Dr. Freeman was called to see a gentleman, set. 37, who was seriously injured by jumping from the railroad cars while they were in motion, and found a backward luxation of the head of the radius of the right arm. "The symptoms," says Dr. Freeman, " were marked; the hand and forearm were prone, and the attempt to place them in the supine position caused great pain; while the head of the radius formed a considerable projection posterior to the external condyle of the humerus, where the cavity on its extremity could be distinctly felt. Assisted by Dr. Walsh, of Fordham, who firmly grasped the humerus, I was enabled to reduce it by extending the forearm and flexing it upon the arm, at the same time pronating the hand, and pressing forwards the head of the radius with my thumb. After the reduction was effected, I requested Dr. Walsh to examine it; when, upon slight extension being made upon the forearm, with supination of the hand, the bone was again dislocated. I immediately reduced it in the same manner as before, and directed the patient to keep the forearm flexed and the hand prone, and, laying it upon a pillow, apply cold water. He complained of severe pain for two days, which gradually subsided, and on the fourth day he was able to move and extend the forearm." Causes. —A direct blow upon the front and upper part of the radius; a fall upon the elbow, or upon the hand; a violent effort to supinate the forearm while it is grasped and held firmly in a state of pronation; probably, also, sometimes it is occasioned by a twisting of the arm in machinery, &c. Pathological Anatomy. —In the only example of which a dissection has been made, reported by Sir Astley Cooper, " the coronary ligament was found to be torn through at its forepart, and the oblique had given way. The capsular ligament was partially torn, and the head would have receded much more, had it not been supported by the fascia which extends over the muscles of the forearm." The head of the radius was thrown behind the external condyle of the humerus, and rather to the outer side. This was an ancient luxation found in the dissecting-room of St. Thomas's Hospital, and the accompanying drawing is copied from the sketch made at the time. If the luxation is not complete, as occasionally happens with children, the annular ligament may not be torn. Symptoms. —The head of the bone is felt rotating behind the outer condyle, and a depression exists corresponding to its original position. The forearm is slightly flexed and prone; and the whole arm is deflected outwards from the elbow downwards; flexion and extension are difficult, while supination is impossible. 566 DISLOCATIONS OF THE HEAD OF THE RADIUS. Treatment. —Most surgeons have agreed that while extension and counter-extension are being made, the forearm should be forcibly Fig. 231. Dislocation of the head of the radius backwards. supinated. At the same time, also, the head of the radius must be strongly pushed forwards. Martin recommends to extend forcibly, and then suddenly flex the arm, in a manner very similar to the plan recommended by Batchelder in dislocations forwards. In Dr. Freeman's case, just quoted, the reduction was effected while the forearm was pronated, and supination seemed to throw it again out of place. According to Markoe, where the accident is complicated with a fracture of the inner condyle, when the reduction is accomplished the arm should be placed in a position about ten degrees less than a right angle, and supported by a splint with bandages, &c. If the dislocation is simple, however, I can see no objections to its being nearly or quite extended, since in this dislocation the action of the biceps would only tend to retain the head of the radius in place. § 3. Dislocation of the Head of the Radius Outwards. Denuce' has collected four examples of this accident, unaccompanied with a fracture, and he proceeds to speak of it as a distinct form of dislocation. In two of the examples, however, mentioned by him, it was consecutive upon a forward luxation, and I have several times seen the head of the radius very much inclined outwards in what are properly termed forward dislocations. For these reasons it is not very plain to me that we ought to consider this as a distinct form of primary dislocation, but rather as a consecutive luxation, or at least as only a modification of the forward or backward luxation. Indeed, I think the radius never will be found thrown directly outwards, but always in a direction inclining forwards or backwards. Parker, of this city, mentions a case which came under his notice, in a child four years old, who six weeks before, had fallen down stairs " backwardly, with the right arm twisted behind the back, in such a position that the whole weight of her body came upon her arm." No attempt was ever made to reduce the bone, and the head of the radius continued to project externally. By pressure it was easily reduced, but became immediately displaced when the forearm was either flexed or extended. The motions of the joint were completely restored. Dr. Parker recommended no treatment. 1 1 Parker, New York Journ. Med., March, 1852, p. 189. 567 DISLOCATIONS OF UPPER END OF ULNA BACKWARDS. CHAPTER VIII. DISLOCATIONS OF THE UPPER END OF THE ULNA BACKWARDS. This accident, the existence of which, as a simple luxation, is rendered probable by a certain number of cases, has nevertheless been described so variously and often indefinitely, that it is impossible to declare its history, except in a few points, with any degree of accuracy. No doubt many of the cases which have been reported were examples only of a subluxation of both radius and ulna backwards. In other cases the radius or the external condyle of the humerus being broken, the ulna has been actually displaced, not only backwards but upwards; indeed, it is very certain that without either a luxation of the radius, or a fracture with displacement of the external condyle of the humerus, or a fracture or bending of the radius, an upward displacement of the ulna, to the degree represented by the reporters of these cases, could never have occurred. The example mentioned by Sir Astley Cooper, and of which a dissection was made, is plainly a case of subluxation of both bones; or if the luxation of the ulna may be regarded as having been complete, the head of the radius was also displaced more or less upwards from its original socket, a new socket, Sir Astley himself informs us, having been formed for its reception, upon the external condyle. But this is the only example, the actual condition of which has been proven by an autopsy. Nevertheless it seems possible that a simple luxation, or subluxation of the ulna backwards, may occur without either of the above Fig. 232. Dislocation of the upper end of the ulna backwards. mentioned complications, and that, to the extent of a few lines, it may be made to pass upwards upon the back of the humerus, by the falling of the forearm to the ulnar side; in which case the character of the accident would probably be recognized by the projection of the ole- 568 DISLOCATIONS OF THE RADIUS AND ULNA. cranon process, while the head of the radius might be felt moving in its socket—by the partial flexion and complete pronation of the forearm, and by the general immobility of the joint. Its reduction ought to be accomplished easily by the same measures which have been found successful in reducing a dislocation of both bones backwards. Pirrie says that in a case occurring in the practice of Mr. Gosset, in which the coronoid process rested on the internal condyle, and the pain on bending the arm was insupportable, owing, it was supposed, to the pressure of the coronoid process against the ulnar nerve, " reduction was accomplished by extension and counter-extension applied by two persons pulling in opposite directions, and by the pressure of the olecranon process downwards and outwards, while the forearm was suddenly flexed." 1 CHAPTER IX. DISLOCATIONS OF THE RADIUS AND ULNA (FOREARM AT THE ELBOW JOINT). The radius and ulna may be dislocated at the elbow-joint, backwards; laterally, that is, either inwards, or outwards; and forwards. § 1. Dislocations op the Radius and Ulna Backwards. Causes. —In forty cases observed by me, the average age is about eighteen years; the youngest being four years old, and the oldest fifty-three. Nineteen of this number occurred in children under fourteen years of age. Generally the dislocation has been produced by a fall upon the palm of the hand, as when in running a person has fallen forwards with the forearm extended in front of the body, or he may have fallen from a height; once I have known it produced by a blow received upon the back and lower part of the humerus. It is said also to be produced, occasionally, by twisting the forearm violently, as when the limb has been caught and wrenched about by machinery, by a blow upon the front and upper part of the forearm, and by forced flexion. Pathology. —The radius and ulna are not only carried backwards behind the articulating-surface of the humerus, but they are also, through the action of the triceps, almost always drawn more or less upwards, 1 Gosset, Pirrie's Surg., Amer. ed., p. 259. DISLOCATION OF RADIUS AND ULNA BACKWARDS. 569 so that often the coronoid process of the ulna rests in the olecranon fossa. In some cases it has been known to mount even higher, while in others it is arrested short of this point. The radius still retaining its relative position to the ulna, lies upon the back of the humerus, or rather upon the posterior margin of its articulating surface. The anterior and two lateral ligaments are generally more or less completely torn asunder; but the posterior ligament and the annular do not usually suffer disruption. The biceps muscle is drawn over the lower articulating surface of the humerus, but is in a condition of only moderate tension, while the brachialis anticus is forcibly stretched or even torn. The median nerve is also pressed upon Fig. 233. Dislocation of the radius and ulna backwards. in front by the humerus, and the ulnar is occasionally painfully stretched over the projecting extremity of the ulna from behind. Symptoms. —Sir Astley Cooper does not mention particularly the position of the arm as to flexion or extension, except to say that " the flexion of the joint is in a great degree lost;" nor, in his original work, published in London in 1823, is there any illustration accompanying the text to indicate in what position he had usually seen the limb; but in the later editions, edited by Mr. Bransby Cooper, is found a drawing which represents the forearm at a right angle with the arm. It is very certain that Sir Astley never sanctioned this error by anything which he had written or communicated to others. It is very certain, I say, because the fact that it seldom, if ever, occupies this position could not have escaped the notice of one whose experience was so large, and whose habits of observation were generally so accurate. The truth is that it is almost constantly found only slightly flexed, or forming an angle in front of about 120°. This fact is especially noticed in my records twenty-one times, and if it had ever been found in any other position it would certainly have been stated. Once, where the dislocation was accompanied with a fracture of the outer condyle of the humerus, the arm was at first straight, a position in which it is said to be found occasionally with children, but never in any instance have I found it flexed to a right angle; yet I will not deny that such unusual phenomena are possible; indeed, it is certain that they have occasionally been presented, but they must be regarded as only exceptional, and as by no means diagnostic of this accident. Sir Astley Cooper and Miller declare that in this dislocation the forearm is usually supinated; Pirrie says: "The hand is between pronation and supination, but more inclined to the latter;" Desault thinks it is sometimes in supination and sometimes in pronation: Denuce concludes that it will occupy that position, whatever it may be, in which 37 570 DISLOCATIONS OF THE RADIUS AND ULNA. the force of the blow has thrown it; while by most surgical writers no allusion is made to the position of the forearm in reference to pronatain or supination. For myself, I can only say that I have found the forearm and hand constantly in a position of moderate, but positive, pronation, and I am compelled to regard it, therefore, as one of the usual signs of a backward dislocation of these bones. The limb can be neither flexed nor extended without force, and such motion is almost always accompanied with pain. It is, however, possible in most cases to give to the arm a slight lateral motion, such as does not belong to it in its natural condition. In front, and deep in the fold of the elbow, is felt the lower end of the humerus, forming a hard, broad, and somewhat irregular projection, over which the integuments and muscles are swollen, and tender to pressure. Behind, the head of the radius may be felt, when not much tumefaction exists, rotating or moving under the finger when the forearm is supinated and pronated; while the olecranon process projects strongly backwards and upwards. If now we flex the arm slightly, this projection of the olecranon process will be sensibly increased; but if an attempt is made to straighten the arm, it will be diminished, the reverse of what we have seen to happen in cases of fracture of the lower end of the humerus (at the base of the condyles). This circumstance becomes, therefore, an important diagnostic mark between these two accidents. The relation of the olecranon process, also, to the condyles is changed, and the upper end of this process, instead of being a little below the internal condyle, as it would be naturally when the arm is slightly flexed, is found generally carried upwards toward the shoulder, from half an inch to one inch or more above the condyle. Measuring from the internal condyle to the styloid process of the ulna, the arm is shortened; the same result will be obtained also by measuring from the acromion process, to either of the styloid processes ; while from the acromion process to the condyle, the length will be the same in both arms. The signs which have now been enumerated will be sufficient to enable us to make the diagnosis promptly in the great majority of cases, but if considerable swelling has already taken place, the diagnosis may be rendered exceedingly difficult, if not impossible; and in such cases we should confine the patient at once to his bed, and proceed to reduce the tumefaction by cool water lotions as rapidly as possible, examining the limb carefully from day to day in order that we may seize the earliest opportunity to ascertain its actual condition and apply the proper remedy. In relation to the difficulty of diagnosis in certain examples of this accident, and under certain circumstances, Mr. Skey, in his Operative Surgery, has made some very judicious remarks. "Severe injuries of the elbow-joint, whether in the form of fracture, dislocation, or a compound of the two, are frequently followed, at a short interval, by swelling of a formidable kind, in which it is impossible, but by the aid of a perfect intimacy with the anatomical structure of the joint, to detect the relations of one part with another; but 571 DISLOCATION OF RADIUS AND ULNA BACKWARDS. even under this difficulty, the two points in question are readily distinguishable. In such forms of swelling, the arm, including the length of six inches both above and below the joint, may be involved in the extravasation, and this swelling may distend the arm to a circumference of one-third beyond its natural size. In such circumstances, in which it is impossible to determine with any certainty whether any, or what bones are broken, or whether or not dislocated, the difficulty of the case should at once be stated to the friends of the patient." Prognosis. —If the luxation is recent, reduction is in general easily effected, but if considerable time has elapsed, the reduction is often accomplished with difficulty. As to the probability of its reluxation, I have already spoken when considering the subject of fractures of the coronoid process. Unless this process is broken, it is not likely to occur except where some violence has again been applied. It has happened to me, however, to find these bones unreduced in several instances. In some of these examples surgeons recognized the accident and supposed that they had accomplished reduction, while in others the dislocation was mistaken for a fracture. A lad, W. F., twelve years old, residing in Brie County, N. Y., was brought to me six weeks after the accident had occurred. The surgeon who was first called declared it to be a dislocation, and told the parents he had reduced it; but the dislocation was now complete, and the arm immovably fixed in its abnormal position. On the tenth of May, 1850, J. P., of Canada "West, set. 25, was thrown from a load of hay, striking upon his left hand, and producing a dislocation backwards of both bones at the elbow-joint. A Canadian surgeon, who saw the patient within three hours, recognized the dislocation, and by pulling the arm straight forwards he supposed he had reduced it; the patient also thought he felt the bones slip into place. No attempt was made subsequently to flex the arm, and it was immediately dressed with a straight splint laid along the palmar surface. On the sixth day it was found to be unreduced, and the surgeon again attempted to reduce it as before, and thought he had succeeded. The same splint was reapplied. At about the end of six weeks three surgeons, residing in Canada also, placed the patient under the complete influence of chloroform, and attempted the reduction. They first made extension for half an hour in a straight line, then five men seized upon the arm and forearm, bending it with great force to a right angle. It was now believed that the ulna was reduced, but not the radius. Four days after, the attempt was renewed. Three months after the accident the young man called upon me, and I found the arm nearly straight, with almost complete anchylosis at the elbow-joint. Both the radius and ulna were displaced backwards, but not upwards. The arm was of the same length with the other, and the relation of the condyles to the olecranon was so manifest, that the absence of the usual displacement upwards was easily determined. I was unwilling to make any further attempts at reduction, not believing that I should succeed after so much time had elapsed, and after so many ineffectual attempts had been made by clever surgeons. 572 DISLOCATIONS OF THE RADIUS AND ULNA. In the following examples the dislocation was supposed to have been a fracture of the lower end of the humerus. A man, residing in Pittsfield, Mass., dislocated his left arm by falling from a horse. The surgeon who was called regarded it as a fracture at the base of the condyles, and treated it accordingly. Ten weeks after, the error was discovered and an attempt was made to reduce it, but without success. A second attempt was also made with the same result. The patient was brought to me eight months after the accident with the bones still unreduced. The forearm hung at a very obtuse angle with the arm, and there was very slight motion at the elbow-joint. I discouraged any further attempts at reduction. Mr. W., of Alleghany Co., N. Y., set. 43, fell from a load of hay striking upon his left arm, Feb. 16, 1853. Four hours after, he was seen by a young, but very intelligent surgeon, who thought the humerus was broken just above the condyles. After eight weeks, the fact that it was a dislocation having become apparent, three surgeons, well known to me as men of large experience, attempted its reduction, aided by pulleys and chloroform. The patient was also bled and nauseated with antimony. The efforts were protracted through many hours, and frequently varied. A second attempt made by these same gentlemen a few days after was equally unsuccessful. On the ninth week Mr. "W. came to me, and I placed him at once in the Buffalo Hospital of the Sisters Of Charity, where, assisted by my friend, Prof. Moore, of Rochester, I renewed the attempts at reduction. The patient was placed under the influence of chloroform, and during a great portion of the time occupied, the pulleys were in use. The elbow was pulled upon, twisted, flexed and extended until there seemed to be neither adhesions, nor ligaments, nor capsule to prevent the reduction. We could move the joint in every direction, even laterally, as well as forwards and backwards. Still the bones would not return to their sockets. Section of the triceps seemed to be the only remaining expedient, but the injury already done to the joint was so great that we did not deem it prudent to prosecute the attempt any further. We had occupied two hours in the various procedures. Violent inflammation supervened, but he was able to return home in about two weeks. Two years after, I learned that the arm still remained unreduced, and nearly anchylosed; the whole limb was also much atrophied and very weak. John Sharkie, eat. 53, fell on the 4th of Aug. 1854. A botanic doctor, who saw him on the same day, and a regular physician, who saw him on the third day, thought he had broken his arm. About six weeks after this he came under the charge of an almshouse doctor, who " rebroke" it, supposing it to be a fracture; and two months later he " broke" it again, but as the arm was not improved by these operations he finally urged the poor fellow to submit to amputation; and it was in reference to this last proposition that Sharkie consulted me. I found the radius and ulna dislocated backwards and upwards one inch; the arm perfectly straight and the elbow anchylosed; no pronation or supination. I did not think it prudent to make any attempt to reduce it, 573 DISLOCATION OF RADIUS AND ULNA BACKWARDS. but assured him that if let alone it would ultimately be quite useful in many ways, and that he should never think of having it cut off. In three or four instances, also, the accident has been overlooked by the patient himself, or by some empiric, no surgeon having been called to see the case until after the lapse of several days or weeks. In general, when the reduction has been effected promptly, the patients have recovered the complete use of the elbow-joint within a few weeks; but many exceptions have from time to time come under my notice. A lad eight years old was brought to me, whose arm had been dislocated six months before, and the reduction of which had been accomplished easily and promptly by Sir Astley Cooper's method. At this time the arm was bent to a right angle, and quite stiff at the elbow-joint. Four years later I learned that the stiffness still continued in a great measure, with only slight improvement. Treatment. —Sir Astley Cooper thus describes his own method of reducing this dislocation (Fig. 234): "The patient is made to sit upon a chair, and the surgeon, placing his knee on the inner side of the elbow-joint, in the bend of the arm, takes hold of the patient's wrist, and bends the arm. At the same time he presses on the radius and ulna with his knee, so as to separate them from the os humeri, and thus the coronoid process is thrown from the posterior fossa of the humerus; and whilst this pressure is supported by the knee, the arm is to be forcibly but slowly bent, and the reduction is soon effected." The same practice has been recommended by Erichsen, Gibson, Samuel Cooper, and others. The plan recommended by Dorsey is nearly identical with that just described, only that, instead of the knee, he advises that the surgeon " interlock his fingers in front of the arm, just above the elbow, and draw it backwards." Fig. 234. Reduction with the knee in the bend of the elbow. On the other hand, Liston and Miller recommend, as a better mode of proceeding, that the patient shall be seated upon a chair, and that the arm and forearm shall be pulled directly backwards, so as to relax as completely as possible the triceps muscle while counter-extension is made against the scapula. Skey says: " Extension of the forearm should be made from the hand or wrist in a straight direction downwards, as if for the purpose of simply elongating the arm." Pirrie prefers that an assistant shall grasp the forearm near its 574 DISLOCATIONS OF THE KADIUS AND ULNA. middle, instead of the wrist, and pull the arm straight forwards, while at the same moment the surgeon seizes upon the olecranon process with the fingers of one hand, and, placing the palm of the other against the front and upper part of the forearm, pulls forcibly backwards, so as to draw out the coronoid process from the olecranon fossa. For myself, having generally practised the method recommended by Sir Astley, and having usually succeeded in the first attempt and with the employment of only moderate force, I confess that my predilections are in its favor; yet I am not entirely certain but that an equal experience with either of the other modes recommended might have changed these convictions. The truth is, I think, that in recent cases very little force is generally requisite to accomplish the reduction, and that it is not very material which of these several modes we adopt; but in case of a failure by one mode, we ought immediately and without hesitation to resort to another, as the following case of failure by flexion will illustrate:— A lad, aet. 11, fell in a gymnasium from a height of six feet, striking probably upon his hand. I saw him within twenty minutes, and found the arm in the usual position. I attempted immediately to reduce it by Sir Astley's method, but, after a fair yet unsuccessful trial, I extended the forearm upon the arm until it was nearly straight, and then, with only moderate force, drew it promptly into place. If we still continue to encounter difficulties, the patient ought at once to be placed under the influence of an anaesthetic, and, if necessary, the pulleys should be employed. When the reduction is accomplished, which is indicated generally by the sudden slipping of the bones and by the restoration of the natural form to the elbow-joint, the surgeon, in order to confirm his opinion, must flex the forearm upon the arm to a right angle. If the bones are in place, and there is not much swelling, this can generally be done without causing much, if any, pain; but if it cannot be done, this fact furnishes presumptive evidence that the reduction is not effected. In one instance, however, of recent luxation, this rule has not held good. A girl, aet. 10, fell from a tree upon her hand. I was in attendance within half an hour, and found the usual signs characterizing this accident. Reduction was accomplished readily by pulling at the hand moderately, with the forearm flexed, while my left hand pressed back the lower part of the humerus. After the reduction it was found impossible to flex the arm to a right angle without causing severe pain, and it became necessary, after placing it in a sling, to allow the hand to drop very low beside the body. A good deal of inflammation followed ; but in a few weeks the arm was well, only that for a period of two years or more the elbow remained very tender. On the other hand, an omission to apply this rule has often led the surgeon to believe the reduction accomplished when it was not. Very recently this same thing has happened to myself, and as it is the only instance in which I have omitted to adopt this test, and the only one also in which I have left a bone unreduced which I believed to have been reduced, it will be proper to state the case and its results more fu %- s :. -J- ., r . *~ ;>. 575 DISLOCATION OF RADIUS AND ULNA BACKWARDS. A lad, set. 11, fell from a fence on the 22d of December, 1858, and dislocated both bones backwards. I saw him within two hours from the occurrence of the accident. The elbow-was already considerably swollen and quite tender, but the signs of dislocation were very manifest. Seizing the wrist with one hand, and placing my knee against the front and lower part of the humerus, I pulled steadily for some time, and with much more force than is usually necessary, until at length two distinct and successive snaps were felt, such as one often feels when the two bones resume their sockets. Relinquishing my grasp, it was observed by myself and the parents that the deformity had disappeared. The reduction seemed to be complete, and so I announced. I then requested the lad to permit me to bend the elbow, and place it in a sling, but this he peremptorily refused to do, and ran away from me, nor would any arguments or entreaties persuade him to allow me again to touch it. I reassured the parents and child, however, that all was right, and left the house. During several successive days I saw the little patient, but although the arm remained swollen and very tender, I did not suspect the cause until the ninth day; and on the tenth day, having placed him under the influence of chloroform, the reduction was easily and satisfactorily accomplished. The recovery has been slow. At the end of six weeks I found the motions of the elbow-joint not completely restored, and the forefinger was partially paralyzed; but from this condition it has gradually recovered, and two months later the functions of the arm and hand were completely restored. The mistake in this instance was the more mortifying because I had just seen a case in a lad only a little older, in which another surgeon had committed the same error, and after the lapse of twelve or fourteen days I had myself made the reduction; and I was fully awake, therefore, to the possibility of the mistake. The circumstance of the diminution, and apparent disappearance of the deformity, and the sensation of a double click, can only be explained by assuming that originally the coronoid process was resting in the olecranon fossa, and that by manipulation the bones had been removed nearer their sockets, yet not actually reduced. The swelling, also, rendered more difficult a diagnosis which, now, nothing but the flexion of the forearm could have determined positively. If much time has elapsed since the occurrence of the dislocation the reduction is accomplished with difficulty, if, indeed, it can be reduced at all. There are many cases upon record, however, in which surgeons have been successful after the lapse of many weeks, or even months. Boyer thought it was not possible to effect the reduction after four or six weeks; but Capelletti, of Trieste, succeeded after seventy days ;* Sir Astley Cooper at three months ; 2 Malgaigne after three months and twenty-one days. 3 Roux succeeded in the case of a young man twentytwo years of age, whose elbow had been dislocated five months. 4 1 Capelletti, Am. Journ. Med., vol. xix., from Annal. Univ. de Med. for Oct. 1835. 2 Sir Astley Cooper, On Dislocations and Fractures, Amer. ed., p. 388. 3 Malgaigne, Amer. Journ. Med. Sci., vol. xxiii. p. 238, from Revue Med., Dec. 1837. 4 Roux, Amer. Jouru. Med. Sci., vol. xvi. p. 52b', from Archives (xen., Dec. 1834. 576 DISLOCATIONS OF THE RADIUS AND ULNA. Blackmail, of Cincinnati, informs me that he has reduced a lateral luxation after five months. Brainard, of Chicago, reduced a dislocated elbow in a boy of nineteen years, after five months and thirteen days. In this case the surgeon who had first seen the patient supposed that he had reduced the dislocation. 1 Gorre, Gerdy, and Drake, succeeded in four cases after six months ; 2 and finally, Starch claims to have been successful after two years and one month. 3 To which enumeration Denuce* has added seventeen other examples, said to have been reduced at various periods, ranging from one month to one hundred and fourteen days. 4 Nevertheless the fact is in the main as stated by Boyer; and if so many cases can be found in which surgeons have succeeded at a later period, they are not probably in the proportion of one to ten as compared with the failures ; but the failures have not received the same publicity. Nor indeed have all the severe accidents, such as violent inflammation, suppuration, gangrene, and even death, been faithfully declared. Denuce' says he has been able to trace out five or six examples in which, although the arm was reduced, grave accidents resulted, and Velpeau's patient actually died in consequence. Dixi Crosby, of New Hampshire, has treated two cases of ancient dislocation of the forearm backwards, by bending the elbow forcibly so as to break the olecranon process, after which the reduction was easily accomplished by extension. R. D. Mussey, of Cincinnati, has succeeded once in the same manner. In all these examples the elbow was restored to a very useful amount of motion.* The dislocation being reduced, it may be a matter of prudence, sometimes, to apply a right-angled splint, first carefully padded, to the palmar surface of the arm and forearm; remembering, however, that considerable swelling will soon occur, and that it ought not therefore to be bandaged to the limb very tightly. At least once a day it should be removed, and the arm examined; and in very few cases can it be necessary or judicious to continue its application beyond one week. At the same time if there is any especial tendency in the radius to become displaced backwards, owing to a rupture of its annular ligament, this must be prevented, if possible, by a compress and bandage. Some surgeons regard these precautions as necessary in all cases, but I have seldom employed any splint or bandage whatever, nor have I ever had reason to regret this omission. Finally, we are to place the arm in a sling, and adopt such measures as are calculated at first to reduce the inflammation; and at a very early day we ought to begin to move the elbow-joint, in order to prevent anchylosis. 1 Brainard, Illinois and Indiana Med. Journ., 1847. 2 Memoire sur les luxations du coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 3 Denuc6, op. cit., p. 87. 4 Op. cit. 6 Crosby, Mussey, Trans. Amer. Med. Assoc., vol. iii. p. 357. 577 DISLOCATION OF RADIUS AND ULNA OUTWARDS. § 2. Dislocation or the Radius and Ulna Outwards (to the Radial Side). The large majority of outward dislocations of the forearm are incomplete; indeed only nine examples of a complete dislocation have been collected by Denuce* including two seen by himself. Malgaigne has since added two more, making in all eleven cases. All these examples have occurred in the practice of French surgeons. So far as I am able to discover, no American or English surgeon has ever reported a single example. Incomplete dislocations must therefore in this case be regarded as typical; but even these are by no means frequent. Causes. —A careful examination of a large number of recorded examples, and of those which have come under my own eye, renders it certain that a majority of these accidents result from a blow received directly upon the inner side of the forearm or upon the outer side of the humerus, or from the action of two forces pressing in an opposite direc- tion. Of course those forces must act upon the bones somewhere in the neighborhood of the elbowjoint. Occasionally it has been produced by a fall upon the hand; sometimes by a violent twist of the arm, as when the hand is caught in machinery; and in other cases it has been found consecutive upon a dislocation backwards, being produced in the attempts made to accomplish reduction of this latter form of dislocation. Pathology. —In most of the examples of simple, incomplete outward luxation of the forearm, the great sigmoid cavity of the ulna still embraces the lower end of the humerus, but instead of reposing upon the trochlea, it is carried outwards half an inch or more so as to rest its central crest upon the depression which separates the condyle from the trochlea. (Fig. 235.) If the annular ligament remains unbroken, the radius is displaced in the same direction and to the same extent, its head resting against and directly below the epicondyle. Occasionally, however, where the violence has been greater, the central crest of the great sigmoid cavity rests fairly upon the condyle, or upon the articulating surface of the humerus where the head of the radius was formerly applied, and the dislocation approaches more nearly to the character of Fig. 235. Must frequent form of incomplete outward dislocation of the forearm. a complete luxation. At the same time, owing perhaps to the resistance afforded by the skin, or some of the ligaments, the head of the radius may be thrown either forwards or backwards, so as to be out of line with the ulna. Such a displacement generally implies a rupture of the annular ligament. We have now only to suppose the action of a more considerable 578 DISLOCATIONS OF THE RADIUS AND ULNA. force in the same direction to render the dislocation complete; in which case the upper end of the radius is sometimes thrown completely forwards, and its head may even be found resting in front of the ulna, occasioning an extreme pronation of the forearm and hand. The anconeus and brachialis anticus are the only muscles in either of these dislocations whose fibres are generally much disturbed; the biceps and triceps being only made to traverse the articulation a little more obliquely. Denuce, Malgaigne, A. Cooper, and others have preferred to speak of the dislocation backwards and outwards as a distinct form or species of dislocation. I prefer to regard it as only a variety of the outward luxation, since it may, and no doubt often does, occur consecutively upon a simple incomplete outward dislocation; and if the dislocation outward is complete, the bones of the forearm can scarcely fail to be drawn more or less upwards. Sometimes also it has been consecutive upon a simple backward dislocation, or upon unsuccessful attempts at reduction where the form of dislocation was originally backwards; yet as it does not so naturally follow upon a complete backward dis location as upon a complete outward luxation, I find sufficient reason for studying its mechanism in this place. The beak of the olecranon process not only, but a large portion of the body of this process now lies above and behind the condyle; the brachialis anticus becomes more stretched if not actually torn, and the biceps is laid against the articulating surface of the humerus; but the triceps becomes again relaxed, as in simple dislocation backwards and upwards. In all these dislocations the capsular ligaments are more or less extensively torn, but the principal arteries and nerves do not generally suffer greatly if at all. Symptoms. —The forearm is usually flexed to about the same angle at which we have found it in dislocations backwards; sometimes it is demi-flexed, and it is also forcibly pronated. The elbow-joint is immovable. The most striking diagnostic sign, however, consists in the unnatural form of the elbow-joint, which is so remarkable as not to be easily misunderstood. The internal condyle of the humerus (epitrochlea) projects strongly to the inner side, leaving a deep depression below; while upon the other side the head of the radius, with its cup-like extremity, can be distinctly felt, and made to rotate outside of its socket. The olecranon process, driven from its fossa, projects more or less posteriorly, and even the fossa itself may sometimes be plainly felt. A girl, twelve years old, had fallen upon the inside of her elbow, producing a dislocation outwards of the forearm. I saw her within half an hour. The forearm was bent upon the arm about fifteen degrees, and immovably fixed. The head of the radius could be distinctly felt external to, and a little in front of the outer condyle, while the olecranon process of the ulna, which rested upon the back and outer surface of the humerus, was less distinctly felt than in the opposite arm. The inner condyle projected sharply to the inside, and the olecranon fossa was plainly felt with the fingers. The child was suffering very little pain. 579 DISLOCATION OF RADIUS AND ULNA OUTWARDS. Seizing the wrist with my right hand and the lower end of the humerus with the left, and making moderate extension in these opposite directions, the bones easily, and after only a moment's effort, resumed their places. Her recovery was rapid and complete. If the dislocation is complete, the position of the arm is usually the same, but the pronation of the hand is greater, and the projection of the inner condyle more striking. If now the bones, by a continuance of the original force, or by the action of the triceps, are drawn upwards also, the arm becomes a little more flexed, and the olecranon process more prominent, while the length of the whole limb is sensibly diminished. Prognosis. —In recent cases of incomplete outward luxation, and where no complications exist, the reduction is generally easily effected; and M. Thierry claims to have reduced an outward and backward luxation after eight months. A patient of whom Debruyn has spoken was not so fortunate. On the 16th of April, 1841, a lad, set. 18, fell upon the palm of his hand and dislocated both bones outwards and backwards; on the following morning a surgeon attempted to reduce the dislocation, and the attempt was repeated on the next day by another surgeon; but on the day following this last attempt, gangrene ensued in consequence of the great violence employed by the surgeons, and although the limb was amputated the patient died. The autopsy showed that both the brachial artery and the median nerve were torn asunder, and that the tendons of the biceps and brachialis anticus were slipped behind the outer condyle, probably having been thrown into this position during the violent twistings to which the arm had been subjected. 1 I have seen three examples of dislocation upwards and outwards which the medical attendants had failed to reduce. The first was in the case of a lad, Win. Kinkaid, fourteen years old, who had fallen from a wagon and struck upon the palm of his left hand. The surgeon who was immediately called made extension, and supposed that the reduction was accomplished. The lad was brought to me a few months after the accident. The arm was slightly flexed, and neither prone nor supine. There existed only a slight motion at the elbowjoint. I did not think it worth while to make any attempt at reduction. Several years after this, in the month of February, 1859, I had an opportunity of examining the arm again. He had now recovered considerable motion in the joint, but he could not tie his cravat. Pronation and supination were perfect. In the second example, a lady, set. 33, had fallen upon the inside of her elbow, and reduction not having been accomplished, I found her, nine weeks after the accident, with scarcely any motion at the elbowjoint, and complaining of a numbness in the forearm and hand. The third instance of unreduced dislocation I will relate more at length. Francis Banfield, aged twenty-two years, a resident of Alleghany County, 1ST. Y., on the 31st of September, 1857, fell from the sweep of a 1 Denuce, op. cit., p. 103. 580 DISLOCATIONS OF THE RADIUS AND ULNA. threshing machine to the ground, a distance of about five feet, striking upon the palm of his hand, his arm being extended in front of him. On rising he found his arm forcibly flexed and abducted. He straightened it without difficulty, and it assumed the position it now occupies. A physician was called and saw the patient an hour and a half after the accident, who pronounced it a case of dislocation of the radius and ulna, and made efforts at reduction, which he continued from 8| A. M. until 2 P. M., a period of five and a half hours, to no purpose, when he abandoned the attempt. During the attempt at reduction, the extension was made at times with the arm flexed, and at others extended. At 9 P. M., another physician was called, who made efforts at reduction until 3 A. M., upwards of six hours, at which time he also abandoned the attempt. On the third day another physician, the patient being under the influence of ether, made efforts at reduction for twenty minutes, when he pronounced it in place, and applied a bandage. From the patient's account the arm was swollen to such an extent as to render this point difficult to determine. On the fifth day the first physician was called, and believing that he discovered a grating, pronounced it a fracture of the external condyle. Four months after the accident, when the patient applied to me, the limb presented the following appearances: " The forearm extended upon the arm; looking at the limb along its radial margin we notice a gentle outward inclination of the forearm from the elbow down, but by manipulation this may be greatly increased; the power of pronation and supination is not affected; the inner condyle projects an inch to the ulnar side; the head of the radius, completely removed from its socket, projects to an equal extent on the radial side. The top of the olecranon process is an inch higher than the top of the inner condyle, so that the radius and ulna are carried upwards as well as outwards." I believe that the external condyle was not broken, as in that case, the arm would be permanently deflected outwards to a much greater extent. For, although this arm may be deflected outwards by the surgeon to an angle of 135°, still the degree of mobility which exists would be adverse to the supposition of its being a fracture of the external condyle. The condyles also can be plainly felt in their natural situations, which would not be the case, if a fracture of the external condyle existed. The patient was advised not to submit to any further attempts at reduction. The following will serve as an illustration of a recent accident of this character:— John Collins, of Buffalo, set. 8, fell while wrestling, his companion falling upon his arm. I found the forearm slightly flexed, pronated, and both radius and ulna thrown over to the radial side and carried upwards. Pressing firmly upon the radius from the outside the bones assumed suddenly the position of a backward and upward dislocation, from which position they were readily reduced to their original sockets by simple extension. Treatment. —In relation to the treatment of these accidents we have little to add to what has already been said of the treatment of dislo- 581 DISLOCATION OF RADIUS AND ULNA INWARDS. cations backwards. The reduction, if effected at all, has generally been accomplished by moderate extension, or by extension combined with lateral pressure. If the head of the radius is in front of the humerus, or of the ulna, the hand should be first supined, and then the extension should be applied. In some cases the reduction has been effected by placing the knee in the bend of the elbow and flexing the forearm, while the surgeon was making extension from the hand. § 3. Dislocation of the Radius and Ulna Inwards (to the Ulnar Side). This form of dislocation is much more rare than the dislocation outwards, a fact which may perhaps find a sufficient explanation in the peculiar form of the trochlea, the inner half of which rises much higher than the outer, forming thus an elevated inclined plane, over which the articulating surface of the ulna must rise before the dislocation can occur. Like the opposite dislocation, the typical form of the accident is that in which the displacement is incomplete; indeed, no example of a complete inward dislocation has, we think, been yet recorded. Causes. —A fall upon the hand or forearm, a blow upon the radial side of the forearm near its upper end, or upon the ulnar side of the arm, near its lower end, a violent wrenching of the limb, are among the causes which may occasion this dislocation. Pathology. —The ridge which divides antero-posteriorly the greater sigmoid cavity of the ulna, having been driven over the elevated inner margin of the trochlea, falls down upon the epitrochlea, so as, in some sense, to embrace it instead of the trochlea ; while the head of the radius passes inwards also, and is made to occupy the trochlea, from which the ulna has escaped. Generally the head of the radius is found in the same line with the ulna (Fig. 236), but it may suffer a luxation and be found a little in advance of the ulna, or possibly a little in the rear. I choose also to regard the dislocation inwards and upwards as only a variety of the dislocation inwards; in which form of the accident the coronoid process of the ulna is thrust upwards above the epicondyle, and the head of the radius occupies the olecranon fossa, or rests upon the back of the humerus somewhere in this vicinity. In addition to the injury suffered by the ligaments and muscles, the ulnar nerve in both varieties of inward dislocation is peculiarly liable to Fig. 236. Most frequent form of incomplete iuward dislocation of the forearm. contusion, in consequence of its being crushed between the olecranon process and the epitrochlea. Symptoms. —If the dislocation is only inwards, the olecranon process can be felt projecting upon the inner side, and completely 582 DISLOCATIONS OF THE RADIUS AND ULNA. concealing the epicondyle; while the head of the radius, having abandoned its socket, may be felt indistinctly in the bend of the arm. The external condyle (epicondyle) is remarkably prominent. The forearm is generally more or less flexed, and the hand forcibly pronated. The natural outward deflexion of the forearm is also lost, or it may be even inclined slightly inwards. This phenomenon is explained by the position of the epicondyle, upon which the greater sigmoid cavity now rests, allowing the ulna to overlap a little upon the humerus; rendering the forearm actually somewhat shorter along its ulnar margin, although the head of the radius may still occupy the summit of the trochlea. If the bones are displaced upwards as well as inwards, a considerable shortening is declared, and the head of the radius may now be felt behind the trochlea, or over the olecranon fossa. In three of the four examples seen by Malgaigne, all of them ancient, the forearm was in a state of supination. Other surgeons have met with cases in which the forearm was supine, but they must be considered as exceptions to the rule. The following example of this dislocation, unreduced after the lapse of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira, N. Y. Thomas Cook, now in his nineteenth year, was four years and ten months old, when he fell from a pile of boards about as high as a man's shoulder. According to his statement, given at the time, his right arm caught between the board, and, in falling he turned a summersault. The mother, to whom the child immediately ran, grasped the arm which he said was broken, and found that it would roll and turn in various ways. When the surgeon arrived, three hours afterwards, the arm was very much swollen, and the accident was supposed to be a fracture. At present flexion and extension are perfect. The forearm has an inward deflection of a hand's breadth more than the other. The power of pronation is complete, but the forearm and hand cannot be supinated entirely. The external condyle is very prominent, but the internal is almost hid by the olecranon, which projects inwards nearly as far as the point of the epicondyle. The finger can be laid in the olecranon fossa behind, and all the back part of the trochlea can be distinctly traced. By flexing the forearm slowly, as it approaches a right angle, the tendon of the triceps may be felt, lodged, as it were, on the back part of the point of the epicondyle, and by continuing the flexion, the tendon suddenly slips over this point and places itself on the anterior aspect of the arm. When the forearm is fully flexed, the tendon is advanced full three-quarters of an inch in front of the epicondyle. The arm is very serviceable, but invariably pains him after a hard day's work. Prognosis. —Malgaigne was unable to reduce the dislocation in a recent case of incomplete internal dislocation, which came under his own notice. Triquet succeeded in a child seven years old, on the fifteenth day, after many trials; but the movements of the elbow-joint were never restored. Debruyn succeeded on the fifth day, but not without difficulty; the case reported by Squier was mistaken for a fracture, and no attempt at reduction was made; and in the only re- 583 DISLOCATION OF RADIUS AND ULNA FORWARDS. maining example which has been put upon record, the precise character of the accident having been determined by Velpeau, reduction was easily accomplished, and on the eighth day the patient was dismissed. 1 Of the four examples of inward and backward luxation seen by Malgaigne, not one was ever reduced; but as the history of them all is not complete, it is by no means to be inferred that reduction could not have been easily accomplished, at least in some of them, at the first. Nor, with such imperfect details before us, can we understand fully what complications may have existed, such as would perhaps render these exceptional, rather that illustrative examples. One of these patients had a completely anchylosed elbow at the end of two years, but pronation and supination were preserved. In the case of another, however, even flexion and extension were as perfect as in the normal condition. Treatment. —The indications of treatment are the same as in dislocations outwards, with only such slight modifications as the judgment of every surgeon must naturally suggest. I prefer to employ by way of illustration the example diagnosticated by Velpeau. On the 10th of May, 1848, Alexandrine Guyot, set. 22, entered the Hospital of La Charite, with an incomplete inward dislocation of the forearm which had just occurred. The hand and forearm were in a state of forced pronation, half-flexed, and the whole limb from the elbow downwards was deflected inwards. There were present also all the other usual signs of this dislocation, and Velpeau had no doubt as to its true character. In order to accomplish reduction, one assistant made counter-extension upon the arm, while a second made direct extension upon the forearm. At first the tractions were made in the direction of the forearm (flexed and prone), but gradually the arm was straightened and supinated. Then the surgeon, seizing with one hand the superior extremity of the forearm, and with the other the inferior extremity of the arm, acted forcibly upon the two portions in opposite directions, and immediately the reduction was effected with a noise. 9 § 4. Dislocation op the Radius and Ulna Forwards. Sir Astley Cooper, Vidal (de Cassis), and others have denied that this dislocation was possible without a fracture of the olecranon process; but Monin, Prior, Velpeau, Canton, 3 and Denuce' have each reported one example, so that its existence may now be considered as established. Nevertheless, it is only as a result of very violent and extraordinary accidents, by which the forearm is forcibly flexed, or greatly extended, or twisted, or in some other unusual and indirect way the olecranon is placed in front of the humerus. The following is a summary of the facts in Velpeau's case. Alexandrine Carelli, set. 23, was knocked down by a carriage, on the first of July, 1848, the wheel passing over the right arm. The arm was 1 Denuce, op. cit., pp. 154-156. 2 Ibid., p. 155. 3 Dub. Quart. Journ. of Med. Sci., Aug. 1860. 584 DISLOCATIONS OF THE RADIUS AND ULNA. found in a right-angled position, and it could neither be flexed nor extended; the forearm was strongly supinated; the projecting angle usually made by the olecranon process was replaced by the irregular Fig. 237. E, Canton's case of Dislocation of the Radius and Dlna forwards. extremity of the humerus; the forearm was shortened upon the arm; the head of the radius resting in the coronoid fossa, and the olecranon process being also carried upwards, and a little outwards. Reduction was easily accomplished, and the patient left on the nineteenth day, with only a slight remaining stiffness in the joint. 1 Chapel has reported a case of dislocation forwards and outwards, which he readily reduced soon after it occurred, while Colson, Leva and Guyot have each reported one example of forwards, in which the extremity of the olecranon process has been found resting upon the extremity of the humeral trochlea. 2 Treatment. —If the dislocation is complete, and the forearm is shortened and flexed upon the arm, the reduction should be first attempted by violent flexion, or by flexion combined with extension from the wrist and counter extension from the lower portion of the humerus. If the dislocation is incomplete, and the forearm is extended upon the arm, the reduction may be readily accomplished by extension alone, or by moderate flexion. 1 Denuce, op. cit., p. 110. 4 Ibid., p. 120. 585 DISLOCATIONS OF THE WRIST. CHAPTER X. DISLOCATIONS OF THE WRIST (RADIO-CARPAL ARTICULATION). Regarded as an accident of not unusual occurrence by Hippocrates, J. L. Petit, Duverney, Boyer, and by most if not all the older writers, its frequency began to be questioned by Pouteau, and finally its existence was almost absolutely denied by Dupuytren, who remarks: "I have for a long time publicly taught that fractures of the carpal end of the radius are extremely common; that I had always found these supposed dislocations of the wrist turn out to be fractures; and that in spite of all which has been said upon the subject, I have never met with, or heard of, one single well authenticated and convincing case of the dislocation in question." Dupuytren subsequently declared that he would not positively deny the possibility of the accident, yet that "it must at least be admitted that the accident is an extremely rare one." Wishing to explain this infrequency, he says: " In examining the structure of the soft parts, one cannot fail to perceive that it is not the ligaments which prevent the displacement of the articular surface forwards, but that this effect is especially due to the multitude of flexor tendons, deprived as they are at this point of all the fleshy parts, and reduced to the simple fibrous tissue which composes them. These tendons are bound together beneath the anterior annular ligament of the wrist; and thus offer so efficient a resistance that severe falls are insufficient to tear them through; the hand is forced into a state of extreme tension, and the tendons are firmly applied on the anterior part of the radio-carpal articulation. If the extension is still further augmented, the wrist-joint is yet more closely clasped by these parts, and their power of resistance is incalculable ; I am convinced that a force equivalent to one thousand pounds weight would be inadequate to overcome it; and the known power of the tendo Achillis is sufficient to prove that this computation is not exaggerated. " The risk of dislocation backwards by a fall on the dorsal surface of the hand is equally precluded by the tendons of the extensor muscles. Their arrangement and relations at the back of the joint are similar ; it is true they are not quite so strong; but we must admit that their power of resistance is very considerable, when we take into consideration how they are inclosed in sheaths as they cross beneath the posterior annular ligament of the wrist. I have not alluded to the ulna, for it has really little or nothing to do with these movements, as it does not articulate (directly) with the hand. " To sum up, then, the extreme rarity of dislocation forwards or 38 586 DISLOCATIONS OF THE WRIST. backwards is owing to the obstacles opposed by the flexor and extensor tendons." The Opinion of such a writer as Dupuytren, whose experience was very great, and who described only what he had seen, is always entitled to profound respect; yet it has been the practice of nearly all who have made any reference to his opinions in this matter to speak of them lightly, and not a few have falsely represented him as saying that such a dislocation was "impossible." The fact is, that surgeons do still constantly mistake fractures of the lower end of the radius for dislocations, as my own personal observation can attest; and notwithstanding examples have been reported by Rene, Marjolin, Padieu, Cruveilhier, Voillemier, Boinet, Malgaigne, Scoutetten, Bransby Cooper, Fergusson, W. Parker, and others, yet the whole number of cases for which the distinction is claimed is, to this day, so inconsiderable as only to establish the value and accuracy of Dupuytren's opinion that the "accident is an extremely rare one." But it is, perhaps, most remarkable that while very few of these supposed examples have been verified by an autopsy, in every instance in which the autopsy has been made, the dislocation has been found to be complicated with a fracture, generally of the lower extremity of the radius or of the styloid apophysis of the ulna. The existence of a complication, however, does not render the accident any the less a dislocation, although it may render the diagnosis more difficult, and modify somewhat the indications of treatment. A knowledge of the fact, also, that such complications have always been observed in the autopsy may leave us in doubt as to what is the natural history of a simple, uncomplicated dislocation, if, indeed, it does not warrant a suspicion that such a case never occurs. We shall, nevertheless, after a careful analysis of the cases as they have been reported, and by a consideration of the anatomy of this articulation, be able to determine with some degree of accuracy, perhaps, what are, or what ought to be the usual causes, signs, treatment, &c, of these accidents. Partial luxations have also been frequently described by surgeons. I have never met with an example, but the following case, related to me by the patient himself, I believe to have been a case in point. Lewis C, of Buffalo, ast. 18, by a fall upon his hand, broke the left forearm below the middle, and at the same time, as he affirms, partially dislocated the carpal bones backwards. Dr. Spaulding, of Williamsville, N. Y., who is now dead, took charge of the limb, and pronounced it a fracture with partial dislocation, and for more than a year after the accident, the bones had a tendency to become displaced in the same direction. Whenever he attempted to lift even the weight of half a pound, with his hand supinated and his forearm extended horizontally, the lower end of the radius would spring suddenly forwards, and all power in the arm would be lost. When this happened, as it did quite often, he always reduced the bones himself, by simply pushing upon them in the direction of the articulation. Fourteen years after the accident, I examined the arm and found it in all respects perfect, except that the forearm was shortened about 587 DISLOCATIONS OF THE CARPAL BONES BACKWARDS. one-third of an inch, which shortening was due, no doubt, to the overlapping of the broken bones. § 1. Dislocations or the Carpal Bones Backwards. Causes. —The same casualty, namely, a fall upon the palm of the hand, which, as we have elsewhere noticed, produces frequently a fracture of the lower end of the radius, occasionally a dislocation of the radius and ulna backwards, at the elbow-joint, may also, it is believed, occasion sometimes a dislocation of the carpal bones backwards. In several of the cases reported, this cause has been assigned; but in the only example of simple dislocation which has ever come under my notice, and which I have every reason to believe was a simple dislocation unaccompanied with a fracture, the carpal bones were thrown back by a fall upon the back of the hand. The following is a brief account of the case:— The Rev. Stephen Porter, of Geneva, N. Y., set. 75, while walking with his son after dark, and holding in his right hand a satchel, slipped and fell. In the effort to save himself, and still retaining his grasp upon the satchel, his right hand struck the side-walk flexed, and in such a way as that the whole force of the fall was received upon the back of the hand and wrist, thus throwing the hand into a state of extreme flexion. In less than twenty minutes he was at my house. No swelling had yet occurred, and the moment I looked at the wrist I said to him, "You have broken your arm;" so much did it resemble a fracture of the lower end of the radius. A farther examination led me to a different conclusion. The palmar surface of the wrist presented an abrupt rising near the radio-carpal articulation, the summit of which was on the same plane and continuous with the bones of the forearm, and a corresponding elevation existed upon the dorsal surface terminating in the carpal bones and hand; the hand was slightly inclined backwards, but the fingers were moderately flexed upon the palm. To this extent the accident bore the features of a fracture of the radius; but the hand did not fall to the radial side; the projections upon the palmar and dorsal surfaces were more abrupt than I had ever seen in a case of fracture, and which, if it were a fracture, would imply that the broken extremities had been driven off from each other completely; the most salient angles of these projections were abrupt, but not sharp or ragged; the styloid apophyses could be distinctly felt, and I was not only able to determine that they were not broken, but by observing their relations to the palmar and dorsal eminences, it was easy to see that these latter corresponded to the situation of the articulation. In addition to these evidences that I had to deal with a dislocation, and not a fracture, we had the testimony furnished by the reduction, which was not made, however, until by every possible means the diagnosis was definitely settled. Seizing the hand of the gentleman with my own hand, palm to palm, and making moderate but steady extension in a straight line, the bones suddenly resumed their places with the usual sensation or sound accompanying reductions. There 588 DISLOCATIONS OF THE WRIST. was no grating, or chafing, or crushing, nor was the reduction accomplished gradually, but suddenly. To test still further the accuracy of the diagnosis, I now pressed forcibly upon the wrist from before back, but without producing any degree of displacement, nor could any crepitus still be detected. No splint was applied, and on the following morning Mr. Porter preached from one of the pulpits in the city, only retaining his arm in a sling. Sixteen months after the accident, Sept. 15, 1858, this gentleman again called upon me, and I found the arm perfect in all respects, except that it was not quite as strong as before; the lower extremity of the ulna was preternaturally movable, and occasionally he felt a sudden slipping in the radio-carpal articulation. Pathological Anatomy. —In the examples of compound or complicated dislocations, which alone have been exposed by dissections, the posterior and lateral ligaments have been found extensively torn, as also frequently the anterior ligament, with or without separation of the radial or ulnar apophyses; the extensor muscles torn up from the lower part of the forearm and displaced; the first row of the carpal bones lying underneath the tendons, and upon the bones of the forearm, sometimes having been carried directly upwards, sometimes upwards and a little inwards, and at other times upwards and outwards; the arteries and nerves have occasionally escaped serious injury, but more often they have been displaced, bruised, or torn asunder. Such are, briefly, the pathological circumstances which may be supposed to exist, in a lesser or greater degree, in nearly all cases of simple dislocations. Fig. 238. Dislocation of the carpal bones backwards. (From Fergnsson.) In compound dislocations, however, the muscles, or rather the tendons, are twisted, torn, and thrust aside, producing very extensive lesions among the deeper structures of the forearm and hand before the integuments can be made to yield. On the 2d of May, 1852, Silas Usher, set. 54, had his right armcaught between the bumpers of two cars, bruising the hand and dislocating the carpal bones backwards, the radius and ulna being thrown forwards and pushed completely through the skin into the palm of the 589 DISLOCATIONS OF THE CARPAL BONES BACKWARDS. hand. Most of the flexor tendons had been merely thrust aside, but one or two were torn asunder; the median nerve was torn off, but the radial and ulnar nerves were apparently uninjured, and there was no fracture. The patient being a temperate man, in perfect health, and the bones having been easily replaced by moderate extension, it was determined to make an effort to save the arm. The limb was therefore laid on a carefully padded splint, and cool water lotions diligently applied. Phlegmonous erysipelas began to develop itself on the third day; and on the ninth, gangrene having attacked the limb, I amputated a little above the middle of the humerus. On the fourteenth day hemorrhage occurred suddenly from the stump, and when I reached him he was pulseless and dying. The result demonstrated the error of the attempt to save the limb without resection of the lower ends of the bones of the forearm. Symptoms. —The usual signs have already been sufficiently stated in the example which we have given. The most important diagnostic marks are found in the abruptness of the angles formed by the projecting bones; the relation of these prominences to the styloid apophyses; in the total absence of crepitus; and in the reduction, which is accomplished easily, suddenly, and with a characteristic sensation. If a fracture complicates the accident, crepitus may also be present. It should be remembered, moreover, that when the styloid process of the radius is broken, if the hand is moved backwards and forwards this process will move also, which might lead to the supposition that the radius was broken higher up, and that it was not a dislocation at all. Prognosis. —In compound dislocations the prognosis is exceedingly grave, unless the surgeon determines Fig. 239. Dislocation of the carpal bones backwards. (From Skey.) to resort to amputation, or, what is generally much preferable, to resection. In dislocations complicated with fracture of the posterior edge of the articulating surface of the radius (" Barton's fracture" 1 ), some difficulty may be experienced in retaining the bones in place; but when this fracture does not exist, the posterior margin of the articulation, considerably elevated above its anterior margin, constitutes a sufficient protection against a reluxation in that direction. In all cases, also, complicated with fracture, even of an apophysis, intense inflammation and swelling are likely to follow, and the danger of a permanent anchylosis is greatly increased. Treatment. —Extension in a straight line has generally been found sufficient to accomplish the reduction; to which may be added a slight rocking or lateral motion, if necessary. The reduction may be effected also by pressing the hand backwards, while the surgeon pushes the carpus downwards from behind and above, in the direction of the articulation. 1 Philadelphia Medical Examiner, 1838. 590 DISLOCATIONS OF THE WRIST. Unless a tendency to displacement exists, no splints or bandages of any kind ought to be applied, but it should be treated by rest and cool water lotions until all danger from inflammation has passed. § 2. Dislocations of the Carpal Bones Forwards. The causes, mechanism, symptoms, pathology, treatment, &c, of this Fig. 240. Dislocation of the carpal bones forwards. (From Fergusson.) accident resemble in so many points those of the preceding dislocation, with only the differences necessarily due to a change in the direction of the bones, that I find it not worth while to do more than to relate one single example contained in Bransby Cooper's edition of Sir Astley's work on Fractures and Dislocations. The case did not come under the observation of Mr. Cooper himself, but was related to him by Mr. Haydon, a surgeon residing in London. It is especially interesting as furnishing an example of a dislocation of both wrists at the same mo- ment, and from similar causes, but in opposite directions. A lad, aged about thirteen years, was thrown violently from a horse on the 11th of June, 1840, striking upon the palms of both hands and upon his forehead. The left carpus was found to be dislocated backwards, the radius lying in front and upon the scaphoides and trapezium. The right carpus was dislocated forwards, the radius and ulna projecting posteriorly, and the bones of the carpus forming an "irregular knotty tumor, terminating abruptly" anteriorly. A very careful examination was made to determine what parts came in contact with the resisting force, but although the palms of both hands were extensively bruised, there was not the slightest bruise on the back of either hand. Nor were the gentlemen present able to find any evidence whatever that the dislocation was accom- Fig. 241. Dislocation of the carpal bones forwards. (From Skey.) panied with a fracture. "Moreover," says Mr. Haydon, "we were strengthened in our opinion that this was a case of dislocation, unattended with any fracture, because the dislocations appeared so perfect; the two tumors in each member so distinct; the reduction so complete; the strength of the parts after reduction so great; and, lastly, by the very trifling pain felt after reduction, for within an hour after, the patient could rotate the hand and supinate it when pronated—this could not, we believe, have been done had there existed a fracture." 591 DISLOCATIONS OF LOWER END OF ULNA BACKWARDS. CHAPTER XI. DISLOCATIONS OF THE LOWER END OF THE ULNA (INFERIOR RADIO-ULNAR ARTICULATION). In connection with fractures of the lower end of the radius this accident is not very uncommon. I have myself met with it under these circumstances several times; but without a fracture it is quite rare. Dupuytren met with but two cases in his long and extensive practice. Sir Astley Cooper does not record a single instance, and many surgeons affirm that they have never seen the dislocation in question. § 1. Dislocations op the Lower End of the Ulna Backwards. To the eleven or twelve examples collected and referred to by Malgaigne, I am only able to add one case of ancient luxation seen by myself. Causes. —Duges mentions the case of a little girl in whom the accident occurred in both arms, but at different periods, by being lifted by the hands. One of the patients seen by Desault, a child five years old, had the ulna dislocated backwards by extension accompanied with forced pronation, and in another example, cited by him, forced pronation alone, as in wringing wet clothes, was found to have been sufficient. In Hurteaux's case the patient had fallen upon her wrist. Pathological Anatomy. —Rupture of the synovial membrane (sacciform ligament), and also of the ligament which binds the ulna to the cuneiform bone: the little head or lower extremity of the ulna abandoning its socket in the radius, and being thrown backwards, or in some cases backwards and outwards so as to cross obliquely the lower end of the radius; or it may incline inwards as well as backwards. Several examples are mentioned also in which the end of the bone has been thrust completely through the integuments. Prognosis. —In recent cases the reduction has generally been accomplished without difficulty, and in only three or four instances has the bone become spontaneously displaced. Loder reduced the ulna after eight weeks, and Rognetta after sixty days. In the example to which I have already referred as having been seen by myself, the dislocation had existed twenty years, the accident having occurred in Ireland when the person was fifteen years old. When I examined the arm, July 21, 1850, the right ulna projected backwards and a little outwards, about half an inch. He said he had been lame with it for several years, but the motions of the 592 DISLOCATIONS OF THE LOWER END OF THE ULNA. wrist-joint were now completely restored, and both pronation and supination were perfect. Symp>toms. —The hand is usually fixed in a position midway between supination and pronation. Boyer, however, found the hand in a state of extreme pronation. The extremity of the ulna is felt and seen distinctly upon the back of the wrist, prominent and movable; and the styloid process is no longer in a line with the metacarpal bone of the little finger; the fingers, hand and forearm are slightly flexed. Treatment. —The reduction may be accomplished by holding firmly upon the radius and at the same moment pushing the ulna forcibly toward its socket; or by simply supinating the hand strongly. Some cases demand also extension and counter-extension. Generally the bone has been found to remain in its place without assistance, yet in three or four of the examples upon record the constant tendency to displacement when the pressure was removed, has rendered it necessary to employ splints and compresses. § 2. Dislocation of the Lower End of the Ulna Forwards. The dislocation forwards is said by Malgaigne to be more rare than the dislocation backwards. In addition to the nine cases collected by him, I have been able to add one reported by Parker, of Liverpool; leaving, therefore, a difference of only three or four in favor of the luxation backwards; and not sufficient, 1 think, to warrant any positive conclusions as to the relative frequency of the two accidents. While the dislocation backwards is usually caused by violent pronation of the hand, this dislocation is most often occasioned by violent supination. The hand is therefore generally found to be supinated forcibly, and the projection formed by the end of the bone is seen upon the front of the wrist instead of the back. By pushing the ulna toward its socket while an attempt is made to flex the hand, or by extension, supination, &c, it is made to resume its position readily. In the case reported by Parker, however, the reduction was effected only while the hand was pronated. Parker's case, already referred to, is thus related:— " John Dalton, aged forty, applied to the hospital Aug. 9th, 1841, under the following circumstances:— " States that he is a carter, and falling down, the shaft of the cart fell upon his hand and forearm, in such a way as to supinate them forcibly. He complains of pain in the left wrist. The forearm is supinated, and cannot be pronated, the attempt causing much suffering. The wrist-joint can be flexed or extended without much pain. On looking at the back of the wrist, the appearance is characteristic ; the natural prominence of the ulna is wanting; an evident depression exists, as if the lower end of the ulna had been dissected out; it can be traced, however, on a plane anterior to the radius, its button-like head being distinctly felt under the flexor tendons. Several ineffectual and very painful attempts were made to accomplish the reduction, by pushing the head of the ulna into its natural situation. This was at last effected by seizing the hand to make extension (counter-extension DISLOCATIONS OF THE CARPAL BONES. 593 being made at the elbow), then forcibly pronating the hand, at the same time pressing backwards the dislocated head of the bone with the fingers of the left hand. After persevering for a short time, the bone was felt to assume its natural position, the wrist acquired its usual appearance, and the ordinary movements of the joint could be readily performed. There was no tendency to re-dislocation, and the man was dismissed with directions to keep the bone quiet, and to foment it. He attended as an out patient for two or three days, after which, complaining of nothing but a little weakness in the part, a bandage was applied, and ordered to be worn for a short time." 1 CHAPTER XII. DISLOCATIONS OF THE CARPAL BONES (AMONG THEMSELVES). Bound together on all sides by strong ligaments, and enjoying only a very limited degree of motion among themselves, the carpal bones seldom become displaced except in gunshot wounds, or in connection with extensive lacerations and fractures of the neighboring parts. Simple dislocations, or rather sub-luxations of these bones do, however, occasionally take place, but so far as we have been able to ascertain, only in one direction, namely, backwards. The bones of the carpus, which are said occasionally to have suffered simple backward subluxation, are the os magnum, cuneiforme, unciforme, and pisiforme. Richerand, the editor of Boyer's Lectures, says that he once met with a subluxation of the os magnum backwards, of which he has given us the following account: " Mrs. B., in a labor pain, seized violently the edge of her mattress, and squeezed it forcibly, turning her wrist forwards; she instantly heard a slight crack, and felt some pain, to which her other sufferings did not allow her to attend. Fifteen days afterwards, happily delivered, and recovered by the care of Professor Baudelocque, she showed her left hand to this celebrated accoucheur, and expressed her disquietude about the tumor which appeared on it, especially when much bent, I was called to visit the lady. I found that this hard circumscribed tumor, which disappeared almost totally by extending the hand, was formed by the head of the os magnum, luxated backwards; I replaced it entirely by extending the hand, and making gentle pressure on it. As the affection did not impede the motion of the part, as the tumor disappeared on extending the hand, and as it would have been but little apparent in any state 1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470; from Lond. andEdin. Month. Journ." Med. Sci., Dec. 1842. 594 DISLOCATIONS OP THE CARPAL BONES. of the hand had Mrs. B. been more in flesh, I advised her not to be uneasy about it, and to apply no remedy to it." 1 Richerand adds also that Boyer and Chopart had each met with the same dislocation. Bransby Cooper saw the os magnum displaced backwards in a stout, muscular young man by a fall upon the back of the hand when in extreme flexion. The hand remained slightly bent, and the projection of the os magnum was very distinct. Reduction was attempted by extending the whole hand, at the same time making pressure upon the displaced bone; this not succeeding, extension was made from the middle and forefingers only, while pressure was kept up on the os magnum, when suddenly the bone resumed its natural position. On flexing the hand, however, the dislocation was immediately reproduced ; and it became necessary to apply a compress and splint. For several days after, he was in the habit of pushing it out by flexing the hand, in order that the young men at Guy's Hospital might see its reduction; which was always easily accomplished by simply pushing upon it. Sir Astley says that both the os magnum and cuneiforme are sometimes thrown a little backwards, from simple relaxation of the ligaments, producing a great degree of weakness, so as to render the hand useless unless the wrist be supported; and he mentions the case of a young lady in whom the os magnum was thus displaced and who was obliged to give up her music in consequence; for when she wished to use her hand she was compelled to wear two short splints, made fast to the back and forepart of the hand and forearm. Another lady whose hand was weak from a similar cause, wore for the purpose of giving it strength, a strong steel chain bracelet, clasped very tightly around the wrist. 3 Gras has described a dislocation of the pisiform bone, 3 and Fergusson says he has known an example in which this bone was detached from its lower connections by the action of the flexor carpi-ulnaris. 4 Little benefit, he thinks, can be expected from any attempts to keep it in place when it is dislocated, nor is its displacement of much consequence. Erichsen thinks he has seen a dislocation of the os lunare produced by a fall upon the hand when forcibly flexed. By extension and pressure it was easily replaced, but when the hand was flexed the dislocation was immediately reproduced. 5 Notwithstanding that Sir Astley, Miller, and others have taught that the cuneiform bone is liable to displacement, and South has affirmed the same of the unciform, I have found no account of an example of simple dislocation of single carpal bones except in the cases of the os magnum, pisiformis, and lunare, as above mentioned. Maisonneuve has reported an example of simple dislocation, without wound of the integuments, at the middle carpal articulation. A man had fallen forty feet, and was carried dying to the Hotel Dieu. The 1 Richerand, Boyer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 261. 2 Sir A. Cooper, op. cit., p. 435. 3 Note to Chelius, by South, op. cit., p. 234. 4 Fergusson, op. cit., p. 190. 6 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 259. 595 DISLOCATION OF THE METACARPAL BONES. symptoms were almost precisely those of a dislocation of both rows of the carpal bones backwards. The reduction was not accomplished during life, but after death a simple effort of traction was sufficient to replace the bones. The dissection showed that the bones of the second row were almost completely separated from those of the first, upon which they were overlapped backwards. A small fragment of both the scaphoides and cuneiform remained attached to the second row, but with this exception, the separation was complete. 1 CHAPTER XIII. DISLOCATION OF THE METACARPAL BONES (AT THE CARPO-METACARPAL ARTICULATIONS). The metacarpal bone of the thumb may be dislocated either backwards or forwards. The former is the most frequent; and it is produced generally by a fall upon the thumb, which throws it into a state of extreme flexion: it has also been occasioned by a force acting in an opposite direction, as when a flash of powder is exploded in the palm of the hand, or a blow is received upon the extremity and volar aspect of the last phalanx. The dislocation may be partial or complete. In the few examples of partial dislocation which have been recorded, the position of the finger has been either moderately flexed or straight, and the signs of the accident have been occasionally so obscure as to have led to an error in the diagnosis, and the luxation has remained unreduced. When the dislocation is recognized, reduction is in most cases easily accomplished by pressure, combined with extension; after which it is sometimes necessary to apply a splint to maintain the apposition. If the reduction is not accomplished the joint is permanently maimed. Complete backward luxations are more frequent than incomplete, and are produced by the same class of causes; generally by a fall upon the palmar surface of the thumb. The symptoms are sufficiently clear, although the position of the thumb is not always the same. It has been found perfectly straight, without any inclination either way, or flexed more or less, with the metacarpal bone also inclined inwards toward the palm. The motions of the joint are interrupted, and the proximal extremity of the metacarpal bone riding upon the back of the trapezium, projects sensibly in this direction, and the trapezium is also felt unusually prominent under the thenar eminence. The overlapping varies from a line or two to three-quarters of an inch. In the patient mentioned by Bourguet, the head of the metacarpal bone almost reached the styloid process of the radius. 1 Maisonneuve, Malgaigne, op. cit., from Mem. de la Soc. de Chirurg., t. ii. 596 DISLOCATION OF THE METACARPAL BONES. The reduction is to be effected by extension alone, or by extension with moderate pressure. In two of the examples reported, although the reduction was accomplished very easily, the dislocation was reproduced when the extension ceased, and it became necessary to apply splints. Malgaigne did not observe, in the case seen by him, any such tendency to displacement. In the case of Bourguet's patient the reduction was never accomplished, although the attempt was made on the second day by a surgeon, and repeated after about two months by Bourguet himself. Fergusson, who has met with several of these dislocations, says that he has seen even a splint and roller fail of keeping the bones in place; and he recommends, for the purpose of security, that the splint should extend some distance upon the forearm. Sir Astley Cooper says that, in the cases of this accident which he has seen, the metacarpal bone of the thumb has been thrown inwards, between the trapezium and the root of the metacarpal bone supporting the forefinger; forming a protuberance toward the palm of the hand; the thumb has been bent backwards, and adduction was impossible. This distinguished surgeon cites no examples, nor are we able to find upon record an instance of complete inward dislocation of this bone, such as Sir Astley has described. Vidal (de Cassis) believes that he has met with a partial forward dislocation, which he reduced readily, but the patient having removed the retentive means, the dislocation was reproduced and the bone was not again replaced. 1 Malgaigne has collected only three examples of a dislocation of either of the other metacarpal bones. One, observed by Bourguet, was a dislocation forwards of the metacarpal bone of the index finger, having been caused by a great force applied to the back of the phalanx near the carpus. Reduction was effected by extension and pressure, the bone resuming its place insensibly and not suddenly. With the aid of splints it was retained in position, and the cure was perfect. The second, seen by Roux, was a backward luxation at the carpometacarpal articulation of the second, or great finger, produced by an explosion in a mine. By pressure made directly upon the projecting bone he was unable to reduce it, but by uniting pressure with extension from the finger, he succeeded readily. After the reduction was effected, it was noticed that when the hand was straightened the bone became reluxated, but that it was easily kept in place when the hand was flexed. The third example (occurring in the same joint), mentioned by Malgaigne, occasioned by a fall upon the clenched hand, was probably incomplete, and Malgaigne is not quite certain that it was not a fracture. In April, 1849, Stephen Peterson, set. 24, was admitted into the Buffalo Hospital of the Sisters of Charity, with a partial dislocation backwards of the proximal ends of the metacarpal bones of the index and great fingers of the right hand ; produced, as he affirms, by striking a man with his clenched fist, about one year previous. He says that 1 Vidal (de Cassis), Traite de Pathologie Externe, etc., 3d Paris ed., t. ii. p. 564. 597 FIRST PHALANX OF THE THUMB BACKWARDS. he called upon a surgeon immediately, but he was unable to keep the bones in place. The projection was very manifest at the time of my examination, and the hand had never recovered the power of grasping bodies firmly. During the same year I found in the hospital a precisely similar case, in the person of Francis M'Coit, set. 32, a sailor, which had occurred four years before, in consequence of a blow given with his fist. The same bones were partially displaced backwards, and remained unreduced. This man had also consulted a surgeon soon after the injury was received. In both of the above examples I instituted a careful examination to determine whether it was not the bones of the carpus thus displaced; but the result was conclusive as to the nature of the accident, and I have obtained casts of both in order to illustrate partial dislocations of the metacarpal bones. CHAPTER XIV. DISLOCATIONS OF THE FIRST PHALANGES OF THE THUMB AND FINGERS (AT THE METACARPO-PHALANGEAL ARTICULATIONS). § 1. Dislocations op the First Phalanx of the Thumb Backwards. This bone may be dislocated backwards or forwards, but most frequently the dislocation is backwards. The backward dislocation is occasioned generally by a fall or blow upon the distal end and palmar surface of the thumb; the proximal extremity of the first phalanx sliding back upon the distal extremity of the metacarpal bone, and standing off from it at nearly a right angle, the last being again flexed upon the first phalanx at about a right angle also; meanwhile the distal end of the metacarpal bone is seen projecting strongly in the palm of the hand. (Fig. 242). These are the usual signs which characterize this accident, and they are always sufficiently diagnostic. In a few cases, however, the phalanges have been found extended upon the metacarpal bone in almost a straight line, indicating, we presume, some extraordinary lesion of the tendon?, or muscles. Fig. 242. Dislocation of the first phalanx of the thumb backwards. The reduction is sometimes, in recent cases, accomplished with great ease, as the following examples will illustrate. A servant girl, set. 25, fell down a flight of steps Nov. 15, 1850, 598 OF FIRST PHALANGES OF THUMB AND FINGERS. striking npon the inside of her right hand and thumb. "When I saw her, only a few minutes afterwards, I found the first phalanx standing back almost at a right angle with the metacarpal bone, and the second phalanx also flexed to a right angle with the first. Assisted by my pupil, Mr. Boardman, the reduction was effected in about twenty seconds, by bending the first phalanx farther back, and at the same moment pressing the proximal end of this phalanx forwards in the direction of the joint. Without employing great force, the reduction took place suddenly and with a snap. Very little swelling followed, and in three weeks she was able to use her needle without inconvenience. Michael Wolf, set. 35, fell from a height, causing a fracture of his left arm, and a dislocation of his right thumb backwards. I saw him within two hours after the accident. The thumb was much swollen, and its position the same as in the case just described. Although Wolf was a strong, muscular man, the reduction was accomplished in a few seconds by applying over the last phalanx the Indian toy called a "puzzle," and making extension in a straight line, while an assistant made counter extension from the hand and wrist. The use of the joint was soon completely restored. Examples, however, are constantly occurring, which are only reduced after long continued and painful efforts, or which, indeed, completely exhaust the patience and baffle the skill of the most experienced surgeons. Mary J. S., set. 23, fell upon her right hand with her fingers and thumb extended, in Sept. 1853, and dislocated this bone backwards. A young surgeon attempted to reduce the dislocation half an hour after the accident, by the same manoeuvre adopted by myself successfully in the case of the servant girl; only that he made extension upon the last phalanx at the same moment. The surgeon believes that the bone was reduced, but one week later he found it displaced, and, as he believes, reduced it again. The same thing occurred a third time. Six months after this, the girl consulted me to ascertain what could be done for her relief. The thumb occupied the usual position, and admitted of no motion except at the carpo-metacarpal articulation. It is quite probable that the dislocation was never reduced, an error which, if it did occur, might easily be excused, when we remember that from the first the thumb was greatly swollen. In May, 1848, having been called to see G. H., who had attempted suicide by cutting his throat, my attention was arrested by the appearance of his left thumb, and which I found to be occasioned by an ancient dislocation of the first phalanx backwards. The accident had occurred, he afterwards told me, twelve years before, in consequence of a fall while wrestling. A very respectable country surgeon was called, and made three several attempts to reduce it, but failed. The several bones of the thumb occupied their usual positions, that is to say, the positions which they usually occupy in this dislocation, yet notwithstanding the almost complete anchylosis of the phalangeal articulations, and the awkward encroachment of the distal end of the metacarpal bone upon the palm, the hand was quite useful. FIRST PHALANX OF THE THUMB BACKWARDS. 599 On the 25th of July, 1857, Catherine Ernst was brought to me, by her parents, having a dislocation of the first phalanx of the right hand, which had already existed some days, and upon which several unsuccessful attempts at reduction had been made. The dislocation was backwards, but the phalanges, instead of standing at a right angle with each other and with the metacarpal bone, as is usually the case, were in a straight line with each other and parallel with the metacarpal bone. Whether this phenomenon existed from the first, or was due to the efforts already made at reduction, I could not determine, but the same thing has been noticed occasionally by other surgeons. The first phalanx, moreover, instead of being placed directly behind the metacarpal bone, occupied a position upon its back a little to the radial side of the centre. During quite half an hour I made continued and varied attempts to reduce the bone, by extension, by forced dorsal flexion, and by pressing the upper end of the first phalanx in the direction of the joint while pressure was made against its lower end so as to bring it into dorsal flexion, and finally by calling to my aid the " puzzle" and chloroform, but all to no purpose. One week later I repeated these efforts, and with no better success. The parents peremptorily refused to allow me to cut the lateral ligaments or flexor tendons, so the bone remains unreduced. Surgical writers have recorded, from time to time, a great many similar cases, and it is asserted upon the authority of Bromfield, quoted by Hey, that the extending force has been increased to such an amount as to tear off the last phalanx without having succeeded in reducing the first; but while surgeons have united in their testimony as to the exceeding obstinacy of a large proportion of these dislocations, they are far from being agreed as to the source of the difficulty. Sir Astley Cooper finds a sufficient explanation in the six short and powerful muscles which are inserted into the first and last phalanx, and especially in the flexors. 1 Hey believes the resistance to be in the lateral ligaments between which the lower end of the metacarpal bone escapes and becomes imprisoned. Ballingall, Malgaigne, Erichsen, and Vidal (de Cassis) think the metacarpal bone is locked between the two heads of the flexor brevis, or rather between the opposing sets of muscles which centre in the sesamoid bones, as a button is fastened into a button-hole. Pailloux, Lawrie, Michel, Leva, Blechy, and Roser affirm that the anterior ligament being torn from one of its attachments falls between the joint surfaces and interposes an effectual obstacle to reduction. Dupuytren ascribes the difficulty to the altered relations of the lateral ligaments, which are naturally parallel to the axis of the metacarpal bone, but which are now placed at a right angle; to the spasm of the muscles, and to the shortness of the member, in consequence of which the force of extension has to be applied very near to the seat of the dislocation. Lisfranc found in an ancient luxa- 1 Lawrie, of Glasgow, says that Sir Astley in a conversation with him declared that the " sesamoid bones" were the sources of the difficulty. See Amer. Journ. Med. Sci., vol. xxii. p. 230, with observations and experiments by Lawrie. 600 OF FIRST PHALANGES OF THUMB AND FINGERS. tion the tendon of the long flexor so displaced inwards and entangled behind the extremity of the bone as to prevent reduction. Deville discovered in an autopsy a similar displacement of this tendon outwards. The modes of reduction practised and recommended by these different surgeons are as diversified and irreconcilable as their views of the mechanism and pathological anatomy of the accident. Sir Astley Cooper recommends that extension shall be made by bending the thumb toward the palm of the hand, to relax the flexor Fig. 243. Clove hitch. muscles as much as possible; and then, by fastening a clove hitch (Fig. 243), upon the first phalanx, previously covered with a piece of soft leather, the extension is to be continued, only inclining the thumb a little inwards toward the palm of the hand. If these means fail after having been continued a considerable length of time, he advises that a weight shall be suspended to the thumb, passing over a pulley. (Fig. 244.) Finally, in the event of the failure of this method also, Sir Astley thought that no further attempts should be made, and especially that no operation for the division of these parts is justifiable. i — o Lizars and Pirrie adopt the views of Sir Astley with little or no qualification. Sir Astley Cooper's method of reducing dislocations of the thumb, with pulleys. Charles Bell proposed flexing the joint, employing also at the same time pressure; and in obstinate cases he advised subcutaneous section of the lateral ligaments with a small knife, a method which has since been practised successfully by Liston, Bernhardt, Gibson, of Philadelphia, Parker, of New York, and others. Syme and Lizars justify the practice in certain cases. Hey declared that neither extension nor flexion was useful, but that the bones could be best brought into place by pressure alone. Roser, from his experiments upon the cadaver, concludes that the dislocated phalanx must first be bent forcibly backwards, or into the position termed by some writers dorsal flexion, so as to throw the head of the phalanx forwards upon the articulating surface of the metacarpal bone. Parker, of New York, in his notes to the American edition of Samuel Cooper's work, recommends the same procedure. 601 FIRST PHALANX OF THE THUMB BACKWARDS. Yidal (de Cassis) recommends also that the extension should be made first backwards, so as to increase the displacement of the first phalanx in this direction, and to throw forwards its articular surface in the direction of the articular surface of the metacarpal bone. This method, namely, dorsal flexion as the first and most essential part of the manoeuvre, seems to have met with more general approval than any other, and the following observations, made by the venerable Reuben D. Mussey, of Cincinnati, illustrate the general practice among American surgeons at this day. "I tilt the dislocated phalanx up until it stands upon its articulating end, place both forefingers so as to hold it in that position, and at the same time press against the distal extremity of the metacarpal bone, make firm pressure with the thumbs against the base of the dislocated phalanx, and slide it into its place, which can generally be accomplished with ease. " More than twenty-five years ago, the chairman of this committee, from attention to the mechanism of the metacarpo-phalangeal joint of the thumb, convinced himself that the principal impediment to the reduction of the first phalanx from backward displacement is the short flexor of the thumb, between the two portions of which (lying close together where they are fastened to the sesamoid bones) the head of the metacarpal bone has been thrust, the contracted part or neck of this bone lying firmly grasped by them. Fifteen years ago, a case occurred of this dislocation which he could not reduce in the ordinary way. A subcutaneous division of one of the heads of this muscle was made with an iris knife, and the reduction was accomplished with the greatest ease. " Last year, another case occurred, in which we failed of reduction by Dr. Crosby's method, which we believe to be the best, and the subcutaneous division of both heads of the muscle was made, and the reduction instantly effected. The punctures were covered with collodion, and the thumb supported by a splint. As the patient was intemperate, entire abstinence from liquor and the adoption of a light diet were enjoined. Neither pain nor inflammation followed, and a month afterwards the joint had free motion. After the intemperate and irregular habits were resumed, the joint in a few weeks was found anchylosed. In these cases, the knife, in the subcutaneous operation, was carried down to the metacarpal bone, so far behind its head as to preclude the possibility of mistaking the lateral ligaments for the muscles. The ligaments are very short and inserted close to the articular surfaces, and are probably, one or both, ruptured in this dislocation." 1 Dr. J. P. Batchelder, of New York, in a paper read before the New York Medical Association in 1856, says: " The surgeon should take the metacarpal portion of the dislocated thumb between the thumb and finger of one hand, and flex or force it as far as may be into the palm of the hand, for the purpose of relaxing the muscles connected with the proximal end of the phalanx, particularly the flexor brevis pollicis. He should then apply the end of the thumb of this hand against the 1 Mussey, Trans. Amer. Med. Assoc., vol. iii. 1850, p. 357. 39 602 OP FIRST PHALANGES OP THUMB AND FINGERS. displaced extremity of the dislocated phalanx, for the purpose of forcing it downwards, and at the same time grasp the displaced thumb with his other hand, and move it forcibly backwards and forwards, as in strongly forced flexion and extension, the pressure against the upper extremity of the first phalanx being kept up. In this way the dislocated bone may be made to descend, so as to be almost or quite on a line with the articulating surface of the metacarpal bone, when the thumb may be forcibly flexed, and, if it be not reduced, as forcibly extended, and brought backwards to a right angle with the metacarpal bone, when, if the downward pressure, with the thumb placed as before directed for that purpose, has been continued (which thumb, by maintaining its position, acts as a fulcrum, as well as by its pressure), the bone will slip into its place, and the reduction be effected in less time than has been spent in describing the process." 1 Six successive cases of treatment by this method are mentioned in the American Journal of Medical Sciences for April, 1858; one by Rickard, one by Morgan, two by Cutter, and two by Crosby. By those who have regarded extension as an important element in the reduction, various instruments have been devised for the purpose of obtaining a secure hold upon the dislocated member. Sir Astley Cooper, as we have already seen, recommended the sailor's clove hitch; 3 Lawrie advises that the thumb shall be thrust into the open handle of a large door key; 3 Charriere and Luer, of Paris, have each invented forceps, so constructed with fenestra and straps, as that when the blades are closed the member is held very firmly in its grasp. Richard J. Levis, of Philadelphia, recommends "a thin strip of hard wood, about ten inches in length, and one inch, or rather more, in width. (Fig. 245). Fig. 245. Levis's instrument for reduction of dislocations of fingers or the thumb. One end of the piece is perforated with six or eight holes. The opposite end is partly cut away, forming a projecting pin, and leaving a shoulder on each side of it. Toward this end of the strip, a sort of handle shape is given to it, so as to insure a secure grasp to the operator. Two pieces of strong tape or other material, about one yard in length, are prepared. One of these is passed through the holes at the end of the strip, leaving a loop on one side. The other tape is passed through another pair of holes, according as it may be a thumb or finger to which it is to be applied, or varied to suit the length of the finger, 1 Batchelder, New York Journ. Med., May, 1856, p. 340. 2 Op. cit., p. 561; also Bost. Med. and Surg. Journ., Oct. 1, 1857. 8 Lawrie, Am. Journ. Med. Sci., vol. xxii. p. 229. FIRST PHALANX OF THE THUMB BACKWARDS. 603 leaving a similar loop. If a dislocated thumb is to be acted on, the second tapes should be passed through the holes nearest the first. The ends of each separate tape are then tied together. *' To apply this apparatus, the finger is passed through the loops. (Fig. 246). The loop nearest the first joint is then tightened by drawing on Fig. 246. Levis's instrument applied to the first finger. the tape, which is then brought along the strip to the opposite end, across one of the shoulders, and secured by winding it firmly around the projecting pin. The other tape is tightened in a like manner, crossing the other shoulder, and winding around the pin in an opposite direction, when, for security, the ends of the tapes are finally tied together. 1 This apparatus enables the operator to apply both extension and flexion or leverage in any direction. The proximal end of the phalanx may be lifted, or even rotated so as to allow one side of the bone to approach the socket before the other. Malgaigne describes an apparatus invented by Kirchoff, which is very similar to, yet not quite so complete, as this of Levis. In the April number of the Buffalo Medical Journal, for 1847, I have described an instrument, or rather a toy, in my possession, which I suggested might be useful for the purpose of making extension upon dislocated fingers; and which, as will be seen by a reference to one of the cases already reported in this chapter, I have since applied successfully. It is made by the Indians, and may always be obtained during the watering season, at the Indian toy shops at Niagara Falls. The Indians call it a "puzzle" (Fig. 247), and know no other Fig. 247. Indian "puzzle," employed for the reduction of dislocations in small joints. use for it than to fasten it upon the thumb or finger of some victim, and then pull him about until he begs to be released. The "puzzle" is an elongated cone of about sixteen or eighteen inches in length, made of ash splittings, and braided; the open end of the cone being about three-fourths of an inch in diameter, and the 1 Levis, Amer. Journ. Med. Sci., Jan. 1857, p. 62 604 OF FIRST PHALANGES OF THUMB AND FINGERS. opposite end terminating in a braided cord. When applied to the finger, it is slipped on lightly, forming a cap to the extremity, and to half the length of the finger, but on traction being made from the opposite end, it fastens itself to the limb with a most uncompromising grasp. If constructed of appropriate size and of suitable materials, it becomes the more securely fastened in proportion as the extension is increased; yet, applying itself equally to all the surfaces, it inflicts the least possible pain and injury upon the limb. When we wish to remove it, we have only to cease pulling, and it drops off spontaneously. Dr. Holmes says that the same instrument is made by the Indians of Maine, and that several years ago Dr. Davis, of Portland, brought one to Boston, and showed it to the Society for Medical Improvement, suggesting that it might be used in the same manner which I have recommended. 1 Finally, in some compound dislocations it would be better not to attempt the reduction of the dislocation until resection has been practised. Samuel Cooper relates a case in which the reduction was followed by inflammation and death within a week after the accident, and Norris, of Philadelphia, mentions an instance which came under his observation, where violent inflammation and tetanus followed the reduction. 2 Boux, Evans, Wardrop, Grooch, Sir Astley Cooper, and many other surgeons, have practised resection successfully in these accidents, and have added their testimony in favor of this mode of procedure. § 2. Dislocations of the First Phalanx of the Thumb forwards. Up to the present moment, I have met with but two examples of this dislocation, while the backward dislocation has been seen by me five times. Horace Kneeland, of Rochester, N. Y., set. 24, dislocated the first phalanx of the right thumb forwards, by striking a man with his clenched fist; the force of the blow being received upon the back of the second joint of the thumb. The dislocation had existed three days when he called upon me, and in the meanwhile several attempts had been made to reduce the bone by simple extension. The first phalanx was in front of the metacarpal bone, and in the same plane; but the last phalanx was slightly inclined backwards. The hand was already swollen and quite painful. Seizing the dislocated thumb in the palm of my right hand, with my fingers resting upon the back of the patient's hand, I forced the two phalanges into flexion by firm and steady pressure continued for a few seconds, when suddenly the bones resumed their places, and all deformity disappeared. Intense inflammation resulted, followed, after a few days, by suppu- 1 Trans. Am. Med. Assoc., vol. i. p. 267. 8 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 16. 605 FIRST PHALANX OF THE THUMB FORWARDS. ration under the palmar fascia; and in the end the thumb was almost completely anchylosed. 1 On the 24th of April, 1855, J. M. Booth, of Buffalo, est. 19, called at my office, having a dislocation forwards of the first phalanx, occasioned, about half an hour before, by being thrown from a horse. The last two phalanges were neither flexed nor extended, but straight, and parallel with the metacarpal bone. By the same manoeuvre adopted in the preceding case, but with only very moderate force, the dislocation was promptly reduced. The usual causes of this accident are, falls or blows upon the thumb while it is flexed; and the symptoms which characterize it are, in general, such as we have seen in the two examples which have just been given. The metacarpal bone projects posteriorly, and the first phalanx produces a corresponding projection toward the palm; the two phalanges are extended upon each other, and parallel with the metacarpal bones. Nelaton saw a case in which the first phalanx was flexed about 45°; and in several examples it has been observed to be slightly rotated inwards. In the few examples of this accident which have been reported, the reduction was easily accomplished; or, at least, we may say that the difficulties in the way of reduction were not so great as they are usually found to be in dislocations backwards. Malgaigne has been able to collect but four undoubted examples, all of which were reduced ; Lenoir was able to effect the reduction by moderate measures, after the bone had been dislocated thirty-eight days. Ward succeeded by simple extension. 2 Lombard, after the trial of other plans, finally succeeded by reversing the phalanx. Employing, as we have before termed it, " dorsal flexion," with extension and lateral motion; but in all, or nearly all the other examples, the reduction has been effected by flexing the thumb forcibly toward the palm; the reverse of the method which we have seen preferred, especially by American surgeons, in dislocations backwards. My own experience also authorizes me to recommend this plan. § 3. Dislocations op the First Phalanx op the Fingers. The index and little fingers, owing to their exposed situations, are most liable to these dislocations. I have met with two examples of traumatic dislocations of these joints, one of which was a forward, and the other a backward luxation, and both had occurred in the index finger. James Nesbitt, of Buffalo, aet. 11, dislocated the index finger of the right hand, backwards, by a fall down a flight of stairs. On the same day, Feb. 11, 1851, he called upon me, and I found the finger neither flexed nor extended, but straight and immovable. The projections occasioned by the ends of the two bones were very marked, and such 1 Trans. N. Y. State Med. Soc, 1855, p. 73. 8 Ward, New York Med. Times, Sept. 8,1860. 606 PHALANGES OP THE THUMB AND FINGERS. as to render an error in the diagnosis impossible. Reduction was accomplished with great ease, by reversing the finger and employing moderate extension, while at the same time the proximal extremity of the first phalanx was pushed toward the distal end of the metacarpal bone. In short, the process was the same as that which we have recommended in dislocations of the thumb backwards. Fig. 248. Backward dislocation of first phalanx. Redaction by extension. In the example of dislocation forwards, occasioned by a blow from a hard ball, received upon the end of the finger, the first phalanx was in a position of extreme extension, and the second moderately flexed. Reduction was effected with great ease by extension in a straight line. But if the surgeon were to experience difficulty in the reduction, it would no doubt be advisable to resort to the method of extreme flexion. In one instance, I have seen nearly all the fingers of the left hand, and the thumb of the right dislocated backwards, by the contraction of the cicatrix after a severe burn. CHAPTER XV. DISLOCATIONS OF THE SECOND AND THIRD PHALANGES OF THE THUMB AND FINGERS. Notwithstanding slight differences in the form of the articulations between the thumb and fingers, and in the size and situation of the bones which compose the phalanges of the fingers, we are disposed, contrary to the practice of some other writers upon this subject, to consider all the dislocations to which these several joints are liable, under one section. Nor, indeed, after the attention which we have given to the dislocations at the metacarpo-phalangeal articulations, do we find much to add in relation to these accidents; since in almost every point of view in which they may be considered, they have so much in common. The last phalanx of the thumb is, of all the phalanges, most liable to dislocation, and this generally takes place backwards. Very 607 PHALANGES OF THE THUMB AND FINGERS. frequently, also, it is accompanied with such a laceration as to render it compound. The dislocated phalanx is usually reversed in the backward dislocation, and straight, or nearly so, in the forward dislocation. Reduction may be accomplished easily by forced dorsal flexion, in the case of the backward luxation, and by forced palmar flexion, in the case of the forward dislocation. In the winter of 1848, a young man was brought into my clinic, who had met with a forward subluxation of this phalanx about one month before. He had fallen upon the end of his thumb, and as the accident was followed by a good deal of inflammation and swelling, he did not notice the displacement until some time afterwards. The proximal end of the last phalanx projected two or three lines toward the palm; the finger was straight, and this joint anchylosed. I did not think the chance of restoring and maintaining the bone in position sufficient to warrant any interference, and he was dismissed with an assurance that after a few months it would occasion him no great inconvenience. On the 2d of March, 1851, Thomas Burton, aged about twenty-two years, by a fall dislocated the second phalanx of the middle finger of the right hand, backwards. The force of the concussion was received upon the extremity of the finger. Nine hours after the accident I found the bones unreduced; the finger nearly straight, or with only slight flexion of the second phalanx upon the first; the third phalanx forcibly straightened upon the second; all the joints rigid; finger very painful and somewhat swollen. By moderate extension alone, applied for a few seconds, the reduction was accomplished. Fig. 249. Dislocation of the second phalanx backwards. James Cooper, of this city, aat. 23, came to me on Sunday morning the 14th of Dec. 1851, to obtain counsel in relation to his finger which had been dislocated the day before, but which he had himself reduced by simple extension made in a straight line. His own account of it was, that he fell upon a slippery side-walk, striking upon the end of his ring finger in such a way that it seemed to double under him. On examination, he found the second bone dislocated inwards, or to the ulnar side, completely, the end of the first phalanx forming a broad projection upon the opposite side; the last two phalanges fell over toward the middle finger, but they were neither flexed nor extended. Seizing upon the end of the finger with his right hand and pulling forcibly, he promptly reduced the dislocation himself. 608 PHALANGES OP THE THUMB AND FINGERS. The bones were now completely in place, but the joints were swollen, tender, and quite stiff. In Sept. 1851, by the politeness of Dr. Briggs, the attending surgeon, I was permitted to see in the hospital of the New York State Prison, at Auburn, a forward dislocation of the second phalanx of the little finger of the left hand, unreduced. This man was at the date of my examination forty-one years old, and the dislocation had existed eighteen years; having been occasioned by a fall. A surgeon in Greene Co., N. Y., had attempted to reduce it soon after the dislocation occurred, but had failed. The joint was nearly anchylosed, yet the finger was quite as useful for all ordinary purposes as before. Fig. 250. Dislocation of the second phalanx forwards. Dislocation of the last phalanx is frequently occasioned in the game of base ball, by the ball being received upon the extremity of the finger. A young man who was studying medicine, and a private pupil of mine, in attempting to catch a very hard ball, received it upon the extremity of the middle finger of the left hand, dislocating the last phalanx forwards. Twenty minutes after the accident, I found the distal extremity of the second phalanx projecting backwards through the skin, the tendon of the extensor muscle being torn completely off from its point of attachment to the last phalanx. The last phalanx was in a position of slight dorsal flexion, or extreme extension. Seizing upon the extremity of the finger, I attempted to reduce the dislocation by direct traction, aided by pressure upon the exposed end of the second phalanx, but I was unable to succeed until I brought the last phalanx into a position of palmar flexion. A slight disposition to reluxation was manifested, and a guttapercha splint was therefore applied; and to prevent inflammation, the young man was directed to keep it moistened with cool water lotions. Only a moderate amount of inflammation followed, and in a few weeks the cure was complete. Such accidents, attended with laceration of the integuments, frequently demand amputation, or at least resection of the projecting bone, but we think Mr. Miller is scarcely right when he says that compound dislocations of the fingers almost always are of such severity as to demand amputation. I have myself met with two other cases which were reduced, and did well. 609 DISLOCATIONS OF THE THIGH. CHAPTER XVI. DISLOCATIONS OF THE THIGH (C OXO-FEMORAL). The femur is especially liable to dislocation in four directions, namely, upwards and backwards upon the dorsum ilii, upwards and backwards into the ischiatic notch, downwards and forwards into the foramen thyroideum, and upwards and forwards upon the pubes. Dislocations are occasionally met with which cannot be arranged properly under either of these divisions; indeed, it is scarcely necessary to say that the head of the bone may be thrown in almost every direction from its socket, upwards, downwards, inwards, and outwards, or in either of the diagonals between these lines; and that while in a vast majority of cases it will assume one of the positions first named, it may in a few exceptional examples fall short of, or much exceed the limits assigned in this division. Thus, we shall have occasion hereafter to mention examples of dislocation directly upwards, in which the head of the bone will be found resting upon the fossa between the upper margin of the acetabulum and the anterior inferior spinous process of the ilium, or still higher between the anterior superior and the anterior inferior spinous processes, or a little to the one side or to the other of these points. Examples will be shown of dislocations directly downwards, in which the head of the femur will rest upon the notch between the lower margin of the acetabulum and the tuber ischii, or still lower, and actually below the tuberosity, or downwards and backwards below the spine of the ischium, into the lower or lesser sacro-sciatic notch. The head may be thrust across the foramen thyroideum, and be only arrested in the perineum upon the ramus, or even beyond the ramus of the ischium and pubes; it may lodge upon the anterior surface of the body of the pubes, as well as upon its superior edge; and finally, it may rest against the posterior margin of the acetabulum instead of rising upon the dorsum, or it may only mount upon its margin, in either of the directions named. In regard to frequency, the four principal dislocations occur in the order in which we have mentioned them; thus, of 104 dislocations of the hip which I have taken the pains to collate, excluding the anomalous or extraordinary dislocations, and which my intelligent pupil, Mr. Frank Hodge, has carefully analyzed, 55 were upon the dorsum ilii, 28 into the great ischiatic notch, 13 upon the foramen thyroideum, and 8 upon the pubes. Chelius and Samuel Cooper have, however, reversed the order of the last two varieties, arranging dislocations upon the pubes, in the order of frequency, before dislocations into the foramen thyroideum. 610 DISLOCATIONS OF THE THIGH. Coxo-femoral dislocations may occur at any period of life; one example is mentioned, in the Gazette Medicate, of a recent dislocation upon the dorsum ilii, in a child eighteen months old. 1 Mr. Kirby has reported, in the Dublin Medical Press for October 26, 1842, a case of recent dislocation in the same direction, in a child of three years, 3 and Dr. Buchanan has seen another, at the same age, in a little girl; the dislocation being into the ischiatic notch. 3 Mr. Image communicated to the Suffolk branch of the Provincial Medical and Surgical Association, the case of a boy, three and a half years old, with a dislocation upon the dorsum ilii. It had existed twelve days when he was admitted to the Suffolk,Hospital in May, 1847, Mr. Image, in reporting this case to the Society, remarked that he had been induced to lay it before them, "in consequence of a charge having been urged against a neighboring surgeon, of pretending to reduce a dislocation of the femur on the dorsum ilii, in a child only four years old, that child being a pauper, and chargeable to the parish. It was agreed and proved by authorities that no such case was recorded, and therefore had not occurred, and that seven years old was the earliest period at which this accident had taken place." 4 J. M. Litten, of Austin, Texas, reports a case of dislocation upon the dorsum ilii, in a girl four years old, which he reduced by manipulation 4 In the Jan. No. for 1847 of the American Journal of Medical Sciences, is reported a forward dislocation in a boy aged 5 years, and a dislocation into the ischiatic notch in a girl of the same age. Dr. J. C. Warren, of Boston, met with an incomplete dislocation toward the foramen thyroideum, in a child six years old, which having been displaced eight or ten weeks, he was unable to reduce. 6 Sir Astley Cooper mentions a case in a girl seven year old. 7 I have myself met with two dislocations upon the dorsum ilii, which occurred at ten years, and one into the foramen thyroideum. 8 Norris reports a case at eleven years, 9 and Gibson at twelve. 10 On the other hand, Gauthier has seen a dislocation of the hip in a woman eighty-six years of age. 11 The large majority, however, occur between the fifteenth and forty-fifth years of life. From an analysis of eighty-four cases, we have obtained the following results:— Under 15 years 15 cases 15 to 30 " 32 « 30 to 45 " 29 " 45 to 60 " 7 " 60 to 85 " 1 case 1 New York Journ. Med., Nov. 1850, p. 416. 2 Amer. Journ. Med. Sci., vol. xxxi. p. 207, Jan. 1843. s Lond. Med.-Chir. Rev., Dec. 1828, p. 251. * New York Journ. Med., Sept. 1848, p. 281. 5 Ibid., March, 1852, p. 259. 6 Boston Med. and Surg. Journ., vol. xxiv. p. 220. 7 A. Cooper, on Disloc, Amer. ed. p. 83, case 27. 8 Buf. Med. Journ., vol. viii. p. 6. Trans. New York State Med. Soc, 1855. My Report on Disloc. 9 Amer. Journ. Med. Sci., Feb. 1839, p. 296. 10 Gibson's Surg., vol. i. p. 389. " Gauthier, Malgaigne, op. cit., p. 805. 611 UPWARDS AND BACKWARDS ON THE DORSUM ILII. The youngest being eighteen months old, the oldest sixty-two years, and the average thirty-four years. They are much more frequent in men than in women; owing, probably, to the greater exposure of the former to the accidents from which these dislocations usually result, and possibly, also, in some measure, to certain peculiarities in the form and structure of the neck of the femur in the male. Of one hundred and fifteen cases collected by me, one hundred and four were in males and eleven in females. Dr. J. K. Rodgers, of New York, mentioned, however, at a meeting of the New York Kappa Lambda Society, that he had seen and reduced four dislocations of the femur upon the dorsum ilii in females, and that a fifth case had recently come to his knowledge in the New York City Hospital. 1 Gibson mentions an example of dislocation of both thighs at the same moment. 2 § 1. Dislocations Upwards and Backwards on the Dorsum Ilii. Syn. —" Upwards on the dorsum ilii;" Sir A. Cooper, Miller, Pirrie. " Upwards and outwards ;" Boyer, Dupuytren. " Upwards and backwards upon the back of the hip bone;" Chelius. "Iliac;" Gerdy, Vidal (de Cassis), Malgaigne. Causes. —Generally they are occasioned by some violence which forces the thigh into a state of extreme adduction, or of adduction united with rotation inwards; and especially when at the same moment the head of the femur is driven upwards and backwards. Thus, a dislocation upon the dorsum may result from a fall from a height, when the force of the concussion is received upon the outside of the knee; the thigh being thus converted into a lever of the first kind, whose long arm is outside of the margin of the acetabulum; or the dislocation may be occasioned by a fall upon the foot or knee, while the limb is adducted, by which the head of the femur will be at the same moment driven upwards and outwards from its socket. The accident is equally liable to result from the fall of a heavy weight, such as a mass of earth, upon the back of the pelvis when the body is much bent forwards. The following case presents an extraordinary example of this form of dislocation, produced by a force acting upon the thigh as a lever of the first kind. t B., of Rochester, N. Y., eet. 10, fell, in Feb. 1841, from the top of the high bank just below the Genesee Falls, at Rochester, a distance of about one hundred feet. Before he reached the bottom of the precipice, he struck upon an oblique plane of ice, from which he slid gradually down upon the surface of the river, which was then completely frozen over. He did not lose his consciousness in the descent, nor after his arrest upon the river, but began immediately to call for assistance. He remembers very well that when he struck the glacier, the concussion was received upon the right side of the right knee, and a » J. K. Rodgers, New York Journ. Med., July, 1839, vol. i. First ser. p. 220. 2 Gibson's Surg., vol. i. p. 385. Sixth ed. 612 DISLOCATIONS OP THE THIGH. mark of contusion at this point confirmed his statement. Dr. Ellwood, of Rochester, assisted by myself, reduced the dislocation within one hour after its occurrence. We employed pulleys, but the reduction was accomplished easily in about two minutes, and without the application of much force; the bone resuming its place with an audible snap. His recovery was rapid and complete. 1 Pathological Anatomy. —The capsule is lacerated more or less extensively, but especially in its posterior half; the round ligament is Fig. 251. Dislocation upon the dorsum ilii. ruptured; some of the small external rotator muscles are generally stretched or torn completely asunder, the glutseus maximus, medius,and minimus are pushed upwards and folded upon each other, the head of the femur resting upon or within the fibres of the deeper muscles; the triceps adductor is put upon the stretch. Surgeons have not been agreed as to the cause of the great difficulty which has usually been experienced in the reduction of this and of all other forms of coxo-femoral dislocations. While some have ascribed it alone to the resistance of the muscles, others have with equal confidence, ascribed the opposition to an entanglement of the head and neck of the bone in the rent capsule; and still others believe that the impediment ought to be looked for sometimes in the muscles and sometimes in the capsule, or in both at the same moment. Sir Astley Cooper thought that the cap- sular ligament was generally too much torn to offer any impediment to reduction, and he refers to some dissections in confirmation of this opinion. Nathan Smith affirmed that the chief obstacle to reduction by extension was to be found in the resistance offered by the gluteii muscles, which, although at first relaxed, would soon become tense under the stimulus of the extension, and which, in order that the bone might resume its position, must actually be stretched considerably beyond their normal length. W. W. Reid declares that the sole resistance is at first in the abductors and rotators, but that finally the psoas magnus, iliacus internus, and triceps adductor become tense where the pulleys are employed. Dr. Fenner, of New Orleans, gives the particulars of a dissection of the hip of a man admitted into the Charity Hospital, who died from injuries received by the bursting of a steamboat boiler. His condition being considered hopeless, no attempt was made to reduce the dislocation. The limb was shortened one inch and a half, and the toes turned inwards. Extensive ecchymosis existed. On raising the glu- 1 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 613 UPWARDS AND BACKWARDS ON THE DORSUM ILII. taeus maximus and medius, the naked head of the femur was found lying on the dorsum ilii with the ligamentum teres hanging to it, but partially torn off. Portions of the obturator externus, pyriformis, and gemelli were ruptured and lacerated. The capsule was torn through one-half of its extent. Dr. Fenner now proceeded to cut away the muscles, and when, all the external muscles about the joint had been removed the thigh could not be brought down; the iliacus internus and psoas magnus were then severed, which permitted it to descend a little, but the head could not be replaced; the triceps adductor was then divided without effect. The ilio-femoral ligament was found tensely stretched. All the muscles between the pelvis and the thigh were then severed, and still it was impossible to reduce the dislocation; the head of the femur could not be forced back through the rent in the capsule from which it had escaped; and it was not until the opening was enlarged from one-half to three-quarters of an inch, that the reduction was accomplished. Dr. Fenner infers that the capsule possesses sufficient elasticity to allow the small head of the femur to pass out through a lacerated opening which might at once contract, so as to offer considerable resistance to its return, and that occasionally this is the true explanation of the difficulty in reduction. 1 Dr. Gunn, of Ann Arbor, Michigan, after repeated experiments made upon the dead body, concludes that the muscles offer no impediment whatever to the reduction, and that the " untorn portion of the capsular ligament, by binding down the head of the dislocated bone, prevents its ready return over the edge of the acetabulum to its place in the socket."* Dr. Moore, of Rochester, who has often repeated the same experiments upon the cadaver, declares also that in attempting to reduce the femur by extension alone he has constantly observed that the untorn portion of the capsule offered the main resistance, and that reduction could not be accomplished until this was more completely broken up ; 3 while Markoe, of New York, attributes the resistance to both the muscles and the capsule, but chiefly to the action of the former, especially the rotators. 4 The conclusion to which we ought to arrive seems to be that in some cases, the capsule being completely, or almost completely torn away, the muscles offer the only resistance; and that according to the exact position of the limb or degree of displacement, one or another set of muscular fibres will oppose the reduction; and in other cases, the muscles being paralyzed by the shock, or by anaesthetics, the partially torn capsule, into which the head of the bone is received as in a buttonhole, prevents its free return into the socket. Symptoms. —Sir Astley Cooper affirmed that the limb was sometimes found shortened in this dislocation, to the extent of three inches. Liston, B. Cooper, Gibson, and others repeat the affirmation. Chelius places the extreme of shortening at two and a half inches, Miller at 1 New York Journ. Med., Sept. 1848, p. 268 ; from New Orleans Med. and Surg. Journ., July, 1848. 2 Ibid., Nov. 1853, p. 423 et seq. 3 Ibid., July, 1855, p. 69. 4 Ibid., Jan. 1855. 614 DISLOCATIONS OF THE THIGH. two inches, while Malgaigne declares that he has never seen the limb shortened more than half an inch, and that in some cases it is not shortened at all, and the very opposite opinions entertained by other surgeons, he attributes to errors in the measurement. I am certain, however, that Malgaigne has fallen into some error, and that, while Fig. 252. Dislocation upon the dorsum ilii. the average shortening is about one inch or one inch and a half, it does occasionally reach three inches. The thigh is rotated inwards, adducted and slightly flexed upon the pelvis. The great toe of the dislocated limb, when the patient stands erect (and in this position the examination ought if possible to be made), rests upon the instep of the foot of the sound limb, and the knee touches the opposite thigh near the upper margin of the patella. It must not be supposed, however, that the position of the limb is in all cases precisely such as we have described. Indeed the degree of rotation, adduction, flexion, &c, will vary according as the head of the femur is more or less displaced, the capsule more or less torn, or as it may be torn in its upper or lower margins, as the muscles may be actually rent asunder, or only put upon the stretch, and perhaps also according to the amount of injury and consequent relaxation which they may have sustained from the shock. The thigh can be easily flexed; adduction is more difficult, but abduction is almost impossible, except to a very limited extent: the body of the patient is a little bent forwards; the roundness of the hip is lost in consequence of the relaxation of the gluteii muscles; the trochanter major is depressed, and approaches the anterior superior spinous process of the ilium, and if the patient is not fat, and swelling has not already taken place, the head of the femur may be felt in its new position rotating under the hand when the limb is turned inwards or outwards, but especially may it be felt when, by flexing or extending the limb, the head is made to move downwards and upwards, upon the dorsum ilii. As we have already said, this examination ought to be made, if possible, in the erect posture; after which, it will be well to place the UPWARDS AND BACKWARDS ON THE DORSUM ILII. 615 patient alternately upon his back, upon his sound side, and upon his belly, until the diagnosis is rendered complete. The differential diagnosis between dislocation upon the dorsum ilii and a fracture of the neck of the femur may be briefly stated as follows. In fracture, we may expect to find crepitus; the limb is in most cases mobile; the toes are generally turned out; the limb is shortened moderately or not all; the patient is sometimes able to walk for a short distance; fractures of the neck of the femur generally occur in advanced life. In dislocation, crepitus is not often present, and only when a fracture coexists ; the limb is immobile, or nearly so ; the toes are turned in; the limb is shortened more; the patient is unable to bear the weight of his body upon his foot for one moment. Skey, however, says he has seen a patient with a recent dislocation, who walked one-quarter of a mile, to the hospital. I do not think any other similar case is upon record. Dislocations of the femur generally occur in middle life. I have been frequently told by persons who have called upon me with children suffering under hip-disease, that they had been informed the hip was out, and they expected me to reduce it. In two or three instances they have blamed their surgeons very much, because they had not detected the accident at the time of its occurrence. Norris, of Philadelphia, mentions an extraordinary example of this kind, as having been presented at the Pennsylvania Hospital, and which ought to serve as a sufficient warning to prevent similar mistakes in future. A lad, twelve years old, was brought to the hospital from a neighboring State, who a short time previous had been suddenly attacked with lameness in his right limb, and which, by his friends, was attributed to some injury received in play. Two physicians, who had been called to see the boy, pronounced him to be laboring under dislocation of the hip, and had made two strong efforts with the pulleys, to reduce it; but after causing great suffering they gave up all hopes of ever replacing the bone, and sent him to Philadelphia. The symptoms were plainly those of hip-joint disease in its early stage. The attitude was that assumed by those laboring under this affection ; the leg seemed lengthened, but a careful measurement showed that it was of the same length with the other; the buttock was flattened and the motions of the joint tolerably free but painful. 1 If the supposed dislocation occurs in a child, or in a person under ten years of age, we ought to take especial pains to ascertain that it is not a separation of the epiphysis, of which accident we have mentioned some examples when speaking of fractures of the neck of the femur. Prognosis. —Boyer says the limb remains always weaker than the other, the round ligament never uniting completely; and that inflammation of the cartilages and synovial glands may ensue, ending in caries of the joint. Such results have, indeed, been occasionally met with, nor are examples wanting in which more rapid inflammation, resulting in the formation of acute abscesses, has followed, but these 1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 280. 616 DISLOCATIONS OF THE THIGH. are only rare accidents. In the large majority of cases the patients recover speedily, and in the course of a few weeks, or months at most, the limb seems to be as sound and as useful as before. Examples of non-reduction, however, from an error of diagnosis, or what is more pertinent to our present purpose, from a failure to accomplish the reduction where the attempt has been made, are numerous. Fortunately, Mr. Chelius, the author of a most excellent "System of Surgery" to which we have already had frequent occasion to refer, has sufficient reputation, the world over, to enable him to bear a portion of these failures, without injury to himself or to the profession which he so eminently adorns. We shall therefore make no apology for reporting the following unsuccessful attempt to reduce a dislocation of the hip in which Mr. Chelius himself was the operator. On the 11th of June, 1851, John Mauren, a German, aet. 19, called at my office and related as follows: " When ten years old, I fell from a tree, a height of six feet, and dislocated my left hip. I was then living twelve miles from Heidelberg, and I was immediately taken there, but I did not see Mr. Chelius until the next morning. He took me to the University, and, before the medical class, attempted to reduce it, but he could not. During several weeks following, he tried six times, using pulleys, &c, but he could never succeed." On examination I found the limb shortened two inches, the head of the femur lying upon the dorsum ilii; the knee was turned in, but the toes were inclined a little outwards. He was able to walk rapidly, of course with a manifest halt, yet without pain and discomfort. Treatment. —Regarding dislocations of the femur upon the dorsum ilii as the type of all the coxo-femoral dislocations, the remarks which we shall make under this section may be considered applicable, with only certain qualifications, to all the others. We shall arrange the various methods' of - reduction which have been employed by surgeons under two principal heads, namely, manipulation and extension. It is not possible, however, to classify rigidly the different procedures, so as to bring them under these two simple divisions without some violence; since neither manipulation nor .extension has usually been employed alone, but almost always some degree of extension has been recommended in connection with the manipulation; if not in the first instance, at least in the event of the failure of manipulation alone ; while on the other hand, extension is seldom if ever practised without manipulation. We intend then to imply by these designations respectively, that either manipulation or extension has constituted the prevailing feature in the treatment. Reduction by manipulation dates from the earliest records of our science. Says Hippocrates : " In some the thigh is reduced with no preparation, with slight extension directed by the hands, and with slight movement; and in some the reduction is effected by bending the limb at the joint, and making rotation." 1 Richard Wiseman, who wrote in 1676, speaks as follows: " If the thigh-bone be luxated inwards, and the patient young and of a tender 1 Works of Hippocrates, Syd. ed., vol. ii. p. 643. 617 UPWARDS AND BACKWARDS ON THE DORSUM ILII. constitution, it may be reduced by the hand of the chirurgeon, viz: he must lay one hand on the thigh, and the other on the patient's leg, and having somewhat extended it toward the sound leg, he must suddenly force the knee up toward the belly, and press back the head of the femur into its acetabulum, and it will snap in. For there is no need of so great extension in this kind of luxation; for the most considerable muscles being upon the stretch, the bowing of the knee as aforesaid reduceth it; yet in rough bodies it may require stronger extension. 1 Richard Boulton repeated, in 1713, almost the same instructions, affirming that this plan was applicable especially to dislocations inwards, in the case of "young and tender children." 2 In 1742 Daniel Turner declared that he had reduced three dislocations of the hip, one of which was a backward dislocation, by a method combining extension with manipulation, but alone "by the strength of the arm or without any other instrument." Extension and counterextension being made by assistants, and "as soon as the surgeon perceives the bone moving out," says Turner, "let him take his opportunity, giving orders to the extenders below suddenly to lift up the patient's thigh toward his belly, pressing with his hands, either to the right or left, as the situation of the same requires, and therewith force back its head toward the acetabulum, whereunto it will, flipping over the tip of the cartilage, snap sometimes with a loud noise." 3 Thomas Anderson, surgeon of Leith, in Scotland, was called, in Sept. 1772, to see a man who had dislocated his left femur into the foramen thyroideum. When he arrived four other surgeons were present, and prepared to use the pulleys, which they did in his presence several times, but to no purpose. After examining the limb carefully, " I was convinced," says Mr. Anderson, " that attempting the reduction in the common method, with the thigh extended, was improper, as the muscles were all put on the stretch, the action of which is, perhaps, sufficient to overbalance any extension we can apply. But by bringing the thigh to near a right angle with the trunk, by which the muscles would be greatly relaxed, I imagined that the reduction might more readily take place, and with much less extension. " When I made this examination, he was lying on a table on his back. I raised the thigh to about a right angle with the trunk, and, with my right hand at the ham, laid hold of the thigh, and made what extension I could. From this trial I found I could dislodge the head of the bone. At the same time that I did this, with my left hand at the head and inside of the thigh, I pressed it toward the acetabulum, while my right gave the femur a little circular turn, so as to bring the rotula inwards to its natural situation; and on the second attempt, it went in with a snap observable to the gentlemen standing around, but more so to the poor man, who instantly cried out he was well and free 1 Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King Charles II. London, 1676. Book vii. chap. viii. 2 A System of Rational and Practical Surgery. By Richard Bovlton. London, 1713, p. 346. ' 3 The Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 339. 40 618 DISLOCATIONS OF THE THIGH. from pain. His knees could then be brought together; the legs were of the same length, and the foot in its natural situation. The knees were kept together for some time, with a roller, to confine the motion of the thigh; and in three weeks he was at his work, without the least stiffness in the joint." Subsequently Mr. Anderson reduced by a similar method a dislocation upon the dorsum ilii in a child eight years old, and which had been out nineteen days. 1 Says Pouteau, in a memoir on dislocations of the thigh upwards and outwards: " "We observe then, first, that the thigh ought to be flexed to a right angle with the body during the extension and counterextension; second, that we ought to rotate the thigh from within outwards, when the extension appears to be sufficient; third, that this position puts into relaxation, as much as possible, the triceps and gluteal muscles which oppose the chief resistance to the extension, thus saving the patient from excessive pain; fourth, that the flexion of the thigh places the head of the bone in the best position for a return to the cotyloid cavity during extension; fifth, that feeble extension suffices for the reduction, because all of the muscles of the thigh are relaxed." 2 On the 7th of Jan. 1811, Dr. Philip Syng Physick, of Philadelphia, reduced an outward dislocation of the hip, after extension had failed, by flexing the thigh to a right angle with the body, and then giving to the limb " an outward circular sweep." 3 So early as 1815, and perhaps much earlier, Nathan Smith, Prof, of Surgery in the New Haven Medical College, taught that the only correct mode of reducing a dislocation upon the ilium was to flex the leg upon the thigh, the thigh upon the pelvis, and then to carry the limb diagonally to the opposite side, from whence it was to be brought outwards and downwards ; 4 and in 1824, Dr. Smith, being under oath, affirmed as follows: " I do not think that the mechanical powers, such as the wheel and axle, or the pulleys, are necessary to reduce a dislocated hip, or any other dislocation." He further adds that he once reduced a dislocation upon the dorsum ilii after he had pulled in every direction but the right, " by carrying the knee toward the patient's face." 5 Subsequently the son of Dr. Smith, Nathan R. Smith, the present distinguished teacher of surgery in the medical college at Baltimore, gave a more full account of his father's method, illustrating his views of the pathology of these dislocations, and the mechanism of their reduction by several drawings. It must be noticed, however, that Dr. Nathan Smith left no written explanation of his views and practice, except that which is to be found in the affidavit already quoted, and that the account published by his son is from memory, and it is 1 Anderson. Medical Commentaries, Edinburgh, 1776, vol. ii. pp. 261-4. 2 Vidal (de Cassis) ; from CEuvres posthumes de Pouteau, Paris, 1783. » Physick, Dorsey's Surg., 1813, vi. p. 242. Mem. of Nathan Smith, 1831, p. 172. Phelps' paper, in Trans. New York State Med. Soc, 1856, p. 169. * Trans. N. H. St. Med. Soc, 1854, p. 55. 5 Report of the Trial of an Action for Malpractice. Lowell v. Faxon and Hawks Machias, Maine, 1824; also Buff. Med. Journ., vol xiii. p. 515. 619 UPWARDS AND BACKWARDS ON THE DORSUM ILII. given as follows: " The patient being prepared for the operation by whatever means may be deemed necessary, may be placed in an attitude convenient for the operation, with the body securely fixed, by placing him in the horizontal posture, on a narrow table covered with blankets, and on the sound side. To the table his body should be firmly fixed, and this can be conveniently done by folding a sheet several times, lengthways—then applying the middle of the broad band thus made to the inner and upper part of the sound thigh— carrying its extremities under the table, crossing them beneath it, and then carrying them obliquely up and crossing them firmly over the trunk, above the injured hip. The ends may then be secured beneath the table. To support the trunk the more firmly, a pillow may be placed on each side of it upon the table, and be included in the bandage. Should the operator design to employ any degree of extension, a counter-extending band may be placed in the perineum, and carried up to the extremity of the table, be fixed to some more firm body, or held by the hands of assistants. " The operator now standing on the side to which the patient's back presents, grasps the knee of the dislocated member with his right hand (if the left femur be dislocated— vice versa, if the right), and the ankle with the left. The first effort which he makes is to flex the leg upon the thigh, in order to make the leg a lever with which he may operate on the thigh-bone. The next movement is a gentle rotation of the thigh outwards, by inclining the foot toward the ground, and rotating the knee outwards. Next the thigh is to be slightly abducted by pressing the knee directly outwards. Lastly, the surgeon freely flexes the thigh upon the pelvis by thrusting the knee upwards toward the face of the patient, and at the same moment the abduction is to be increased. " Professor N. Smith regarded the free flexion of the thigh upon the pelvis as a very important part of the compound movement. He believed that it threw the head of the bone downwards, behind the acetabulum, where the margin of the cup is less prominent, and over which, therefore, the adductor muscles would drag it with less difficulty into its place. " The operator may slightly vary these movements, as he increases them, so as to give some degree of rocking motion to the head of the os femoris, which will thereby be disengaged with the more facility from its confined situation among the muscles." 1 Dr. Luke Howe, of who was a pupil of Nathan Smith's, gives the following account of the method practised by him successfully, about the year 1820, and which method, he says, was recommended by his preceptor: " The patient was permitted to lie on his back on the bed where I found him, the knee of the luxated limb turned in and over the other. I raised the knee in the direction it inclined to take, which was toward the breast of the opposite side, 1 Medical and Surgical Memoirs, by Nathan Smith, late Prof, of Surgery, &c, in Yale College. Edited by Nathan R. Smith, Prof, of Surgery in Univ. of Maryland. Baltimore, 1831, pp. 163-182. 620 DISLOCATION'S OF THE THIGH. till the descent of the head of the bone gave an inclination of the knee outwards, when I made use of the leg, being at right angle with the thigh, as a lever to rotate the latter and turn the head of it inwards. It then readily returned to its socket, with an audible snap. Fig. 253. Nathan Smith's method of reduction by manipulation. (From Smith's "Memoirs.' ) During this operation, the two assistants who had been placed to make the lateral extension and counter-extension, if ultimately required, were directed to draw moderately at their towels. How much of the success of the operation is to be imputed to their extension, and the rotation of the thigh by the leg, I am unable to determine;. but as Dr. Smith succeeded without the aid of either, and as the head of the femur seemed to descend by an easy and natural process, I am inclined to believe that all that is necessary in such cases, is to elevate the knee, when the ilium, the muscles attached to it, and perhaps the ligaments, become the natural fulcrum, over which the thigh, as a lever, acts to bring the head down and inwards into the socket." 1 Kluge, in 1825, combined moderate extension with manipulation, by flexing both the leg and thigh, while at the same moment the thigh was abducted and the knee rotated inwards. 2 Wathman, in 1826, directed that in this dislocation the limb should be seized by the knee and ankle and slowly lifted forwards until it came to a right angle with the long axis of the body; when, if the outward " selftwisting of the thigh" occurs, " which cannot be prevented by fast 1 Howe, Boston Med. and Surg. Journ., vol. xxii. p. 249, May, 1840. 8 Chelius's Surg., by South, Amer. ed., vol. ii. p. 241. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 621 holding," the movement of the head of the bone is declared, and it will only remain for the surgeon to let down the thigh gradually upon the bed so that the two limbs will come side by side, and the reduction will be accomplished. 1 Rust recommended also, in 1826, a similar plan, combining moderate extension by the hands, with flexion and abduction of the thigh. 2 Colombat, whose opinions date from 1830, suggested that the patient should lay himself forwards upon a bed or a table no higher than his hips, with the sound leg and foot resting upon the floor, and that then the surgeon seizing the foot with one hand, so as to flex the leg, should, with the other hand, exercise a moderate degree of extension, and at the same time move the limb to the right or to the left, backwards and forwards, in order to disengage the head of the femur; and, finally, that he should communicate to the thigh a sudden movement of circular rotation, either from within outwards, or from without inwards, as the surgeon may choose. Collin states that, in 1833, he had reduced four dislocations of the hip by a method very similar to this recommended by Colombat. 4 Dr. William Ingalls, of Chelsea, Mass., reduced a compound dislocation of the femur, in which the head of the bone rested upon the pubes, after an unsuccessful attempt had been made to reduce it by extension. " An assistant, taking the ankle of the dislocated limb in his right hand, and placing his left in the ham, bent the leg at right angles upon the thigh, and the thigh upon the pelvis, then lifting with a power little more than sufficient to elevate the whole limb, he carried it to its greatest state of abduction, at the same time rotating the femur inwards while Dr. Ingalls passed his thumb through the wound, and pressing upon the head of the femur, directed it toward the acetabulum. At this moment he directed the limb to be forced toward its fellow, by which the reduction was effected with the greatest possible ease and elegance." 4 Similar methods of reduction, with only such slight variations as scarcely deserve a special notice, have been suggested and practised from time to time by Palletta, in 1818 ; 8 Desprez, in 1835 ; 7 Yial, in 1841 ; 8 Fischer, Mahr, and Clarke, in 1849. 9 In 1851, Dr. W. W. Reid, of Rochester, N. Y., published an account of the method practised by himself successfully in three cases of dislocation upon the dorsum ilii, the first of which dated from the year 1844. His method, as applied to a dislocation upon the dorsum ilii, consists in " flexing the leg upon the thigh, carrying the thigh over the sound one, upwards over the pelvis as high as the umbilicus, and then abducting and rotating it." 10 Dr. Markoe, of New York, adopts the same procedure, except that 1 Chelius's Surg, by South, Amer. ed. vol. ii. p. 240. 2 Ibid., p. 241, note by South. 1 Malgaigne, op. cit., vol. ii. p. 825. 4 Malgaigne, op. cit., p. 823. 5 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer. ed., 1852. 6 Chelius's Surg. ; note by South. ' Malgaigne. s Ibid. 9 Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1852. 10 Reid, Buf. Med. Journ., vol. vii., August, 1851, pp. 129-143. 622 DISLOCATIONS OF THE THIGH. when the limb has been sufficiently flexed and abducted, he directs that the limb shall be gradually brought down, and he affirms that it is during this last manoeuvre that he has usually found the bone resume its place in the socket. 1 Reduction by extension dates from a period equally early with reduction by manipulation. Hippocrates recommended, when other and gentler means had failed, to make extension and counter-extension; the extending bands being made fast above the knee and above the ankle, so as to distribute the points of pressure; and the counter-extending bands being secured around the chest under the armpits, and also, if thought necessary, in the perineum of the sound side. Fig. 254. Hippocrates's mode of reducing dislocations of the hip by extension. Among the methods recommended and practised by Hippocrates, was sitting across the upper round of a ladder with a weight attached to the thigh of the dislocated limb; or suspending the patient from a sort of gallows with the head downwards, and if the weight of the patient's own body proved insufficient, the surgeon might add his also; a method which Hippocrates characterizes as " a good, proper, and natural mode of reduction, and one which has something of display in it, if any one takes delight in such ostentatious modes of procedure." 3 With various modifications as to the position of the limb, and as to the points upon which the extending and counter-extending forces are to be applied, and with differently constructed appliances, surgeons have continued to employ extension down to this day. The great majority have regarded flexion of the thigh as essential to success; some holding the limb only slightly flexed, and others insisting that a flexion should be increased to a right angle with the body. The French surgeons, including Boyer and Vidal (de Cassis), prefer generally to apply the extending bands to the feet, in order that the muscles of the thigh may not be stimulated to contraction by the pressure of the bandages. Mr. Skey adopts the same method. Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 1 Markoe, New York Journ. Med., Jan. 1855. a Works of Hippocrates, Syd. ed., London, vol. ii. p. 641. 623 UPWARDS AND BACKWARDS ON THE DORSUM ILII. Pirrie, Erichsen, and the English surgeons generally, make fast the lacq above the knee. J. L. Petit and Duverney, among the French, and Dorsey, Gibson, with most of the American surgeons, recommend the same, but Gerdy seeks to multiply the points of application, and for this purpose secures the extending band to the whole length of the leg, and to a small portion of the thigh above the knee. The counter-extending bands are now almost universally made to operate against the perineum of the dislocated limb, but Roux, following the practice of Hippocrates, places it in the perineum of the sound limb. Gibson recommends the same practice. Lizars recommends that sometimes the reduction should be attempted by simply placing the heel in the perineum and making the extension with the hands, very much as Sir Astley Cooper advises us to proceed in dislocations of the humerus. Morgan and Cock, of Guy's Hospital, have reduced six cases of dislocation of the hip-joint by placing the foot between the thighs, so that it pressed against the upper part of the dislocated bone, and thrust it away from the pelvis; extension and rotation of the limb being made at the same time by assistants. 1 Three of these were examples of dislocation upon the dorsum ilii, two upon the pubes, and one into the foramen thyroideum; and most of them had occurred in weak or elderly persons. Ambrose Pare was among the first to recommend the use of pulleys for the reduction of dislocations. Most surgeons since his day have employed them for the purpose of making extension more energetic and steady, and that it might be longer continued. Sir Astley Cooper's plan of procedure is as follows:— The patient having been bled freely and the muscles still farther relaxed by nauseating doses of antimony and by the hot bath, he is to Fig. 255. Reduction of a dislocation on the dorsum ilii, by pulleys. be placed on his back upon a table of convenient height between two staples; a strong padded leathern girth or perineal band, constructed so as to receive the thigh and to press at the same moment against the perineum and the outer surface of the pelvis, is then applied and made fast to one of the staples situated behind the patient in the direction of 1 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. 624 DISLOCATIONS OF THE THIGH. the axis of the limb. A wetted linen roller is next to be tightly applied just above the knee, and upon this a leathern strap is to be buckled, having two short straps with rings at right angles with the circular part; or instead of this, a round towel made in the knot called the clove-hitch. The knee is to be slightly bent, but not quite to a right angle, and brought across the opposite thigh a little above the knee. The pulleys being now attached, the extension is to be commenced. A very simple and efficient mode of making the extension, if one has not the pulleys, is to employ for this purpose a small rope, the ends being tied together and the rope being then doubled upon itself once or twice, so as to make four or eight parallel cords. The opposite ends of this bundle of ropes being made fast to the limb and the Fig. 256. Reduction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.) staple, the extension is made by thrusting a stick through its centre and twisting it. I have several times had occasion to resort to this plan; and indeed it has been for some time known and practised among surgeons in this country, 1 having been first, according to Prof. Gilbert, introduced by Fahnestock, of Pittsburg, Pa. Jarvis's adjuster, to which I have already made allusion when speaking of dislocations of the humerus, has been often used with success in dislocations of the hip as well as in dislocations of the shoulder. 2 Its power is equal to that of the pulleys, while the direction of the force can be varied with much greater ease. The most serious objections to the instrument as employed for the reduction of dislocations, are its complexity and its expensiveness. Mr. Fergusson says that the Lancet for July 26, 1845, contains a 1 Gilbert, of Philadelphia. Note to Pirrie's Surg.; also Am. Journ. Med. Sci., vol. xxxv. April, 1845. 2 Crandall, Bost. Med. and Surg. Journ., vol. xxxix. p. 77 ; Atlee, Trans. Amer. Med. Assoc., vol. iii. 1850, p. 357. 625 UPWARDS AND BACKWARDS ON THE DORSUM ILII. description of a similar apparatus constructed by Coxeter at the suggestion of G. N. Eppsand L'Estrange, of Dublin, has invented Fig. 257. Jarvis's adjuster, applied for reduction of a dislocation of the hip. a " windlass" for making extension, with a " forceps" by which the extending power can be instantly disengaged. 2 Mr. Bloxham's " dislocation tourniquet" is also very simple, and Mr. Erichsen affirms Fig. 258. Bloxham's "dislocation tourniquet," applied for reduction of a dislocation on the pubes. that by it "any amount of extending force that may be required can be readily set up and maintained." 3 Sedillot, a French surgeon, has suggested that when pulleys are used, we should measure the exact power 1 Fergusson, 4th Amer. ed., p. 200. 2 Ibid., p. 198. 3 Erichsen, Amer. ed., 1858, p. 242. 626 DISLOCATIONS OF THE THIGH. employed in the reduction, by an ingeniously contrived apparatus called the dynamometer. 1 Such an instrument might occasionally be useful in preventing the application of excessive force, especially when the patient is under the influence of an anaesthetic. Finally, without attempting to determine the precise relative value of these different procedures, all of which claim for themselves the testimony of experience, we are prepared to admit that no one of them is without merit, and that each may in certain cases possess advantages over the others. Precisely what the cases are to which each individual method may be especially applicable, we believe it would be impossible to declare unless the cases were actually before us; and even then it would probably be found difficult to say which was the best until a fair trial of one or more, and a final success, had determined the question. The time has not yet arrived in which we may institute a rigid comparison between the relative merits of the two leading plans of reduction, manipulation, and extension, for while it is true that reduction by manipulation has been practised from the earliest day, it is equally true that extension has been generally preferred and practised by surgeons in all ages, and especially since Sir Astley Cooper gave his admirable instructions upon the method of applying extension and counter-extension. Indeed it was not until Dr. Reid, of Rochester, again called the attention of the profession to this subject, illustrating his views by the results of several successful experiments and by ingenious arguments, that reduction by manipulation could be said to have been fairly introduced as an established method of practice; a large majority of all the cases upon record of reduction by manipulation having been reported since the year 1851, the period of Dr. Reid's first communication to the Buffalo Medical Journal. The following summary of a paper prepared by myself, with the view of determining, if possible, the relative value of the two methods, and exhibiting an analysis of sixty-four cases in which manipulation was employed, will enable the reader to form some estimate of the difficulty in which this subject is involved; and if it does not actually decide a moot-point, it will at least demonstrate that the method by manipulation is not without its hazards. 2 Of forty-one cases in which the fact is stated, twenty-eight were reduced on the first attempt, seven on the second, four on the third, and two on the seventh. In seven examples the head of the femur has been thrown from one position to another upon the pelvis, travelling from the dorsum of the ilium to the ischiatic notch, and from thence to the foramen ovale; or directly from the dorsum to the foramen, and back again; or in other directions, according to the character of the original dislocation; in some instances these changes being made as often as seven times in succession. In the majority of cases no evil consequences seem to have followed upon these changes of position. 1 Amer. Journ. Med. Sci., vol. xv. p. 530. 2 Reduction of Dislocation of the Femur by Manipulation. By the Author. Buffalo Medical Journal, Nov. 1857; Feb., March, June, 1859. With tables constructed by my very intelligent pupil, Lucien Damaiuville. 627 UPWARDS AND BACKWARDS ON THE DORSUM ILII. One of my own cases will especially serve to show with what impunity sometimes these changes may be made. John Caswell, aet. 28, was admitted to the Buffalo Hospital of the Sisters of Charity on the 13th of January, 1858, with a dislocation of the left femur upon the dorsum ilii, which had occurred six days before. His own account of the accident was that he was standing at the bottom of a well, bent forwards until his body was at a right angle with his thighs, when a bucket holding five hundred pounds of earth fell upon his back and hips. No attempt had been made to reduce the dislocation. Five times in succession manipulation made by myself failed, leaving the head of the bone each time upon the dorsum ilii; the sixth attempt, made with the addition of moderate extension by the hands, threw the head into the foramen thyroideum. By reversing the movements, it was easily replaced upon the dorsum ilii. The seventh trial was made in the same manner, except that when I supposed the head of the bone to be opposite the lower margin of the socket I did not permit the limb to turn either outwards or inwards, but while lifting at the knee with my hands, with sufficient power to raise his hips from the table, I brought the limb down gradually to a line parallel with the opposite, and thus finally the reduction was accomplished. No pain or inflammation followed, and in two weeks he left the hospital; but whether he was able to walk or not at that time, I am unable to say. 1 In Markoe's paper published in the New York Journal for January, 1855, several similar cases are reported, in which the results have been equally fortunate; but the case mentioned as having been under the care of Dr. Post, of the New York Hospital, had a more serious termination. This patient, John Kelly, set. 21, had a dislocation into the ischiatic notch, and on the same day the reduction was attempted by manipulation. On the first trial the head of the bone was thrown into the foramen ovale; and, after having been moved backwards and forwards between these two points several times, it was finally carried directly from the foramen ovale into the socket by manual extension applied in the ordinary way, but without pulleys. " In this case," says Markoe, " the cure was very slow, and he left the hospital with some degree of pain and swelling about the joint. I learned that an abscess formed in or about the joint, which was opened, and when I saw him, a year after, there was every appearance of seated morbus coxarius." In Case 14, of Markoe's paper, the thigh was broken at the neck after manipulation had been employed, but while extension was being made by the hands, united with "a lifting outwards." Whether the fracture was due to the extension, or to the manipulation, seems not to 1 be clearly determined. The dislocation had existed seven weeks when this attempt at reduction was made. So far as I am able to say, these are all the examples in which a serious injury has been, with any propriety, charged to the manipulation. Assisted by my pupil, Mr. Hodge, I have also succeeded in collecting sixty-two cases of attempts at reduction by extension; a great 1 Buffalo Medical Journal, vol. xiii. p. 682. 628 DISLOCATIONS OF THE THIGH. majority of which, we find, were reduced in the first trials; but five oases of recent dislocation were not reduced until after several attempts had been made. In five cases the femur was broken. The first occurred in St. Thomas's Hospital, London. Ben. Whittenburg, aet. 40, was admitted Nov. 4, 1827, with a dislocation into the ischiatic notch, of twenty-two weeks' duration. After bleeding, &c, had been practised, an attempt was made to reduce the bone by pulleys, in which the reporter professes to believe they were successful, but on the following day it was plainly enough not in place. Mr. Travers again resorted to extension, and while extension was kept up and the assistants were rotating the limb outwards, the neck of the femur gave way. 1 Malgaigne mentions a case in which, while he was himself directing the operation, the thigh was broken through its lower third. He was attempting to reduce the bone by extension, but it was not until he gave the signal for rotation outwards that the bone gave way. 3 Gibson says that Dr. Physick, at the Pennsylvania Hospital, while engaged in reducing a dislocated thigh by the pulleys, broke the femur in consequence of exerting too much force upon it in a lateral direction by an additional pulley; and that a similar accident is supposed to have happened to Drs. Harris and Randolph in the same hospital, in the year 1838, while using the pulleys upon a boy twelve years of age; for during extension and counter-extension, at the moment of rotating the limb, and of drawing it forcibly outwards by a towel, a sudden crack was heard. 3 The fifth case is related by Sir Astley Cooper, as having occurred at the Brighton Hospital, under the care of Mr. Gwynne; the dislocation was upon the dorsum ilii, and was supposed to have existed about one month. The neck of the femur was broken in the first attempt at reduction, and while the surgeon was making extension, with gentle rotation. 4 Sir Astley says: "There are plenty of cases upon record, of fatal abscesses from violent attempts at the reduction of dislocated hips." We presume that this remark has reference to attempts at reduction by extension, since, in his day, this was almost the only mode in use among surgeons. He adds, moreover, that Mr. Skey has mentioned, in the Lancet, 5 a fatal case of phlebitis following protracted extension of the hip. Malgaigne has collected no less than eight similar examples, with several more in which serious consequences and even death followed promptly upon violent attempts at reduction by mechanical means. 0 The head of the bone has been repeatedly thrown from the dorsum ilii into the ischiatic notch, and B. Cooper mentions a case in which the bone was carried from the foramen ovale into the ischiatic notch, from which latter position it could not afterwards be changed. 7 1 London Med.-Chir. Rev., Nov. 1828,p. 239. 2 Malgaigne, op. cit., vol. ii. pp. 146 and 830. 3 Gibson's Surgery, sixth ed., vol. i. p. 389. 4 Sir Astley Cooper on Disloc, &c, Amer. ed.,p. 88. 6 Op. cit., vol. i. p. 767, 1840-41. Cooper on Disloc, p. 69. 6 Malgaigne, op. cit., vol. ii. p. 164 et seq. 7 Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 629 UPWARDS AND BACKWARDS ON THE DORSUM ILII. As to the relative chances of failure by the two methods, the testimony of the recorded cases is equally unsatisfactory. Of the failures by extension, the experience of almost every surgeon, the journals and the treatises furnish a sufficient number of examples; while among the sixty-four cases of attempts at reduction by manipulation collected by me, and excepting the cases in which the bone was broken, only two were positive failures. It is somewhat remarkable, however, that these two cases occurred in the experience of the New York City Hospital; and that they are taken from a total of fifteen, this being the whole number which had been treated by this method at the date of these observations, in the New York Hospital. One had existed one month, and after repeated trials by manipulation and frequent changes of position, it was finally reduced by pulleys. The other, a dislocation into the ischiatic notch, had existed only a few hours. At least seven or eight trials were made to accomplish the reduction by manipulation, but without success. The first attempt by extension failed also, but in the second attempt the femur was kept at a right angle with the body, and the bone was soon brought into its socket. 1 We have in these two examples, not only a record of failure by manipulation, but an equal record of success by extension; while, on the other hand, we find in an analysis of the sixty-four cases, sixteen triumphs of manipulation over extension. We must not omit to mention, in order that the reader may form a just estimate of the value of these statistics, that the great majority, especially of the cases treated by manipulation, have occurred in private practice, and it is unnecessary to say that such statistics do not furnish the most reliable basis for conclusions. As a general rule, unsuccessful cases are not published by private practitioners, but successful cases are pretty certain to be made known; while, on the other hand, a series of cases furnished by any single hospital will generally be found to have given both unsuccessful and successful cases. The writer has heard lately of a complete failure to reduce by manipulation in a recent luxation of the hip, after repeated efforts on several successive days, and where skilful surgeons were in attendance; but it is believed that no account of the result has been published. We have already called attention to the fact, that in the New York City Hospital, two of the fifteen cases reported were failures; a circumstance of remarkable significance, especially when we consider the skill of the several gentlemen who were the operators in these cases ; and it plainly renders a new series of statistics necessary, drawn solely from the experience of one or more similar large establishments, before we shall be prepared to decide positively upon the relative value of the two procedures. Nevertheless, we shall not hesitate to express our present convictions upon this subject, reserving to ourselves the right of a change of opinion whenever the proofs shall warrant it. Manipulation, owing to the great power which may be brought to bear upon the neck and head of the bone through the action of the 1 Van Buren, New York Med. Times, Jan. 1856, p. 126. 630 DISLOCATIONS OF THE THIGH. shaft of the femur as a lever, is most liable to throw the head of the bone into new positions, and consequently most liable to rupture the various soft tissues about the joint, to produce inflammation, suppuration, and caries. For the same reason it is most liable, also, to fracture the neck of the femur. It is not certain in our mind but that, when the principles which control the reduction are more completely understood, these evils may be lessened; yet we can scarcely persuade ourselves that by any future observations, the state of the question will ever be greatly changed. "We cannot but think, also, that some conclusions ought to be drawn from the circumstance that, since the time of Hippocrates to the present day, manipulation has been occasionally recommended and successful examples reported; the reduction being accomplished in most instances by processes identical, or nearly so, with those now adopted; yet generally the writers appear to have been ignorant of what had been done before, and, indeed, they have generally avowed their belief that the method suggested by themselves was altogether new and original. Possibly, this slowness to establish, and total inability to sustain and perpetuate a reputation, was not the fault of the method, and had no relation to its failures. Until within a few years, the number of surgical books, and especially of medical journals, was comparatively very small, so that valuable truths often died with their discoverers, or were known and remembered only by a few; but it is possible, also, that it has a deeper significance, and that it implies some defect in the procedure, or serious danger, in consequence of which it has from time to time lapsed into desuetude and finally into complete oblivion. The rules which the author would give for the employment of manipulation are very simple. The patient being laid on his back upon a mattress, the surgeon, assuming that it is a dislocation upon the dorsum ilii, should seize the foot with one hand and the other he should place under the knee; then, flexing the leg upon the thigh, the knee is to be carefully lifted toward the face of the patient, until it meets with some resistance; it must then be moved outwards and slightly rotated in the same direction until resistance is again encountered, when it must be gradually brought downwards again to the bed. We do not know that the whole process could be expressed in simpler or more intelligible terms, than to say, that the limb should follow constantly its own inclinations. All writers have united in the necessity of flexion; and, indeed, with very few exceptions, the advocates of extension have insisted upon carrying the dislocated limb more or less across the sound one; they have also been nearly unanimous in their statements that the thigh should then be abducted and finally brought down. Nathan Smith has added the injunction to rotate the shaft of the femur outwards, and to press gently upon the inside of the knee while the thigh is being flexed upon the body, so as to compel the head of the bone to hug the outer margin of the acetabulum and to prevent its falling into the ischiatic notch; a suggestion which has been erroneously interpreted by some writers to mean that he would carry up the limb 631 UPWARDS AND BACKWARDS ON THE DORSUM ILII. abducted, a thing which is simply impossible until the reduction is accomplished. In adopting this practice, however, we must not forget the danger which we incur when the limb is completely flexed, and the head of the femur is below the edge of the acetabulum, of throwing it over into the foramen ovale. Dr. Nathan Smith has also noticed the advantage which sometimes may be gained by giving to the limb at this moment a slight rocking motion. These movements of the limb, with perhaps other slight modifications, such as lifting the knee moderately when the bone refuses to mount over the margin of the acetabulum, pressing with the hand upon the head of the bone, &c, are all which have been usually practised in successful manipulation. We repeat, however, that as a general rule, the knee must be carried only in those directions which offer no resistance, and these will be found almost always to be the same; the knee of the dislocated femur hanging over the sound one will be made easily to ascend to about a right angle with the body, we can then carry it outwards a short distance, probably not more than four or five degrees; at this moment, frequently the thigh will begin to rotate outwards of itself, and with considerable force, or as Wathman says, " a self-twisting of the thigh occurs which cannot be prevented by fast holding." When this action takes place the reduction is immediately accomplished; and it is in fact at this moment, before the limb begins to descend, that the bone most frequently resumes its socket. If it does not, then as soon as the limb begins to fall the reduction occurs; generally with a loud snap. It is pretty certain that this manipulation is to fail if the knee has descended more than a few inches without the reduction having taken place; and it will be better to repeat the manoeuvre at once, rather than to bring the limb completely down. Generally anaesthetics ought not to be employed, since the operation, if successful, is not usually painful, and we need that the patient should preserve his consciousness in order to admonish us when we are using improper violence. It is probable, also, that the action of certain muscles sometimes affords material assistance in the reduction. If, however, the patient is very sensitive, or the parts about the joint are very tender, or manipulation without anaesthetics has failed, then certainly these agents may be properly and advantageously employed. If we propose to attempt reduction by extension, it is no longer necessary to resort to the lancet, antimony, and the hot bath, as preliminary measures, since the muscles can be at once overcome by the much more certain and more powerful agents, chloroform, ether, &c. The patient is therefore to be placed at once upon a bed of suitable height, reclining on his back, but partly over upon the sound side. Observing now the line of the axis of the dislocated thigh, one strong staple is to be secured into the wall upon one side of the room, and another upon the opposite side, both of which shall correspond as nearly as possible with the line of the shaft of the femur. The staple in front of the body will be higher than the bed, and the staple behind will be, in the same proportion, lower than the bed. The limb being stripped, two pieces of strong factory cloth, each about four inches 632 DISLOCATIONS OF THE THIGH. wide and two feet long, should be laid parallel with and on each side of the limb; the centre of each strip being about opposite that portion of the thigh which is just above the two condyles. Over the centre of these strips, above the condyles and patella, a strong roller, three inches wide and at least three yards long, previously wetted in water, is to be turned as tightly as it can be drawn until the whole roller is exhausted; the extremity of the roller being made fast with a needle and thread rather than with pins. The upper ends of the side strips are then to be brought down and tied to the lower ends, forming thus two lateral loops upon which one of the hooks of the compound pulleys is to be made fast, while the other hook is secured to the front staple in the wall. Instead of these rollers we may employ, if we choose, a leathern thigh belt. (Fig. 259). For the purpose of counter-extension a sheet is folded diagonally, and its centre being applied to the perineum of the dislocated limb, the ends are tied firmly into the back staple. To prevent the body from moving laterally, under the action of the pulleys, one assistant should be seated upon the bed, with his back against Fig. 259. Reduction of dislocation upwards and backwards upon the dorsum ilii, by the pulleys and thigh belt. the side and back of the patient, and his right arm thrown over the body ; it is well also to station another beside the sound limb, so as to retain it also in its place upon the bed. Underneath the upper part of the dislocated limb a strong and broad bandage should be placed, of sufficient length to tie over the neck of the surgeon when he is standing about half bent over the body of the patient. Everything being arranged, and all portions of the apparatus having been sufficiently tested to make sure that nothing will give way during the operation, the anaesthetic is to be administered, and as the patient falls gradually under its influence, the action of the pulleys should commence, and be slowly but steadily increased, a third assistant managing the rope, so as to leave the surgeon unembarrassed, and able to direct his whole attention to the position of the trochanter major and of the head of the femur. In order to this, he should place one hand upon each of these prominences, and watch carefully their descent. The length of time which will be required to bring down the limb 633 UPWARDS AND BACKWARDS ON THE DORSUM ILII. must differ greatly in different persons, according to the peculiar circumstances of the case, and the condition, age, &c, of the patient; but it must never be forgotten that a slow and steady action is much more effective than rapid and irregular tractions, and it is in this especially, rather than in the relative amount of power, that the pulleys possess always so great an advantage over the hands. When the surgeon finds that the head of the bone has nearly or quite reached the socket, if it does not take its place spontaneously, he may place his neck in the noose which passes underneath the thigh, and lift upwards, in order to raise the trochanter major, and thus enable the head to rotate toward the acetabulum. It is in this part of the manoeuvre, and especially when at the same moment one of the assistants, after bending the leg upon the thigh so as to make of it a lever, has rotated the thigh outwards, that the fracture of the neck has generally taken place; and we cannot be too cautious, therefore, particularly in old persons, not to bear very strongly upon the noose, nor to permit the assistant to rotate outwards with great force. If the bone does not enter the socket, we may increase or diminish the flexion, or suddenly release the tension, or, in fine, again resort to manipulation alone. When the reduction is accomplished, the patient should be laid upon his back, with the knees resting over a pillow, and tied together lightly with a towel or a strip of cotton cloth. In order also the more certainly to prevent a reluxation, the thigh of the dislocated limb should be gently rotated outwards, by which the head will be pressed forwards against the anterior portion of the capsule. Such an accident, however, as a recurrence of the dislocation, in the case of the femur, is exceedingly rare; and I should have deemed it altogether impossible, except as the result of considerable violence again applied, had not at least two examples been reported to us upon very excellent authority. Malgaigne says he has himself seen an example of reluxation upon the dorsum ilii, occasioned by an untimely movement ;* and Verneuil has seen, six days after the reduction of a dislocation upon the ischiatic notch, the dislocation reproduced by a sudden effort of the patient to sit up. 2 Of course, in these remarks we mean to except those cases in which the upper margin of the acetabulum is broken and the head of the femur has consequently lost its natural support in this direction. Sir Astley Cooper mentions the case of a man who could throw out the head of the thigh bone from the acetabulum at pleasure, and reduce it with equal facility. A similar case is alluded to by Samuel Cooper, 3 and another is related in an inaugural essay by Dr. Lewis, of North Carolina, who graduated at the University of Pennsylvania in These are only examples of extraordinary relaxation and extension of the capsular ligament. 1 Malgaigne, op. cit., torn. ii. p. 830. 2 Ibid., p. 840. 3 S. Cooper's First Lines, vol. ii. p. 386, Amer. ed., 1844. 4 Gibson's Surgery, vol. i. p. 387, 6th ed. 41 634 DISLOCATIONS OF THE THIGH. § 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch. Syn. —"Upwards and backwards into the ischiatic notch;" Sir A. Cooper. "Upwards and backwards into the great sacro-sciatic notch ;" Lizars. " Backwards into the sacro-sciatic foramen ;" S. Cooper. " Backwards into the ischiatic notch ;" Liston, B. Cooper, Miller, Pirrie, Erichsen, Skey, Gibson. "Downwards and outwards on the os ischium ;" Boyer, Dorsey. " Backwards and downwards into the ischiatic notch;" Chelius, Petit, Duverney. " Upon the ischium ;" Bertrandi. " Sacro-sciatic ;" Gerdy. " Ischiatic;" Malgaigne. Boyer considers this dislocation as only secondary npon a dislocation upon the dorsum ilii; but it is very certain that it often occurs Fig. 260. Dislocation upwards and backwards into the great ischiatic notch. (From A. Cooper.) as a primary accident. Not unfrequently, also, what was primarily a dislocation into the ischiatic notch, becomes subsequently a dislocation upon the dorsum ilii. Causes. —A fall upon the foot or knee, when the limb is very much in advance of the body; or the fall of a heavy weight upon the back and pelvis when the thigh is nearly, or quite at a right angle with the body. Indeed the causes are very similar to those which produce dislocations upon the dorsum ilii, except that it is necessary to suppose the limb in a position more nearly at a right angle with the trunk, at the moment in which the force is applied. Pathological Anatomy. —Mr. Syme, who dissected the body of a man recently dead, whose thigh had been dislocated into the ischiatic notch, found the glutseus maximus nearly torn asunder, the head of the femur being imbedded in its substance; the glutaeus minimus, the pyriformis, and the gemellus superior lacerated; the capsular ligament extensively torn close to the edge of the acetabulum, and the round ligament completely separated from the femur. The head of the femur was lying in the great ischiatic notch, upon the gemelli and the sacro-sciatic nerve, behind the acetabulum and a little above it; being situated between the upper margin of the notch, and the great sacro-sciatic ligaments. 1 Figure 260 is a representation of this specimen. Symptoms. —The position of the limb is in some cases nearly the same as in certain dislocations upon the dorsum. It is shortened usually about a half an inch, the thigh being flexed upon the body, adducted and rotated inwards; but the flexion is usually less than in dislocations upon the dorsum, while on the other hand, it is sometimes 1 Amer. Journ. Med. Sci., vol. xxxii. p. 460. 635 UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. much greater. Generally it is such that when the patient is standing the end of the great toe of the dislocated limb touches the ball of the great toe of the sound limb. The head of the femur may also often be distinctly felt in its new position, especially when the limb is moved upwards or downwards. The trochanter major is approximated to- ward the anterior superior spinous process of the ilium. Sir Astley Cooper remarks that this dislocation is the most difficult to detect and to reduce, and Mr. Syme mentions a case in which the nature of the accident was overlooked by himself, and the thigh was not reduced until the thirteenth day; 1 and subsequently Mr. Syme has called attention to what he considers as one of the most important diagnostic marks; indeed, he says it is never absent, nor is it ever met with in any other injury of the hip-joint, "whether dislocation, fracture, or bruise;" this is "an arched form of the lumbar part of the spine, which cannot be straightened so long as the thigh is straight, or on a line with the patient's trunk. When the limb is raised or bent upwards upon the pelvis, the back rests flat upon the bed; but so soon as the limb is allowed to descend, the back becomes arched as before." 2 This Fig. 261. Dislocation upwards and backwards, into the great ischiatic notch. position, assumed by the back when an attempt is made to straighten and depress the limb, is due to the action of the psoas magnus and iliacus internus. But in addition to this valuable sign, the inversion of the toes, immobility of the limb, and the absence of crepitus, are 1 Amer. Journ. Med. Sci., vol. xviii. p. 242. 2 Amer. Journ. of Med. Sci., Oct. 1843, p. 461, from Lond. and Edinb. Month. Journ., July, 1843. 636 DISLOCATIONS OF THE THIGH. generally sufficient in themselves to distinguish it from a fracture of the neck. Dr. Squires, of Elmira, N. Y., in a note addressed to me in March, 1860, suggests, also, that in ancient cases the projection of the head of the femur may be felt by passing the finger into the rectum or vagina. Prognosis. —I have seen one dislocation of this character which was not recognized by the surgeon at the time of the receipt of the injury, nor for some weeks afterwards. This was in a lad twelve years old, who was brought to me from an adjacent county in August, 1847. The accident had happened eight weeks before. His limb was shortened one inch; it was also forcibly adducted and rotated inwards. Dr. Colegrove, a very excellent surgeon, practising near the city, had made a thorough attempt to reduce the dislocation with pulleys a few days before he was brought to me, and I did not deem it advisable to subject him again to the trial. Notwithstanding the dislocation his limb was quite useful. Treatment. —In employing manipulation, we may follow, with only a slight modification, the directions already given in dislocations upon the dorsum ilii. We find the head of the femur lower, consequently the extent of the circuit to be described in the manoeuvre is diminished, but in other respects the processes are identical. We must not forget, however, that there is especial danger, while attempting to reduce this dislocation by manipulation, that the head of the bone will be thrown across into the foramen thyroideum. I have already mentioned one case occurring under the care of Dr. Post in the New York Hospital, in which the head of the femur, originally in the ischiatic notch, passed backwards and forwards between the ischiatic notch and the foramen ovale many times, and which, although the reduction was finally accomplished, was followed by morbus coxarius. Parker mentions a second case in the same paper, 1 in which his first attempt to reduce by manipulation carried the head of the bone into the foramen ovale; but the second attempt was successful. Malgaigne refers to a patient of Lenoir's, and to another of his own, in which the head of the bone was lodged under the margin of the acetabulum during the attempts at reduction. 2 On the 23d of March, 1855, Charles McCorrnick, aet. 21, a laborer on the "State Line Eailroad," was caught between two cars, with his back resting against one car, and his right knee against the other, the right thigh being raised to a right angle with his body. As the cars came together he felt a " cracking" at his hip-joint, and found himself immediately unable to walk or stand. Two hours after the accident, assisted by my son Theodore, and Austin Flint, Jr., I examined the limb carefully, and made arrangements for the reduction with the pulleys, in case the attempt by mani-pulation should fail. The patient lying upon his back, I seized the right leg and thigh with my hands, the leg being moderately flexed upon the thigh, and 1 Markoe's Paper, N. Y. Journ. of Med., Jan. 1855. 2 Malgaigne, op. cit., torn. ii. p. 839. UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 637 carried the knee slowly up toward the belly, until it had approached within twelve or fifteen inches, when noticing a slight resistance to further progress in this directioD, I carried the knee across the body outwards, until I again encountered a slight resistance, and immediately I began to allow the limb to descend. At this moment a sudden slip or snap occurred near the joint, and I supposed reduction was accomplished ; but on bringing the limb down completely, I found it was still in the ischiatic notch. I think the head had slipped off from the lower lip of the acetabulum, after having been gradually lifted upon it. Without delay I commenced to repeat the manipulation, and in precisely the same manner. Again, at the same point, when the limb was just beginning to descend, a much more distinct sensation of slipping was felt, and on dropping the limb it was found to be in place and in form, with all its mobility completely restored. No anaesthetic was employed, and no person supported the body or interfered in any way to assist in the reduction. No outcry was made by the patient, yet he informed me that the manipulation hurt him considerably. The amount of force employed by myself was just sufficient to lift the limb, and the time occupied in the whole procedure was only a few seconds. Fig. 262. Reduction of dislocation upwards and backwards into the great ischiatic notch, by extension After the reduction he remained upon his back, in bed, eleven days, in pursuance of my instructions. At the end of this time he began to walk about, but was unable to resume work until after eight weeks or more. It is probable that he could have walked immediately after 638 DISLOCATIONS OF THE THIGH. the reduction, without much, if any inconvenience, so trivial was the inflammation which resulted from the accident. He never complained of pain, but only of a slight soreness back of the trochanter major, near the head of the bone. This soreness continued several weeks, and was especially present when he bent forwards. After the lapse of four months, when I last saw him, he occasionally felt a pain at this point in stooping, but the motions of the joint were free; he walked rapidly and without halt. If the reduction is attempted by extension, we ought to remember that the head of the bone lies more behind than above the socket, and that it is not requisite to carry it downwards so much as forwards; and especially that it must mount over the most elevated margin of the socket, in order to resume its position. The extension ought, therefore, to be made at an angle of 45°; and if this is not alone sufficient, the head of the bone should be lifted by a jack-towel upwards and in the direction of the socket. Bransby Cooper thought that the limb should be flexed quite to a right angle whilst the extension was being made; but this can only be necessary when the head of the bone is dislocated directly backwards. Care must be taken that the counter-extending band does not slide off from the pelvis, toward the upper part of the thigh, as it is constantly disposed to do, when the limb is so much flexed. This disposition may be restrained, in some measure, by attaching to the counter-extending band another band which shall pass off from the first at a right angle, and embrace the pelvis upon the opposite or sound side. Dr. Annan, of Baltimore, believes that the great difficulty which surgeons have experienced in their attempts to reduce this dislocation, has arisen from this malposition of the counter-extending band; and, as he has been unable to prevent its sliding off from the pelvis where the method of Sir Astley Cooper has been tried, he suggests the following plan: The patient is to be placed upon his face on a table; the pelvis secured by a band passing around it, and going off laterally at right angles from the sound side, to be fastened to a post or a ring fixed in the wall; another band is to be put around the upper part of the thigh of the injured limb, which should be given to the assistants, or attached to the pulleys, in case they are to be employed; this band also acting at a right angle with the axis of the body, but in the opposite direction, so as to antagonize the band which acts upon the pelvis. The extending band, made fast in the usual manner, above the knee, is then to be tightened, but only sufficiently to prevent the head of the bone from ascending. The ankle of the dislocated limb should now be laid hold of, and adducted, or drawn over the back of the sound limb; "which," says Dr. Annan, "will force the head of the bone out of the notch, and make it describe the segment of a circle, and pass a little downwards in the direction of the acetabulum. Care must be taken," he adds, "that the extending band is sufficiently tightened, and that it does not yield, otherwise the drawing of the leg across the other will only move the head of the bone in the notch, as if it was a joint. If lateral extension only was employed in this case, 639 INTO THE FORAMEN THYROIDEUM. the head of the femur would be drawn out of the notch, but it would ascend upon the dorsum of the ilium, above the acetabulum. Whereas, by simply drawing the limb laterally as much as is required to make the extending band serve as a fulcrum, and then using the leg as a lever, the head of the bone is not only forced inwards, but is moved downwards, and must necessarily pass into the socket." 1 Lente relates a case under the care of Dr. Hoffman, in the New York City Hospital, in which, when the extension was suddenly relaxed by cutting the cord, and the thigh, at the same instant, was abducted and rotated outwards, the head of the femur left the ischiatic notch and rose upon the dorsum ilii, assuming a position directly above the acetabulum, and below the anterior superior spinous process; and from which position it was subsequently, with great difficulty, returned to the socket. 2 § 3. Dislocations Downwards and Forwards into the Foramen Thyroideum. Si/n. —" Downwards into the foramen ovale ;" Sir A. Cooper. " Downwards into the obturator foramen ;" Lizars. "Downwards and forwards into the foramen obturatorinm ;" B. Cooper. " Inwards and downwards into the oval hole ;" Chelius. " Downwards and forwards into the foramen ovale;" Pirrie. " Downwards and inwards;" Boyer. M Sub-pubic ;" Gerdy. " Ischio-pubic ;" Malgaigne. Causes. —In order to produce this dislocation the limb must be, at the moment of the receipt of the injury, in a position of abduction. Perhaps most often it is occasioned by the fall of a heavy weight upon the back of the pelvis when the body is bent and the thighs spread asunder. Pathological Anatomy. —The capsule gives way upon the inner side especially; the round ligament is torn from its attachment, and the head of the femur pressing forwards and downwards, finds a lodgement upon the obturator externus muscle, over the foramen thyroideum. Symptoms. —The thigh is lengthened from one to two inches, greatly abducted and flexed, the body being also bent forwards or flexed upon the thigh. The dislocated limb is advanced before the other, and the toes generally point directly forwards, but they may incline either outwards or inwards. The hip is flattened ; the trochanter major is less prominent than upon the opposite side; and the head of the bone may sometimes be felt in its new position. The lengthening of the limb alone is sufficient to distinguish this accident from a fracture of the neck. Treatment. —It is pretty certain that in the following example there was a spontaneous reduction, or rather, I ought to say, an accidental reduction of a dislocated femur from the thyroid foramen. Perhaps it was only an example of a partial luxation; of which species of forward luxation I shall hereafter relate another case as having come under my own notice. 1 Annan, Amer. Journ. Med. Sci., vol. xix. p. 382, Feb. 1837. 2 Lente, New York Journ. Med., Nov. 1850, p. 314. 640 DISLOCATIONS OF THE THIGH. Jacob Lower, set. 10, fell from a tree, a height of about twelve feet, to the ground. It is not known how he struck. He became imme- Fig. 263. Dislocation downwards and forwards into the foramen thyroideum. diately quite faint, and when he had partly recovered, he attempted to get up, but could not. He said his leg was broken, and cried out lustily whenever it was moved. The father arrived in about an hour, and found him still lying on his back where he had fallen with his right leg carried away from the other and turned outwards. He lifted him up to place him in a small hand-wagon, which was long enough for his body, but Fig. 264. Dislocation downwards and forwards into the foramen thyroideum. only one foot and a half in width. Finding that his right leg was so much abducted as to prevent his being laid in so narrow a space, he seized upon it, and with some force pressed the knee inwards across the opposite leg, when suddenly it resumed its position with a loud snap like a " cannon." I use the language of the father. On the following day I examined the limb carefully and found its motions free. He was, however, vomiting the contents of his stomach, and passing blood from the bladder quite freely. The vomiting soon ceased, but the hemorrhage from the bladder continued three or four days. On the ninth day he walked out, and on the twelfth he was seen climbing upon the top of a house. I saw him again after the lapse of a year, and found that he was still complaining of an occasional soreness in the region of the hip-joint. 641 INTO THE FORAMEN THYROIDEUM. If we attempt to reduce by manipulation, it will be necessary to follow the same rule which we have stated as applicable to dislocations backwards, namely, to carry the limb only in those directions in which it is found to move easily. Instead, therefore, of holding the leg in a position of adduction while the thigh is flexed upon the abdomen, it will be necessary to carry it up abducted; and when the further progress of the knee toward the belly is arrested, the limb must be moved inwards, and finally brought down adducted. When the knee is about opposite the pubes, or a little lower in its descent, the femur should be gently rotated inwards for the purpose of directing the head toward the acetabulum. The reduction may also be sometimes facilitated by giving to the shaft of the femur a slight rocking motion when it is about to enter the socket; and also by pressing with the hand against the head of the bone, or by lifting at the knee moderately. In one of the examples recorded by Markoe (Case 8), the reduction was accomplished in the second attempt, by rotating the thigh inwards just as the thigh had descended below a right angle with the body, in the manner which we have above directed; but in a second example (Case 9), a similar manoeuvre carried the head across into the ischiatic notch, while the reduction was finally accomplished by rotating the thigh outwards, and at the same moment adducting the limb strongly in a direction which carried the knee behind the other one. Markoe concludes that the latter mode is preferable, because it will throw the head of the bone a little upwards as well as outwards; in which direction it will find a more gently inclined plane toward the socket. He admits, however, that both methods may accomplish the same result. But I am quite certain that the method by rotation of the shaft of the femur inwards is in general most likely to succeed. In this way also, I think, both W. H. Van Buren, of New York, 1 and R. L. Brodie, of the IT. S. Army, were successful ; 2 but it is especially worthy of notice that Anderson, so long ago as 1772, in the case already quoted, when we were considering the history of reduction by manipulation, practised successfully almost precisely the same method. In one example mentioned by Markoe (Case 7), it is pretty evident that the head of the femur was thrown into the ischiatic notch, by having flexed the thigh too much, so that " the knee touched the thorax." Indeed, it is questionable whether it will be best ever to bring the thigh much, if at all, above a right angle with the body, since any further flexion can only throw the head below the acetabulum, when in fact it is already too low. July 21,1858, Nathaniel Smith, a painter by trade, set. 33, fell from the second story window of the city post office, upon a stone pavement, striking, as he believes, upon the inside of his right knee. I saw him within an hour, and found the right tibia partially dislocated outwards, the corresponding patella dislocated completely outwards, and the right femur in the foramen thyroideum. His thigh was forci- 1 W. H. Van Buren, New York Med. Times, Jan. 1856, p. 127. 2 R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 90; from Charleston Med. Rev. 642 DISLOCATIONS OF THE THIGH. bly abducted ; slightly rotated outwards, and lengthened, by measurement made from the pelvis to the ankle, one inch and a half. The distance from the anterior superior spinous process to the fold of the groin was ten inches, but upon the sound side it was only eight and a half. The head of the femur could be distinctly felt in front, just under the pubes. Having administered chloroform, I first reduced the tibia and the patella, then seizing the thigh and leg, I flexed the thigh upon the body, carrying the limb upwards abducted until it was nearly or quite at a right angle with the body, then inclining the knee slightly inwards, I brought it down again, and when the thigh had nearly reached the bed, it fell into its socket with a dull flapping sensation. In every step of the procedure I followed the inclination of the limb. The recovery was rapid and complete. Sir Astley Cooper says that this dislocation is in general reduced very easily by the aid of pulleys; at least if the accident is recent. Fig. 265. Sir Astley Cooper's mode of reducing recent luxations into the foramen thyroideum. He advises that the patient shall be placed upon his back with his thighs separated as far as possible. The pulleys are to be made fast to a band drawn through the perineum of the dislocated limb, in a direction upwards and outwards; while a counter-band is to be passed around the pelvis through the band attached to the pulleys, and secured to a staple, or delivered to assistants placed upon the sound side of the body. When everything is arranged, the pulleys should be acted upon until the head of the femur is felt moving from the foramen ovale; at this moment the surgeon must pass his hand behind the sound limb, UPWARDS AND FORWARDS UPON THE PUBES. 643 and seizing upon the ankle of the dislocated limb, adduct it forcibly, thus converting the limb into a lever of the first order. If the dislocation has existed some time, he recommends that this procedure shall be varied by placing the patient upon his sound side instead of his back, and attaching the pulleys perpendicularly over the body. Sir Astley especially cautions us not to flex the thigh during these manoeuvres, lest we force the head of the bone backwards into the ischiatic notch, from whence he affirms that it cannot afterwards be returned to its socket; but the experience of surgeons has since shown that this latter statement is incorrect, and that it may, in some cases, be afterwards reduced, although it has fallen into the ischiatic notch. Mr. Liston says that this accident happened to himself while attempting to reduce a dislocation of only a few hours' standing, in a young and powerful man, but he had no difficulty in returning it to its first position. 1 Brainard, of Chicago, reduced a dislocation of that form of which we are now speaking, after both the compound pulleys and Jarvis's adjuster had failed, by placing between the thighs a piece of wood wrapped about with several layers of a wadded quilt, and making use of this as a fulcrum upon which the thigh operated as a lever. The legs were simply pressed together, care being taken to keep the knees straight. 3 After the reduction is accomplished, the patient should be laid upon his back in bed, but instead of rotating the limb outwards, as we have advised after a dislocation upon the dorsum ilii, or into the ischiatic notch, it should be gently rotated inwards, and the knees thus bound together. § 4. Dislocations Upwards and Forwards upon the Pubes. Si/n. —" Upwards and forwards on the horizontal branch of the share-bone ;" Chelius. " Forwards upon the pubes;" Pirrie. " On the body of the pubes, below the spine and transverse part of the bone;" Skey. " Snr-pubic ;" Gerdy. " Uio-pubic;" Malgaigne. Causes.- —This accident is generally occasioned by a fall upon the foot when the leg is thrown backwards behind the centre of gravity; as in a fall from the back end of a wagon, the foot being instinctively thrown backwards in order to save the head; or it may happen to a person who, while walking, suddenly puts one foot into a hole, in consequence of which the pelvis advances, but the leg and upper part of the body incline forcibly backwards. Occasionally it has resulted from a fall upon the back of the pelvis, or from a severe blow received upon the same part. A patient was admitted under the care of Dr. lire, into St. Mary's Hospital, London, with a dislocation upon the pubes, occasioned by swimming. His account of it was, that, when in the act of "striking out" he felt a catch in the right groin which he thought was cramp, and that he was able to walk after the accident, but with a 1 Practical Surg., Amer. ed., p. 93. 2 Brainard, North Western Med. and Surg. Journ., 1852. 644 DISLOCATIONS OF THE THIGH. good deal of difficulty. The examination proved that he had a dislocation upon the pubes, which Dr. Ure easily reduced. 1 Pathological Anatomy. —Sir Astley Cooper dissected the hip of a person whose thigh had been dislocated upon the pubes for some time, the true nature of the accident not having been at first recognized. The acetabulum was partly filled by bone, and partly occupied by the trochanter major, both of which were much altered in their form. The capsular ligament was extensively torn and the ligamentum teres broken off completely. The head and neck of the femur had torn up Poupart's ligament, so as to penetrate between it and the pubes, and lay underneath the iliacus internus and psoas muscles; the anterior crural nerve was lying upon these muscles, over the neck of the femur. The head and neck were flattened and otherwise much changed in form. Upon the pubes a socket was formed for the neck of the thigh bone, the head being above the level of the pubes. The femoral artery and vein were to the inner side. This specimen is still preserved in St. Thomas's Hospital. (Fig. 266.) Fig. 266. Specimen of dislocation upon the pubes, iu St. Thomas's Hospital. (From Sir A. Cooper.) In many cases, however, the head of the bone does not rise so far upon the pubes, but rests either upon its upper or its anterior margin. Symptoms. —The thigh is shortened, abducted, flexed slightly, rarely extended, and rotated outwards. (Fig. 267.) The trochanter major is lost, or nearly so, while the head of the bone may be generally felt like a round ball, lying upon or in front of the body of the pubes to the outside of the femoral artery and vein. Larrey saw a patient in whom the femur was placed nearly at a right angle with the body; and Physick once met with a dislocation upon the pubes " directly before the aceta- 1 Medical News and Library, vol. xvi. p. 1; from Lond. Lancet, Nov. 7, 1857. UPWARDS AND FORWARDS UPON THE PUBES. 645 bulum," in which the limb was not at all shortened, but, on the contrary, a very little lengthened. 1 Other surgeons have occasionally seen similar examples. The differential diagnosis between a fracture of the neck of the femur and this dislocation may be thus briefly stated. In the fracture there is crepitus, mobility, slight eversion easily overcome, moderate or no shortening, no abduction, the trochanter major rotates on a short radius, the head of the bone cannot be felt. In this dislocation there is no crepitus, the limb is immobile, the eversion is extreme and not easily overcome, there is generally more shortening, the thigh is abducted, the trochanter major rotates upon a longer radius, and the head of the bone can generally be distinctly felt in its unnatural position. Prognosis. —Sir Astley Cooper remarks that although this accident is easy of detection, he has known three instances in which it was overlooked, and he cannot but regard such errors as evidence of great carelessness on the part of the surgeon who is employed. The reduction has generally been accomplished, in recent cases, with no great difficulty; and when not reduced the patients have occasionally recovered with very useful limbs. Treatment. —From the several reported examples of dislocation upon the pubes reduced by manipulation, it would be difficult to draw any practical conclusions, since the methods have differed so widely from each other. I shall mention only three, which may be found in our own journals. One of these has already been mentioned in connection with the history of this process, as a case of compound dislocation, reduced by Dr. Ingalls, of Chelsea, Mass., Fig. 267. Dislocation upwards and forwards upon the pubes. and the two remaining examples were both reported by E. J. Fountain of Davenport, Iowa. Dr. Ingalls succeeded by carrying the limb 1 Dorsey's Surgery, vol. i. p. 238, 1813. 646 DISLOCATION'S OF THE THIGH. into its greatest state of abduction and rotating the thigh inwards; the replacement of the bone being aided also by pressing upon its head with his fingers thrust into the wound; while Dr. Fountain succeeded equally in both of his cases, by an almost opposite mode of procedure, namely, by adducting the limb forcibly, rotating the thigh inwards and then flexing the thigh upon the body. The first of Dr. Fountain's cases occurred in June, 1854. The patient, an adult male, had fallen from the second story of a house to the ground, fracturing his lower jaw, and dislocating his left hip. The limb was a trifle shortened, and the foot strongly everted. The prominence of the trochanter was lessened, and the head of the bone could be felt upon the pubes. Assisted by Dr. Arnold, he reduced the limb in the following manner : The patient was laid on the floor, and placed completely under the influence of chloroform. The dislocated limb was then " seized by the foot and knee and rotated outwards, the leg flexed and carried over the opposite knee and thigh, the heel kept well up, and the knee pressed down. This motion was continued by carrying the thigh over the sound one as high as the upper part of the middle third, the foot being kept firmly elevated. Then the limb was carried directly upwards by elevating the knee, while the foot was held firm and steady, at the same time making gentle oscillations by the knee, when the head of the bone suddenly dropped into its socket." 1 The time occupied was not more than thirty seconds, and the force employed was very slight. The second case occurred on the 31st of Oct. 1855, in the person of John McCarthy, an Irish laborer; the dislocation having been occasioned by falling with a horse, while riding. The reduction was effected in about twenty seconds by the same process, and without the aid of chloroform. It is probable that no one method will succeed equally well in all cases; but if the head of the bone, as in the case dissected by Sir Astley Cooper, has not only actually surmounted the pubes, but pushed itself fairly into the pelvis, then the limb ought to be abducted in the manner practised by Ingalls, and forcibly rotated outwards, in order that the head may be thus lifted over the pubes; and subsequently it should be flexed upon the body, adducted and brought down. But in this manoeuvre we ought to be careful not to continue the rotation outwards after the head of the femur has risen above the pubes, lest the head and neck should grasp, as it were, the psoas magnus and iliacus internus muscles, underneath which they have been thrust. On the contrary, it will be necessary at this point to rotate the thigh again gently inwards, which, by compelling the head to hug the front of the pubes, will enable it, while the flexion is being made, to slide downwards under these muscles toward the socket. If, however, the head of the bone has never risen upon the summit of the pubes, and is not actually engaged under the muscles which pass over it at this point, then the rotation outwards will not be necessary in any part of the procedure. Fountain. New York Journ. Med., Jan. 1856, p. 69 et seq. 647 ANOMALOUS DISLOCATIONS. Baron Larrey has reported a case of dislocation " before the horizontal portion of the pubes," which he reduced " by suddenly raising with his shoulder the lower extremity of the femur, while with both hands he depressed the head of the bone." 1 This is the same of which we have already spoken as being attended with the unusual phenomenon of the thigh placed at a right angle with the body. If reduction is attempted by extension, the patient ought to be laid on his back upon a table, with the dislocated limb falling off slightly from its side. The extending band, made fast above the knee, should then be secured to a staple in the line of the axis of the dislocated thigh, and of course, below the table; while the counter-extending band, crossing under the perineum, should be made fast in the same line, above the level of the table, and beyond the head of the patient. When extension is commenced, and the head of the femur has begun to move, the reduction may sometimes be facilitated by lifting- Fig. 268. Reduction of dislocation upon the pubes, by extension. the upper part of the thigh with a jack towel or a band passed under the thigh and over the neck of the surgeon, as we have recommended in both of the backward dislocations. § 5. Anomalous Dislocations, or Dislocations which do not properly belong to either op the four principal divisions before described.- 1 1. Dislocations directly Upwards. Syn.—" Sus-Cotyloidiennes;" Malgaigne. " Sixth dislocation ;" Mutter. Malgaigne affirms that the head, in this dislocation, is situated external to the anterior inferior spinous process, and about one inch ' Larrey, Lond. Med.-Chir. Rev., Dec. 1820, p. 500 ; vol. i. first ser.,from Bullet, de la Fac. de Med., No. 1. 2 Malgaigne, Traite des Frac. et des Lux., torn. ii. p. 869 et seq. Samuel Cooper, First Lines, vol. ii. p. 391. Pirrie's Surg., Amer. ed.,1852, p. 275. Skey's Surg., Amer. ed.,1851, p. 110 et seq. Gibson's Surg., sixth Amer. ed., vol. i. p. 386. Guy's Hospital Reports, vol. i. 1836, pp. 79 and 97 ; vol. iii. 1838, p. 163. London Lancet, 648 DISLOCATIONS OF THE THIGH. below the anterior superior spinous process. But this position is not uniform. It may be found in front of the inferior process, or above as well as behind, or external to it. The symptoms which characterize this accident are shortening of the limb, slight abduction and extension, with extreme eversion or rotation outwards. The eversion of the toes, together with the slight amount of shortening which has in general been observed, has led several times to the supposition that it was a fracture of the neck of the femur; but the rigidity, and the position of the trochanter and head will usually render the diagnosis clear. Cummins reports a case which occurred in the practice of Gibson, of New Lanark, where the head of the bone was believed to be situated just below the anterior superior spinous process, and inwards toward the pubes. The limb was shortened fully three inches; the toes everted; adduction and abduction were exceedingly painful and difficult, but flexion was more easily performed. The head of the bone could be felt in its new position, especially when the thigh was moved. At first it was supposed to be a fracture, but this error having been corrected, the surgeons proceeded to attempt reduction on the eleventh day. Extension was made by pulleys, and when the head of the bone had descended to the margin of the cavity, Mr. Gibson lifted the upper end of the femur by means of a towel, at the same moment pressing the knee toward the opposite thigh and forcibly rotating the limb inwards ; by which means the reduction was accomplished. 1 Lente has seen the head of the femur in the same position as in the case reported by Cummins, not as a primitive dislocation, but consequent upon an attempt to reduce a dislocation into the ischiatic notch. The shortening was about two inches; the limb very much rotated outwards; the rotundity of the affected hip greater than that of the other, and the trochanter major one inch further removed from the anterior superior spinous process. The head of the bone could be felt distinctly in its new position. The reduction was effected finally with pulleys, by the aid of chloroform, and by rotation of the limb in various directions. 2 Morgan also reports a case in which the head of the femur was above the acetabulum, and a little to the outside of the ilio-pectineal eminence. 3 In a majority of cases these dislocations have been reduced by manipulation alone, or by manipulation aided by pressure. The limb should be seized in the usual manner, at the knee and ankle, carried up toward the face, abducted, then rotated inwards, gently ad- Lond. ed., vol. i. 1848, p. 184; vol. ii., 1840. p. 281 ; vol. i., 1845, p. 412; vol. ii. p. 159. London Med. Gaz., vol. xix. pp. 657 and 659; vol. x. p. 19 ; vol. xxxiii. p. 404. Med.-Chir. Trans., vol. xx. p. 112. Lente's paper on " Anomalous Dislocations of the 'Hip-Joint," in New York Journ. Med. for Nov. 1850, p. 314 etseq. Philadelphia Med. Examiner, No. 51. Amer. Journ. Med. Sci., vol. xvi. p. 14. New York Med. and Phys. Journ. 1826, vol. v. p. 597. New York Jour. Med., Jan. 1860, Dr. Shndy's case. 1 Cummins, Guy's Hospital Reports, vol. iii. p. 163, 1838. 2 Lente, New York Journ. of Med., Nov. 1850, p. 314. 3 Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper. 649 ANOMALOUS DISLOCATIONS. ducted, and finally brought down again to the bed. At the moment when the rotation and adduction commence, the head of the bone should be pressed toward the socket by the hands, and, if necessary, lifted a little over the margin of the acetabulum, by moderate extension at a right angle with the body. 2. Dislocations Downwards and Backwards upon the Posterior Part of the Body of the Ischium, between its Tuberosity and its Spine. James C , aet. 35, was admitted to the Pennsylvania Hospital on the 23d of January, 1835, under the care of Dr. Hewson. The patient, a muscular man, had been crushed under a falling roof, and, as he thought, with his right thigh separated from his body. When received into the hospital, one hour after the accident, the right thigh was flexed upon the pelvis, and rested upon the left; the right leg was also flexed upon the thigh; the knee was below its fellow, the toes turned inwards, and the whole limb shortened at least one inch. The head of the bone could be felt distinctly resting upon that portion of the ischium which lies between the acetabulum, the tuberosity of the ischium and the spine. On the following day, the muscles of the patient having been sufficiently relaxed by suitable means, the pulleys were applied; but, after a second attempt, some of the bands having given way suddenly, the pulleys were removed, when it was found that the reduction had been accomplished, although neither the patient nor his attendants had noticed the return of the bone to its socket. For several days there was entire loss of sensibility and motion in the leg, owing probably to the pressure which had been made upon the sciatic nerve; but these symptoms gradually disappeared, and at the time when the case was reported, about two months after the accident, he was walking with crutches. Dr. Kirkbride, who has reported this unusual case of dislocation, doubts whether the extension was necessary to the reduction, as the head of the bone was brought very near the margin of the acetabulum by lifting the thigh with a towel, and it probably afterwards entered the socket so soon as the extension was relaxed. 1 Malgaigne has referred to several similar examples. 3. Dislocations Downwards and Backwards into the lesser or lower Ischiatic Notch. Syn. —" Behind tuber ischii;" Gibson, S. Cooper. " Fifth dislocation ;" Gibson. September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a spirited horse, when the animal, being restive, suddenly reared and fell back on his rider, in such a manner as that the weight of the horse was received on the inside of the left thigh; Mr. Lowell having fallen on his back, a little inclined to the left side. The surgeon, who was 1 Kirkbride, Amer. Journ. of Med. Sci., vol. xvi. p. 13. 42 650 DISLOCATIONS OF THE THIGH. immediately called, recognized it as a dislocation, and thought he had succeeded in reducing it; but a day or two later it was seen by a second surgeon, who declared that it was still out of place, and repeated the attempt at reduction, but without success, as the result proved. In December of the same year Mr. Lowell called upon John C. Warren, of Boston, who was now able to determine, easily, as he affirms, the precise character of the accident. The limb was elongated, contracted, and the head could be felt in its unnatural position. By advice of Dr. Warren, he was taken to the Massachusetts General Hospital, and a persevering attempt was there made to reduce the bone, but with no better success than had attended the efforts previously made. 1 Mr. Keate has reported a case produced in a very similar way by a horse having fallen backwards with the rider into a deep and narrow ditch; but the position of the limb was somewhat extraordinary, considering that it was a dislocation backwards, the whole limb being very much abducted and the toes being turned outwards, as if the head of the bone was in front of the tuber ischii, rather than behind it. The thigh and leg were much flexed, and the whole limb was shortened from three to three inches and a half. The head of the femur could be distinctly felt "inferior to the ischiatic notch, and on a level with the tuberosity of the ischium." In the first attempt at reduction the head of the bone was thrown into the foramen ovale, from which it was, however, after one or two more attempts by extension, and by lifting with a jack-towel, restored to the socket. Mr. Keate believes that the dislocation was originally into the foramen ovale, but that in the struggles made by the patient to extricate himself, it was thrown backwards into the position in which he found it. 2 Mr. Wormald has reported a primitive accident of the same kind, occasioned by jumping from a third story window. The patient died soon after, and at the autopsy the head of the femur was found under the outer edge of the glutseus maximus, projecting through the torn capsule opposite the upper part of the tuber ischii. The shaft of the femur lay across the pubes, and the limb was considerably shortened and turned inwards. 3 4. Dislocations Directly Downwards. Syn. —" Sous-cotyloidiennes ;" Malgaigne. The following is one of several similar examples now upon record:— A man, set. 50, was admitted into the London Hospital under the care of Mr. Luke. A dislocation of the left femur was easily diagnosticated, but the symptoms were peculiar, inasmuch as the limb was lengthened one inch, without either inversion or eversion; yet the 1 New York Med. and Phys. Journ., vol. v. p. 597; 1826. Letter to the Hon. Isaac Parker, &c, by John C. Warren: 1826. North Amer. Med. Journ., vol. iii. p. 169. 8 Amer. Journ. Med. Sci., vol. xvi. p. 226,1835. From Lond. Med. Gaz., vol. x. p. 19. 8 Wormald Lond. Med. Gaz., 1836. 651 ANOMALOUS DISLOCATIONS. head of the bone could be easily felt, and was thought to be in the ischiatic notch. By manipular movements reduction was easily effected about an hour after the accident. The man subsequently died from the effects of broken ribs. At the autopsy, Mr. Forbes, the housesurgeon, before dissecting the parts, again dislocated the bone. This was done with ease, and it was clear that the original form of dislocation had been reproduced, as the bone could not be made to assume any other position. The head of the bone proved to be displaced neither into the ischiatic notch nor the thyroid hole, but midway between the two, immediately beneath the lower border of the acetabulum. The gemellus inferior and the quadratus femoris had been torn, the ligamentum teres had been wholly detached, and there was a laceration in the lower part of the capsular ligament. 1 Dr. Blackman, of Cincinnati, informs me that in Jan. 1859, he reduced a sub-cotyloid, incomplete dislocation, in a man set. 70, by manipulation, Dr. Judkins lifting the thigh upwards and outwards by means of a towel, while Dr. Blackman first flexed and then abducted the limb. 5. Dislocations Forwards into the Perineum. Syn. —" Perineales ;" Malgaigne. " Luxation sur la branche ascendante de l'iscbion ;" D'Amblard. " Inwards on the ramus of the os pubis ;" Skey. D'Amblard published an example of this accident in 1821, occasioned by a violent muscular exertion made by the patient in an effort to spring into his carriage, the symptoms attending which did not differ materially from those which were found to be present in the two following examples, except that while in Parker's patient the toes were turned slightly inwards, in D'Amblard's patient they were a little turned outwards. 2 Mr. B , set. 35, a calker by occupation. The injury was received while at work under the bottom of a canal boat, July 20, 1831, the boat being raised upon props three and a half feet long. The patient was standing very much bent forwards, with his feet far apart, between which lay a piece of round timber one foot in diameter, when the props gave way, letting the whole weight of the boat upon himself and his companions. One of the workmen was killed outright. On extricating Mr. E. from his situation, the left leg and thigh were found extended at a right angle with the body, the toes turned slightly inwards, the natural form of the nates was lost, and the head of the femur could be felt distinctly moving, when the limb was rotated, in the perineum, behind the scrotum, and near the bulb of the urethra. For the purpose of reduction, the patient was laid on his back upon a table, and the pelvis made fast by a muslin band. Extension, accompanied with moderate rotation, was then made in a direction outwards and downwards, bringing the head of the bone over the ascending ramus of the ischium, beyond which it was lying, into the 1 Luke, Med. News and Library, vol. xvi. p. 34, March, 1858 ; from Med. Times and Gaz., Jan. 2, 1858. 2 Malgaigne, op. cit., torn. ii. p. 876. 652 DISLOCATIONS OF THE THIGH. foramen thyroideum; and from this position the bone was replaced in the acetabulum, by carrying the dislocated limb forcibly across the opposite one. The patient soon recovered the use of the joint. 1 J. B., an Irishman, set. 40, on entering the St. Louis Hospital, gave the following account of his accident, which had occurred six hours previously. He was engaged in excavating earth, and having undermined a bank, it unexpectedly fell upon his back while he was standing in a bent position, with his thighs stretched widely apart. The weight crushed him to the earth, breaking both bones of his right leg, the radius of the same side and dislocating the left hip into the perineum. The thigh presented a peculiar appearance, being placed quite at a right angle with the body, but somewhat inclined forwards. The part of the hip naturally occupied by the trochanter major presented a depression deep enough to receive the clenched fist; while the head of the bone could be both seen and felt projecting beneath the skin of the raphe in the perineum. Rotation of the limb, which was difficult and excessively painful, rendered the position of the head still more manifest. The patient had also retention of urine, occasioned probably by the pressure of the femur upon the urethra. Having dressed the fractures, Dr. Pope placed the patient under the full influence of chloroform, and then proceeded to reduce the dislocated thigh; for which purpose " two loops were applied, interlocking each other in the groin, and using the leg as a lever, extension, by means of the pulleys, was made transversely to the axis of the body. A steady force was kept up for a short time, and the thigh-bone glided into its socket with a snap that was heard by every attendant and patient in the large ward." 2 § 6. Ancient Dislocations op the Femur. Says Sir Astley Cooper: " I am of opinion that three months after the accident, for the shoulder, and eight weeks for the hip, may be fixed as the period at which it would be imprudent to attempt to make the reduction, except in persons of extremely relaxed fibre, or of advanced age. At the same time, I am fully aware that dislocations have been reduced at a more distant period than that which I have mentioned; but in many instances the reduction has been attended with the evil results which I have just been deprecating." A remark which later surgeons do not seem always to have correctly understood, or which, if they have understood, they have not correctly represented ; since it has many times been affirmed of this distinguished surgeon, that he regarded reduction of the hip as impossible after eight weeks, and they have proceeded to cite examples which would prove that he was in error. But long before Sir Astley's day, Gockel mentioned a case of reduction of the femur after six months, and Guillaume de Salicet declared that he had reduced a similar dislocation 1 W. Parker, New York Med. Gaz., 1841; N. Y. Journ. Med., March, 1852, p. 188. 2 Pope, St. Louis Med. and Surg. Journ., July, 1850 ; N. Y. Journ. Med., March, 1852, p. 198. ANCIENT DISLOCATIONS OP THE FEMUR. 653 after one year, 1 and Sir Astley says, that he is " fully aware" of the existence of such facts; yet with a knowledge of what has so frequently followed these attempts, he would not recommend the trial after eight weeks, except under the circumstances by him stated; and notwithstanding the number of these reported successes has been considerably increased in our day, we suspect that Sir Astley's rule will continue to govern experienced and discreet surgeons. Two examples which have recently been published of successful reduction after six months by manipulation, would encourage a hope that the period might be greatly extended, were it not that manipulation also has already failed many times in the case of ancient luxations, and that the attempt has sometimes been followed with disastrous results, even in recent cases. The following are the two examples of reduction by manipulation after the lapse of six months:— On the 21st of March, 1856, a man presented himself at the Commercial Hospital, Cincinnati, with a dislocation of the femur upon the dorsum ilii, of six months' standing. The limb was shortened two inches. Dr. Blackman, under whose care he was admitted, administered chloroform, and by manipulating after the method described by Dr. Reid, the reduction was accomplished. 2 In a letter addressed to me by Dr. Blackman, and dated April 21st, 1859, he informs me that this patient presented himself again before the class about six months since, and the restoration of the functions of the limb was found to be complete. The second example occurred in the practice of Martial Dupierris, of Havana, Cuba. A Chinese boy named A-sin, aged about sixteen years, arrived at Havana on the fourth of June, 1856, suffering under a severe illness, which confined him for a month or more to his bed, and the existence of the dislocation was not discovered until he had sufficiently recovered to rise upon his feet. It was then ascertained that he had a dislocation of the left femur upon the dorsum ilii. Upon inquiry, Dr. Dupierris learned that the accident had occurred before leaving China, a period of more than six months. The boy was still feeble, the limb somewhat emaciated, and instead of being rigid from muscular contraction, all the muscles " were in a flaccid condition, except the great gluteal, which was painful to the touch." Deeming the use of anaesthetics improper, on account of the boy's feeble condition, these agents were not employed. Dr. Dupierris describes the method of reduction as follows: " The body being held by two assistants by means of two bands, one of which passed beneath the perineum, and the other under the axillae, traction was made upon the limb by two strong and intelligent assistants. The movement of the head of the bone, resulting from this manoeuvre, was very limited, even when the force was much increased; and the excruciating pain, which the patient referred to the iliac region, compelled us for the moment to desist. 1 Malgaigne, op. cit., torn. ii. p. 185 ; from Gallicinium Medico-practicum, Ulm, 1700, p. 288. 2 Blackman, Ohio Med. and Surg. Journ., vol. viii. p. 522. 654 DISLOCATIONS OF THE THIGH. " The following day, the patient having obtained a tolerable night's rest by means of a narcotic potion, I concluded to attempt the reduction by flexion, believing that I could thus better prevent any accident which the necessary force might produce; the operator, in adopting this method, having it in his power to follow the head of the bone by pressure upon it with the hand, aiding its movement in the proper direction, or correcting any deviation that may occur. The emaciated condition of the boy was eminently favorable for such a procedure. " The patient being placed upon his back, and the trunk of the body made steady by assistants, with the left hand I grasped the upper part of the leg, placed the right hand upon the head of the bone in the iliac fossa, and then proceeded to flex the leg upon the thigh, and the thigh upon the pelvis. By this movement the great gluteal muscle was relaxed, and the head of the bone advanced, while with the right hand I directed the latter toward the cotyloid cavity. As soon as I judged the head to be immediately above the centre of the socket, I extended the leg, the thigh remaining flexed at a right angle; and then using the limb as a lever, I rotated it from within outwards, and at the same time extended it by making a movement of circumduction in a similar direction. When by these procedures the limb was brought near to its opposite fellow, a snap audible to the assistants, and of a deeper character than is ordinarly observed in the reduction of recent dislocations, indicated the return of the head of the bone to its natural position; a fact which was further substantiated by the establishment of the original length and form of the member and the subsidence of the pain. " The after-treatment consisted in placing a pad between the knees, and another between the internal malleoli, and confining the limbs together by two bands, one above the knees, and the other around the lower part of the legs. But in spite of these precautions to prevent re-displacement, the next morning I found that the dislocation had been reproduced. It was again reduced, but for three successive days there was a re-displacement. After this, however, the head of the bone kept its place; passive motion was daily employed, and all suffering ceased. After twenty days of rest, and a liberal use of the lactate of iron, the patient was allowed to get up; and, being provided with a pair of crutches, upon which he exercised himself daily, improved very rapidly. The muscles gradually recovered their bulk and vigor; and at the end of forty-eight days he was enabled to walk without crutches, although with some fear of falling. About the middle of August, he was put to work in a cigar manufactory, and has continued well ever since." § 7. Partial Dislocations of the Femur. Malgaigne declares that certain experiments made upon the cadaver led him, at one time, to the conclusion that all primitive luxations of the femur were incomplete, and that the old complete luxations found in autopsies, had become so consecutively. Later observations have taught him to correct this error, yet he still finds " incomplete back- PARTIAL DISLOCATIONS OP THE FEMUR. 655 ward luxations quite common, and incomplete dislocations in all the other directions much more common." I have more than once found occasion to call in question the accuracy of Malgaigne's views in relation to partial dislocations, the relative frequency of which he seems constantly disposed to greatly exaggerate. We cannot see the propriety of calling those cases partial dislocations, in which the head of the bone has fairly left the cotyloid cavity, and mounted upon its margin; even if it remains in this position without tearing the capsule; since the articular surfaces are now as completely separated as if the capsule had given way, and the head of the bone had escaped through the laceration. It is in fact a complete luxation. But I doubt very much whether the head of the bone ever rests upon the margin of the acetabulum without tearing the capsule, unless it has previously undergone certain pathological changes, such as I have already described; at least I cannot hesitate to reject all those examples in which the head of the femur is supposed to rest upon the upper or outer margin of the acetabulum; and if I permit myself to speak of incomplete dislocations at all in this connection, I shall reserve the term for those rare cases in which the head of the femur becomes engaged in the cotyloid notch, after breaking down the fibrous band which, in the natural state, is continuous with the rim of the acetabulum. Of this form of dislocation, I think I have met with two examples; one of which was in the person of the boy Lower, already mentioned, whose thigh was reduced accidentally by his father; and the other occurred in a boy fifteen years of age, residing at that time in Rutland, Vermont. He was brought to me on the 28th of May, 1842, by Dr. Haynes, of Rutland, at which time the dislocation had existed five years. His account of himself was that in walking upon a slippery floor, his left leg slid outwards and backwards in such a manner as that when he fell it was fairly doubled under his back. On the tenth day following the accident, he began to walk with some help, and he has continued to walk ever since, but with a manifest halt. Three months after the injury was received, it was first seen by several surgeons, who pronounced it a dislocation, and attempted reduction without mechanical aid, but were unsuccessful. When the young man was brought to me, the limb was neither lengthened nor shortened, but the thigh was forcibly abducted and rotated outwards. It could not be flexed nor greatly extended. The head of the femur could be distinctly felt, as it lay anterior to the socket, but not sufficiently far forwards to rest upon the foramen ovale. J. C. Warren, of Boston, has reported a similar example in a child six years old, who was brought, April 21, 1841, to the Massachusetts General Hospital. Dr. Hale, who saw the lad at the end of two weeks, thought it a dislocation, but it had been treated by another surgeon as a case of hip-disease. The dislocation had now existed eight or ten weeks. The limb was a little lengthened, abducted, turned outwards, and advanced in front of the body, with very slight motion of either flexion or extension, and almost no tenderness about the joint. 656 DISLOCATIONS OF THE THIGH. Dr. Warren, also, was able to feel indistinctly the bead of the bone " immediately external to, and in contact with, the insertion of the triceps and gracilis muscles." An attempt was made by manual extension and manipulation to accomplish the reduction, but without success. 1 It is probable that both the above cases which I have described at length, were examples of partial dislocation; yet I cannot conceal from others a doubt which I actually entertain whether they were not, after all, only examples of hip-joint disease, arrested after having wrought certain slight pathological changes in the joint and the tissues adjacent. If, however, they were not examples of incomplete dislocations of the hip-joint, then I question whether any such cases have ever occurred. § 8. coxo-femoral dislocations, complicated with fracture of the Femur. Such complications are exceedingly rare, but it will not do to deny their possibility; although in some of the cases reported, the testimony is not so clear as not to leave a doubt whether the surgeons have not erred in their diagnosis. James Douglas has reported a case of dislocation upon the pubes, complicated with a fracture of the neck of the femur, the actual condition of which was verified by an autopsy; the patient having died twelve years after the injury was received. The head of the femur still remained above the pubes, and was in no way connected with its neck or shaft. The upper end of the femur projected in the groin, lying upon the inside of the femoral artery and vein. Many other curious pathological changes had also occurred. 3 The well-authenticated examples of reduction of the dislocation, where the femur was broken also, are still more rare; and several of the recorded examples which my researches have discovered, need additional confirmation. John Bloxham, of Newport, in the Isle of Wight, claims to have reduced a dislocation of the femur on the pubes, which was accompanied with a fracture of the thigh a little above its middle. The following is the account of this interesting case which we find' in the London Medico-Chirurgical Review, copied from the Medical Gazette of Aug. 24th, 1833. We regret that we are unable to see the account as published in the Gazette, which might supply some circumstances important to a full appreciation of the case :— On the seventh or eighth day after the accident, "the patient was laid upon his back on the bed and kept in that position by means of a sheet passed across the pelvis, and fastened to the bedstead; another sheet was also passed over the left groin, and secured in a similar manner. The dislocated and fractured limb was then inclosed in 1 Warren, Bost. Med. and Surg. Journ., vol. xxiv. p. 220. 2 Amer. Journ. Med. Sci., vol. xxxiii. p. 455, from Lond. and Edin. Month. Journ. of Med. Sci., Dec. 1843. 657 COXO-FEMORAL DISLOCATIONS WITH FRACTURE. splints, one of which extended np the back of the thigh as far as the tuberosity of the ischium. Pulleys, which were secured to a staple in the ceiling, placed at the distance of a foot to the right of a point vertical to the patient's navel, were then attached to a bandage fastened round the splints as high up as possible. " The foot was raised with the knee extended, so as to bring the limb nearly to a right angle with the line of the tackle, when, by drawing gradually on the cord, in the course of about ten or fifteen minutes, the head of the bone was rendered movable, and was brought considerably more forward. I then began to press on the head of the bone, so as to push it downwards, whilst the pulleys held it partially disengaged from the pelvis. In a few minutes the head of the bone passed over the ridge of the os pubis, and I then directed the foot to be raised a little higher, which, by putting the gluteii muscles more upon the stretch, was calculated to render them more efficient in drawing the bone into its proper place. By this manoeuvre, the head of the bone was drawn backwards, and on the foot being more elevated and the cord slackened, it continued to recede from my fingers till the trochanter major made its appearance in the natural situation, and the reduction was found to be perfectly complete. "Lest the head of the bone should slip backwards on the dorsum ilii, I directed an assistant to apply firm pressure during the latter part of the process, above and behind the acetabulum. "The apparatus was then removed, the thigh bound up in short splints, and the patient laid upon a double inclined plane. No symptoms of inflammation appeared afterwards about the joint. Passive motion was employed at the end of a week, and occasionally repeated during the whole reparatory process." 1 Without intending to question the accuracy of the statements in this case, which, in the main, seem to bear the marks of credibility, we must express our surprise that so little difficulty was experienced in the reduction, if the femur was actually broken, no more, indeed, than is usually experienced when the bone is not broken; and that Mr. Bloxham was able to employ safely passive motion at the end of a week. Charles Thornhill relates, in the London Medical Gazette for July, 1836, a case of fracture of the femur through its upper third, in a man set. 40, with dislocation into the ischiatic notch; which dislocation, he assures us, was reduced at the end of six weeks. But it is much more probable that, instead of reducing a dislocation, he refractured the bone. During more than one hour and a half, aided by pulleys, tractions and manipulations were made in almost every direction. The upper part of the thigh was lifted with all the strength of one man by means of a jack towel; it was violently rotated, adducted, and abducted. Both the perineal and the knee band gave way, from the excess of the force employed; and, finally, the head of the femur resumed its place with an audible crash. After which the "limb was Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833. 658 DISLOCATIONS OF THE THIGH. of nearly equal length with the other;" but there remained an " immense deposit" around the acetabulum. 1 Malgaigne says that M. Eteve found a poor fellow with a dislocation of his left thigh backwards, a fracture near its middle, a penetrating wound of the knee, and a fracture of the fibula in the same leg. "Without delay he proceeded to reduce the dislocation by directing two assistants to support the body, three to support the leg, and two more to make extension from a towel tied not very tightly around the thigh above the fracture. The leg was then extended upon the thigh and the thigh flexed upon the pelvis until it was at a right angle with the body; and after a gradual extension had been made in this direction, M. Eteve pushed with all his strength the head of the bone into its socket. Of which case Malgaigne justly remarks, that the " extension" practised by the surgeon was only imaginary. 2 If the reduction was accomplished at all, it was by manipulation and pressure. Finally, Markoe relates in the paper to which we have already several times made allusion, the case of a boy set. 8, who was admitted into the New York City Hospital on the 29th of June, 1853, with a compound fracture of the right thigh, a simple fracture of the left, and a dislocation of the head of the right femur upwards and backwards upon the dorsum ilii. When placed upon the bed, the right limb lay obliquely across the abdomen of the boy, with the foot resting against the axilla of the left side. "The house-surgeon, to whose care the case fell on admission, took the injured limb in his hands and very carefully carried it over the abdomen to the right side, and then adducted it and brought it down toward the straight position," during which procedure the head of the bone is supposed to have resumed its place in the socket. 3 Such is the account furnished of the symptoms and treatment of this extraordinary case; too meagre certainly to entitle it to much confidence, or to permit us to draw from it any practical inferences. We are not even informed what was the name of the young man who alone saw and treated the case, nor what was his responsibility as a surgeon. I have been unable to find any other examples of fracture of the femur complicated with dislocation ; and, rejecting at least Mr. Thornhill's case as altogether incredible, the proper conclusion would be, that reduction is sometimes possible in recent cases, if the surgeon will resort promptly, before swelling and muscular contraction have taken place, to manipulation combined with pressure upon the head of the bone. Indeed, it is probable that pressure alone is the means upon which the success will finally depend. Richet says that he has several times dislocated the femur in the cadaver; and then having sawn off the head so as to represent a fracture, he has always been able to push the head of the bone easily into its socket. 4 By seizing the moment then when the patient is laboring under the shock, 1 Amer. Journ. Med. Sci., vol. xxv. p. 218. 2 Malgaigne, op. cit., torn. ii. p. 206 ; from Gazette Med., 1838, p. 757. 3 New York Journ. Med., Jan. 1855, p. 30. * New York Journ. Med., March, 1854, p. 293 ; from Bullet, de Ther. 659 DISLOCATIONS OF THE PATELLA OUTWARDS. or by placing him completely under the influence of an anaesthetic, no resistance will be offered by the muscles any more than in the cadaver, and the reduction may, perhaps, be easily effected. I have no confidence that anything can be accomplished by extension ; nor do I think it will be best to wait until the femur has united, since such delay will probably render the reduction impossible. CHAPTER XVII. DISLOCATIONS OF THE PATELLA. § 1. Dislocations of the Patella Outwards. Causes. —In the majority of cases it has been occasioned by muscular action ; and especially is this liable to occur in persons who are knockkneed, or whose external condyles have not the usual prominence anteriorly. It may be caused by suddenly twisting the thigh inwards while the weight of the body rests upon the foot, and the leg is thus kept turned outwards; or by falling with the knee turned inwards and the foot outwards. Occasionally it is the result of a blow received upon the inside, or upon the front and inner margin of the patella. In some persons there seems to exist a preternatural laxity of the ligamentum patellae or of the tendon of the quadriceps extensor which exposes the subject to this accident from very trifling causes. Fergusson says he has known it to be occasioned by a child's stepping upon the knee of a person lying in bed: and Skey says he has seen two cases which occurred spontaneously during sleep. B. Cooper has seen a young lady who frequently dislocated her patella outwards by merely striking her toe against the carpet, or in dancing. Boyer, Sir Astley Cooper, and others, mention similar examples. Pathological Anatomy. —Most frequently the dislocation is only partial, the inner half of the patella resting upon the articular surface of the outer condyle; and in consequence of the peculiar obliquity of these surfaces, together with the action of the vasti and rectus femoris, the outer margin of the patella becomes tilted forwards. If the dislocation is more complete, this margin begins to fall over backwards, as in the accompanying drawing; and in more extreme cases the patella lies flat upon the outer side of the condyle, with its inner margin directed forwards. When the dislocation is partial, it is probable that neither the capsule nor the ligamentum patellae usually suffers much laceration ; but in complete dislocations, the capsule at least must have given way more or less. Norris, of Philadelphia, reports a case of partial luxation in which the complications were more serious. John Scanlin, aet. 32, was admitted to the Pennsylvania Hospital, on the 27th of August, 1839, in consequence of injuries received a short time previous by 660 DISLOCATIONS OF THE PATELLA. having become entangled in machinery. In addition to several fractures in other limbs, he was found to have a subluxation of his left Fig. 269. Dislocation of the patella outwards. patella outwards, its outer edge being much raised and resting on the side of the external condyle of the femur, while its inner edge was depressed, and firmly fixed in the hollow between the condyles. The internal lateral ligament of the knee was ruptured, allowing the head of the tibia to be moved considerably outwards. A depression existed, also, between the tubercle of the tibia and the lower end of the patella, at the middle and inner side of the knee, evidently produced by a rupture of the ligamentum patellae in nearly its whole extent. There was almost no swelling, and the limb was moderately flexed. By firm pressure the patella could be restored to position, but as soon as the hand was removed it returned to its original position. At the end of two months " a good degree of motion existed at the knee-joint, which was in no way inflamed or painful." 1 Symptoms. —The limb is slightly bent, but immovable ; the breadth of the knee is considerably increased; the inner condyle projects unnaturally, and the patella is distinctly felt upon the outer side. If the dislocation is partial, the outer margin of the patella forms an irregular sharp ridge in front of the external condyle. If it is complete, the inner margin presents itself in front of the external condyle, and the outer margin looks backwards. Usually the patient suffers great pain so long as the dislocation remains unreduced. Watson, of New York, saw a case of complete dislocation of the patella outwards in a fat young lady, with lax fibre, and occasioned by dancing. He says the knee was slightly but firmly flexed. It was reduced by a very slight pressure with the fingers, and although some inflammation with effusion into the joint ensued, the use of the limb was completely restored in a week or ten days. 8 Prognosis. —Reduction is in general easily accomplished, but a reluxation is very prone to occur. In the few examples reported of a permanent luxation, the patients have eventually recovered the use of the limb in a great measure. Boyer saw four cases of this kind, in three of which it existed in the left leg and had remained from infancy. The patellae were easily replaced, but unless confined they soon became displaced again; not one of them found it necessary to apply for surgical aid, as " they suffered no great inconvenience from the luxation, and it exempted them from military service." After reduction, very little or no inflammation usually follows. Mr. Key has, however, narrated a case in Guy's Hospital Reports, of death from suppuration in the knee-joint, following upon the reduction 1 Norris, Amer. Journ. Med. Sci., vol. xxv., Feb. 1840, p. 276. * Watson, New York Journ. Med., vol. i. p. 306. DISLOCATIONS OF THE PATELLA INWARDS. 661 of an inward subluxation. The dislocation was produced by a fall while carrying a pail, and was reduced by very gentle pressure; but the patient, a girl, aet. 20, although apparently in good health, was believed to be somewhat strumous. 1 Treatment. —In order to relax completely the quadriceps extensor, by whose action chiefly the patella is held in its unnatural position, the body should be bent forwards, while at the same moment the leg is extended upon the thigh and the thigh flexed upon the body. The surgeon will accomplish these indications in the most simple manner, by placing the patient in a chair, and then lifting the foot upon his own shoulder, as he kneels or sits before him. Sometimes the patella will resume its position at once when this manoeuvre is adopted; but if it does not, slight lateral pressure, made with the fingers, will generally be found sufficient to accomplish the reduction. In some instances, where other means have failed, the reduction has been effected by violent flexion and extension of the knee, aided by lateral pressure. I have already mentioned, when speaking of dislocations into the foramen thyroideum, the case of N. Smith, in whose person I found at the same moment a dislocation of the thigh, a subluxation outwards of the tibia, and a complete outward luxation of the corresponding patella. This was occasioned by a fall from a height upon the inside of the knee. I reduced the tibia first, and then easily replaced the patella by lifting the leg and pushing with my fingers against its outer margin. In many cases the patients themselves have reduced the dislocation immediately, and the surgeon is only consulted in relation to the after treatment. Liston says that this is so constantly the fact, or else such dislocations are really so rare, that it has never happened to him to have an opportunity of reducing any form of dislocation of the patella. Not long since, a young gentleman aet. 25, residing in Somerset, N. Y., called upon me in consequence of having discovered a floating cartilage in his knee-joint. His account of the matter was that on the first of February, 1858, he was kicked by a cow upon the outside of the right leg about six inches below the knee, and that he immediately found the patella dislocated outwards. After several efforts he finally succeeded in reducing it himself. His knee soon became greatly swollen, so that for five weeks he was unable to walk, and he has been more or less lame to this time. Six months after the accident he discovered a floating cartilage on the inside of the patella about one inch in diameter, which occasionally slips between the joint surfaces, and suddenly trips him up. § 2. Dislocations op the Patella Inwards. Causes. —Less frequent than dislocations outwards, they are occasioned generally by direct blows received upon the outer margin of the patella. 1 Op. cit., vol. i. p. 260. 662 DISLOCATIONS OF THE PATELLA Fig. 270. Dislocation of the patella inwards. The symptoms, pathological anatomy, and treatment will be the same as in dislocations outwards, except so far as these must necessarily vary from the opposite position of the patella. § 3. Dislocations op the Patella upon its Axis. Syn. —"Semi-rotation;" Miller. " Luxation Vertioale ;" Malgaigne. These accidents, of which up to the present moment not more than fifteen examples have been recorded, seem to be the result of the same causes which produce lateral luxations; and indeed they may be regarded as only exaggerated forms of incomplete lateral dislocations. In these latter accidents, as we have already noticed, the external or the internal margin of the patella, according as the subluxation is to the outer or inner side, is thrown more or less obliquely forwards; a position into which it is carried partly by the peculiar form of the articulating surfaces, and partly by the action of the vasti and rectus femoris muscles. If now these muscles were to contract suddenly and violently, and the return of the patella to its normal position was prevented by the lodgment of one of its margins in the inter-condyloidean fossa, the other or free margin would be compelled to rise until it became perpendicular to the limb, or it might perhaps even become completely reversed in its socket. The signs of this accident are such as to render an error in the diagnosis almost impossible. The limb is generally found forcibly extended, occasionally it is in a position of moderate flexion, but the projection of the sharp border of the patella directly forwards under the skin, is itself sufficient to determine the true nature of the injury. Reduction may be effected by the same manoeuvres which we have recommended in lateral luxations; but if these measures do not succeed, we may direct the patient to make a violent effort himself to flex and extend the limb, or the surgeon may force the limb into flexion and extension alternately, or he may rotate the tibia upon the femur, and then flex. Finally, he ought to make use of lateral pressure also, upon both margins of the upright patella, but in opposite directions. Watson, of New York, has related the following example of rotation of the patella upon its inner margin ("Luxation Yerticale Externe," Malg). Henry Burton, aged about thirty-five years, of rather slender frame, while riding on horseback in a crowd, received a blow upon his knee from a horse ridden by another person. When seen by Dr. Watson, soon after the accident, the leg was perfectly straight, but could be flexed to about an angle of 140° without causing pain. " The patella appeared to be slightly drawn up, and it was twisted upon its axis, presenting its outer edge, in a prominent hard line, in front of the 663 DISLOCATIONS OF THE PATELLA UPON ITS AXIS. knee; its inner edge was resting either in the groove between the condyles of the femur, upon which its posterior face should naturally play, or in the small depression on the anterior face of the femur, immediately above this groove. The anterior surface of the patella was turned inwards, its posterior surface outwards, and it rested nearly at right angles with its natural position. Its upper and lower attachments were both preserved, and could be distinctly felt; and a sort of band appeared to pass from its under, or, as it now lay, its outer face, inwards to the deeper portion of the knee-joint. This band, as I conceived, was caused either by the tension of the capsular ligament, or by the rupture of its edge, as it passes from the outer side of the patella. The position of the bone was so well marked that no one at all acquainted with the anatomy of the part could mistake the nature of the accident. "With the leg extended, and the anterior muscles of the thigh forced downwards as much as possible, pressure was made upon the patella with the expectation of forcing down its prominent edge. The effort was followed only by an increase of pain, the bone remaining permanently fixed. Another attempt was made to cant its posterior edge inwards, and to bring its anterior edge outwards, without pressing it against the condyles of the femur, by forcing the head of a key against the posterior, now the outer face of the patella (using this as a fulcrum), and pressing the prominent edge of the bone toward the outer condyle. This manoeuvre gave him no pain, but was as fruitless in its result as the other. At length the knee was forcibly bent and immediately straightened again; and then by canting the patella as before, and pushing it slightly downwards and inwards, it sprung with a sudden snap into its proper position." 1 Dr. Joseph P. Gazzam, of Pittsburg, Pa., has met with a similar case. On the 10th of Sept., 1842, James Porter was thrown while wrestling, and immediately found himself unable to rise. Dr. Gazzam saw him about an hour after the accident, and found the patella of the right leg dislocated on its axis, and resting on its inner edge in the groove between the condyles of the femur. Dr. G. proceeded to attempt reduction, but failed, after having made repeated trials by lifting the limb toward the body and by pressure in opposite directions. In consultation with Dr. Addison, it was now determined to divide the ligamentum patellae, which was done by introducing beneath the skin a narrow-bladed knife, and cutting close to the tubercle of the tibia. Again the attempts at reduction were renewed, but without success. The patella could be moved on its edge more freely than before the cutting, but resisted every effort to replace it. The patient was now bled in the erect posture and until the approach of syncope, but to no purpose. On the following morning, it was determined to adopt, with some modification, the mode practised so successfully by Dr. Watson. "The thigh was strongly flexed," says Dr. Gazzam, "on the pelvis, and the heel elevated. Then the leg was flexed steadily and forcibly on the thigh, and suddenly straightened. Watson, New York Journ. Med., Oct. 1839, p. 302. 664 DISLOCATIONS OF THE PATELLA. At the moment of straightening the leg, I pressed very strongly against the lower edge of the patella from without, with the head of a door key well wrapped, while Dr. Addison pressed with both thumbs against the upper edge of the bone toward the external condyle. On the fourth trial this manoeuvre succeeded, the bone springing into its place with a snap." Recovery was uninterrupted, and two or three months after, the patient had the complete use of his limb. 1 In a case of the same kind, published originally in Rusts Magazine, and which is copied at length by Mr. B. Cooper in his edition of Sir Astley's great work, the reduction was found impossible, notwithstanding the surgeon finally had the temerity to sever completely the tendon of the quadriceps extensor, and the ligamentum patellae. Extensive suppuration followed, under which the poor fellow finally sank and died. It is scarcely necessary to say that, rather than expose the patient to such hazards, it would be better to leave the bone unreduced. § 4. Dislocations op the Patella Upwards. Occasionally the ligamentum patellae has been found so much elongated and relaxed, as to permit the patella to glide upwards upon the front of the femur. Heister and Ravaton have each seen an example in which a displacement from this cause existed to the extent of three inches. It is much more common, however, to meet with this dislocation as a result of a rupture of the ligamentum patellae, as the following example will illustrate. On the 18th of Dec. 1850, Dennis Mullards, aet. 50, was admitted to the surgical wards of the Buffalo Hospital of the Sisters of Charity. While at work on this same day, he had slipped and fallen, with his knee forcibly flexed under his body. I found the ligament of the patella torn asunder and the patella drawn up two or three inches upon the front of the thigh. We applied at once the dressings used by me for a broken patella, and were able to bring the bone down completely to its place. Three weeks from the time of the receipt of the injury, the dressings were removed, and the patella was found to be nearly but not quite in its original place. From this time we commenced to move the joint: in about ten days more he left the hospital, and I lost sight of him, so that I am unable to speak more definitely of the result. (For examples of rupture of the quadriceps femoris, which some writers have incorrectly named Dislocations of the Patella Downwards, see Velpeau's Surgery, 1st Amer. ed., vol. i. p. 422; New York Med. Times, April, 6, 1861, p. 226, and two cases reported by myself in the same vol. of the Med. Times.) 1 Gazzam, Amer. Journ. Med. Sci., vol. xxxi. April, 1843, p. 363. DISLOCATIONS OF THE HEAD OF THE TIBIA. 665 CHAPTER XVIII. DISLOCATIONS OP THE HEAD OF THE TIBIA. Syn. —" Tibia upon the femur ;" " dislocations of the leg." In consequence of the great size and irregularity of the articular surfaces between the tibia and femur, together with the remarkable number and strength of the ligaments which bind the two bones together, dislocations at this joint are exceedingly rare. They are known to take place, however, in four principal directions, namely, backwards, forwards, inwards, and outwards. A dislocation may also occur in either of the diagonals between these points, that is, anterolaterally, or postero-laterally. They may be either complete or incomplete. Velpeau has found upon record thirteen examples of complete dislocations forwards, and eight backwards, but not one of a complete lateral luxation. Velpeau thought also that the antero-posterior luxations were always complete, but Malgaigne has shown that this opinion is erroneous. Simple flexion and extension, however extreme, are generally insufficient to produce either of these dislocations. They may be produced by a violent blow upon the lower end of the femur, or upon the upper end of the tibia, or by twisting the tibia upon the femur, as when the foot is made fast in a hole, and the body swings around upon the knee. § 1. Dislocations op the Head op the Tibia Backwards. Symptoms. —The head of the tibia is felt in the popliteal space ; and, if the dislocation is complete, the pressure upon the popliteal nerve becomes excessively painful. A marked depression exists in front, immediately below the patella, and especially upon the sides of the ligamentum patellae; the condyles of the femur project strongly in front; the leg may be not at all, or only slightly shortened, or the shortening may amount to one inch or more, and usually it is in a position of extreme extension, or thrown forwards from the line of the axis of the femur; but its position has been found to vary greatly in different cases, the limb being sometimes very much flexed, and in others very slightly flexed, or perfectly straight." Pathological Anatomy. —The posterior ligament of the joint is torn ; the muscles of the ham are put upon the stretch; the popliteal nerves and vessels compressed ; and the head of the tibia either rests partly upon the posterior half of the lower articulating surface of the femur, 43 & 666 DISLOCATIONS OF THE HEAD OF THE TIBIA. or it passes up and rests only against its posterior articulating surface, which in this direction extends an inch or more upwards. If the dis- Fig. 271. Dislocation of the head of the tibia backwards. location is complete, the crucial ligaments are also torn, and all the parts about the joint suffer extensive injury from stretching, laceration, or compression. Prognosis. —Malgaigne has seen three examples of incomplete backward luxations which were not reduced, and neither of the persons were very greatly maimed in consequence. One walked with crutches after three or four days, and with a cane after about five weeks. Another did not leave his bed under one month, and it was nearly one year before he could lay aside his crutches ; but both of them were finally able to walk at least twelve leagues per day. Malgaigne informs us, however, that in a similar case seen by Lassus, the patient was confined to his bed two years, although he finally recovered a tolerable use of his limb. If the reduction is promptly effected, the limb kept perfectly quiet a sufficient length of time, and in other respects properly managed, not much inflammation need generally to be anticipated, and the limb may suffer in the end very little, if any maiming. Treatment. —It will be proper, at first, to attempt the reduction by simple manipulation, as this is often found to succeed when the dislocation is recent and incomplete, and especially when the system is greatly depressed by the shock of the injury. If the dislocation is complete, however, we can hardly anticipate success without the application of some extending force. In the employment of manipulation we ought to be governed at first by the same rule which we have found so generally applicable in dislocations of the femur, namely, to carry the limb in those directions in which it will move easily, or without much force. If this fails, we may at once resort to forced flexion alternating with extension, rotating or rocking the limb also occasionally from one side to the other, while at the same moment strong pressure is made upon the projecting bones at the knee-joint in opposite directions or in the direction of the articulation. Finally, it may be necessary to resort to extension, made by means of a lacq, or by the hands of strong assistants, above the ankle, always at first in the direction of the axis of the tibia; the counter-extending band being applied to the perineum, if the leg is straight, but to the lower and under part of the thigh, if the leg is flexed. A very convenient mode of making extension where we wish to apply more than usual force, is to lay the whole limb over a firm double inclined plane, or fracture splint, securing the thigh to the thigh-piece with a roller, and making the extension with the screw attached to the foot-board. This method, however, while it enables us to use great DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 667 force in the extension, prevents the surgeon from employing, at the same time, those flexions, extensions, and other manipulations, upon which success so often depends. Mr. Rose has related in the Provincial Medical Journal of June 11th, 1842, a characteristic example of this accident, except that the patella had also suffered a lateral displacement, presenting the usual favorable termination. A woman was standing upon a low ladder, when a carriage driven furiously came in contact with it, and precipitated her to the ground. Dr. Rose, who saw her almost immediately, found the tibia completely dislocated at the knee, the head being driven behind the condyles of the femur into the ham, with the patella thrown to the outside of the external condyle, and the leg in a state of fixed 'extension. Immediately, and without difficulty, the bones were restored by applying one hand to the patella, the other to the back of the upper portion of the tibia, and simultaneously pulling and pushing those bones toward their natural positions. The patient was then removed to a bed, and by the diligent use of antiphlogistic remedies inflammation was kept in check, and the case reached a favorable termination without one untoward symptom. After the lapse of only a few weeks, she had completely recovered the use of the knee-joint. 1 Dr. Walsham communicated a case to Sir Astley Cooper, in which the dislocation was not only complete, but the tendon of the quadriceps extensor was ruptured. The leg was bent forwards. The reduction was accomplished very easily by extension made with the hands by four men, in the line of the axis of the limb. In about one month, this man began to walk with crutches, but he was not perfectly recovered until after five months; at which time the crutches were finallv laid aside. 2 § 2. Dislocations of the Head of the Tibia Forwards. The signs of this accident are the reverse of those which belong to dislocations backwards. The patella, tibia, and fibula, are prominent in front, while the condyles of the femur may be felt behind, pressing strongly upon the muscles, nerves, and bloodvessels which occupy the popliteal space. In case the dislocation is complete, a shortening may exist to the extent of one or even three inches. Dr. O'Beirne, of Dublin, has mentioned a case to Mr. B. Cooper, in which the shortening was three inches and a half, and Mr. Mayo has seen one example in which the dislocated limb was " fully four inches" shorter than the other. 3 It is quite probable, however, that these latter statements are somewhat exaggerated. In consequence of the pressure upon the popliteal artery, the pulsations in the branches below are frequently interrupted, and in one instance this pressure was sufficient to produce finally a dry gangrene. 1 Rose, Amer. Journ. Med. Sci., vol. xxxi. p. 21b'. 2 Walsham, Sir A. Cooper on Disloc, 2d Lond. ed., p. 188. 3 B. Cooper's ed. of Sir Astley Cooper on Disloc, &c, pp. 214-215. 668 DISLOCATIONS OF THE HEAD OF THE TIBIA. Dr. Gorde relates a case in the Bulletin de Therapeutique, occurring in a woman nearly sixty years old. This woman was returning home Fig. 272. Dislocation of the head of the tibia forwards. at night with a heavy burden, and in a state of intoxication, when she stepped into a ditch as deep as up to the middle of her thighs. The body was thrown forwards by the fall, while the feet stuck at the bottom of the ditch; the whole force of the impulse being sustained by the thighs. The lower end of the femur was found driven downwards and backwards, and lodged under the muscles of the calf of the leg; the limb being shortened three inches. Reduction was promptly effected, and without inflicting any pain of which the patient complained. In six weeks the patient was cured. 1 Mr. Toogood has reported also, in the Provincial Medical Journal of June 18th, 1842, an example of complete dislocation in this direction, in which the appearance was so dreadful, that Mr. Toogood at first despaired of being able to reduce it; but by directing two men to make counter-extension while he made extension, the reduction was immediately effected. At the end of one month the patient was able to leave his bed; and sixteen years after, Dr. Toogood saw him walking "with very little lameness." 2 Parker, of Liverpool, has reported another example in the London and Edinburgh Monthly Journal for December, 1842, which was occasioned by the fall of a heavy spar upon a man's back, and the consequent violent bending of the knee under his body. In this case the limb was slightly flexed, and the patella was loose and floating. The reduction was effected without much difficulty by extension and counter-extension made by two men, while the operator, placing his knee in the ham of the patient, attempted to bring the leg to a right angle with the thigh. 3 B. Cooper, Malgaigne, Little, 4 and others, have recorded examples of this accident. Dr. White, of Buffalo, politely invited me to see with him a lad, 33t. 10, whose tibia had been partially dislocated forwards eight weeks before, by a boy's having hit the top of his knee with his head, while they were at play. His father, who is himself a physician residing near town, reduced the limb very easily, by extension made with his own hands, and by pressing upon the projecting bones. Violent inflammation ensued, but at the time when I saw him, the knee was free from soreness or swelling, and the motions of the joint were nearly restored. 1 Gorde. Amer. Journ. Med. Sci., vol. xvi. p. 225, May, 1835. 2 Toogood, Amer. Journ. Med. Sci., vol. xxxi. p. 465. 4 Little, New York, Med. Times, Aug. 17, 1861. 3 E. Parker, ibid. 669 DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. § 3. Dislocations of the Head of the Tibia Outwards. Occasionally, owing to a violent wrencli of the knee-joint, the lateral ligaments upon one side or the other are ruptured, and consequently the joint surfaces separate somewhat from each other, or when the limb is moved, the head of the tibia may slide a little forwards or backwards, or to either side. These are not properly examples of subluxation: nor should we consider as belonging to this class the accident originally described by Mr. Hey, as an " internal derangement of the knee-joint," but which also by some writers has been termed a " subluxation of the knee." Of this latter accident, I will take occasion hereafter to speak a little more particularly. In subluxation, properly so called, if the direction of the dislocation is outwards, the outer condyle of the femur rests upon the inner articulating surface of the tibia, and if the direction of the dislocation is inwards, the inner condyle of the femur rests upon the outer articulating surface of the tibia. The signs which characterize this accident are such as cannot easil} T be mistaken. The limb is not shortened, nor is there anything especially diagnostic in its position, since it has been found to be sometimes flexed, and at other times straight; but the strong lateral projections made by the inner condyle of the femur on the one hand, and by the heads of the tibia and fibula on the other, cannot fail to inform us as to the true nature of the accident. The treatment will not differ essentially from that which has already been recommended in dislocation of the tibia backwards or forwards. If any other expedients can prove useful, they must be left to the judgment of the surgeon whenever the exigencies of the case shall demand them. I have already mentioned the case of N. Smith, who, in consequence of a fall from a window, had a dislocation of the right femur, tibia, and patella. The tibia was subluxated outwards, and the legwas partially flexed upon the thigh, with the toes everted. By moderate extension, made with my own hands, united with alternate flexion and extension, the bone was easily and promptly restored to its place. Having reduced the femur also, the limb was laid over a gently inclined plane made of pillows; and cloths moistened with cool water were kept constantly applied to the knee for many days. Very little swelling followed the accident, and his recovery was rapid and complete. A man was received into the North London Hospital, with a partial dislocation of the tibia outwards, and, although the knee was much swollen, the nature of the injury was easily determined. Fig. 273. Subluxation of the head of the tibia outwards. The knee was immovable, and the toes turned outwards. Mr. Hallam, 670 DISLOCATIONS OF THE HEAD OF THE TIBIA. the house surgeon, reduced it by extension and counter-extension made by his own hands. 1 Mr. Pitt records a similar case in a young lady, produced by a fall down a flight of stairs. It was reduced easily by extension and counter-extension. Inflammation followed, but it was finally controlled, and she regained the use of her limb. 2 In one case of subluxation, mentioned by Sir Astley Cooper, and in a second recorded by Bransby Cooper, the recovery of the functions of the joint did not seem to have been so rapid; the joint remaining unstable and tender for a long time afterwards. 3 § 4. Dislocations op the Head op the Tibia Inwards. There is nothing peculiar in either the signs, condition, or treatment of this accident, as distinguished from a dislocation outwards, to demand of us a special consideration. Sir Astley Cooper has mentioned two cases of subluxation inwards, and Mr. B. Cooper has added to these a third. Sir Astley remarks that in the first accident, the only one indeed which he had himself ever seen, he was struck with three circumstances: first, the great deformity of the knee from the projection of the tibia; second, the ease with which the bone was reduced by direct extension; and third, by the little inflammation which followed. The second case of which Sir Astley speaks was communicated to him by a Mr. Richards. In this case the fibula was also broken, and the reduction was accom- Fig. 274. Subluxation of the head of the tibia inwards. plished only after extension had been made by several persons for half an hour. The limb became excessively swollen, and remained so for many weeks. Eighteen months after the accident the knee continued somewhat stiff) and there was an unnatural lateral motion in the joint, from the injury which the ligaments had sustained. The patient referred to by Bransby Cooper had met with the accident by a fall upon the foot with his leg bent under him; and a fellow workman had reduced the bone by extension and pressure. Mr. Cooper thinks that not only the internal lateral ligament was torn, but also some fibres of the vastus externus and the crucial ligaments. Violent inflammation ensued, which did not permit him to leave the hospital until after about two weeks. 4 Fergusson has seen two examples of unreduced subluxation inwards, in both of which the patients had regained useful limbs. 5 Malgaigne mentions that Boyer, Costallat, and Key, had each seen one similar example; and he also enumerates two additional cases of complete luxation attended 1 Hallam, Amer. Journ. Med. Sci., vol. xix. p. 251. 2 Pitt, ibid., vol. xxxi. p. 4(55. s B. Cooper's ed. of Sir Ast., op. cit., pp. 111-13. * B. Cooper, ed. of Sir Ast., op. cit., pp. 211-13. 5 Fergusson, op. cit., p. 284. 671 HEAD OF THE TIBIA BACKWARDS AND OUTWARDS. with a protrusion of the bone through an external wound; in both of which the reduction was easily effected and the patients recovered 1 § 5. Dislocations op the Head op the Tibia Backwards and Outwards. In June, 1853, Henry J., of Dansville, 1ST. Y., set. 24, was thrown by an enraged bull, and his left leg being caught under the knee by the horns, was twisted violently. Dr. Prior, of Dansville, and Batton, of Burns, were called, and found the left knee completely dislocated; the tibia being displaced backwards beyond the condyles of the femur and also a little outwards. The foot and leg were inclined outwards. With the assistance of four men, extension and counter-extension were made in the line of the axis of the limb, and the reduction was easily accomplished. Pasteboard splints, bandages, &c, were applied to maintain the bones in place; but the swelling came on rapidly, and in the evening these dressings were removed. The limb was now laid over a double inclined plane carefully padded, in order to press the upper end of the tibia forwards, as it manifested a constant inclination to become displaced backwards. This apparatus was employed six weeks, with the exception of two or three days, during which the limb was laid upon pillows, but as the pillows did not sufficiently support the back of the tibia, the double inclined plane was resumed. After the removal of the plane, during seven weeks longer, an angular splint was kept closely applied to the back of the limb. Seven months after the accident, on the 23d of January, 1854, Dr. Robinson, of Hornellsville, brought the gentleman to me. I found the bones displaced backwards about three-quarters of an inch, and half an inch outwards, or to the fibular side. This was the position of the bones when he was sitting with his leg bent at a right angle with the thigh, but when he stood erect and bore some weight upon his foot, the outward displacement ceased, and the backward displacement only remained. It was very easy, however, in whatever position the leg might be, to push the bones forwards by the hands until nearly all deformity had disappeared. He could flex the leg to a right angle with the thigh, and straighten it completely, but he could not lift the foot and leg from the floor while sitting with his limb extended in front of him. He was unable to bear sufficient weight upon the foot to use it at all in progression, on account of the inability to fix and steady the limb, but not on account of any pain or soreness which it occasioned. It was very plain that the surgeons were not in fault for this unfortunate condition; indeed they seem to have exercised throughout great ingenuity and skill in its management. I directed the young man to Mr. John 0. Seiffert, of Buffalo, a very ingenious instrument maker, who has since succeeded, I learn, in adapting to his knee a mechanical contrivance which enables him to walk quite well. 1 Malgaigne, op. cit., torn. ii. p. 956. 672 DISLOCATIONS OF THE HEAD OF THE TIBIA. Thomas Wells, of Columbia, South Carolina, bas described a similar accident, the tibia being dislocated outwards and backwards, which terminated fatally on the fourth day, in consequence mainly of exposure, intemperance, and neglect to apply for surgical aid. The bones were never reduced, and the autopsy disclosed also a fracture of the internal condyle of the femur. 1 § 6. Internal Derangement op the Knee-Joint. Si/n. —" Slipping of the semilunar fibro-cartilages ;" Hey. " Partial dislocation of the thigh-bone from the semilunar cartilages ;" Sir Astley Cooper. " Subluxation of the semilunar cartilages ;" Malgaigne. " Subluxation of the knee ;" Erichsen. To these we think it proper to add, as giving rise to the same class of symptoms, " Floating cartilages in the knee-joint." We have already expressed our opinion that this accident is in no proper sense a subluxation of the knee; and we should not, therefore, think it worth while to make any farther allusion to it, were it not necessary in order to enable the student of surgery to distinguish between the phenomena which belong to it and those which belong strictly to subluxations of this joint. Symptoms. —The patient is suddenly thrown to the ground while walking, as if by an instantaneous loss of power in the affected limb, this loss of control over the limb being accompanied usually with sharp pain, referred to the region of the knee-joint; or he trips his toe against something in his path, and the toes becoming everted, the leg suddenly gives way under him; in some cases it has happened when the patient was turning in bed, the weight of the bedclothes hanging upon the toes so as to occasion a strain and rotation outwards at the knee-joint, or it follows upon a subluxation of the joint, as in one example which I shall presently relate. If the patient is walking when the accident takes place, and he falls to the ground, he finds himself unable to move the limb, or to stand upon it; but by manipulation, the difficulty is, in most cases, as easily overcome as it occurred, when immediately the motions of the joint become free, and he walks off as if nothing had happened. When the accident has once taken place, it is afterwards exceedingly liable to occur from very slight causes, and eventually the kneejoint becomes tender and the capsule fills with synovia, indicating the existence of subacute synovitis. A single example will illustrate the usual history of these cases. A young man, from Colesville, "N". Y.,set. 23, consulted me on the 27th of Oct. 1858, in relation to the condition of his knee-joint. He stated that on the 13th of Aug. 1858, while standing with the whole weight of his body resting upon the left leg, a mate struck him on the inside of the lower end of the left femur. The blow was made with the palm of the hand, but with sufficient force to throw him down. It was immediately noticed that the tibia was partially dislocated inwards at the knee-joint. The whole lower part of the limb was inclined 1 Wells, Amer. Journ. Med. Sci., vol. x. p. 25, May, 1S32. 673 INTERNAL DERANGEMENT OF THE KNEE-JOINT. outwards. A person present in the room seized upon the foot and by extension easily brought it back to place; the bone resuming its position with an audible snap. After this he continued to walk about until night. Two days after, the knee had become so much inflamed that he was obliged to take to his bed, on which he was confined three weeks. Gradually the swelling subsided, and in about five weeks after the accident he began to walk on crutches. On the 23d of Sept., he was walking in the store without crutches, when he suddenly felt a sensation of slipping in the joint, and he fell to the floor as if he had been tripped up. At the time when he called upon me, this had happened many times, but it has never been attended with pain. The joint was filled with synovia, and tender, yet I could distinctly feel a hard body just to the inside of the ligamentum patellae, and which moved freely under the finger. Pathological Anatomy. —The same class of symptoms, with only very slight modifications, belongs probably to several varieties of "internal derangement of the knee-joint;" and first it will be remembered that the semilunar cartilages upon which the margins of the condyles of the femur rest, are attached to the tibia by several ligaments ; but when, from relaxation or a violent strain, any one of these ligaments becomes elongated or gives way, the portion of cartilage which it restrains is permitted to become partially displaced, and by interposing its thick margin between the deeper articulating surfaces the bones are separated and the muscles lose their control over the joint; second, these ligaments may not only yield, but a fragment of one of the cartilages may become actually broken off from the main portion; third, the femur may perhaps escape behind some portion of an interarticular cartilage, and thus, instead of the cartilage placing itself between the joint surfaces, the femur itself may have thrust it into this position; fourth, a cartilage or some portion of a cartilage may become hypertrophied, and thus give rise to the symptoms described; fifth, in other cases still, a bony, cartilaginous, fibrinous, or calcareous growth or concretion forming within the joint, and if originally attached, becoming separated from the capsule, may move about more or less freely, and give rise to the same class of symptoms which we have described. This last variety has generally been described under the name of "floating cartilages;" but since these bodies are not always cartilaginous, and especially since they do not always by any means move so freely as to be properly designated as " floating," the term is less appropriate than that originally given by Hey, and which we have chosen to adopt. Treatment. —For the purpose of obtaining immediate relief it is generally sufficient to flex the leg. completely and then suddenly extend it, or to combine this motion with a slight twisting or rocking of the knee-joint. Sometimes this experiment has to be repeated several times before it is completely successful, and in a few instances it has failed altogether. I think I must have met with ten or twelve examples in the course of my practice, and in no instance has the sudden flexion and extension of the limb failed to overcome the difficulty. 674 DISLOCATIONS OF THE LOWER END OF THE TIBIA. As to the question of subsequent treatment, especially as to whether it is proper to attempt their extirpation when they are found to be loose, or to make any other surgical interference, I prefer to leave its consideration to those general treatises upon surgery where it more properly belongs. CHAPTER XIX. DISLOCATIONS OF THE LOWER END OF THE TIBIA. Syn. —"Tibio-tarsal luxations;" Malgaigne. "Dislocations of the ankle-joint;" Chelius and others. The tibia may be dislocated at its lower end in four directions; namely, inwards, outwards, forwards, and backwards. Most of these dislocations complicate themselves with fractures of the fibula, or of the tibia, or with fractures of both bones. Dupuytren, Malgaigne, and a few other surgeons have reported examples also of dislocations forwards and inwards. Boyer, with a majority of the French writers, and several English and German surgeons, speak of these dislocations as belonging to the foot; consequently the outward dislocation of Boyer is the inward dislocation of Sir Astley Cooper, Malgaigne, myself and others, who prefer to regard the tibia as the bone dislocated. § 1. Dislocations op the Lower End of the Tibia Inwards. Syn, —" Inward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot outwards ;" Boyer and others. >. Causes. —This dislocation is occasioned generally by a fall from a height, upon the bottom of the foot, the foot receiving at the same moment a sufficient inclination outwards to determine the main force of the impulse toward the inner side of the ankle. It may be produced also by a blow received directly upon the outside of the leg just above the ankle, or by a violent twist or wrench of the foot outwards. Pathological Anatomy. —I have already, in the chapter on fractures of the fibula, stated my opinion that a large majority of those accidents which have been called inward and outward dislocations of the tibia, were merely examples of lateral rotation of the astragalus within the half ginglimoid and half orbicular socket formed by the lower extremities of the tibia and fibula; and that true dislocations, either partial or complete, are at this joint and in these directions very rare occurrences. We shall continue, however, in accordance with the general practice of writers, to call them all dislocations, whether the 675 DISLOCATIONS OF LOWER END OF TIBIA INWARDS. astragalus simply rotates on its axis, or is displaced laterally and horizontally from the tibia. In the most common form of the accident, then, when the foot is violently twisted outwards, the astragalus becomes tilted upon its outer and upper margin in such a way as that this margin slides inwards and places itself underneath the middle portion of the lower articulating surface of the tibia; its upper and inner margin descends toward the extremity of the malleolus internus, and the outer face of the astragalus presents obliquely upwards and outwards, instead of directly outwards as it would do in its natural position. This cannot occur without a rupture of the internal tibio-tarsal ligaments, or a fracture of the malleolus internus, or both; indeed a fracture of the internal malleolus is a very common circumstance in connection with this form of dislocation. Much more frequently, however, the fibula Fig. 275. Dislocation of the lower end of the tibia inwards. itself gives way at a point within from two to five inches of its lower extremity; or sometimes the fracture in the fibula occurs through that portion which forms the malleolus externus. For more particular information as to the causes and relative frequency of these fractures, I refer the reader to the chapter on fractures of the fibula. Rarely it happens that instead of this lateral rotation of the astragalus, there occurs a true lateral displacement of the tibia inwards upon the astragalus, and the outer portion of the lower articulating surface of the tibia comes to rest upon the inner portion of the upper articulating surface of the astragalus; or it may slide completely off in the same direction; a result which is usually attended with a laceration of the muscles and integuments, converting the accident into a compound dislocation. In some cases this extreme displacement occurs without such lacerations. In this form of the accident, the true lateral luxation, the fibula may remain unbroken and undisturbed, the tibia merely having become displaced inwards ; or the fibula may give way also above the articulation, while the malleolus internus, and the internal lateral ligaments are equally liable to rupture as in the other form of the accident. Sometimes in addition to these complications, the lower end of the tibia is found to be broken obliquely upwards and outwards from the articulating surface, leaving that fragment attached to the fibula which corresponds to the inferior peroneo-tibial articulation. Symptoms. —The foot is more or less violently abducted, the sole of the foot presenting downwards and outwards instead of directly downwards; the malleolus internus projects strongly at the inner side of the joint; and at the outer side there is a corresponding depression, 676 DISLOCATIONS OF THE LOWER END OF THE TIBIA. generally most marked a little above the articulation near the point of fracture in the fibula. The pain is very great and the foot is immovably fixed, so far as the volition of the patient can determine motion, but the surgeon can generally move it prettly freely, yet not without causing a great increase of the pain. When the dislocation is complete, and the fibula also is broken, the limb becomes slightly shortened Fig. 27(5. Dislocation of the lower eud of the tibia inwards. Treatment. —When the accident is of the nature of a simple rotation of the astragalus upon its axis, the reduction is often accomplished with the greatest ease by seizing upon the foot, and forcibly adducting it. Not unfrequently the patient himself, or some other person who is present, has effected the reduction before the surgeon is called. In other cases, and especially when it partakes of the nature of a true dislocation, much difficulty is sometimes experienced in the reduction. The surgeon ought then to flex the leg upon the thigh, in order to relax the gastrocnemii muscles, and holding the foot midway between flexion and extension, he should pull steadily upon it with his own hands, while an assistant makes counter-extension, and supports the limb with his hands, grasping the thigh above the knee. At the same moment lateral pressure should be made upon the projecting bone in the direction of the articulation. It is of some use, also, to occasionally flex and extend the limb moderately, and to give to the foot a gentle rocking motion. If more force is needed, it may be applied by placing the limb over a firm double inclined fracture splint, 677 DISLOCATIONS OF LOWER END OF TIBIA INWARDS. and making the extension by the aid of a screw attached to the footboard, as we have suggested in certain cases of dislocation at the knee. Or we may employ the pulleys after the manner represented in the accompanying drawing. Fig. 277. Charles Saner, of this city, aged about thirty years, while carrying a weight upon his shoulders, on the 6th of May, 1854, slipped upon the side walk and fell, dislocating the left tibia inwards and fracturing the fibula four inches from its lower end. I was in attendance soon after the accident occurred, and found the tibia projecting inwards, with the other symptoms usually accompanying a simple rotation of the astragalus upon its axis. Seizing the foot with my hands, and flexing the leg, while an assistant held up the thigh and made counterextension, I had scarcely begun to pull upon the foot before the reduction was effected. Dupuytren's splint was at once applied, and the subsequent inflammation was so trivial as scarcely to deserve notice. In six weeks the limb was sound, and free from all anchylosis. In my report on dislocations, made to the New York State Medical Society for the year 1855,1 have mentioned twelve similar examples, in addition to some examples of compound dislocations, all of which were easily reduced, but the results were not always so favorable. If, as rarely happens, the tibia is broken obliquely into the joint, the complete reduction of the dislocated tibia may be found impossible, owing to the obstacle presented by the displaced fragment. The following I am disposed to regard as examples of dislocation accompanied with fracture of the tibia within the articulation. Brockway, of Cortland, N. Y., aged about twenty-seven years, consulted me at my office a few years since in relation to the condition of his foot. I found the tibia dislocated inwards and projecting more than an inch beyond the astragalus; the foot was turned outwards, compelling him to walk upon the inside of his foot; the fibula was bent inwards against the tibia, at a point about four inches above the ankle, which seemed to have been the seat of fracture of this bone. He stated to me that immediately after the receipt of the injury, which was occasioned by a fall from a height upon 'the bottom of his 678 DISLOCATIONS OF THE LOWER END OF THE TIBIA. foot, lie had consulted a surgeon, Dr. A. B. Shipman, of Cortland, and that although Dr. Shipman made repeated and violent efforts to effect the reduction, he had been unable to do so. Indeed the bone had never been removed from the position in which it was at first placed. J. Borland, of Erie Co., N. Y., set. 31, fell under a rolling log and dislocated his left tibia inwards, breaking off the internal malleolus, and fracturing the fibula four inches from its lower end. Dr. Sweetland, an old and experienced practitioner, was immediately called, who, with another surgeon, failed, after repeated efforts, to reduce the dislocation. I saw the patient, in consultation with these gentlemen, twenty-four hours after the accident. The foot and ankle were somewhat swollen, and discolored. The lower end of the tibia projected so far inwards as to threaten a rupture of the skin; the foot was strongly everted. We first flexed the leg upon the thigh, and made extension with our hands, in the manner I have already directed. This we continued several minutes; finally moving the limb in various directions, and adding forcible pressure upon the inside of the projecting tibia. We then placed the leg over a double-inclined plane, and, securing it firmly in place, we attached a screw to the foot through a sandal and gaiter, and while the leg was well flexed upon the thigh, we renewed the extension and lateral pressure. This was continued with the application of more or less power, during half an hour, meanwhile changing the position of the limb occasionally by varying the angle of the splint. Our efforts were prolonged in all more than one hour, when, as we had made no impression upon the bone, and the patient had repeatedly implored us to desist, the attempt was given over. The end of the tibia seemed to rest partly upon the astragalus, and the extension was plainly all that was demanded, but the obstacle was beyond doubt within the articulation, or rather between the tibia and fibula. Four weeks after the accident, Mr. Borland walked on crutches, and during a year he was compelled to use a cane, but since that time, a period of twelve years, he has walked without any artificial support. For a year or two he felt a yielding in his ankle, as the weight of his body settled upon his limb ; but this gradually ceased, and for some years past he has walked without any halt, and seems to step as firmly as before the accident. The foot still inclines outwards; the tibia projects inwards one inch, and the broken ends of the fibula can be felt resting against the tibia, where they are united. Not long since I had occasion to amputate a limb for a compound dislocation inwards at the ankle-joint, and the possibility of this fracture was confirmed by the dissection. About one-third of the outer portion of the articular surface was broken off obliquely, and the fragment was lying so displaced that a reduction would have been rendered impossible. Dr. Townsend, of Boston, has reported a case of compound dislocation, in which also amputation became necessary; and, with other injuries, the dissection showed a fragment from the outer margin of the tibia, one inch and a half long, and one inch thick at its widest 679 DISLOCATIONS OF LOWER END OF TIBIA OUTWARDS. part, with a very sharp point, displaced and lying almost transversely over the astragalus. 1 For a more full account of the prognosis and the general management of these cases subsequent to the reduction, I beg again to refer the reader to the chapter on fractures of the fibula; and for my views in relation to the treatment of compound dislocations of the ankle-joint I will refer also to the chapter on compound dislocations of the long bones. § 2. Dislocations or the Lower End of the Tibia Outwards. Syn. —"Outward tibio-tarsal luxation ;" Malgaigne. " Dislocations of the foot inwards," of others. The causes are the same or similar to those which are known gene- rally to produce dislocations inwards ; only that the force of the concussion or the direction of the rotation must have been reversed. The external lateral ligaments, peroneo-tarsal, are either ruptured or the lower portion of the fibula gives way, or both of these circumstances may have happened ; while the internal malleolus may also yield to the shock and to the weight of the body now resting upon it. The nature of the accident may vary also in respect to the relative position of the articular surfaces; the astragalus may simply rotate on its inner and upper margin, or the tibia, with the fibula of course, may actually slide outwards until the lower end of the tibia more or less completely abandons the upper surface of the astragalus. The modes of reduction and the general principles of treatment subsequently, will not differ from those which we have mentioned as suitable for dislocations in the opposite direction. The Fig. 278. Dislocation of the lower end of the tibia outwards. examples which have fallen under my observation are not numerous, tf e reduction has always been easily effected. Thus a man, aet. 21, fell from a scaffolding, alighting upon his feet. He says that his 1 Townsend, Mass. Hosp. Reports, Bost. Med. and Surg. Journ., vol. xxxiii. p. 277. 680 DISLOCATIONS OF THE LOWER END OF THE TIBIA. left foot struck the ground obliquely and upon its outer margin. I found the fibula projecting very strongly outwards, evidently carrying with it the tibia, the malleolus internus was broken off, and the foot forcibly turned inwards. Without either flexing the leg upon the thigh or calling to my aid any degree of counter-extension except what was made by the weight of the body, I grasped the foot and drew upon it gently, while at the same moment I rotated the foot outwards. Immediately the bones resumed their places. In June of 1846, Henry Wilson, ast. 38, consulted me in relation to his foot, which he said had been dislocated four weeks before. He had fallen upon the outside of his foot and turned it suddenly inwards, so that when he looked at it he found the sole presenting toward the opposite side. Seizing upon it with both hands, he pressed it forcibly outwards, and the reduction immediately took place with a snap. Very little soreness followed, nor was he confined to his house a single day. He had continued to walk about with only a slight halt in his gait, nor would he have thought it necessary to consult me at all except that the tenderness had not yet disappeared. He was not aware that the fibula had been broken also, until I called his attention to the fact. The fracture had taken place two inches above the ankle; and, although it was already united, the depression occasioned by its having fallen in somewhat toward the tibia was very plainly felt and recognized. § 3. Dislocations op the Lower End of the Tibia Forwards. Syn. —" Forward tibio-tarsal luxations ;" Malgaigne. "Dislocations of the foot backwards," of others. Causes. —This dislocation may be produced by a violent extension of the foot upon the leg; as, for example, when, the foot being engaged under a piece of timber, the body falls backwards to the ground; or when, the leg remaining fixed, a heavy weight descends upon the front of the foot; or it may be caused by a fall upon the bottom of the foot, the foot resting upon an inclined plane; by a blow upon the back of the tibia, or possibly, even by the toes being brought violently in contact with some firm body. Pathological Anatomy. —The displacement may be very slight, so that the end of the tibia is only a little advanced upon the astragalus; or it may be such that the tibia rests one-half upon the naviculare and one-half upon the astragalus, or it may even desert the astragalus entirely. In these latter examples, the lateral ligaments suffer more or less complete laceration. The fibula is generally broken on a level with the articulation, the malleolus internus also in some cases, and still more rarely a fracture occurs through the posterior margin of the articular surface of the tibia. Symptoms. —The length of the foot in front of the tibia is diminished, while the projection of the heel is correspondingly increased; the toes are turned downwards, and the heel drawn upwards, and fixed in this position; the end of the tibia may generally be distinctly felt 681 LOWER END OF THE TIBIA FORWARDS. in front of the astragalus; the extensor tendons of the toes are sharplydefined, while the tendo-Achillis is curved forwards, and tense. Treatment. —The reduction is to be attempted by flexing the leg upon the thigh, and making extension from the foot, while, at the same moment, pressure is made upon the front of the tibia and against the heel. When the bone begins to slide into place, the foot should be forcibly flexed upon the leg. A slight lateral motion or rotation in either direction may assist in restoring the bones to place. Fig. 279. Fig. 280. Dislocations of the lower end of the tibia forwards In general, the dislocation has been easily reduced, but in a majority of the examples recorded great difficulty has been experienced in maintaining the reduction; and in a few cases it has been found impossible to do so. In order to maintain the reduction, the leg, flexed upon the thigh, should be laid on its back in a box; and the foot supported firmly against a foot-piece placed at a right angle with the box. In this position, the weight of the leg will tend somewhat to overcome the action of the muscles which are disposed to displace the foot backwards. Generally it will be found necessary to make additional pressure directly upon the front of the leg above the ankle; which, in order that it may not prove mischievous, must be effected with some soft material, and must be applied over a broad surface. Perhaps nothing will better answer these indications than to pass a cotton band, six or eight inches in width, through slits or mortises in the sides of the box; these slits being of a width equal to the width of the band, and placed at a point sufficiently below the level of the spine of the tibia, so that when the band is made fast underneath the box it shall press the leg firmly backwards. To prevent the heel from suffering m consequence of this pressure, it also should be supported, or suspended by another band passing underneath the heel and fastened above to the top of the foot board. 44 * 682 DISLOCATIONS OF THE LOWER END OF THE TIBIA. Dupuytren relates the following example of this rare accident:— Pierre Froment, set. 33, was carrying a heavy weight upon his back, and had his right foot in advance, when by accident he came suddenly in contact with a beam placed across his path. Under the fear of being precipitated forwards, he made a sudden effort to throw his body backwards, by which he lost his balance, and fell with the point of the left foot inclined inwards and forwards, and his whole weight was thrown first on the outer side, and then on the front of the anklejoint. On examination the leg seemed to be planted upon the middle of the foot; the toes were directed downwards and the heel drawn up. On the instep there was a large bony prominence, over which the extensor tendons of the toes were stretched like tense cords. Behind the joint was a deep hollow, at the bottom of which the tendo-Achillis cOuld be felt, forming a tense, resisting, semicircular cord, with its concavity directed backwards. The fibula was also broken; the lower end of the lower fragment remaining attached to the foot, while the upper end of the same fragment was carried forwards by the displacement of the tibia, so that it lay nearly horizontally, with its broken extremity directed forwards. Dupuytren directed one assistant to fix the leg, and a second to make extension from the foot, while Dupuytren himself, standing on the outer side of the limb, forced the heel forwards and the tibia backwards. The first attempt succeeded partially, and the second completed the reduction. The limb was then placed in the apparatus employed by this surgeon for a fractured fibula, which we have before described, and laid on its outer side in a semiflexed position. The patient recovered rapidly, and in little more than a month he was able to walk.' But such fortunate results have not usually been observed; indeed Dupuytren encountered much more serious difficulties in two other cases which came-under his own notice, one of which he has himself recorded. This was in the person of a woman set. 48, who was brought to the Hotel Dieu in 1815, the accident having just happened from a slip in going down stairs. The fibula was broken, and also a fragment was broken from the tibia. The house surgeon reduced the bones and placed the limb in the ordinary apparatus for broken legs, but on the following day Dupuytren found them reluxated, and laid the limb on his own splint, but the pressure requisite to keep the tibia in place soon induced sloughing, ulceration, and abscesses, and after four months' treatment, during which time the tibia had been repeatedly displaced, she left the hospital able to use her limb, but with a certain amount of incurable deformity. 2 Malgaigne mentions the third example as having been seen by himself in Dupuytren's service in 1832, in which case the attempt to maintain the reduction by a tourniquet resulted in gangrene and finally the death of the patient. 3 Earle lost a patient after amputation 1 Dupuytren, Injuries and Dis. of Bones. London ed., p. 278. 2 Op. cit., p. 276. 3 Malgaigne, op. cit., p. 1044. 683 LOWER END OF THE TIBIA BACKWARDS. made on the eighth day. The tibia could not be kept in place, and the amputation became necessary on account of the final protrusion of the bone through the integuments, which had sloughed. 1 § 4. Dislocations of the Lower End of the Tibia Backwards. Syn. —" Backward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot forwards," of others. More rare even than the dislocations forwards, Malgaigne has nevertheless succeeded in collecting five examples. They appear to have been produced generally by a cause the reverse of that which we have seen to produce so often the preceding dislocation. Thus while the dislocation forwards is produced most frequently when the foot is in violent extension, this dislocation has occurred in at least two or three cases, when the foot was forcibly flexed upon the leg. The symptoms are strongly marked and characteristic. The length of the foot from the tibia to the ends of the toes is increased one inch or more; the heel being correspondingly shortened, or rather wholly obliterated ; a portion of the articulating surface of the astragalus may be distinctly felt in front of the tibia; the posterior surface of the tibia touches the tendo-Achillis; the leg is shortened and the malleoli approach the sole of the foot. In most cases one or both of the malleoli have been broken; and R. W. Smith, who has reported one of the examples alluded to, believes that the dislocation is never complete. Fig. 281. Fig. 281. Fig. 282. Dislocations of the lower end of the tihia backwards Reduction should be attempted by a method similar to that which has been recommended in all the other dislocations of the ankle; only with such modifications as the peculiarities of the case must necessarily suggest. 1 Malgaigne, op. cit., p. 1044. 684 DISLOCATIONS OF THE UPPER END OF THE FIBULA. CHAPTER XX. DISLOCATIONS OF THE UPPER END OF THE FIBULA. Syn. —"Luxations of the superiorperoneo-tibial-articulation;" Malgaigne. Surgeons have frequently described a condition of the peroneotibial articulation, in which the ligaments have become relaxed, giving a preternatural mobility to the head of the bone. It is also not unfrequently displaced upwards, in consequence of an oblique fracture of the tibia. I have myself seen several examples of both these accidents ; but simple traumatic dislocations, which can only occur forwards or backwards, are very rare. § 1. Dislocations op the Upper End of the Fibula Forwards. • Malgaigne has collected three examples of this luxation, uncomplicated with any other accident, and not apparently due to any abnormal condition of the ligaments, two of which at least seemed to have been produced by the violent action of the muscles which are attached to the anterior face of the fibula. The third example, reported by Thompson, in the London Lancet, 1 permits a doubt as to whether the displacement was occasioned by muscular action, or by a direct blow upon the part. The signs which characterize the anterior luxation are the absence of the head of the fibula in its natural position, and its presence in front, near the ligamentum patellae; the altered direction of the biceps flexor cruris muscle; and, in one case, considerable deformity in the shape and position of the leg has been observed. Thompson and Jobard were unable to accomplish the reduction while the leg was extended upon the thigh, but succeeded readily after having flexed the leg. On the other hand, Savournin succeeded with the leg extended, but with the foot flexed upon the leg. Malgaigne, to whom I am indebted for these observations, thinks that flexion of the leg, combined with flexion of the foot, would render the reduction more easy. In whatever position the limb is placed, the surgeon must rely chiefly upon forcible pressure made with the fingers against the front and upper portion of the displaced bone. J. E. Hawley, of Ithaca, N. Y., a distinguished practitioner, and late Prof, of Surgery in the Geneva Medical College, has furnished me with a brief account of a case which came under his own observation. Op. cit., 1850, vol. i. p. 385. UPPER END OF THE FIBULA BACKWARDS. 685 On the 29th of March, 1854, Bambak, while vaulting upon the parallel bars in a gymnasium, unintentionally made a complete somerset, and fell with his right foot upon the edge of a plank. Dr. Hawley, who was immediately called, found his right leg semi-flexed and immovably fixed. The head of the fibula was plainly felt in front of its natural position, near the ligamentum patellae. The patient was suffering the most intense pain. Extension and counter-extension were made, and while the doctor was pressing with both of his thumbs upon the head of the fibula, it went into its place with an audible snap. The relief was instantaneous. Complete rest was observed for a few days, while cooling lotions were constantly applied, and within a week he was able to attend to his usual duties. § 2. Dislocations op the Upper End of the Fibula Backwards. Sanson has recorded one example, in which the passage of the wheel of a carriage across the upper part of the leg, precisely on a level with the peroneo-tibial articulation, ruptured the ligaments which bind the fibula to the tibia, and caused a displacement which, however, seems to have been spontaneously overcome. Nevertheless there remained a preternatural mobility, permitting the fibula to be pushed easily backwards or forwards upon the tibia. The only example of a permanent backward displacement is related by Dubreuil. A man, aet. 62, in order to save himself from falling sprang suddenly, with his right leg in a position of extreme abduction, and at the same moment he experienced a severe pain in the region of the peroneo-tibial articulation. The head of the fibula was found to be thrown backwards, and formed under the skin a marked prominence ; the foot was drawn outwards, and the whole outside of the limb became cold and numb. Dubreuil flexed the leg moderately, and pressing the head of the fibula from behind forwards, the reduction was easily effected. On the following day, the limb having been straightened, the dislocation was found to be reproduced. It was again replaced, and the knee covered with a leather cap, secured moderately tight. After twelve days of complete rest, the knee was moved gently, and on the seventeenth day the patient walked with the help of a cane. For some time the leg had a tendency to incline outwards; but in about three months the cure was perfectly established 1 It is probable that in 'this case the dislocation resulted from the violent action of the biceps flexor cruris. Such at least is the opinion of both Dubreuil and Malgaigne, and I see no reason to question the correctness of their theory. Malgaigne, op. cit., torn. ii. p. 386. 686 TARSAL LUXATIONS. CHAPTER XXI. DISLOCATIONS OF THE INFERIOR PERONEO-TIBIAL ARTICULATION. Nelaton relates the only example of a simple luxation of this articulation of which we have any information. The patient who was the subject of this accident, presented himself at the hospital under the care of M. Gerdy on the thirty-ninth day after the accident, which had been occasioned by the passage of the wheel of a carriage obliquely across the leg in such a manner as to push the malleolus externus directly backwards. The lower end of the fibula was in almost direct contact with the outer margin of the tendo-Achillis; the outer face of the astragalus, abandoned by the fibula, could be distinctly felt in nearly its whole extent; the foot preserved its natural position ; and he could walk pretty well, only that he was obliged to step with some care. M. Gerdy believed that the bone was too firmly fixed in its new position to be moved, and therefore made no attempt at reduction. CHAPTER XXII. TARSAL LUXATIONS. § I. Dislocations of the Astragalus. Malgaigne, who speaks also of luxations " sub-astragaloid," has thought proper to call the dislocations which we now propose to consider " double dislocations of the astragalus." In the variety first named, the astragalus retains its connections with the tibia, but separates from the scaphoid bone, while its relations to the calcaneum are only slightly disturbed. This we prefer to regard as one of the many varieties of tarsal luxations, and shall appropriate to it no specific appellation, except to designate it as astragalo-scaphoid, or astragalocalcaneo-scaphoid, according as more or less of the several articulations are disturbed. In the second named variety, called by Malgaigne a " double" luxation, and which constitutes the subject of this chapter, the astragalus abandons all the articular surfaces against which it is naturally 687 DISLOCATIONS OF THE ASTRAGALUS. applied, and thrusts itself out from between the tibia, fibula, calcaneum, and scaphoides; so that it may be said to have suffered a triple or quadruple rather than a " double" dislocation, as is implied by the nomenclature adopted by Malgaigne. This we choose to regard as the only true dislocation of the astragalus, and as such we propose to designate it by the simple term " dislocation of the astragalus." The astragalus may be dislocated forwards, outwards, inwards, backwards ; or it may be dislocated obliquely in either of the diagonals between these lines; it may be simply rotated upon its lateral axis without much, if any, lateral displacement; and, finally, it has been occasionally driven between the tibia and fibula, tearing away the intermediate ligaments, and generally fracturing one or both bones of the leg. Causes. —The causes which have been found chiefly operative in the production of this dislocation are very much the same as those which produce, under other circumstances, a dislocation of the lower end of the tibia. Fig. 283. Dislocation of astragalus outwards. Anatomical relations. Thus, a fall from a height upon the bottom of the foot, accompanied with a violent abduction, adduction, flexion, or extension, may determine a dislocation of the astragalus inwards, outwards, backwards, or forwards. Sometimes it is accomplished by a mere wrenching and twisting of the foot in machinery, or in the wheel of a carriage, or by being caught between two irregular bodies. It may be produced also by a direct blow. Symptoms. —The great prominence occasioned by the displacement of the bone in either of these several directions, accompanied generally with more or less lateral deviation of the foot, is alone sufficient to indicate the true nature of the accident. In some cases, also, the foot is forcibly flexed or extended; the leg is shortened in consequence of the tibia having fallen down upon the calcaneum ; the superincumbent skin and tendons are rendered tense ; blood is effused, and swelling speedily occurs. In the backward dislocation, the position of the foot is not much changed, but the tibia being slightly carried forwards, the length of the dorsal aspect of the foot is proportionably diminished. Such are the symptoms which plainly enough indicate the dislocation in the most simple cases; but in a majority of the examples which have been seen, the integuments have been more or less extensively torn, exposing to the eye at once the naked bone, and thus removing all chance of error in the diagnosis. Norris mentions a case, seen by Hammersley, in which the astragalus was thrown completely out, and was subsequently found in the 688 TARSAL LUXATIONS. earth where the patient had received his injury. Inflammation, gangrene and tetanus supervened, and the patient died on the seventh day. 1 Fig. 284. Simple dislocation of the astragalus outwards. Fig. 285. Compound dislocation of the astragalus inwards. Prognosis. —It will be readily understood that nothing short of very great violence could disturb and completely break up the connections of a bone so compactly and firmly seated as is the astragalus, and that aside of any unusual complications, under the most favorable circumstances, intense inflammation must naturally be anticipated; and with few exceptions this has actually taken place. Even when reduction has been promptly and easily effected, inflammation, gangrene, and death have sometimes speedily ensued. But more often the reduction has been found to be exceedingly difficult or impossible, and complete removal of the bone or amputation has been immediately demanded. In a limited number of cases, on the other hand, the bone has been easily reduced, and recovery has taken place with a tolerably useful limb; or resection has been practised with an equally favorable result; in still other cases the bone has been left protruding, and the patient has finally recovered so far as to be able to walk again, but in such a crippled condition as to render the achievement a very doubtful triumph of conservative surgery. Norris, of Philadelphia, relates the following case, illustrating the imminent danger to which even the life of the patient may be exposed in those examples which are apparently the most simple. William Summerill, set. 30, was admitted to the Pennsylvania Hospital on the twenty-sixth of September, 1831. An hour previous, 1 Norris, Amer. Journ. Med. Sci., 1837, p. 383. 689 DISLOCATIONS OF THE ASTRAGALUS. while descending a ladder, he slipped and fell in such a manner as to throw the entire weight of his body upon the outer part of his left foot. The foot was turned inwards, and nearly immovable; a slight depression existed immediately below the lower end of the tibia, and there was a hard rounded projection on the outer part of the foot a little below and in front of the extremity of the fibula; the skin over this projection was not broken or excoriated, but reddened; there was no fracture of either bone of the leg. The symptoms rendered it plain that the astragalus was dislocated forwards and outwards. Dr. Barton, under whose care the patient was received, proceeded soon after to make attempts at reduction. The muscles of the leg were relaxed as much as possible, and extension made from the foot by seizing the heel and front part of the foot while an assistant made counter-extension at the knee. The bone was also pushed inwards toward the joint by the surgeon. These efforts were continued for a considerable time, but had no effect in changing the position of the bone. Six hours afterwards, Drs. Harris and Hewson being in consultation, the attempt was again made to accomplish the reduction, but without success; and the surgeons immediately proceeded to excise the bone. An incision was made parallel with the tendons, commencing a short distance above the projection and extending down far enough to expose fairly the astragalus and its torn ligaments. The bone was then seized with the forceps and easily removed after the division of a few ligamentous fibres that continued to connect it with the adjoining parts. Very little bleeding occurred, only two small arteries requiring the ligature. After removal, it was discovered that about one-half of the surface which plays in the lower end of the tibia had been fractured, and that it remained firmly attached to the extremity of that bone. No attempt was made to remove this fragment; but the joint being carefully sponged out, the sides of the wound were brought together and closed by sutures, adhesive straps and a roller; after which the foot, placed in its natural position, was laid in a fracture-box. On the fifth day a slough began to form upon the outside of the foot, which was followed by suppuration at other points, and on the thirteenth day an opening was made to evacuate the pus near the malleolus internus. At the end of about eight weeks the fragment of the astragalus which had been suffered to remain, was found to be carious, and it was removed; the heel also had ulcerated from pressure, and several other bones of the tarsus were discovered to be carious. Fifteen months later, this poor fellow was still in the hospital suffering from hectic, with extensive disease in the bones of the tarsus and anklejoint. Finally, amputation of the leg was practised by Dr. Barton, a few days after which he died. 1 Norris mentions also two examples of simple dislocation of the astragalus at the Pennsylvania Hospital which came under the observation of Dr. Barton, in both of which the bone was left unreduced. 1 Norris, Amer. Journ. Med. Sci., Aug. 1837, p. 378. 690 TARSAL LUXATIONS. In one case inflammation and sloughing soon effected a complete exposure of the protruding bone, but after a time the skin cicatrized. At the end of five months the patient walked and had good use of the joint, though great deformity of the foot existed, and he continued to be subject to ulceration of the newly-formed skin on its outer part. In the other case gangrene supervened soon after the accident, and the patient died. m Norris adds that "the late Professor Wistar removed the astragalus in a case of compound dislocation, and the patient was cured with some motion at the joint." Dr. Alexander Stevens, of New York, made the same operation in a case of compound dislocation, and after several months, he affirms that the patient " has recovered with very trifling deformity of the foot, and with a flexible joint. He walks with very slight lameness." 1 The dislocations backwards, of which seven examples only have been recorded, have all with but one exception been left unreduced; yet in at least four instances the patients have recovered with pretty useful limbs. Such was the fact with Liston's and Lizar's patients, and also with Mr. Phillips' two cases, to all of which I shall again refer. It must be noticed, however, that in each of the cases mentioned as followed by a successful termination without reduction, the dislocations were simple. Turner, of Manchester, has reported one example of compound luxation outwards and backwards, which, finding himself unable to reduce, he removed the astragalus with a tolerably successful result. 2 Finally a case was presented in one of the London hospitals in 1839, of a dislocation inwards and backwards, which was reduced in about ten minutes, by extension accompanied with lateral pressure. 3 Treatment. —Yarious attempts have been made by surgical writers to determine the line of treatment which should be adopted in these unfortunate cases, but with very unsatisfactory results, since they are far from having arrived at similar conclusions, nor have they been able always to settle the question definitely for themselves. The difficulty consists in the multiplicity, and lack of uniformity in the complications which attend these accidents, rendering it impossible to establish a classification upon which an uniform treatment may be safely based. There are certain principles, however, which seem to be sufficiently settled to allow of an authoritative announcement; these may be briefly stated as follows: If the dislocation is simple, reduce the astragalus immediately, provided this is. possible. If the luxation is complete, and it cannot be reduced, even partially, proceed at once to resection or to amputation. In compound dislocations, resection or amputation affords the only safe resource. In all cases the inflammation is likely to be intense, in order to prevent which complication the surgeon must be unremitting in his use of the appropriate remedies. 1 Stevens, North Amer. Med. and Surg. Journ., Jan. 1827, p. 200. 2 Turner, Trans. Proviu. Med. and Surg. Journ., vol. ix. Essay on Disloc. of Astrag. with nearly fifty cases. 3 London Lancet, vol. ii. p. 559. DISLOCATIONS OF THE ASTRAGALUS. 691 Out of eighteen cases of complete excision of the astragalus, collected by Turner, fourteen made good recoveries, and in only one of these fourteen was there anchylosis. These several points we shall proceed to illustrate a little more fully. In a recent simple luxation of the astragalus forwards, the leg should be flexed to a right angle with the thigh, and for the purpose of making extension, one assistant should take hold of the foot with both hands in the same manner that a servant draws a boot, that is, with the right hand grasping the heel, and the left placed upon the dorsum of the foot near the toes. A second assistant should seize the lower part of the thigh in order to make counter-extension, while the surgeon presses with the ball of his hand against the head of the astragalus, upwards and backwards. If these simple measures fail, the pulleys ought to be employed as a substitute for the hands in making extension. In applying the extension, the toes must be kept well down, and occasionally the foot should be moved gently from one side to the other. An oblique dislocation must be reduced, if possible, to an anterior luxation, before an attempt is made to carry the head of the bone back to its place, as by this mode the reduction will be greatly facilitated. Lateral luxations may be reduced by the same means; but if the astragalus is dislocated outwards the foot must be held forcibly adducted during the extension, and if it is dislocated inwards, the foot must be held strongly in the opposite direction. Lizars says that he has seen one case of backward luxation, and that all attempts at reduction were unavailing, The limb was, however, preserved, and proved to be useful. 1 Liston was equally unsuccessful in a case which came under his notice. 2 Phillips has reported two cases, in neither of which was the reduction accomplished 3 Nelaton has seen a compound dislocation which he could not reduce. 4 Mr. Erichsen, however, who admits that when dislocated backwards it has not hitherto been reduced, declares that the surgeons at University Hospital have succeeded in one case recently, in which both the tibia and fibula were broken also. 5 Mr. Erichsen suggests also that in case of a failure by the ordinary means, we should resort to a subcutaneous section of the tendo-Achillis. Mr. Williams, of Dublin, in a similar case, which had been left unreduced, was obliged finally to extract the bone, in consequence of the integuments having sloughed* Compound dislocations, and such as are otherwise complicated, demand of the surgeon immediate amputation, or exsection, the latter of which ought to be preferred whenever the condition of the limb encourages a reasonable hope that the foot may be saved. 1 Lizars, System of Practical Surg., Edinburgh ed., 1847, p. 161. 2 Liston, Elements of Surgery, vol. iii. p. 348. 3 Phillips, Lond. Med. Gaz., vol. xiv. p. 596. 4 Nelaton, Pathologie Chirurg., t. ii. p. 482. 6 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 270. 6 Williams, Erichsen, op. cit., p. 271. 692 TARSAL LUXATIONS. When exsection is practised, and the bone is found to be broken, as it often is, all the fragments should be carefully removed, since they are certain to become necrosed if left in place. Nor ought the surgeon to hesitate to lay open freely the tissues in every direction, in order that he may accomplish this purpose; even the tendons lying over the protruding bone may be sacrificed unhesitatingly, since after having been so severely bruised, stretched, and lacerated, they are pretty certain to slough. Indeed the more freely the tissues are divided over the bone, the less will be the danger of inflammation, and the safer will be the life and limb of the patient. In addition to the examples already cited of compound dislocation in which the astragalus was removed, the following, reported by Dr. W. A. Gillespie, of Ellisville, Va., will also illustrate the occasional value of exsection in these severe accidents. Mrs. A., aged about fifty years, fell from a horse on the 23d of May, 1833, dislocating both ankles. The luxation of the right foot was accompanied with a luxation of the astragalus outwards, which projected through a very large wound in the integuments, and its trochlea was placed at an angle of about 45° with its natural position. Early on the following day it was removed by severing its few remaining connections, and the wound was immediately closed by stitches, adhesive plasters, and light dressings. From the moment of the receipt of the injury, and for several days afterwards, she suffered excruciating pain in the limb, and on the third day tetanus was apprehended, but its full accession was prevented by the free use of opiates. The limb was suspended in N. E. Smith's fracture apparatus; and as gangrene with hectic fever soon threatened the life of the patient, fermenting poultices were diligently applied, and the patient was sustained by wine, bark, and other tonics. Two months after the injury was received, the date at which the report is given, the wound had entirely healed, and her complete recovery was regarded as certain. 1 Many other similar examples have been reported by foreign surgeons. One word more with regard to the treatment of the wound after excision. A considerable experience in accidents and wounds of this class, that is, wounds accompanied with great contusion and laceration, has convinced me that the practice of closing the surface with sutures, adhesive plasters, bandages, &c, is eminently pernicious. The effusions which must necessarily occur, and which indeed we think ought to occur, are thus imprisoned beneath the skin, giving rise to swelling, pain, inflammation, and finally suppuration or sloughing. It is far better, in our opinion, to leave the wound open, covering it only with cloths constantly kept moist with cool water. For this latter purpose some mode of irrigation is preferable, as being more constant and uniform. To those who have never adopted this treatment of contused wounds, or of wounds generally, we would recommend an early trial, feeling confident that they will never have occasion to regret the experiment. 1 Gillespie, Amer. Journ. Med. Sci., Aug. 1833, p. 552. 693 ASTR AGALO- CALCANEO- SC APHOI D DISLOCATIONS. § 2. Astragalo-Calcaneo-Scaphoid Dislocations. It is perhaps quite as common for the astragalus to be dislocated from the scaphoid bone and calcaneum, while it retains its connections with the tibia, as to be luxated from all these bones at the same time. This astragalo-calcaneo-scaphoid dislocation is that which Malgaigne has termed "sub-astragaloid." Produced by the same causes which determine true dislocations of the astragalus, it may occur in the same directions, and is liable to the same complications ; nor will either the prognosis or treatment differ essentially from that which is recognized and established in the other accident. As in dislocations proper of the astragalus, so also in this accident, opposite results have occasionally followed from similar modes of treatment. Thus, Dr. Detmold, of New York, stated in 1856 to the New York Academy of Medicine, that he had recently met with a dislocation of the astragalus, in which the bone retained its proper relations with the tibia, but not with the bones of the tarsus. The patient had fallen from a wagon and caught his foot in the wheel. Dr. Detmold made extension with pulleys, but could not effect the reduction. Subsequently he was obliged to remove the astragalus on account of the suppuration which followed and the consequent exposure of the bone. The wound did not heal kindly, and at length amputation of the leg became necessary. Dr. Detmold concludes, from this example and others which have come to his knowledge, that if a similar case were to present itself to him again, he would amputate at once. 1 The following case, reported by Dr. Thomas Wells, of Columbia, S. C, is of unusual interest, as illustrating the danger of leaving the bone displaced, and also the benefit which may, even under the most unfavorable circumstances, result from its final removal. Doctor S., set. 30, was riding in an open carriage, some time during the year of 1819, when his horses became frightened and ran, and in leaping from his vehicle he struck upon his left foot, dislocating the astragalus from its junction with the scaphoid bone, upwards and slightly outwards. Several medical gentlemen made violent efforts to reduce the bone, but without effect. Inflammation and suppuration, accompanied by a high fever, soon followed, and the head of the astragalus becoming carious, protruded through the skin. On the 18th of August, about seven months after the injury was received, he was still suffering from a copious discharge, pain, swelling, and general irritative fever, and it was determined to excise the bone; which was accordingly done by enlarging the wound and detaching its loose connections with the adjacent tissues. The astragalus extracted left a frightful wound, the foot seeming to be nearly separated from the leg. A hollow splint was adjusted to the inside of the foot and leg, so as to preserve the limb perfectly steady and in a proper direction; simple dressings were applied, and an anodyne administered internally. • Detmold, New York Journ. Med., May, 1856, p. 383. 694 -TARSAL LUXATIONS. No accidents followed, and at the end of September the wound was healed, and the swelling of the parts had entirely subsided. One year after the operation, he walked without the least difficulty; the ankle being then "perfectly sound." The leg was shortened about one inch, and this deficiency was supplied by a thick heel upon his shoe. 1 Examples might be cited illustrative of the value of early exsection where reduction could not be accomplished; but after what has already been said upon the subject of dislocations of the astragalus, we shall not regard any farther references as either necessary or useful. If other principles of treatment are to govern the surgeon than those which we have already laid down, they cannot here be stated. They are among those unwritten rules whose existence we cannot always recognize until the case arises upon which they may apply. Yet in the exigency supposed they are as clearly defined, and as imperative, in the mind of the clever surgeon, as any of those laws which have been made the subjects of special record. § 3. Dislocations of the Calcaneum. The calcaneum may, as a consequence of a fall upon the heel, or of a direct blow, be dislocated outwards from the astragalus alone, or upwards and outwards from the cuboid bone at the same time. It has been found also at the same moment dislocated outwards from the astragalus, and inwards upon the cuboid bone. Chelius says he has seen an old dislocation of the calcaneum, produced in early life by pulling off a boot; from which there finally resulted a degeneration like elephantiasis of the leg, rendering amputation necessary. 2 Mr. South remarks in his Notes to Chelius, that the two cases of dislocation outwards of this bone, mentioned by Sir Astley Cooper, were from his (South's) Notes (cases 199 and 200). In the first case, that of Martin Bentley, occasioned by the falling of a heavy stone upon his foot, the integuments were not broken, and the position of the foot resembled a varus. " The dislocation was easily reduced, having bent the thigh and knee on the body and fixed the leg, by laying hold of the metatarsus and of the tuberosity of the heel-bone, and drawing the foot gently and directly from the leg, during which extension Cline put his knee against the outside of the joint, and the foot being pressed against it, the heel and the navicular bone readily slipped into their place, and the deformity disappeared." He was discharged from the hospital in five weeks, " having the complete use of his foot." In the second case, the dislocation, produced also by the fall of a stone upon the foot, was compound, and the patient, Thomas Gilmore, having been brought into St. Thomas's Hospital, the reduction was effected by extending the foot, and rotating it outwards. Six months after, when he left the hospital, he was able to walk pretty well with a stick. 1 Wells, Amer. Journ. Med. Sci., May, 1832, p. 21. 2 Chelius, System of Surg., Amer. ed., vol. ii. p. 354. 695 DISLOCATIONS OF THE OS SCAPHOIDES. § 4. Middle Tarsal Dislocations. The scaphoid and cuboid bones may be dislocated from the astragalus and calcaneum, constituting what is termed, by Malgaigne, a middle tarsal dislocation. It is probable that to some extent the same thing has occurred in many of those cases which are reported as simple dislocations of the astragalus, or as dislocations at the astragaloscaphoid articulation; but it occurs also occasionally in a degree so perfect and complete as to leave no doubt as to the true nature of the disjunction, and to entitle it to a separate consideration. Mr. Liston mentions the case of a boy, set. 14, who fell from a height of forty feet, striking, apparently, upon the extremity of the foot. The scaphoid and cuboid bones were found to be displaced upwards and forwards, so that the foot was shortened about half an inch, and had a clubbed appearance. No attempt was made to reduce the bones, and he left the hospital in three weeks, able to stand on the foot. 1 Sir Astley Cooper has recorded in more detail a similar example. A man, working at the Southwark bridge, London, received upon the top of his foot a stone of great weight. He was immediately carried to Guy's Hospital, and his condition is described as follows: " The os calcis and the astragalus remained in their natural situations, but the fore part of the foot was turned inwards upon the bones. "When examined by the students, the appearance was so precisely like that of a club-foot, that they could not at first believe but that it was a natural defect of that kind," but upon the assurance of the man, that previously to the accident his foot was not distorted, extension was made, and the reduction was effected. He was discharged from the hospital in five weeks, having the complete use of his foot. 2 § 5. Dislocations or the Os Cuboides. According to Pie'dagnel, quoted by Chelius, the cuboid bone may be dislocated upwards, inwards, and downwards, but Malgaigne affirms that he has found no case recorded in which the dislocation has occurred alone, or unaccompained with a dislocation of one or more of the other tarsal bones. § 6. Dislocations of the Os Scaphoides. Burnett has seen a luxation of the scaphoid bone in which its connections with the astragalus were undisturbed, while at the same time it was completely separated from the cuneiform bones. By strong pressure exercised during several minutes, the os scaphoides was made to fall into its place. The dislocation was compound, yet the wound healed rapidly, and in a short time the recovery was almost complete. 3 1 Practical Surg., also London Lancet, vol. xxxvii. p. 133. 2 Sir A. Cooper on Disloc, &c, London ed., 1823, p. 37b\ 3 Burnett, Lond. Med. Gazette, 1837, vol. xix. p. 221. 696 TARSAL LUXATIONS. Several examples are recorded of a true luxation of the os scaphoides, in which the bone had abandoned both the astragalus on the one hand, and the cuneiform bones on the other. Pie'dagnel mentions a case in which the scaphoid bone was broken longitudinally, and its internal fragment, constituting the largest portion, was displaced inwards through a tegumentary wound. He was unable to effect reduction, and was compelled to amputate the foot. 1 Walker has reported the first example of luxation forwards, occasioned by jumping upon the ball of the foot. The bone formed a marked projection upon the top of the foot, and a corresponding depression existed below. An attempt was first made to accomplish the reduction by simple pressure with the thumbs; but this having failed, the surgeon bent the extremity of the foot forcibly downwards, and by continuing to press upon the os scaphoides, it fell into its position easily and with a distinct click. In about three weeks the patient was able to walk with only a slight halt, and no deformity remained. 2 § 7. Dislocations of the Cuneiform Bones. The cuneiform bones may be luxated partially, and without having separated from each other, of which two or three examples are recorded ; or, which is more common, the cuneiforme internum may be luxated alone. Says Sir Astley Cooper: " I have twice seen this bone dislocated; once in a gentleman who called upon me some weeks after the accident, and a second time in a case which occurred in Gruy's Hospital very lately. In both instances the same appearances presented themselves. There was a great projection of the bone inwards, and some degree of elevation, from its being drawn up by the action of the tibialis anticus muscle; and it no longer remained in a direct line with the metatarsal bone of the great toe. In neither case was the bone reduced; the subject of the first of these accidents walked with but little halting, and I believe would in time recover the use of the foot, so as not to appear lame. The cause of the accident was a fall from a considerable height, by which the ligament was ruptured which connects this bone with the os cuneiforme, and with the os naviculare. The second case, which was in Cuy's Hospital, my apprentice, Mr. Babington informs me, happened by the fall of a horse, and the foot was caught between the horse and the curb-stone." 3 In a case of compound luxation seen by Mr. Key, reduction was effected, and in two months the cure was so far completed that the patient walked with only a slight lameness. 4 Nelaton, in a similar case of compound luxation, unable to reduce the bone, removed it completely, and the patient recovered. 3 Robert Smith has called attention to a species of dislocation of the internal cuneiform bone not before very accurately described; but of which he has presented two examples. It consists in simultaneous 1 Piedagnel, Journ. Univ. et Heb., torn. ii. p. 208. 2 Walker, The Medical Examiner, 1851, p. 203. 3 Sir Ast. Cooper, op. cit., p. 383. 4 Key, Guy's Hosp. Rep., 1836, vol. i. p. 544 6 Nelaton, Malgaigne, op. cit., p. 1076. 697 DISLOCATIONS OF THE CUNEIFORM BONES. dislocation of the metatarsus and internal cuneiform; that is to say, the first metatarsal bone together with the internal cuneiform is dislocated upwards and backwards upon the tarsus, carrying with it also the four remaining metatarsal bones. In both of the examples seen and recorded by him, the dislocations were ancient, and no account could be obtained of the precise manner in which the accidents had been produced. The feet were foreshortened to the extent of an inch or more, in consequence of the overlapping of the bones, yet the heel in each case preserved its natural relations to the tibia, not being proportionately lengthened as is the case in dislocations of the tibia forwards. The plantar surface of the foot was turned inwards, and instead of being concave it was convex, both in its antero-posterior and transverse diameters. A transverse ridge on the top of the foot also indicated the line of the projecting bones. Both of these cases were verified by a careful dissection. 1 Dupuytren has reported in his Treatise on Injuries of the Bones, a similar case, occurring in a woman ast. 30, who was brought immediately to Hotel Dieu. She stated that in descending from the bridge of St. Michael with a burden of two hundred pounds, she fell in such a way that the whole weight of the body was received on the right foot, and that at the moment she made an effort to check herself in falling, she experienced extremely severe pain in this part, and heard a very distinct snap; she was unable to raise herself from the ground. On the following morning Dupuytren reduced the bones with very little difficulty by extension, combined with pressure against the dislocated ends. The bones went into place with a loud snap, and in two or three months she left the hospital with only a little lameness. 2 Mr. Smith, without intending to question the possibility of a simple luxation of the metatarsal bones, of which, indeed, Malgaigne has collected a number of well authenticated examples, is inclined to believe that, when a luxation of the bones of the metatarsus is the consequence of a fall from a height, the individual alighting upon the anterior part of the foot, it is, in general, that variety which has now been described. And this aptness on the part of the cuneiform bone to maintain its connection with the first metatarsal bone, he would ascribe mainly to the fact that both the peroneus longus and tibialis anticus have attachments to each of the bones in question. 1 Robert Smith, Treatise on Fractures, &c, Dublin ed., 1854, p. 224 et seq. 2 Dupuytren, op. cit., p. 326. 45 698 DISLOCATIONS OF THE METATARSAL BONES. CHAPTER XXIII. DISLOCATIONS OF THE METATARSAL BONES. Luxations of one or more of the metatarsal bones, at the points of their articulations with the tarsus, have been known to occur in almost every direction. They may be occasioned by crushing accidents, by machinery, or more often perhaps they have been caused by a fall backwards or forwards, when the anterior extremity of the foot was wedged under some solid body and immovably fixed. They may be produced also, probably, by simply striking upon the ball of the foot in falling from a height. We have noticed, however, that Mr. Smith inclines to the opinion that this will, in general, only produce the species of dislocation which he has particularly described. The symptoms which characterize the dislocation of the whole range of metatarsal bones upwards and backwards will, when the dislocation is complete, resemble very much those which belong to the dislocation described by Smith. The dorsum of the foot will be shortened anteroposteriorly, the two arches of the foot will be lost upon the plantar surface, or even actually reversed, a ridge will traverse the back of the foot and a corresponding depression will exist underneath. In some cases, however, the dislocation is not complete, the articulations being only sprung, and then there can exist no foreshortening of the foot, and all the other signs will be less striking. If only a single bone is luxated the diagnosis is generally very easily made out, unless indeed considerable swelling has already occurred. . Mr. South says that, in 1835, a case was admitted to St. Thomas's Hospital, under Mr. Green's care, of dislocation of the last two metatarsal bones, occasioned by the falling of a heavy chest upon the inside of the foot. Upon the top of the foot was a large swelling below and in front of the outer ankle, and behind it a cavity in which two fingers could be easily buried, in consequence of the bases of the metatarsal bones having been thrown upwards and backwards upon the top of the cuboid bone. The reduction was accomplished with much difficulty by continued extension, and as the bones resumed their place a distinct crackling was heard. 1 Liston reduced a dislocation upwards of the first metatarsal bone; Malgaigne mistook a dislocation of the fourth bone for a fracture, and did not attempt the reduction until the seventh day, when, after five successive trials, the head entered with a noise into its cavity. In a dislocation of the second, third, and fourth metatarsal bones, he also 1 South, Note to Chelius's Surg., vol. ii. p. 256. DISLOCATIONS OF THE METATARSAL BONES. 699 failed to detect the true nature of the accident until the tenth day, when he proceeded to attempt reduction, but failed. Inflammation, suppuration, and delirium followed, and the patient died on the fortyfirst day. Tufnell failed in a similar case, although his patient finally recovered with a not very useful limb. Malgaigne failed to reduce the bones also in a recent case of luxation of the first four bones, although he used chloroform, and diligently tried various means. The same writer has seen one example of ancient dislocation, which was not recognized by the surgeon. Finally, Monteggia reports a case of dislocation of the last two metatarsal bones, which was not at the time recognized. On the tenth day swelling commenced, and soon after the patient died in convulsions.' These references, drawn chiefly from Malgaigne, sufficiently illustrate the difficulty which surgeons have experienced in the reduction of these bones, when a portion only is displaced. A difficulty which is probably due to the fact that it is almost impossible to make extension upon a single metatarsal bone; indeed, it is probable that by pressure only upon the displaced head can we expect to accomplish much in these accidents, and even this cannot be made to act very effectively, owing to the small amount of surface presented against which the force can be properly applied. If, on the other hand, all the bones are dislocated at once, the reduction is generally accomplished with ease by simple extension, combined with properly directed pressure. Bouchard and Meynier succeeded without difficulty in two cases of backward dislocation; Smyly was equally successful on the sixth day, in a case of dislocation downwards. Laugier reduced an outward dislocation of all the bones by pressure and extension easily; and Kirk succeeded as well, in an example of the opposite character, all the bones being carried inwards. 2 Mr. Sandwith has given us an account of a case which occurred in his own person, from the fall of his horse upon his foot. " I was instantly sensible," says Mr. Sandwith, "of the nature of the injury, and as soon as I was upon my feet, the metatarsus was found to be drawn upwards, and obliquely outwards upon the tarsus, by the action of the flexor muscles. On the removal of the boot, which was cut away, these were the appearances: the foot considerably shortened, the toes turned a little outwards, and a hard swelling, bigger than an egg, upon the tarsus, with tumefaction of the integuments. The pain, which was great at first, was kept under by a warm fomentation. " The reduction was easily effected by my friends, Messrs. Williams and Brereton, and leeches and bread and water poultices prevented inflammation. For several nights the foot was violently shaken by spasmodic action of the muscles, but the parts preserved their relative situation; and, although it was nearly a year before all lameness ceased, yet at the end of six weeks I was enabled to lay aside my crutches. For the ability to use the foot in so short a time, I was indebted to a contrivance which rendered the foot and ankle inflexible. 1 Malgaigne, op. cit., p. 1077 et seq. 2 Ibid., p. 1081. 700 DISLOCATIONS OF THE PHALANGES OF THE TOES. "Instead of an elastic sole to the shoe part of the apparatus, one of wood was procured, around the heel of which was nailed a piece of firm unbending leather; this reached as high as the calf of the leg; three small straps with buckles held the leg in situ, and a broader one across the instep secured the foot. The comfort I experienced from this simple apparatus is my reason for describing it so particularly; it has since been found useful in various injuries of the foot and ankle." 1 In one extraordinary case, however, Dupuytren was not so successful. Paul Eudes, aet. 24, fell, while drunk, into a ditch six feet deep, and alighted on the soles of his feet. The accident was followed by great swelling, and he did not suspect the nature of the injury, or present himself at the hospital until three weeks after. Dupuytren then ascertained that he had dislocated the metatarsal bones of both feet. Several fruitless attempts were made to accomplish the reduction, but to no purpose, and in about two weeks he. left the hospital. 2 CHAPTER XXIV. DISLOCATIONS OF THE PHALANGES OF THETOES. Dislocations of the toes are less common than those of the fingers, yet a considerable number of cases have been recorded by different surgeons. They are occasioned by blows received directly upon the ends of the toes, by the weight of the body brought to bear suddenly upon their plantar surfaces, as when a horseman springs in his stirrup, or by a fall, in consequence of which the rider hangs in his stirrup, by leaping, &c. They may be partial or complete; and in the latter case, a slight overlapping is generally observed. In a great majority of cases the direction of the displacement is backwards, or with only a slight lateral deviation. Occasionally, several bones are displaced at the same time, but usually only one suffers displacement. t It is more common here to find compound and complicated dislocations than in the case of the fingers. The position of the toes is not always the same in the same form of dislocations. Thus, in the dislocation backwards, the toe is sometimes reversed upon the foot to nearly a right angle, and at other times it is found lying in the same axis as the metatarsal bone, or the phalanx, from which it is luxated. About one year since, I reduced a backward dislocation of the -first phalanx of the second toe in the person of Lewis Brittin, a3t. 60, who had fallen from a four story window, striking upon his feet, and breaking both thighs. I did not discover the dislocation 1 Sandwith, Amer. Journ. Med. Sci., Nov. 1828, p. 216, from Lond. Med. Gaz., vol. i. 2 Dupuytren, op. cit., p. 329. COMPOUND DISLOCATIONS OF THE LONG BONES. 701 of the toe until sixteen hours after the accident. It was then lying parallel with the axis of the metatarsal bone, upon which it was slightly overlapped. The reduction was effected easily by pulling upon the last phalanx with my fingers, while, at the same moment, I pushed the head of the bone toward the socket. No swelling followed, nor has it troubled him at all since his recovery. With regard to the treatment, surgeons have experienced the same difficulty in certain cases of dislocation of the great toe as we have seen experienced in similar dislocations of the thumb. Occasionally, indeed, the reduction has been found to be impossible. The same doubts have existed also in relation to the causes of this difficulty, and in reference to the means by which it was to be overcome. We shall therefore refer the reader to the chapter on Dislocations of the First Phalanges of the Thumb and Fingers for a more full consideration of this matter. In case the smaller toes are luxated, the reduction is generally effected with ease, by simple extension, or by extension combined with pressure; sometimes, also, the bone will be more easily put in place by reversing the phalanx more completely, as we have advised in certain cases of dislocation of the fingers. If the skin is penetrated, it will often be found necessary either to amputate or to practise resection upon the exposed phalanx. Sir Astley Cooper relates a case of luxation of "all the smaller toes," from the metatarsus, which had not been reduced, and the subject of which was, in consequence, so much maimed that he was unable to labor. It had been occasioned by a fall, from a considerable height, upon the extremities of the toes. A projection existed at the roots of all the smaller toes, the extremity of each metatarsal bone being placed under the first phalanx of its corresponding toe. The swelling, which immediately followed the receipt of the injury, had concealed its nature, and now, several months having elapsed, reduction could not be effected. The only relief which could be afforded him, therefore, was in wearing a piece of hollow cork at the bottom of the inner part of the shoe, to prevent the pressure of the metatarsal bones upon the nerves and bloodvessels. 1 CHAPTER XXV. COMPOUND DISLOCATIONS OF THE LONG BONES. Frequency of Compound as compared with Simple Dislocations.—Compound dislocations, as compared with simple, are of rare occurrence. Of ninety-four dislocations reported by Norris as having been received into the Pennsylvania Hospital for the ten years ending in 1 Sir Ast. Cooper, op. cit., p. 385. 702 COMPOUND DISLOCATIONS OF THE LONG BONES. 1840, only two were compound ; ! and of one hundred and sixty-six dislocations recorded in my observation, only eight were compound 2 Relative Frequency in the Different Joints. —In my own recorded cases, four were dislocations of the tibia inwards at the ankle-joint, one was a partial (pathological) luxation forwards at the same joint, one was a luxation of the astragalus, one a luxation of the head of the humerus into the axilla, and one a forward luxation of the radius and ulna at the wrist-joint. I have also met with several examples of compound dislocations of the fingers. Both of the cases reported by Norris were dislocations of the thumb. Sir Astley Cooper, speaking upon this point, says that the elbow, wrist, ankle, and finger-joints are most subject to these accidents; and that he has seen but two in the shoulder-joint, and one in the kneejoint. He had never seen a compound dislocation at the hip-joint, and he believed that it was "scarcely ever" so dislocated. Mr. Bransby Cooper has, however, reported in detail a very interesting case of this accident, communicated to him by Dr. Walker, of Charlestown, Mass., in which reduction was accomplished by manipulation alone, by Dr. Ingalls, on the second day. The patient died at the end of about three weeks. 3 So far as I know, this is the only case upon record. Malgaigne says that a compound dislocation at the hip-joint has probably never occurred. Among the cases of compound dislocation recorded by Sir Astley and Bransby Cooper, most of which were communicated to these gentlemen by other surgeons, 45 were dislocations of the ankle, 10 of the astragalus, 4 of the ulna at the wrist-joint, 4 of the thumb, 2 of the knee, 1 of the shoulder, 1 of the elbow, 1 of the radius and ulna at the wrist, 1 of the scaphoid bone, and 1 of the metatarsal bone of the great toe. Other writers have occasionally described compound dislocations of the clavicle, but I know of no record of a compound dislocation of the lower jaw. Prognosis, as determinedly the Mode of Treatment adopted by most of the Ancient and many of the Modern Surgeons. —By most of the early writers these accidents, whenever they occurred in the larger joints, were regarded as nearly beyond the reach of art. Says Hippocrates: " In cases of complete dislocation at the ankle-joint, complicated with an external wound, whether the displacement be inwards or outwards, you are not to reduce the parts, but let any other physician reduce them if he choose. For this you should know for certain, that the patient will die if the parts are allowed to remain reduced, and that he will not survive more than a few days, for few of them pass the seventh day, being cut off by convulsions, and sometimes the leg and foot are seized with gangrene." Hippocrates adds: " But if not re- 1 Norris, Amer. Journ. Med. Sci., April, 1841, p. 335. 2 For the most of these cases, see Transactions of the New York State Med. Soc. for 1855 ; article entitled "Report on Dislocations, with especial reference to their Results." By F. H. Hamilton. 3 A. Cooper, on Dislocations, &c, by B. Cooper, p. 59. COMPOUND DISLOCATIONS OF THE LONG BONES. 703 duced, nor any attempts at first made to reduce them, most of such cases recover." 1 The same remarks are applied by Hippocrates to compound dislocations of the head of the tibia, of the lower end of the femur, of the wrist, elbow, and shoulder-joints; death occurring in all cases, as he believes, more or less speedily whenever the bones are reduced and retained in place a sufficient length of time, and " were it not that the physician would be exposed to censure," he would not reduce even the bones of the fingers, since it must be expected, he thinks, that their articular extremities will exfoliate even when the reduction is most successful. I shall presently show, however, that even Hippocrates advised and probably practised resection in certain cases of these accidents. Both Celsus and Galen adopt almost without qualification the line of practice laid down by Hippocrates, and affirm equally the danger and almost certain death, consequent upon the reduction of compound dislocations in large joints. 8 Celsus recommends resection in some cases. Paulus iEgineta, however, and after him Albucasis, Haly Abbas, and R, hazes, do not regard the rules established by Hippocrates, in relation to the non-reduction of the bones, as so imperative, nor the results of the opposite practice as so uniformly fatal. " Hippocrates remarks," says Paulus " in the case of dislocations with a wound, the utmost discretion is required. For these, if reduced, occasion the most imminent danger, and sometimes death, the surrounding nerves and muscles being inflamed by the extension, so that strong pains, spasms, and acute fevers are produced, more particularly in the case of the elbows, knees, and joints above, for the nearer they are to the vital parts the greater is the danger they induce. Wherefore, Hippocrates, by all means, forbids us to apply reduction and strong bandaging to them, and directs us to use only anti-inflammatory and soothing applications to them at the commencement, for that by this treatment life may sometimes be preserved. But what he recommends for the fingers alone, we would attempt to do for all the other joints; at first, and while the parts remain free from inflammation, we would reduce the dislocated joint by moderate extension, and if we succeed in our object, we may persist in using the anti-inflammatory treatment only. But if inflammation, spasm, or any of the afore-mentioned symptoms come on, we must dislocate it again if it can be done without violence. If, however, we are apprehensive of this danger (for perhaps if inflammation should come on it will not yield), it will be better to defer the reduction of the greater joints at the commencement: and when the inflammation subsides, which happens about the seventh or ninth day, then, having foretold the danger from reduction, and explained how, if not reduced, they will be mutilated for life, we may try to make the attempt without violence, using also the lever to facilitate the process." 3 1 Works of Hippocrates, Sydenham ed., London, vol. ii. p. 634. 2 Paulus Syd. ed., vol. ii. p. 510. 3 Ibid., p. 509. 704 COMPOUND DISLOCATIONS OF THE LONG BONES. In the following quotations from three of the most celebrated writers of the last two centuries, we find but little, if any evidence that the opinions of the fathers upon this subject were not still held in general respect: " If the joint be dislocated, so that it is either uncovered, or a little thrust forth without the skin, the accident is mortal, and of more danger to be reduced than if it be not reduced. For if it be not reduced, inflammation will come upon it, convulsion, and sometimes death. 2. There will be a filthiness of the part itself. 8. An incurable ulcer, and if perhaps it be brought to cicatrize at all, it will easily be dissolved by reason of the softness of it: but if it be reduced, it brings extreme danger of convulsion, gangrene, and death." 1 " Si vero in magnis articulis tam valida fuit facta luxatio, ut ligamentis ruptis os articuli multum sit protrusum per integumenta, haec pars ossis vasis privata moritur, citius autem si reponatur, quam si non reponitur; quare sola amputatio restat ad conservationem vitas." 2 Heister, who makes no allusion to this subject in the first edition of his great work, published at Amsterdam in 1739, adds the following remarks in his last edition, translated and published in London in 1768 : " Dislocations attended with a wound, especially of the shoulder or thigh-bone, are of very bad consequence, and often endanger the life of the patient; in Celsus's opinion (Book VIII. Chap. XXV.), whether the bones be replaced or not, there is generally great danger; and so much the more the nearer the wound is to the joint. Hippocrates has declared that no bones can be reduced with security, beside those of the hands and feet. ( Veciiar. 19, 5). See more on this subject in that passage of Celsus just now quoted, though I by no means recommend the following him implicitly." 3 Such were the extreme views as to the fatality of these accidents, and of the feebleness of our resources entertained by the ancient, and even by the more modern writers almost down to our own day; with only rare exceptions these limbs were condemned either to great and inevitable deformity, or to amputation. Nor, if we speak only of their fatality, have surgeons ceased to regard these accidents as among the most grave with which they have to deal. Pathology and Appreciation of the Sources of Danger as compared especially with Compound Fractures. —The danger, according to Sir Astley Cooper, consists in the rapid inflammation of the synovial membranes, which is speedily followed by suppuration and ulceration whereby the ends of the bones become exposed; and for the repair of which lesions, great general as well as local efforts are required, and a high degree of constitutional irritation results. In addition to which circumstances, "the violence inflicted on the neighboring parts, the injury of the muscles and tendons, and the laceration of bloodvessels, necessarily lead to more important and dangerous consequences than those which follow simple dislocations." 1 " Chirurgeon's Storehouse." By Johannes Scultetus, of Ulme, in Suevia. London ed., 1674, p. 31. 2 Johannes de Gorter. Chirurgia repurgata. Lugduni Batavorem, 1742, t. 86. 3 General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768. Vol. i. p. 164 705 COMPOUND DISLOCATIONS OF THE LONG BONES. The sources of danger enumerated by Sir Astley Cooper have been regarded as sufficient to account for their extraordinary fatality by the majority of those modern surgical writers who have alluded to the subject; but I must confess that to me they do not appear so. In compound fractures the mortality is far less; yet one might naturally suppose, that when the sharp and irregular fragments are pressing into the flesh, among nerves and bloodvessels, the irritation and inflammation would be equal, if not more than equal to the irritation and consequent inflammation produced by exposing a joint surface to the air; indeed, modern experience has sufficiently shown that these surfaces are much more tolerant of atmospheric exposure, and of the action of many other irritants, than surgeons formerly supposed. A clean incision into a large joint, which exposes the synovial membranes to the air, and which permits the products of inflammation to escape freely, is attended with much less danger than a small puncture which does not at all permit the air to enter, nor the increased synovia and the pus to escape. Very grave results sometimes follow from large wounds into large joints, but under judicious treatment such results are the exception and not the rule. 1 But Sir Astley evidently attributes more of the bad consequences to the exhausting effects of the efforts at repair, than to the immediate inflammation resulting from the exposure of the joint. It is pretty certain, however, that a majority of these patients die at a period too early to render this cause in any considerable degree operative. As to the bruising of the "muscles and tendons, and laceration of bloodvessels," it cannot be denied that it must usually be greater than in "simple dislocations;" and I will not say that it is not in a given number of instances greater than in the same number of instances of compound fractures. The tissues have often been thrust rudely through by a large and smooth bone, and the tendons have been stretched violently or torn completely asunder; while occasionally large arteries, which are prone to hug the bones about the joints, are lacerated and left to bleed. That the importance of these complications, however, may not be over-estimated, we must state that Sir Astley Cooper himself has remarked how seldom, in compound dislocations of the ankle-joint, the large arteries are injured; that a tearing of the ligaments and of the tendons is almost as likely to occur in simple dislocations as in compound; and, indeed, that in neither case are the tendons usually ruptured, but only thrust aside. Moreover, the skin is often made to give way not so much from the pressure of the round head within, as from the equal pressure of some sharp angular body from without. In all these respects, there are many examples of compound fractures which possess not a whit of advantage; in which cases, nevertheless, the surgeon feels very little doubt as to the ultimate cure. In short, the causes which, according to Sir Astley Cooper, determine the extraordinary fatality of these accidents, do not sufficiently 1 Upon this point see the very able article entitled " Amputations and Compound Fractures," by John O. Stone, in the New York Journal of Medicine, vol. iii. of 2d series, p. 316, Nov. 1849. 706 COMPOUND DISLOCATIONS OF THE LONG BONES. differ from those which operate in compound fractures to occasion so great a difference in results, and the fatality of compound dislocations remains unexplained; or if surgical writers have here and there intimated the true cause, they have failed to give it its proper place and value. I think the cause of the greater fatality of compound dislocations over compound fractures is to be found in the simple fact that dislocations are generally reduced, and by splints or other apparatus successfully maintained in place, while compound fractures, as my statistical report of cases has proven, are not generally reduced completely, nor can they by any means yet devised, except in a few cases, be maintained in place if reduced. Broken limbs, whether simple or compound in their character, will in a great majority of cases shorten upon themselves in spite of the most assiduous and skilful attempts to prevent it. 1 In adults most bones break obliquely, and cannot be made to support each other, and even in transverse fractures the broken ends are generally small compared with the articular ends of the same bones, and afford a very uncertain and inadequate support for themselves; not to speak of the difficulty of once bringing their ends into exact apposition where the muscles are powerful, or where they lie imbedded in a large mass of flesh so that they cannot be felt. While, on the other hand, dislocated bones, whether simple or compound, are capable when restored to place of supporting themselves; or with only slight assistance, their reduction may be maintained ; it is also ordinarily a work of no great difficulty to reduce them. Herein, then, consists the most important difference between these two classes of accidents, which are in other respects so similar. In the one, the very nature of the injury prevents the complete reduction, and the consequent violent strain of the muscles, tendons, and other soft tissues; while in the other, the nature of the accident leaves it in the power of the surgeon to reduce the bones, and modern surgery has in a great measure sanctioned the practice of maintaining them in place, in defiance of the efforts of the muscles, and sometimes, no doubt, at the imminent hazard of the life of the patient. Is it not fair to presume that tissues which have been stretched and lacerated, require rest in order that they may recover from the effects of their injuries? And if the soft parts are really more injured in dislocations than in fractures, does not ihe indication for rest become, for this very reason, more imperative ? General Inferences. —We have come, then, to regard the shortening of limbs after fractures, within certain limits and in certain cases, as a conservative circumstance rather than as a circumstance which the surgeon should in all cases seek to prevent. There is abundant evidence that the ancients had some knowledge of the value of rest to the muscles, tendons, &c, in the prevention of inflammation after compound dislocations, since they constantly urge 1 "Report on Deformities after Fractures." Trans. Am. Med. Assoc., vol. viii. ix. and x. COMPOUND DISLOCATIONS OF THE LONG BONES. 707 the greater danger of reducing these dislocations, than of leaving them unreduced; and they do not hesitate to recommend, that in case violent inflammation supervenes upon the reduction, the bone shall immediately be again dislocated. Galen speaks very explicitly on this subject, and says that "the danger in reduction consists partly in the additional violence inflicted on the muscles, and partly in their being then put into a stretched state, whereby spasms or convulsions are brought on, and gangrene as the result of the intense inflammation which ensues;" and Paulus iEgineta remarks: " For these, if reduced, occasion the most imminent danger, and sometimes death; the surrounding nerves and muscles being inflamed by the extension," &c. I have already quoted from Sir Astley Cooper the causes or reasons which he has assigned for the fatality of compound dislocations; and the same reasons have generally been assigned by those who have written since his day; but he has elsewhere, when speaking of exsection, given place to the very idea for which we claim so much prominence, the danger arising from a stretching of the muscles. Mr. Liston, also, and Mr. Miller, when speaking especially of dislocations of the tibia at the ankle-joint, refer to the same source of danger. Treatment. —Let us see now the alternatives which surgery presents for the treatment of these intractable accidents. 1. Reduction of the bone. 2. Non-reduction. 3. Amputation. 4. Tenotomy. 5. Resection and reduction. The questions for us to consider are, first, by which of these several methods is the life of the patient rendered most secure? and second, where, of two or more methods, all are equally safe, by which will he suffer the least maiming or mutilation? By Reduction. —"We have seen already how the old surgeons regarded the practice of reducing compound dislocations of the larger joints. It is not difficult, however, to find in the records of surgery numerous examples of successful terminations under this practice. Dr. White, of Hudson, N". Y., has reported a case of this kind in which the dislocation was at the ankle-joint. 1 Pott says he has seen this practice occasionally succeed, 2 and Mr. Scott communicated to the Lancet in March, 1837, a case of compound dislocation of the humerus successfully treated by reduction. Sir Astley Cooper also records several cases of compound dislocations at the lower end of the tibia and fibula, successfully treated by reduction. A careful examination, however, of those cases reported by Sir Astley as having been reduced without resection, and which resulted in cures, does not, in my opinion, leave much substantial evidence in favor of the practice; or perhaps we ought rather to say that it leaves only a qualified evidence of its propriety in certain cases. He has mentioned about sixteen of these examples, comprising dislocations of 1 White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 2 Pott, Chirurg. Works, vol. ii. p. 243. 708 COMPOUND DISLOCATIONS OF THE LONG BONES. the lower end of the tibia, or of the tibia and fibula, outwards, also inwards and forwards, all of which, save one quoted from Mr. Liston, have been reported to him by other surgeons, and not one of which had he ever seen himself. Many of the cases are reported very loosely, evidently in reply to circular letters, and from memory, without recorded notes, and by unknown, and in some sense irresponsible surgeons. It is not always said whether the wounds in the soft parts were made by the protrusion of the bones, or by some external violence; yet this is certainly a very material point in determining whether reduction is to be followed by inflammation or not. The results, sometimes only attained after exposure to great hazards, are, after all, often sufficiently unfavorable. It will be noticed, also, that in Cases 152 and 153, the astragalus was comminuted and removed, either at first or at a later day; and in Cases 154, 155, 156, and 160, the tibia, and also probably the fibula, were broken, and it does not appear but that in consequence of this complication the limb became shortened, and the muscles were thus put at rest, very much as if the bones had been retracted; and in one of the cases enumerated under 161, the lower end of the tibia spontaneously exfoliated. That a comminution, or that any fracture of the astragalus or of the tibia and fibula, should be regarded .in these cases as rendering the accident less grave, can only be comprehended by a full appreciation of the value of relaxation of the muscles. The few cases which remain after this exclusion do indeed illustrate how nature and skill may triumph over great difficulties, but nothing more. It is possible, also, that some of these examples of recovery after reduction may admit of an explanation entirely consistent with our own views of the true source of the danger in these accidents, if indeed they do not tend actually to confirm our doctrines. I have myself seen one example of complete recovery after the reduction of a compound dislocation at the ankle-joint, although resection was not practised; but in this case, all the tissues, or nearly all which suffered any injury, were completely torn asunder, and therefore wholly removed from the danger of which we have spoken. The example to which we allude is the following: On the 30th of Oct. 1858, John Bourquard, ast. 30, was caught in the tow-line of a canal boat, causing a compound dislocation of the right ankle-joint. I found the foot, immediately after the accident, thrown completely back against the lower part of the leg, the integuments in front of the joint, as well as all of the tendons and ligaments on this side, being completely torn asunder, while the tendo-Achillis, and the tendons behind both of the malleoli, with the corresponding integuments, were uninjured. This immunity of the tissues behind the malleoli was due to the direction in which the foot was drawn, namely, directly backwards. Everything which had suffered a strain being thoroughly severed, I did not hesitate to attempt to save the limb without resection. The reduction was accomplished very easily. The leg and foot were placed in a box filled with bran, and cool water dressings were applied to the portion which was exposed. On the 22d of No- 709 COMPOUND DISLOCATIONS OF THE LONG BONES. vember, the limb was removed from the bran to a pillow, the union being sufficient not to demand so much lateral support. About the first of March he left the hospital, the wound having closed, but the ankle remaining swollen and stiff. I have also during the last year seen two cases in which the foot has been nearly severed from the leg through the ankle-joint, by means of a " reaper." In each case the patient was standing with his back to the machine, and one of the blades cut horizontally from side to side, severing everything except about three inches of integument in front, and the extensor tendons of the toes. In the first instance, having seen the patient, a gentleman nearly sixty years of age, within three or four hours of the time of the receipt of the injury, I found him exceedingly exhausted by the hemorrhage. Both malleoli were cut off smoothly, the knife having severed the limb so exactly through the joint, as to have touched the cartilage at but one or two points. Having secured the bloodvessels, I replaced the foot, and after a few days of attendance I left him in the charge of an excellent young surgeon, Dr. Robertson, of Lancaster, N. Y., to whose diligence and skill the patient is no doubt mainly indebted for his recovery. After the lapse of nearly one year he is able, by the assistance of a shoe furnished with lateral supports, to walk very well. In the second case, which was only brought to my notice some months after the accident occurred, in consequence of a troublesome fistula near the ankle-joint, the recovery had been complete except that a small fragment of one of the malleoli was necrosed and required removal. Dr. Eli Hurd, of Niagara Co., N. Y., was equally fortunate in a case of compound dislocation of the shoulder-joint. This was in the person of G. T., set. 30, who was caught in the gearing of a thrashing machine on the 18th of Feb. 1852, which having drawn him in with great force dislocated the head of the left humerus downwards through the integuments into the axilla. Reduction was accomplished according to the method recommended b}' Nathan Smith, by pulling from each wrist at right angles with the body, while the operator himself seized the naked head of the humerus with his left hand, his right resting upon the top of the shoulder, and pushed it into place. The time occupied in the reduction was about thirty seconds. The forearm was then suspended in a sling, and the venous hemorrhage, occasioned by a rupture of the subclavian vein, was arrested by compression. The tegumentary wound, between three and four inches in length, was subsequently closed by sutures, and cool water-dressings were applied. On the fourth day the wound had united by first intention, and the man was walking about his room. In less than a month he was dismissed cured, and in the following harvest he was able to cut his own hay and grain, and to use his arm as before the accident. 1 Miller and Hoffman reduced successfully a compound dislocation of the knee, 2 and Galli has communicated a similar case to Malgaigne. 3 1 Hurd, Buffalo Med. Journ., vol. ix. p. 119. 2 Miller and Hoffman, London Med. Repos., vol. xxiv. p. 343. 3 Galli, Malgaigne, op. cit., t. ii. p. 958. 710 COMPOUND DISLOCATIONS OF THE LONG BONES. Whether either of the last three mentioned examples admit of the same explanation as the preceding three, I am unable to say, but whether they do or do not, they are too exceptional in their character to prejudice the argument materially which we shall hereafter make in favor of resection. Non-Reduction, —On the other hand, it will be very difficult to find an equal number of cases of compound dislocations, unreduced, which have terminated favorably. The fact is, no doubt, that at the present day very few surgeons would feel themselves justified in leaving a bone out of place unless they proceeded to amputate. In the Transactions of the New York State Medical Society for 1855, I have reported (Case 16 of Tibia and Fibula, p. 87) a compound dislocation at the ankle-joint, which, being unreduced, terminated fatally on the twenty-eighth day. This is the only example of a compound dislocation of a long bone, left unreduced, which has fallen under my observation; excepting, of course, those cases in which amputation was immediately practised. The united testimony, however, of the old surgeons, who generally neither amputated nor adopted the method of resection, but who recommended and practised non-reduction, is, that it is much more safe to leave these bones unreduced, than to reduce them without resection ; and I see no reason to doubt the correctness of their opinions in this matter. But whether it would be more safe to leave such limbs unreduced, or having practised resection to restore them, is another question, in which the advantage and comparative safety of the latter practice is too obvious to require explanation or defence. Amputation. —Says Pott: "When this accident (dislocation of the ankle) is accompanied, as it sometimes is, with a wound of the integuments of the inner ankle, and that made by the protrusion of the bone, it not unfrequently ends in a fatal gangrene, unless prevented by timely amputation, though I have several times seen it do very well without." And Sir Astley Cooper, speaking of compound dislocations of the ankle-joint, remarks: " Thirty years ago it was the practice to amputate limbs for this accident, arid the operation was then thought absolutely necessary for the preservation of life, by some of our best surgeons." Nor is it difficult to see by what reasoning surgeons of " thirty years ago" had fallen back upon this desperate remedy. Both reduction and non-reduction having proven eminently hazardous, in the absence of perhaps both knowledge and experience in resection, they finally adopted the alternative of amputation, as that which after all must give to the patient the best chance for life; and were no other alternatives to be presented, this would be our choice in a large proportion of cases. It must not be understood, however, that amputation is an expedient wholly free from danger; or, indeed, that the chances of the patient are in the average very greatly increased by this practice. Of thirteen amputations made for compound dislocations at the ankle-joint, in the Royal Infirmary at Edinburgh, only two resulted in the recovery of the patients. 1 Alluding to which, Mr. Fergusson remarks: " An 1 Edinb. Med. Monthly, Aug. 1S44. 711 COMPOUND DISLOCATIONS OF THE LONG BONES. amount of mortality which may well incline the surgeon to act upon the doctrine inculcated by Sir Astley Cooper." (To attempt to save the limb by reduction). But Mr. Fergusson has added a sentiment which accords very closely with my own experience and opinions. " I fear, however, that in the attempts which have been made to save the foot (by reduction) the results in all the cases have not met with the same publicity; that the instances where amputation has been afterwards necessary, or where death has been the consequence, have not always been recorded; and, from what I have myself seen, I would caution the inexperienced practitioner from being over-sanguine in anticipating a happy result in every example." By Tenotomy. —As a means of overcoming the resistance of the muscles, and for the purpose especially of facilitating the reduction, tenotomy has been proposed. First by Dieffenbaeh in cases of ancient unreduced luxations ; but Wm. Hey, Jr., was the first to make a practical application of this suggestion in a case of compound dislocation. After cutting the tendo-Achillis, the ankle being dislocated, the reduction was easily effected, but a strong tendency to displacement backwards remained, and he was obliged afterwards to cut the tendons of the tibialis posticus and flexor longus digitorum. 1 This method, based in some degree upon a very correct notion of the principal sources of difficulty, I regard as totally impracticable, at least to any useful or adequate extent. In order to be efficient, all the tendons passing the articulations must be cut, or nearly all of them; and I doubt whether the judgment of any discreet surgeon will ever sanction such an extreme, I might almost say, such an absurd measure. Nor do I think that in the point of view in which we are now considering this subject, having reference only to the question of danger, if the cutting of the tendons was sufficiently extensive to have any real effect in facilitating the reduction, the practice would be found to have any advantage over other methods known to be eminently dangerous. By Resection. —Finally, resection presents itself for our consideration as the only remaining surgical expedient. We have seen that most of the early writers understood the effects of a constant strain upon the muscles in increasing the danger of spasms, inflammation, and death; but in general they have suggested no remedy but non-reduction or amputation. Hippocrates, however, uses the following language, after speaking of resection of protruding bones in accidental amputations, or in fractures of the fingers; " Complete resections of bones at the joints, whether the foot, the hand, the leg, the ankle, the forearm, the wrist, for the most part, are not attended with danger, unless one be cut off at once by deliquium animi, or if continued fever supervene on the fourth day." To which passage the translator adds the following note: " This paragraph on resection of the bones in compound dislocations and fractures contains almost all the information on the subject which is to be found in the works of ancient medicine." Celsus notices the practice of resection in com- 1 Hey, Trans, of Provinc. Med. and Surg. Assoc., vol. xii. p. 171, 1844. 712 COMPOUND DISLOCATIONS OF THE LONG BONES. pound dislocations very "briefly, as follows: "Si nudum os eminet, impedimentum semper futurum est; ideo quod excedit, abscindendum est." Mr. Hey, of Leeds, was the first of modern surgeons who called especial attention to the value of resection in compound dislocations. Subsequently, Mr. Parks, of Liverpool, in an " Account of a new method of treating Diseases of the Joints of the Knee and Elbow," advocates the practice of resection in certain cases of diseases of these joints, but especially in "affections of the joints produced by external violence." Mr. Leveille, in France also, following, as he affirms, the guidance of Hippocrates, has advocated a similar practice. Velpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, Gibson, Norris, under certain circumstances, and especially where the bones cannot otherwise be reduced, and where the dislocations occur in certain joints, and especially the elbow and ankle-joints, recommend resection. To which names we may add that of Sir Astley Cooper, who has considered the subject, as applied to the ankle-joint, quite at length, and who says: " I have known no case of death when the extremities of the bone" (tibia, at the ankle) "have been sawed off, although I shall have occasion to mention some cases which terminated fatally when this was not done." Why resection should diminish the danger to life, by placing at rest the injured muscles, has been already sufficiently considered; but it seems not improbable that, if synovial membranes are actually more susceptible of violent and dangerous inflammations than the other tissues about the joints, then would this source of danger be removed just in proportion as the synovial membranes themselves are removed. Such, indeed, was the argument used by Sir Astley; and Mr. South, in a note to Chelius, when referring to this fact, has made the following statement: — " In compound dislocations of the ankle-joint, with protrusion of the shin-bone through the wound, most English surgeons saw off the joint end, not merely to render reduction more easy, but also, according to Sir Astley Cooper's opinions, to lessen the suppurative process, by diminishing the synovial surface. This mode of practice is certainly not commonly followed in reference to other joints, and the younger Cline was always opposed to its being resorted to in dislocated ankle." The following case, having occurred under my own eye, will serve to illustrate the value of the principle which I have been endeavoring to establish: — Samuel Adamson, of Buffalo, set. 24, was caught by the cable of a vessel, June 17,1855, dislocating the left tibia at its lower end inwards, and breaking the fibula two inches above the ankle. I was immediately called, and found the tibia protruding through the skin about three inches. The periosteum was torn up, and the cartilaginous surface of the end of the bone was roughened. His thigh was also severely bruised and lacerated, but the bone was not broken. Dr. Boardman assisting me, we attempted to reduce the bones, but with our hands we found it impossible to do so. I proceeded imme- 713 COMPOUND DISLOCATIONS OF THE LONG BONES. diately to remove about one inch and a half of the lower end of the tibia with the saw. The remaining portion was then brought easily into place, and the wound dressed with sutures, adhesive straps, bandages, and light splints. On the same day he became an inmate of the marine wards at the Hospital of the Sisters of Charity, and was placed under the care of Dr. Wilcox, through whose politeness I was permitted to see him frequently. The wound in the leg healed kindly, with only a slight amount of inflammation and suppuration. Violent inflammation, however, occurred in the thigh, followed by extensive suppuration and sloughing. This, in fact, proved to be by far the most serious injury, and that which most endangered his life and delayed his recovery. After about two months, the ankle was in such a condition as to require little or no further attention. The fragments of the fibula had shortened upon each other and were united, so that the tibia rested upon the astragalus. It was nearly two months, however, before he began to walk, owing to the condition of his thigh. Aug. 24, 1856, fourteen months after the accident, Adamson called at my office. He was then employed again as a sailor on board the schooner Sebastopol, and performed all the duties of an ordinary deck hand. His leg is shortened one inch and a quarter; from which, it seems, that there has been some deposit upon the end of the bone, which has compensated for one-quarter of an inch of that which I removed. The ankle is perfect in its form, being neither turned to the right nor to the left, and he treads square and firm upon the sole of his foot. There is considerable freedom of motion, especially in flexion and extension. Occasionally it becomes a little swollen and painful. In a case of compound dislocation of the upper end of the humerus, occurring also under my own observation, and recorded in the Transactions of the New York State Medical Society for 1855 (p. 27, Case 14), in which reduction was followed by death, I have now much reason to believe that if I had practised resection before the reduction, my patient's chances for recovery would have been greatly increased; perhaps also the case of compound dislocation at the wrist-joint recorded in the same vol. (p. 68), in which, having reduced the bones, I was subsequently compelled to amputate, may equally illustrate the hazard to which the practice of reduction without resection must often expose the patient. _ The same remarks I will venture to apply to the case of compound dislocation of the hip, of which I have already spoken as having occurred in the practice of Dr. Walker, of Charlestown, Mass. Had the head of the femur been resected before its reduction, I cannot doubt but that the unfortunate man's chances for recovery would have been very greatly improved. Thus, if we consider the question of the life of the patient only, the argument and the testimony seem to favor resection in a great majority of cases of compound dislocations occurring in large joints, and in a considerable number of cases of similar accidents in the smaller joints. It is certainly more safe than non-reduction or reduction 46 714 COMPOUND DISLOCATIONS OF THE LONG BONES. without resection, and it is probably quite as safe as amputation or tenotomy. But there is another question, which is, in our estimation, secondary to the one now considered, but which is often in the estimation of the patient himself, of the first importance—namely, by which method will he suffer the least maiming or mutilation? This question I do not find it difficult to answer. Certainly it is not by non-reduction or by amputation; and, putting tenotomy aside, it is now a question only between reduction without resection, and reduction with resection. These two methods, one of which experience has shown to be fraught with danger, and the other of which experience has shown to be relatively safe, are now to be compared in a point of view in which their antagonisms are perhaps less conspicuous, yet sufficiently marked. First. In either case the inflammation consequent upon the injury may be violent, and the recovery slow and tedious. The same arguments, however, which we have applied to the question of the comparative danger of the two modes, must apply with nearly equal force to this question of maiming; since the amount of maiming must often be governed by the intensity and duration of the inflammation, and upon this point the testimony has been shown to be in favor of resection. It will be observed that not only is the danger of maiming rendered more considerable by reduction without resection, because the inflammation is so much more likely to extend to the tendons and muscles, causing them to adhere to each other, and to become subsequently atrophied, a condition from which they often never completely recover, but also because the ligaments and capsules of the joints, with the synovial surfaces, are in consequence encroached upon, and the freedom of motion is ever afterwards greatly restricted, if not completely lost. This marked impairment of the functions of the joint does not always happen, but it cannot be denied that it does generally. Indeed it is by no means uncommon for these accidents to be followed, after ulcerations of the cartilage, by copious bony deposits in and around the joints. How is it, on the other hand, with these joints after resection ? I have thus far heard of no cases in which complete anchylosis resulted; but in all considerable freedom of motion has returned, and in some the restoration in this respect has been nearly or quite as complete as before the accident. Says Dr. Kerr, of Northampton: "Several cases of compound dislocation of the ankle have fallen under my care, and it has been uniformly my practice to take off the lower extremity of the tibia, and to lay the limb in a state of semiflexion upon splints; by this means a great degree of painful extension, and the consequent high degree of inflammation, are avoided. The splints I used are excavated wood, and much wider than those in common use, with thick movable pads stuffed with wool. I keep the parts constantly wetted with a solution of liquor ammonias acetatis, without removing the bandage. In my very early life, upwards of sixty years ago, I saw many attempts to reduce 715 COMPOUND DISLOCATIONS OF THE LONG BONES. compound dislocations without removing any part of the tibia; but, to the best of my recollection, they all ended unfavorably, or, at least, in amputation. By the method which I have pursued, as above mentioned, I have generally succeeded in saving the foot, and in preserving a tolerable articulation." Sir Astley Cooper has made a valuable experiment*to determine the condition of the new joint under these circumstances; and the vast number of cases in which resection has now been practised in cases of caries of the articulating surfaces, and their results, add still more substantial proofs as to the usefulness of the joints after such operations. " I made an incision upon the lower extremity of the tibia, at the inner ankle of a dog, and cutting the inner portion of the ligament of the ankle-joint, I produced a compound dislocation of the bone inwards. I then sawed off the whole cartilaginous extremity of the tibia, returned the bone upon the astragalus, closed the integuments by suture, and bandaged the limb to preserve the bone in this situation. Considerable inflammation and suppuration followed; and in a week the bandage was removed. When the wound had been for several weeks perfectly healed, I dissected the limb. The ligament of the joint was still defective at the part at which it had been cut. From the sawn surface of the tibia there grew a ligamento-cartilaginous substance, which proceeded to the surface of the cartilage of the astragalus to which it adhered. The cartilage of the astragalus appeared to be absorbed only in one small part; there was no cavity between the end of the tibia and the cartilaginous surface of the astragalus. A free motion existed between the tibia and astragalus which was permitted by the length and flexibility of the ligamentous substance above described, so as to give the advantage of a joint where no synovial articulation or cavity was to be found. This experiment not only shows the manner in which the parts are restored, but also the advantage of passive motion; for if the part be frequently moved, the intervening substance becomes entirely ligamentous; but if it be left perfectly at rest for a length of time, ossiflc action proceeds from the extremity of the tibia into the ligamentous substance, and thus produces an ossiflc anchylosis." Second. It is not probable, moreover, since the limb can be retained in place so much more easily after resection, that it will actually, in a majority of cases, be found to have been retained in place more perfectly? Even after simple dislocations, especially in those occurring at the ankle-joint, great deformity and much maiming are the not unfrequent results, and that too when all diligence and care have been employed. It has been impossible always to maintain a perfect apposition in the articulating surfaces. How much greater must be this difficulty in cases of compound dislocations! Third. The only argument which remains in favor of reduction without resection is the necessary shortening of the limb after resection. But this need seldom perhaps to exceed three-quarters of an inch, and often not more than half an inch; an amount of shortening which, as I have had occasion to prove when treating of fractures, does 716 CONGENITAL DISLOCATIONS. not necessarily produce a halt, and which indeed is often not known to exist by the patient himself. Finally. It must not be inferred that the author intends to recommend resection as a universal practice in cases of compound dislocations of the long bones. He has only sought to determine in a general manner its relative value as compared with other modes of procedure; and especially has it been his intention to bring more prominently into view the importance of rest and relaxation to the muscles, as an element in the treatment most essential to success. To declare its special application to cases would demand a treatise more elaborate than it was proposed to write. If, however, one were to speak of the individual bones only, there seems sufficient authority in the facts and arguments already presented to conclude that resection is applicable to certain compound dislocations of the clavicle, humerus, radius and ulna, fingers, femur, tibia and fibula, and toes; in short, to a certain proportion of all these accidents occurring in the long bones of the extremities. If an attempt is made to save the limb without resection, it is scarcely necessary to say that the success will depend, in a great measure, upon the care, attention, and skill bestowed upon the treatment. Cool or tepid water-dressings, according as the indications or the sensations of the patient seem to demand, are among the most valuable remedial agents. The limb must be maintained in a position of rest, combined with moderate elevation; and the bran-dressings, recommended in compound fractures, will be found occasionally useful. CHAPTER XXVI. CONGENITAL DISLOCATIONS. § 1. General Observations and History. We have omitted, until this moment, to speak of Congenital Dislocations, because, whatever theory of causation we adopt, dissections have shown that they are generally, in some sense, pathologic, or are accompanied with such essential modifications of the anatomical structures as to separate them entirely from ordinary traumatic luxations, which alone constitute the proper subjects of consideration in the present treatise. In relation to congenital dislocations, we shall find it necessary to establish systems of etiology, symptomatology, prognosis, and treatment, having very few points in common with traumatic dislocations. Exceptions to this rule will occur, in examples of intrauterine traumatic luxations, existing at birth without either original or accidental malformations of the articulations, or of the adjacent muscular, tendinous, or ligamentous structures; yet only in sufficient numbers to warrant the intrusion of the subject in this place. It is probable that congenital displacements may occur in all the articulations of the skeleton; and in most of them their existence has been already established by dissections. Until within a few years, 717 GENERAL OBSERVATIONS AND HISTORY. however, the attention of surgeons has been almost entirely directed to congenital dislocations of the shoulder and hip. Hippocrates, in his treatise " De Articulis," speaks expressly of dislocations of the hip occurring in the mother's womb, comprising them under the same order with the different varieties of club-foot. Avicenna and Ambrose Pare* have each mentioned original dislocations of the hip ; but the first to record an example with any degree of accuracy was Kerkring; in which case, death having occurred during infancy, he was able to verify his opinion by an autopsy. Chaussier has reported, in the Bulletin de la Faculte et de la Societe de Medecine, An. 1811 and 1812, the case of an infant, upon which he discovered, at birth, two dislocations, one at the scapulo-humeral articulation, and the other at the coxo-femoral. In 1788, Palletta, of Milan, published, under the title of Adversaria Ghirurgica, a collection of observations, in which, among other things, he has described certain congenital malformations of the hip-joint; and in 1820, he published another work, entitled Exercitationes Pathologicse, where he enters into a more complete exposition of the nature and causes of these deformities. In 1826, Dupuytren read, before the Academy of Sciences, a memoir upon the lameness produced by the original displacement of the femur; and in the Lecons Orales, published in the collections of the Sydenham Society, may be found a full record of the views and observations of this distinguished surgeon. The writings of Dupuytren seem, more than anything previously written, to have directed the attention of surgeons and pathologists to this interesting subject, and to have given a new impulse to investigation. From this time, various treatises have been written by eminent surgeons, many of which are characterized by profound thought, careful investigation, and practical experiment. Among those who have furnished us lately with elaborate treatises, or with more precise practical information upon this subject, the following names deserve to be especially mentioned: Breschet, 1 Caillard- Billioniere, 2 Lehoux, 3 Sandiforte, 4 Duval and Lafond, Humbert and Jacquier, Bouvier, 4 Sedillot, 0 Gerdy, Poliniere, Wrolik, 7 Guerin, 8 Parise 9 Pravaz,' Carnochan, 11 and Robert Smith. 11 1 Breschet, Repertoire d'Anatomie et de Physiologie. 2 Caillard-Billioniere, These Inaugurale, 1828. 3 Lehoux, These Inaugurale, 1834, Paris. 4 Sandiforte, Thesis, Sustained before the Faculty of Med. of Leyden. 5 Duval and Lafond, Humbert and Jacquier, Bouvier. See Pravaz. 6 Sedillot, Journ. de Conuais. Med.-Chirurg., 1838. 7 Gerdy, Poliniere, Wrolik. See Pravaz. 8 Guerin, Recherches sur les Luxations Congenitales ; par Jules Guerin, Paris, 1841. 9 Parise, Archiv. Gen. de Med., 1842. 10 Pravaz, Traite Theorique et Pratique des Luxations Congenitales du Femur, suivi d'un Appendice sur la Prophylaxie des Luxations Spontauees: par Ch. G. Pravaz, Lyon,1847. 11 Carnochan, A Treatise on the Etiology, Pathology, and Treatment of Congenital Dislocations of the Head of the Femur; by John Murray Carnochan, New York, 1850. 12 R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain Accidental and Congenital Dislocations, Dublin, 1854. 718 CONGENITAL DISLOCATIONS. § 2. Etiology. Hippocrates says that the bones of the extremities may be disarticulated during intra-uterine life by falls or blows, or by injuries of any kind, inflicted directly upon the abdomen of the mother. Ambrose Pare, while admitting the efficiency of the several causes named by Hippocrates, believed also that the contractions of the womb, and violence employed by the accoucheur were occasionally adequate to the production of the same results. He taught, moreover, that the position of the foetus itself might favor the displacement; and that, in some instances, an articular abscess, insufficient depth of the socket with a laxity of the ligaments, were competent to determine the expulsion of the head of the femur from its natural position. Sedillot regards a softening and relaxation of the ligaments as the most frequent cause. Parise and Malgaigne are disposed to attribute a majority of these cases to hydrarthrosis, or water in the joints. Says Malgaigne : " For myself, after having long meditated upon this subject, I have come to think that inflammation of the joints enjoys a grand role, both in coxo-femoral dislocations and in many others, and even also in various congenital malformations generally ascribed to arrest of development." This writer admits, however, that it will not do to generalize too much in this matter, and that the etiology of congenital luxations is probably as complex as that of luxations after birth. Chaussier seems to have regarded muscular contraction, or the occurrence of an intra-uterine convulsion, as the cause of the example of congenital dislocation of both humerus and femur seen and recorded by him. Since whom Guerin has greatly extended the application of this doctrine, having embraced in the same etiologic formula all or nearly all congenital dislocations. Guerin ascribes to muscular contraction in one form or another, and to corresponding muscular paralysis, not only dislocations of the femur and other long bones, but also club-foot, torticollis, and various other deviations of the spine. He affirms, moreover, that he has established incontestably the dependence of this abnormal state of the muscular system upon the absence or disappearance more or less complete of corresponding portions of the central nervous systems. Breschet and Delpech maintained similar views, especially in relation to the dependence of the several varieties of club-foot upon some morbid condition of the cerebro-spinal axis. While Carnochan remarks as follows: " It appears most in accordance with science to. refer the muscular spasmodic retraction, upon which congenital dislocations of the head of the femur from the cotyloid cavity depend, to a perverted condition of the excito-motor apparatus of the medulla spinalis, and more especially of that portion of it which is in direct relation with the reflex-motor nervous fibres, distributed to the pelvifemoral muscles surrounding, and in connection with, the ilio-femoral articulation." Palletta ascribes these deformities solely to an original defect of the CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 719 germ; and Dupuytren also declares that, in the case of a congenital dislocation of the hip, the causes are coeval with the earliest organization of the parts, and that the displacement is due rather to a defect in the depth or completeness of the acetabulum, than to accident or disease. Breschet and Delpech, both of whom, as we have already stated, refer them to some morbid condition of the cerebro-spinal axis, imagine that in consequence of this morbid condition of the nervous centres, there exists an arrest of development in the bones, muscles ligaments, sockets, and, in short, through all the apparatus of the joint which is the seat of the deformity. If we proceed to analyze these various opinions, we shall find that they are so far susceptible of classification, as that they may be arranged under the three following divisions. First, the physiological doctrines; according to which congenital dislocations are due to an original defect in the germ, or to an arrest of development. Second, the pathologic doctrines; which refer them to some supposed lesion of the nervous centres, to contraction or paralysis of the muscles, to a laxity of the ligaments, to hydrarthrosis, or to some other diseased condition of the articulating apparatus. Third, the mechanical doctrines; which recognize no intra-uterine dislocations except those which are strictly traumatic. The causes being understood to be the peculiar position of the foetus in utero, violent contractions or the constant pressure of the walls of the uterus, falls and blows upon the abdomen, and unskilful manipulation of the child in delivery. After a full and careful consideration of this subject, we are prepared to admit the occasional agency of all the causes enumerated, and the probable concurrence of two or more in many instances; nor do we see the propriety of rejecting, as Malgaigne has done, all that large class of malformations which seem to depend upon an arrest of development, or those which appear to be due mainly or solely to intra-uterine paralysis, of both of which many examples have been reported. § 3. Congenital Dislocations of the Inferior Maxilla. Malgaigne affirms that "we know of no congenital dislocation of the jaw," and that we are "not to take seriously the pretended luxation observed by Guerin upon a derencephalous infant." The example recorded by Robert Smith he rejects also, declaring that he does "not comprehend how one can see in it a luxation." For myself, I know of no reason why we should not take "seriously" the case mentioned by Guerin, since, so far as appears in his very brief report of the same, it might have been a true luxation. The specimen was before the academy, and if Malgaigne, from a personal examination, has become satisfied that a dislocation did not exist, he ought to have so informed us. But since he does not speak of having made it 720 CONGENITAL DISLOCATIONS. the subject of especial examination, we shall feel compelled to accept of it as reported by Guerin. As to the objections offered to Mr. Smith's case, namely, that "aside of the complete absence of its history, the subject did not present the characteristic signs of a luxation; and the dissection discovered neither maxillary condyle, nor glenoid cavity," we must reply, the dissection seems to us to have furnished such evidence that the deformity was congenital as to render its history unnecessary; the signs were characteristic, not indeed of a traumatic luxation, but of a congenital dislocation, such as may be supposed to have been the result of an arrest of development, or of an original aberration of the germ. The following is a summary of the very complete account of this case given by Robert Smith. On the fifth of May, 1840, Edward Lacy, set. 38, an idiot from infancy, died at the Hardwick Hospital, in consequence of gangrene of the lungs. While making the autopsy, a singular deformity of the face was discovered. The right and left sides seemed as though they did not belong to the same individual, the left being in every respect more fully developed. Upon removing the integuments, the muscles of the right side were found to be much smaller than those of the left, and especially the masseter. These latter having been removed also, the condition of the right temporo-maxillary articulation was carefully studied, When the mouth was closed, the external lateral ligament, instead of being directed backwards, was seen descending obliquely forwards, to be attached to a very imperfectly developed condyle situated at least one-quarter of an inch in front of its natural position. There was neither an inter-articular cartilage nor cartilage of incrustation, the joint surfaces being invested by a thick periosteum alone; nor was there any distinct capsular ligament. Nearly the whole of the right side of the inferior maxilla was smaller than the left. The condyle was short and curved, being directed nearly horizontally inwards, and resembling much more the coracoid process than the condyle of the inferior maxilla. The coronoid process was very small and thin, and the sigmoid notch could scarcely be said to exist. The articular eminence of the temporal bone was absent, there being in its place merely a flat surface destitute of cartilage; which surface presented upon its inner side a shallow and semicircular sulcus where the hook-like condyle of the lower jaw had played. The malar, superior maxillary, and sphenoid bones of the right side had also suffered corresponding changes of form and relative size. The motions permitted in the lower jaw were more extensive than those which it enjoys in its normal condition, that is, upon the right side the ramus could be moved very freely forwards and backwards, while upon the left, the condyle underwent a species of rotation upon its axis. During life the patient was observed to be constantly performing this motion, and the right side of the face was continually affected with spasmodic twitches. When the mouth was closed, the 721 CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. front teeth of the upper jaw projected beyond those of the lower, and when opened the deformity was in all respects greatly increased. 1 Mr. Smith takes this occasion also to express his dissent from the views maintained by Ribes, namely, that the formation of the glenoid cavity is consequent upon the growth of the condyle, and that, were this process not formed, there would not exist either a glenoid cavity or an articular eminence. It is true that neither the glenoid cavity nor the articular eminence is found in the foetus. Until the seventh month of intra-uterine life, there exists at this point of the temporal bone only a plane surface, and the glenoid cavity with its corresponding eminence is developed in proportion to the growth and development of the condyle. But Mr. Smith justly observes that although the development of the condyle does precede that of the glenoid cavity, l< it by no means follows that the formation of the latter is due to the pressure of the former." The cavity, or rather the transverse eminence in front of the plane surface, does not exist in foetal life, because, owing to the peculiar form of the inferior maxilla at this period, its existence is not necessary. The vertical portion of the jaw (vertical only in the adult) is in the foetus nearly in the same line with the axis of the shaft, and consequently when the mouth is opened by the action of the muscles, the condyles are pressed upwards and backwards instead of upwards and forwards, as in the adult. A displacement forwards cannot therefore very well occur; and the protection of the articular eminences is not required. As age advances the angles of the jaw increase, the portions upon which the condyles rest become more vertical, and finally a displacement forwards would occur whenever the mouth was well opened if the articular eminences were not present to afford a sufficient protection in front. In the case of Lacy the foetal condition of the bones upon one side remained during life, there being neither cavity nor eminence, and the condyle itself being only imperfectly developed; but the angle of the jaw had assumed the form which belongs to the adult, and the ascending ramus was vertical, consequently the condyle became somewhat displaced forwards. Chronic rheumatic arthritis is occasionally found in the temporomaxillary articulation of old persons; and it may be important to distinguish it from congenital luxation, with which, owing to the absorption of the articular eminence, and the consequent displacement of the condyle, it might possibly be confounded. Says Mr. Smith: " In a majority of instances, this remarkable disease attacks those of advanced age, and is symmetrical; but occasionally it occurs during the period of adult life. In the latter case it is generally more rapid in its progress, is accompanied by greater pain, and is more liable to implicate the neck of the condyle, and the ramus of the jaw." When the condyle is implicated it becomes enlarged, and can be felt beneath the zygoma, in front of the meatus externus. The lymphatic glands of this region are sometimes enlarged, and the progress 1 Robert Smith, op. cit., p. 283. 722 CONGENITAL DISLOCATIONS. of the malady is attended with a constant but not generally severe pain. The deformity of the face varies according as one or both articulations are affected. When the malady is confined to one joint, the chin is thrown slightly forwards, but chiefly to the opposite side; and when both are implicated the chin is simply advanced so that the teeth project beyond those of the upper jaw. As the disease progresses, the glenoid cavity enlarges by absorption, and at length a considerable portion or the whole of the articular eminence disappears, and the jaw becomes gradually displaced through the action of the external pterygoids. The disease does not extend in the temporal bone beyond the articulating surface of the glenoid cavity. The condyle assumes a variety of forms, sometimes being greatly enlarged in all its diameters, while its upper surface may be flattened, or conical. The inter-articular cartilage disappears; but Mr. Smith has never yet found any foreign bodies in the joint, and in only one instance have the surfaces been polished or eburnated as we often see in examples of chronic rheumatic arthritis occurring in the hip, knee, and other joints. The following is an excellent summary of the diagnostic marks between congenital, accidental, and rheumatic dislocations, given by this writer:— "1. In the congenital luxation, the mouth can be freely opened and closed; in chronic rheumatism these motions can be performed, but not without uneasiness to the patient, an uneasiness which sometimes amounts to severe pain; in luxations from accident, the mouth cannot be closed. "2. An involuntary flow of saliva accompanies the accidental luxation alone, although in some cases of chronic rheumatism there is an increased secretion of that fluid. " 3. In congenital luxation, the teeth of the upper jaw project beyond those of the lower; the reverse is observed in accidental luxation and in chronic rheumatism. " 4. In congenital luxation there is no fulness in the cheek, such as the coronoid process produces in cases of accidental luxation, and the enlarged condyle in some instances of chronic rheumatic arthritis." 1 § 4. Congenital Dislocations op the Spine. Says Guerin, of the subluxation occipito-atloidean there are two varieties: " First. Backwards, consisting in an exaggerated flexion of the head upon the front of the neck and chest, with a commencement of sliding backwards of the occipital condyles upon the articular facets of the atlas. Here are two examples in foetal enencephalous monsters. Second. Forwards. Those who follow my consultations can recollect having seen last year an infant, about two or three months old, who offered a remarkable example. The head was exactly applied against the posterior part of the neck, and upper part of the back. 1 R. Smith, op. cit., p. 292. 723 CONGENITAL DISLOCATIONS OF THE STERNUM. There was probably a sliding of the condyles forwards, with elongation of the anterior ligaments." 1 The existence of the first of these varieties has since been denied by Guerin himself; 2 and it will be noticed that he only speaks of the second as a probable subluxation forwards. Neither of them can therefore be regarded as established. Guerin farther remarks that he has observed subluxations in the other regions of the spinal column many times; and he showed to the Academy a foetus in which the spine presented, besides the occipitoatloidean displacement, a series of angular flexions in the anteroposterior direction, with sliding of the articular surfaces. In attempting to appreciate the value of Guerin's observations upon this point, it must be remembered that he regards all cases of congenital torticollis, and other deviations of the spine, as examples of subluxation ; and. in some sense, we think the theory of this distinguished surgeon may be regarded as correct. The amount of articular displacement between each of the adjacent vertebrae may be very inconsiderable in any such case, yet, however trivial, if it exceeds the limits of natural motion, it may properly enough be regarded as the commencement of a luxation. § 5. Congenital Dislocations op the Pelvic Bones. Bassius speaks of a diastasis or separation of the sacro-iliac symphysis, observed by him in newly-born children, and in infants; but, according to Malgaigne, his account of these cases is not such as to warrant any conclusions as to the true nature of the displacements. Congenital extrophy of the bladder is accompanied always with a deficiency of the central and upper portions of the pubic bones, the result manifestly of an arrest of development; but these cases, of which I have seen two examples, are not properly examples of congenital dislocations, but only of diastases, the separated portions remaining in their normal positions with reference to each other except that they are not prolonged sufficiently to meet in the median line. Guerin declares, however, that he has seen congenital displacement, or overriding of the iliac bone upon the sacrum, accompanied with coxo-femoral dislocation and curvature of the spine. The same writer mentions an example, in a foetal monster, of diastasis of the pubic bones, and of the sacro-iliac symphysis, accompanied with a turning out of the pubis upon the external face of the ischium. 3 § 6. Congenital Dislocations op the Sternum. Seger alone has reported one example of luxation of the xiphoid cartilage from the sternum. A woman in her fifth month of pregnancy, fell and dislocated her shoulder. Just four months after this, she was brought to bed with 1 Guerin, op. cit., 1841, p. 29. 2 Guerin, Gaz. Med., 1851, p. 227. 3 Guerin, op. cit., p. 32. 724 CONGENITAL DISLOCATIONS. an infant, well formed, except that, soon after it was born, the ensiform cartilage was observed to be remarkably movable, especially when the child hiccoughed, to which it was very subject. The cartilage was separated from the sternum by the breadth of the little finger. No treatment was employed ; the cartilage gradually became restored to its place, and in about one year it was firmly united to the sternum. 1 § 7. Congenital Dislocations of the Clavicle. Malgaigne says that a congenital dislocation at the sterno-clavicular articulation has never been observed ; but Guerin declares that he has established the existence of three varieties, namely:— 1. A luxation of the sternal end of the clavicle inwards and forwards ; this extremity of the clavicle lying in front of the sternal fourchette. In illustration of which he presented to the Academy a plaster cast of a girl eight years old, in whom the displacement existed upon both sides. 2. Inwards and upwards. Observed by him in a girl eight years old; but which displacement took place only when the arm was moved, and through the contraction of the sterno-cleido-mastoideus muscle. 3. Backwards. Of which he presented two examples in the corresponding sides of a foetal monster. I believe I have already referred to Fergusson's case of dislocation of the sternal end of the clavicle forwards, which occurred during birth. The end rested in front of the sternum, and could be pushed into its place with great ease; but when left alone it immediately slipped out again. Nothing was done, a new joint formed, and the child afterwards possessed as much power in the one arm as in the other. 2 Guerin says that he has seen a dislocation upwards and outwards at the acromial end of the clavicle in a foetus of three months. In regard to the treatment of either of these displacements of the clavicle, we need only remark that a reduction ought to be attempted: and, if practicable, without much confinement of the little patient, it should be maintained until the bones have become fixed in their natural positions. It is quite probable that this can never be accomplished, at least perfectly; but it will nevertheless be proper always to make the attempt. § 8. Congenital Dislocations of the Shoulder. ( Upper End of the Humerus.) Guerin affirms that he has established the existence of three varieties of scapulo-humeral dislocations, namely:— 1. Dislocation of the head of the humerus downwards; of which variety he presented to the Academy a plaster cast taken from a boy 1 Seger, Ephem. Nat. Curios., 1677, from Malg.,op. oit., p. 410. 2 Fergusson, System of Surg., 4th Amer. ed., 1853, p. 203. CONGENITAL DISLOCATIONS OF THE SHOULDER. 725 ten years old. The displacement existed in both arms, but much more pronounced in the right than in the left arm. It was due wholly to paralysis of the muscles about the joint, and to elongation of the capsule. 2. Downwards and inwards; complete upon one side and incomplete upon the other, in the same person. The head of each humerus was applied against the ribs, and the arms maintained in an abduction almost horizontal, under the influence of the retraction of the deltoidmuscles. " The same case," Guerin remarks, " has been confirmed by Roux." 3. Subluxation upwards and outwards: seen on both sides in a foetal monster, which was offered to the Academy for examination; and in one arm of a young man fifteen years old, of which Guerin presented a plaster cast. " It is characterized by a sliding of the head of the humerus in the direction indicated; this sliding being favored by a corresponding displacement of the coracoid and acromion processes. 1 Malgaigne, who regards " all luxations in consequence of paralysis as essentially posterior to birth," will not admit the first example mentioned by Guerin; but, as we stated before, the objections made by Malgaigne have failed to convince us of the propriety of rejecting all of this class of reported examples. Of the second case, mentioned by Guerin as having been confirmed by Roux, Malgaigne declares that he has consulted Roux upon this matter, and that he affirms that " he has never seen a congenital luxation of the shoulder." Robert Smith has met with but two of the forms of congenital luxation of the humerus described by Gue'rin, namely, that in which the head of the humerus is displaced forwards, and that in which it is displaced backwards. Of the first variety he has seen several examples. The first was in the person of Alexander Steele, aet. 29, who presented both a dislocation of the head of the humerus under the coracoid process of the left scapula, and pes equinus in the foot of the left leg. The muscles of the arm and shoulder upon that side were feeble and greatly atrophied. The humerus was shortened; its head being of the natural size and form, but when the arm hung by the side it dropped so far from its socket as to permit the thumb to be placed between the head and the acromion process. By pressing the humerus forwards the finger could be placed in the outer part of the glenoid cavity; and, although the head could be moved about thus freely, it seemed naturally to occupy only the anterior half of the glenoid fossa. Robert Smith's second example of subcoracoid congenital luxation was presented in the person of Mr. H., aet. 20, the condition of whose left shoulder resembled almost precisely that of Mr. Steele. "The deformity had existed from his birth, but became much more obvious and striking as he increased in age and stature." In the third example the child had attained nearly the age of one year before the condition of the limb attracted attention, which was Guerin, op. cit., p. 30. 726 CONGENITAL DISLOCATIONS. then excited, not by the deformity of the shoulder, but by the atrophied condition of the muscles of the arm. The child had never complained of pain about the joint, nor had he ever met with any accident. No doubt this also was an example of paralysis, and it is not improbable that it was congenital, but the evidence upon this point is not very conclusive. When seen by Mr. Smith, he was nine years old, the shoulder and arm presenting the same appearance as in the other cases * mentioned. The fourth was also subcoracoid and symmetrical, the same deformity existing in both shoulders. This was in the person of a female, aat. 21, who had been for many years a patient in a lunatic asylum, and who died of chronic inflammation of the meninges of the brain. Mr. Smith, who himself made the autopsy, first noticed the condition of the left shoulder. The muscles were atrophied; the head of the humerus could be felt lying under the coracoid process; the elbow projected from the side, but could be readily brought into contact with it. The right shoulder presented the same appearance, but the deformity was somewhat less, and the head of the humerus was not so directly underneath the coracoid process. From the external appearances presented by the two shoulders, Mr. Smith did not doubt that these deviations from the natural state of the parts were not the result of violence. Proceeding to remove the soft parts upon the left side, scarcely any trace was found of a glenoid cavity in its natural situation, but immediately underneath the coracoid process, upon the costal surface of the scapula, was formed an oblong socket completely surrounded by a capsular ligament, which ligament included also that small portion of the original socket which remained. The head of the humerus was changed in form, being oval, and fitted, in some measure, to both the old and new sockets upon which it seemed to rest alternately. Upon the right side, although the condition of the bones was somewhat different, the characteristic features of the deformity were similar. Malgaigne, who quotes Mr. Smith as saying that these dislocations must have been congenital, and for no other reason than because they were symmetrical, has scarcely done this author justice. Says Mr. Smith: "The position of the glenoid cavity, the remarkable form of the head of the humerus, the presence of a perfect glenoid ligament, the absence of any trace of disease, and the existence of the deformity upon each side, all indicate the original nature of the malformation." The only example of backward luxation seen by Mr. Smith was also sy mmetrical, and seems to be equally well authenticated. This was in the person of a woman named Doyle, ast. 42, a lunatic also, who died Feb. 8, 1839, in Dublin. She had been a patient in the lunatic asylum fifteen years, and was subject to severe epileptic convulsions, which ultimately proved fatal. Mr. Smith made the autopsy on the day following her death. The convolutions of the brain were small and atrophied, as is frequently observed in idiots. The two shoulders resembled each other so perfectly, both in ex- CONGENITAL DISLOCATIONS OF THE SHOULDER. 727 ternal appearance and in their anatomy, that Mr. Smith has only found it necessary to describe particularly the condition of one. The coracoid process was remarkably prominent, but the acromion was not so prominent as in accidental dislocations of the shoulder. The head of the humerus could be seen and felt distinctly moving with the shaft, upon the dorsal surface of the scapula. On removing the integuments, muscles, &c, no trace of a glenoid cavity was found in its natural situation; but upon the external surface of the neck of the scapula was a well-formed socket, which received the head of the humerus. This socket was covered with cartilage of incrustation, and surrounded by a perfect capsule. The tendon of the biceps arose from the top and internal margin of the socket. The form of the acromion process was changed; the capsule smaller than natural; the head of the humerus irregularly oval, its anterior half alone being in contact with the glenoid cavity; the great turbercle natural, but the lesser was elongated and curved, forming a process of an inch in length, around the base of which the tendon of the biceps muscles played. 1 Gaillard relates the case of a female child, upon whom the left arm was discovered to be deformed a few days after birth, and the elbow separated from the side. Later, the arm was found to be nearly immovable, and only at the end of four years was the dislocation recognized ; but no attempt at reduction was then made. When sixteen years old, she was seen by Gaillard, who found the head of the humerus in the infra-spinous fossa. The scapula, clavicle, and arm were preternaturally small; the forearm, although well developed, could not be completely extended nor supinated. Despite these unfavorable circumstances, Gaillard determined to make an attempt to accomplish the reduction. Four times in the space of eight days he submitted the arms to extension made at right angles with the body, by means of sixteen pound weights, the extension being continued from twenty to twenty-five minutes, and occasionally his own exertions being added to the weights. On the fourth attempt, the head of the bone was drawn gradually forwards, and by a rotatory motion it was finally made to slip into its socket; but it became immediately displaced. The next day Gaillard reduced it anew, and retained it in place one hour. Six days later it was again reduced, and, by the aid of bandages, permanently retained in place. The slight pain and swelling which followed soon disappeared; and by the aid of careful exercise, at the end of two years the arm had increased in length, and the patient could use the arm and hand so much better than before, as to encourage a hope that the recovery would be complete 2 Aristide Rodrigue, of Hollidaysburg, Penn., in a letter to the editor of the American Journal of Medical Sciences, gives the following brief account of a case of intra-uterine dislocation of the shoulder, complicated with a fracture of the forearm. 1 Robert Smith, op. cit. 2 Gaillard, Mem. de l'Acad. de Med., 1841, from Malg., p. 569. 728 CONGENITAL DISLOCATIONS. " The woman, when about four months gone with child, fell on her left side, striking a board, and felt herself much hurt at the time: at the full period she was delivered of a full-grown large boy with the following deformity: dislocation of the humerus into the axilla; fracture of both bones of the forearm of left side, lower third. Dislocation could not be reduced; union of the bones of the forearm by ossiflc matter complete; bones passing each other, and hand at an angle of about 40° ; the child did well otherwise ; now, four years old, strong and healthy; humerus has grown nearly apace with the other; forearm has not, and remains short and deformed as in birth; the hand is of the same size with that of the sound side." 1 § 9. Congenital Dislocations of the Radius and Ulna Backwards. It is not uncommon to meet with examples of a slight subluxation backwards of these bones in feeble and newly-born infants; which condition is probably due to a relaxation and elongation of the capsule. It is characterized by a preternatural mobility of the joint, and especially by the circumstance that the limb is capable of abnormal extension, or flexion backwards, as it is sometimes called. Guerin has seen this condition more advanced, the bones of the forearm having actually overlapped somewhat upon the lower end of the humerus, so that the articular surface of this latter presented itself in the fold of the elbow. This was especially observed in a girl of fourteen and a boy of thirteen years, and also in the two arms of a foetal monster. 2 Chaussier relates that a young woman at the commencement of the ninth month of pregnancy, perceived suddenly movements of the foetus so violent that she almost lost her consciousness. These movements were repeated three times in the space of six minutes, after which everything returned to its natural order, and the accouchement took place naturally and at the usual term. The infant was pale and feeble, and presented a complete backward luxation of the radius and ulna. 3 § 10. Congenital Dislocations of the Head of the Radius. Examples of this luxation have been reported by Dupuytren, Cruveilhier, Sandiforte, Adams, Dubois, Verneuil, Deville, Robert Smith, and Guerin, most of which were in the direction backwards, some outwards, but only one of them forwards; some were double, the same deformity being presented in both arms, and others were single. In a few examples the dislocations were complicated with a consolidation of the radius to the ulna, and in others with a deficiency of the ulna or with some deformity indicating its congenital origin. Of the symmetrical or double dislocation backwards Dupuytren furnishes the following example, presented to him in 1830, by M. Loir: "The abnormal position which the head of either radius had 1 Rodrigue, loc. cit., Jan. 1854, p. 272. 2 Guerin, op. cit., p. 31. 3 Chaussier, from Malgaigne, op. cit., t. ii. p. 2G8. 729 CONGENITAL DISLOCATIONS OF THE WRIST. assumed was at the back part of the lower extremity of the humerus, beyond which it extended for the space of at least an inch. This disposition of parts was absolutely identical on the two sides, and had all the characters of a congenital affection." 1 In "the example of outward luxation, mentioned by Deville, there was an almost complete absence of the ulna, the head of the radius mounting upwards more than three centimetres above the level of the articulation. 2 Guerin, who has described the only example of a forward luxation, says it was observed by him in a girl of seven years, and that it was symmetrical. The two radii lay in front of the humeri near the coronary fossettes. 3 §11. Congenital Dislocations of the Wrist. Guerin thinks he has seen three forms of congenital luxation of the wrist. First, a dislocation forwards characterized by a sliding of the wrist before the bones of the forearm, and by the projection posteriorly of the lower ends of the radius and ulna; seen in an infant of six months, and in two adults. Second, backwards and upwards; seen in a child of six years, and accompanied with an incomplete paralysis of all the muscles of the forearm and hand. Third, backwards and outwards; in a girl of fourteen years, accompanied with incomplete paralysis. 4 Guerin has also seen three examples of dislocation outwards in fcetal monsters, and one of dislocation inwards, as the result of arrest of development. Eobert Smith believes that the case of simple dislocation of the wrist or of the carpus forwards, mentioned by Cruveilhier in his Anatomic Pathologique, was an example of congenital luxation; and he relates two other cases equally remarkable which came under his own observation. One was in the person of Deborah O'Neil, a lunatic and epileptic, who died when thirty-six years old. Both upper extremities were deformed from birth; the right presenting an example of dislocation of the carpus forwards, and the left of dislocation of the carpus backwards. The dissection showed that there had been an arrest of development, especially in the bones of the forearm and carpus. The second was in the person of a young woman who died of phthisis in the Richmond Hospital; the right wrist presenting an example of congenital dislocation of the carpus forwards from arrest of development also.* Marrigues describes a very singular congenital displacement which he found upon a newly-born infant. The radius and ulna were widely separated below, and in the interspace was lodged the whole of the 1 Dupuytren, Injuries and Dis. of Bones, p. 117. 2 Deville, Bulletins de la Soc. Anat., 1849, p. 153. 3 Guerin, op. cit., p. 31. 4 Ibid., p. 717. 5 R. Smith, op. cit., pp. 238, 251. 47 730 CONGENITAL DISLOCATIONS. first range of the carpal bones; the hand being strongly turned inwards 1 §12. Congenital Dislocations op the Fingers. Chaussier found in a foetus the last three fingers of the left hand dislocated at the metacarpo-phalangeal articulation. The thighs, knees, and feet were also dislocated. 2 A. Berard speaks of an incurvation backwards of the last two phalanges of the fingers as having been occasionally seen in newly-born children of the female sex; and Malgaigne adds that he has himself seen a woman who had, from birth, all the phalangettes carried backwards to an angle of 135°, leaving the heads of the phalanges projecting forward under the skin. 3 Robert has seen, in a girl six years old, a congenital lateral luxation of the phalangette of the index finger, which was inclined outwards at an obtuse angle. The external condyle of the lower extremity of the proximal phalanx was slightly atrophied, and the internal presented a corresponding projection. Robert cut the internal lateral ligament by a subcutaneous incision, but without any favorable result. 4 §13. Congenital Dislocations op the Hip. Dupuytren thought that double dislocations of the hip-joint, as congenital accidents, were more common than single dislocations, but in the experience of Pravaz the rule has been reversed, he having met with but four double dislocations in a total of nineteen. Congenital dislocations of the femur have been noticed much offcener in females than in males. Of forty-five examples mentioned by Dupuytren and Pravaz, only seven or eight were males. They may be complete or incomplete. Of the complete luxations, four varieties have been noticed. Upwards and backwards, upon the dorsum ilii. This variety is by far the most common. Upwards and forwards; the head of the femur resting upon the eminentia ilio-pectinea. Downwards and forwards into the foramen thyroideum; of which variety Chaussier alone mentions one example ; but Delpech found in an infant, born paralytic, the head of the femur lodged habitually near the foramen thyroideum. Directly upwards; seen by Guerin, Pravaz, and others; the head of the femur being placed immediately without the anterior inferior spinous process of the ilium. Guerin has observed, moreover, a single variety of subluxation; characterized by the incomplete displacement of the head of the femur in the direction upwards and backwards, so that it rested upon the 1 Marrigues, Malgaigne, from Journ. de Med., 1775, t. ii. p. 31. 2 Chaussier, Malgaigne, op. cit., t. ii. p. 751. 3 Berard, Malgaigne, op. cit., p. 773. 4 Robert, from Malg., op. cit., p. 773. 731 CONGENITAL DISLOCATIONS OF THE HIP. edge of the cotyloid cavity : " Observed often in newly-born children, and with those in whom the muscular dislocations are effected spontaneously after birth." Both Delpech and Guerin have called attention to two varieties of what the latter terms, pseudo-luxations; of which the first simulates a dislocation upwards and backwards, and the second a dislocation downwards and forwards. In these examples, the extreme adduction or abduction of the thighs might lead to a belief that the bones were dislocated, when in fact the abnormal position of the limbs are due only to muscular contraction, without actual articular displacement. In the remarks which follow, we shall have special reference to that form of congenital dislocation of the femur in which the head of the bone rests upon the dorsum ilii, as being that which will be presented in a vast majority of cases, and which, characterized by the same general phenomena, may be regarded as typical of all the others. Symptomatology. —First, When the dislocation is double. In these examples the deformity is often found to be symmetrical; the opposite limbs being precisely the same length, and in the same relative positions; a circumstance which, when it exists, may render the diagnosis more difficult, or may cause it to be for a long time entirely overlooked. It is in such cases especially that the deformity is not usually discovered until the child begins to walk. The first circumstance which would naturally arrest our attention, if the person who is the subject of this double dislocation is stripped and placed erect before us, is the great apparent length of the arms and of the body in comparison with the lower extremities. We may next observe that the great trochanters are carried upwards and backwards, so as to make a remarkable projection in this direction • the lumbar portion of the spinal column is thrown very much forwards, and the dorsal portion backwards. The thighs incline inwards, so as almost to cross each other; the whole of the lower extremities are imperfectly developed and feeble, the toes are generally pointed directly forwards, or they may be noticed to turn inwards. When the person stands, and his limbs are not in motion, the heel is usually brought down fairly to the floor; but in walking, and especially in the attempt to run, he touches only the balls and toes of his feet. " When they are about to walk," says Pravaz, " we see them lift themselves upon the points of the feet,-to incline the superior part of the trunk toward the member which is about to support the weight of the body, and to lift the other from the ground with an effort, in order to carry it forwards. At this moment one of the trochanters, that which corresponds to the column of sustentation, appears to approach the iliac crest more nearly than when the patient is standing upon his two feet." In consequence of which mobility of the thighbones, the patient assumes a peculiar waddling gait, which is not only ungraceful but exceedingly fatiguing. The difficulty of progression is, however, very variable in different persons. Sometimes the patient requires no aid whatever, and at other times he cannot walk without assistance. Generally it increases with age. It is especially deserving of notice that in rapid progression 732 CONGENITAL "DISLOCATIONS. the mobility of the heads of the femurs is appreciably less than in slow progression, which is explained by the more constant and vigorous contraction of the muscles about the joint, when the motions of the limb are rapid. In the recumbent posture, the thighs may be drawn down easily to almost their natural positions. The only exception to this rule, according to Carnochan, " is when the head of the femur has escaped from the natural capsule in which it was originally inclosed, and a new socket has been formed upon the dorsum of the ilium." Abduction is performed with difficulty; adduction and rotation, especially inwards, being less restricted. Second. When the dislocation is only upon one side. In these cases the symptoms are essentially the same as in the double dislocation; with only such slight differences and peculiarities as would naturally suggest themselves to the surgeon, and which will not, therefore, demand from us a special consideration. Pathology. —The head of the femur is sometimes merely changed in form and consistence, the neck also undergoing corresponding alterations in its size, form, direction, &c.; at other times the head is absent altogether, and with it a considerable portion, or the whole of the neck has disappeared. The pelvic bones are usually more or less deformed. The acetabulum may be entirely deficient, or it may present itself as an irregular bony protuberance, without cartilage, fibro-cartilage, or ligaments. Sometimes it exists as an oval or triangular cavity, which is expanded at its superior and posterior margin into a distinct fossa, where the head of the femur, descending from the dorsum ilii, occasionally rests. A new cavity is formed usually upon the side of the pelvis, which is shallow and without an elevated margin, or it may be deeper, and more complete in its construction, by the addition of an osseous border. In either case, the new socket is often lined with a true periosteum and synovial membrane; but not unfrequently it is unprotected by any soft tissue, the surface being hard and polished like ivory. The head of the femur, having escaped from its original capsule, through a button-like opening, rests in this socket constantly. In still other examples the head of the femur remains within its capsule, and may be observed to play backwards and forwards between the two sockets; or the head and neck being absorbed, and the capsule remaining entire, the latter is converted into a long narrow sac, somewhat contracted in its centre, or finally into a firm ligamentous cord, which being attached to the stunted upper extremity of the femur, limits its motions in the direction of the crest of the ilium. In this case no new socket is formed. A portion of the pelvi-femoral muscles are contracted, in consequence of an approximation of their points of origin and insertion, and remaining in a state of comparative, if not absolute, inertia, they become atrophied, or pass into a condition of fatty degeneration, while other muscles, in consequence of the increased labor which they have to perform, become hypertrophied, or degenerate into a fibrous tissue. Treatment. —Says Dupuytren: " Of what possible utility can it be to CONGENITAL DISLOCATIONS OF THE HIP. 733 practise extension of the lower extremities in these cases, even supposing the limbs ( could be thus brought to their natural length? Is it not evident that the head of the femur, finding no cavity fitted to receive and hold it, would, when abandoned to itself, resume its former abnormal position ? There is something more rational and feasible in adopting a palliative course of treatment. When we call to mind the natural proneness which the heads of thigh bones have to ascend to the external iliac fossae, and that this tendency is partly due to the superincumbent weight of the body, and in part to muscular action, a just conception may be formed of the indications on which the employment of palliative remedies should be founded. The object should be to relieve the lower limbs of the superincumbent weight, on the one hand, and on the other to moderate the muscular action. Both of these indications are in part fulfilled by repose; and the attitude most conducive to this effect is the sitting posture, in which the weight of the upper part of the body is not transmitted to the lower extremities, but is centred in the tuberosities of the ischia. Therefore, laboring persons afflicted with this infirmity should be recommended to adopt a sedentary occupation, as a calling which requires much standing and walking about would dangerously aggravate their deformity. Yet one would scarcely be willing to condemn such individuals to perpetual repose; and to avoid this it is necessary to discover some means for diminishing the inconveniences which attend the upright posture, the act of walking and other exercises. Experience has taught me hitherto but two methods of obtaining this important object: the first consists in the daily employment of a perfectly cold bath, in which all the body should be immersed for the space of three or four minutes, the head being protected by an oiled-silk cap; the water may be fresh or salt; and the only precautions necessary to take are to avoid bathing when the body is in a state of perspiration, or when the catamenial discharge is present. These baths have a local, as well as general, tonic effect. The second method consists in the constant use, at least during the day, of a belt, which embraces the pelvis, fitting closely over the great trochanters, and keeping them at a constant height, so as to bind the parts together, and prevent that continual unsteadiness of the body which results from the loose connections of the heads of the thigh bones. For the proper fulfilment of these indications, certain precautions are necessary in the construction of this cincture; in the first place, it should occupy the narrow interval between the crest of the ilium and great trochanters, completely filling this space, and therefore being about three or four fingers' breadth, according to the age and size of the patient. It should further be well padded with wool or cotton, and covered with doe-skin, so that it may not abrade the parts to which it is applied; and there should be a piece let in on either side, so as to receive and support the trochanters without entirely covering them; it should be buckled behind, and padded straps be carried under the thigh, and across the tuberosity of the ischium, on either side, to prevent the zone from slipping up. I do not mean to assert that I have ever succeeded in completely getting rid of the inconveniences of congenital dislocations of the thigh-bones, but I have 734 CONGENITAL DISLOCATIONS. prevented their increasing, and have rendered supportable what I could not cure. The testimony of some patients to the value of this treatment has been of a most unequivocal character; for being worried by the pressure of the belt, they have laid it aside, but have speedily restored it again, as they found that without it they had neither a sense of firmness in the hip, nor confidence in walking." In relation to which opinions the same excellent writer subsequently made the following candid admissions: " I at first thought that no benefit would be derived in these cases from the employment of continual traction on the lower extremities, for reasons already stated: but the experiments of MM. Lafond and Duval tend to throw some doubt on the correctness of this conclusion. These distinguished practitioners tested the influence of extension, in their orthopaedic institution, on a child eight or nine years of age, who was the subject of double congenital dislocation of the hip; after the uninterrupted employment of this treatment for some weeks, I satisfied myself that the limbs had resumed their natural length and direction; but I was not a little astonished to find that, after extension had been persisted in for three or four months continuously, the greater part of the beneficial results remained for several weeks undiminished. It would be idle, it is true, to generalize on this single case; but as an isolated example of the utility of extension it is interesting, and it may be the forerunner of more important results." 1 Since which time Humbert and Jacquier, who, as well as Duval and Lafond, confined themselves to the treatment of deformities, claim to have met with equal success in the management of these cases by extension alone; and, still more lately, Guerin, of Paris, and Pravas, of Lyons, by the adoption of the same general principle more or less modified, have added new triumphs, and greatly enlarged its application. The means recommended and practised by Guerin, are: first, preparatory extension destined to elongate the muscles as much as possible ; second, subcutaneous section of the muscles which mechanical extension has not sufficiently elongated; third, extension of the ligaments, and even, if extension does not suffice, their subcutaneous section; fourth, manoeuvres destined to effect reduction; fifth, treatment designed to consolidate the reduction, and consisting in the application of the apparatus proper to maintain the extension and separation of the divided tissues, and to retain the head of the femur in its place; finally, in the gradual execution of movements proper to complete the coaptation of the surfaces, and to establish little by little the physiological movements of the joint. Other surgeons have confined their efforts to the reduction of the dislocation, and they have, consequently, abandoned all those cases in which, owing to the complete absence of the natural socket, or to the want of sufficient mobility in the limb, the reduction was deemed impossible; but Guerin has gone a step farther, and has sought to establish a new socket upon some point of the pelvic bones as near as 1 Dupuytren, op. cit., pp. 176-8. 735 CONGENITAL DISLOCATIONS OF THE HIP. possible to its natural articular fossa. "The means which I adopt," says Guerin, "are based upon a recognition of the processes which nature employs for the attainment of the same purpose, and of which mine are but an imitation. I have shown th§,t the essential condition of the formation of artificial cavities is perforation of the articular capsule, and the placing in contact of the luxated extremity with an osseous surface, and that the condition of the maintenance of this abnormal rapport is the intimate adherence of the borders of the rent with the circumference of the new cavity. Now it appeared to me that art could realize, in all points, the conditions which preside at the spontaneous formation of artificial joints. To this end I commence by practising under the skin, and at the point corresponding to that where it is most convenient to fix the luxated extremity, scarifications of the capsule, down to the bone to which it is attached. By this means the dislocated extremity is placed in immediate contact with the bony surface upon which it reposes. It makes upon this point a beginning of the work of organization resulting from the adhesion and fusion of the scarified points with the corresponding points of this surface. Then, in order to circumscribe and imprison the luxated extremity, in this place of election, I practise all about deep scarifications, which tend to excite the same work of organization and to establish fibrocellular adhesions between the incised borders of the capsule and the contiguous bony surfaces. " Finally, when the fibro-cellular adhesions are supposed to be sufficiently solid to resist the movements of the new articulation, I provoke, little by little, the development of the cavity destined to embrace the luxated extremity by the means which nature herself employs in analogous circumstances; that is to say, by circumscribed and frequent movements of this articulation." 1 The treatment ought to be commenced as early as possible, no examples of success having been recorded in persons over fifteen years of age; while the youngest child whose treatment is reported as successful was three years of age. For the purpose of making the requisite extension, and of maintaining the bone in place, Pravaz (who does not, however, adopt Guerin's practice of establishing for the head of the bone a new socket but only seeks to reduce and maintain it in its old socket) has invented several forms of apparatus adapted to the different stages of progress in the treatment. Heine, of Cannstadt, Guerin, and others have also suggested special contrivances for the same purpose; but no surgeon who understands fully the principle upon which the cure is supposed to be accomplished, will be at a loss for apparatus suitable for making the necessary extension, or for maintaining the reduction when once it has been effected. The length of time required for the completion of a cure, where a cure is possible, must vary according to the age and health of the patient, and according to the pathological condition of the joint, and may be found to extend from a few months to one or more years. It 1 Guerin, op. cit., pp. 81-3. 736 CONGENITAL DISLOCATIONS. is unnecessary to say that where the accomplishment of the cure demands a period of several years, the treatment must be intermittent and greatly varied, so as to suit all the changing circumstances in the condition of the patient.. Finally, if after a fair trial we fail to accomplish a cure, or if the condition of the child will not warrant even the attempt, we ought as far as possible to seek to prevent an increase of the deformity, by such means as our ingenuity may suggest, or by such judicious appliances and general management as we have seen recommended by Dupuytren. South says that he has seen one case of double dislocation in which the walking was at first extremely difficult, but from the fifteenth year and onwards the patient so improved, that at the twentieth year scarcely any trace of the peculiar gait could be discovered. 1 §14. Congenital Dislocations op the Patella. Palletta' found a dislocation of the patella in the cadaver of a young man, which he supposed to be congenital. 2 Michae'lis has reported two cases; one in a young man of seventeen years, and the other in a girl of fourteen, each of whom affirmed that it had existed from birth. 3 Both of these examples presented themselves at the hospital on account of hydrarthrosis of the knee-joints, and Malgaigne, who had himself seen a similar case, is disposed to regard them all as examples of pathological rather than congenital luxations. Periat reports a case in which the dislocation was only produced by walking, and in relation to the authenticity or pertinence of which Malgaigne seems also to entertain a doubt. 4 South says that he has seen a congenital dislocation on both legs, in an aged man. The patella rested entirely upon the outer faces of the external condyles, leaving the front of the knee-joint completely uncovered. When the limbs were extended the patellae could be easily made to resume their natural positions, but on the patient's making the slightest movement they were again displaced. The knees were very much inclined inwards, the feet outwards, and his gait was difficult and unsteady. 5 §15. Congenital Dislocations of the Knee. The head of the tibia has been found, at birth, dislocated forwards, backwards, inwards, outwards, inwards and backwards, outwards and backwards, and simply rotated inwards. Most of these luxations were incomplete; and of them all, the dislocation forwards has been observed much the most often. A subluxation forwards of the head of the tibia has been seen by Guerin in a foetal monster, accompanied with extreme retraction of 1 South, Note to Chelius, op. cit., vol. ii. p. 245. 2 Palletta, Exercitationes Pathologicse, p. 91. 3 Michaelis, Rev. M6d.-Chirurg., torn. xv. p. 56. 4 Periat, Malgaigne, op. cit., torn. ii. p. 932. 5 South, Note to Chelius, op. cit., vol. ii. p. 247. CONGENITAL DISLOCATIONS OF THE KNEE. 737 the extensor muscles of the leg. 1 Cruveilhier has dissected a foetus affected with a similar subluxation. 2 In these examples the displacement forwards at the articular surface was but slight, and the anterior flexion of the limb inconsiderable; but when the dislocation is complete, or nearly so, the deformity is in all respects very much increased; as the following examples will illustrate:— Dr. D. H. Bard, of Troy, Vermont, has reported an example of complete anterior luxation of the tibia, seen by himself, in a new-born infant. The leg was found drawn forwards upon the thigh at an acute angle, so that the toes pointed toward the face of the child, and the bottom of the foot was directed forwards. By the application of moderate force, the limb could be straightened and even flexed completely. These motions inflicted no pain. It was especially noticed that in bringing down the leg from its position of extreme anterior flexion (extension) more force was required in the first part of the manoeuvre than in the last; and that if, having brought the leg down, it was left to itself, it immediately resumed the abnormal position, moving at first slowly, but after a time much more rapidly. The limb was confined by bandages for a short time, and it did not afterwards show any disposition to return to its unnatural position. The child did well, and when it began to use its legs, no difference could be discovered between them. 3 J. Youmans, of Portageville, N. Y., reports a similar case which occurred in his own practice. A healthy woman was delivered on the 16th of Aug. 1859, of a full grown female child, whose left knee was so completely dislocated that the toes rested upon the anterior part of the the thigh near the groin. Dr. Youmans immediately took hold of the limb and brought it to its natural form, but as soon as he relinquished his hold, it flew back to its original position. Having again straightened the leg it was retained in place easily by two pieces of whalebone tied upon each side of the thigh and body. Some soreness and swelling ensued, and it was some weeks before the splint could be safely removed. At the time of the report, Oct. 11, 1860, the child was using the limb with as much freedom and dexterity as other children of her own age. In the report, in evidence of its being an interesting malposition, particular attention is called to the disposition on the part of the limb to resume its unnatural position with a spring, showing contraction of the anterior muscles of the thigh; to the fact that the patella of this knee was smaller than the other, and that the skin on the front of the knee was wrinkled as it is usually back of the knee in fat children. 4 Chatelan was consulted in relation to a similar case, in which the restoration of the limb to its natural position was also easily effected, and by means of three metallic splints, applied during about fifteen 1 Guerin, op. cit., p. 33. 2 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 3 Bard, Amer. Journ. Med. Sci., Feb. 1835, p. 555, from Bost. Med. and Surg. Journ., Nov. 26, 1834. 4 Youmans, Bost. Med. and Surg, Journ., Oct. 25, 1860, vol. 63, p. 250. 738 CONGENITAL DISLOCATIONS. days, the cure was consummated. Chatelain directed, however, that the leg should be kept flexed upon the thigh eight days longer. 1 Kleeberg found a child with the leg so much flexed forwards (extended) upon the thigh that the popliteal region became the lowest point of the limb; in front and above the articular extremity of the tibia could be felt, and the condyles of the femur made a corresponding projection behind into the popliteal space. This was plainly an example of complete luxation; and, contrary to what was observed in Bard's, case, flexion of the limb backwards was difficult and painful. The treatment was commenced by securing the limb in a straight position by means of a splint and roller; subsequently, Kleeberg carried the limb back to an obtuse angle, and finally, it was kept eight days in a position of extreme flexion. A complete cure was said to have been accomplished in about two weeks. 2 Guerin has seen a subluxation backwards, accompanied with a slight rotation of the head of the tibia outwards, in a girl fourteen years old; and which, he affirms, was congenital, characterized by a permanent flexion (backwards) of the leg upon the thigh, and a sliding of the condyles of the tibia backwards. This girl was under Guerin's treatment, but with what result is not stated. 8 Chaussier found both tibiae displaced backwards in an infant otherwise deformed. 4 Robert speaks of an example of lateral subluxation in a man, which had existed from birth. The right knee was thrown inwards, and the left outwards. 1 Guerin " operated" publicly upon a child, two years old, who had a congenital dislocation of the head of the tibia backwards and inwards, accompanied with a slight rotation of the leg inwards. 6 In what manner he operated, and with what result, he does not inform us. The same writer speaks of a subluxation backwards and outwards, with rotation in the same direction, a deformity which, he affirms, is very frequent, and which appears especially after birth, although the causes which produce it have given their first impulse during intrauterine life. The case quoted from Robert, by Malgaigne, as an example of dislocation inwards, seems to have been rather a case of semi-rotation of the articular surfaces, the inner condyle being thrown back into the popliteal space, while the outer condyle still retained its natural position. §16. Congenital Dislocations of the Tarsal Bones. Under this general term may be included all those varieties of subluxation of the several bones which compose the tarsus, and which are known as examples of talipes or club-foot; such as tibio-astragaloid luxations, astragalo-scaphoid, calcaneo-astragaloid, calcaneo-cuboid, &c. 1 Chatelain, Bibliotheque Med., torn. lxxv. p. 85. 2 Kleeberg, Malgaigne, op. cit., p. 983. 3 Guerin, sur les Lux. Congen., p. 33. * Chaussier, Malgaigne, op. cit., p. 984. 5 Robert, Malg., op. cit., p. 985. 6 Guerin, sur les Lux. Congen., p. 33. GUNSHOT FRACTURES. 739 Although these deformities may properly enough claim a place in a chapter on congenital dislocations, they have so long been the subjects of special treatises as to justify their exclusion from the present volume. § 17. Congenital Dislocations op the Toes. Observed occasionally at the metatarso-phalangeal articulations; the articular facets of the first phalanges suffering a subluxation upwards, or laterally upon the corresponding metatarsal bones. Guerin has noticed especially a congenital, lateral subluxation of the great toe. 1 CHAPTER XXVII. GUNSHOT FRACTURES. Gunshot fractures have already been considered, more or less in detail, in the several portions of this work, wherever it seemed to be necessary to call especial attention to them. The only justification, therefore, for a farther allusion to this class of accidents must be found in the special interest which they possess at this moment in my own country. I propose to condense my remarks upon this subject rather into the form of aphorisms, than to give at length the opinions of surgeons and their discussions; accordingly, this chapter will constitute only a brief resume' of what I have myself observed, and of the well attested observations of others. Causes. —Gunshot fractures are caused by a great variety of missiles, such as musket and rifle balls, solid shot and shell, grape, canister, shrapnel, chain and bar shot, fragments of iron, stone, splinters of wood, &c. &c. The only qualities which these missiles possess in common is, that they are all projected by the elastic power of gunpowder, and generally strike the body with great force; and that they cause fractures by direct violence —seldom, if ever, by counterstroke. Round, smooth balls frequently impinge upon bones without causing a fracture, for the reason that they are easily deflected; and this happens especially when they are not moving with great velocity. Minnie rifle balls seldom fail to fracture the bones which lie in their direct course: never, perhaps, when, at the moment of contact, the ball is moving with its average velocity. The peculiar destructiveness of this missile is due to its weight, momentum, and form. Canister, grape, shrapnel, solid shot, shells, chain and bar shot are still more destructive; generally tearing the limbs from the body in such a manner as to render readjustment and restoration impossible. 1 Guerin, op. cit., p. 31. 740 GUNSHOT FRACTURES. Pathology.—These fractures may be simple, compound, comminuted, or complicated; and in addition to these common varieties of fractures there is occasionally presented an example of simple "perforation," or mere penetration of the bone without fissure or other fracture; and still more frequently are seen examples of perforation with fissures. Probably ninety-nine per cent, of all gunshot fractures are both compound and comminuted: the comminution being, in general, excessive. As in gunshot wounds of the soft parts it has been generally observed that the point of entrance is more round, more smooth, and somewhat smaller than the point of exit, and that the tissues are a little depressed at the entrance, while they are slightly protruded at the exit; so, also, in gunshot fractures it will often be found that the side of the bone on which the ball has entered, or upon which it first impinged, is less comminuted than the opposite side; and, if it is a " perforation," that the opening is smaller upon the one side than upon the other; that the edges are slightly depressed upon the one side, and elevated or protruded upon the other; and finally that numerous small, as well as some large fragments of bone, have been carried into that portion of the track of the wound which lies between the bone and the point of exit of the missile. When a ball fractures the shaft of a long bone, although the blow may have been received three, four, or even six inches from an articulation, the comminution, or a single longitudinal fissure, may sometimes be found extending into the joint. These fissures, or splittings of the shaft, often extend also a long distance up or down, without terminating in the joint. Perforations without fissure occur most often in the broad bones of the pelvis, in the scapula, or in the spongy extremities of the long bones. In the latter, however, it is exceedingly rare to find perforation without fissure. Perforations with fissure are pretty common in the head of the humerus and in the head of the tibia; they occur also, but less often, in the lower ends of the femur and tibia, in the trochanteric portion of the femur, and in the head of the femur. We wish to be understood to say that fissures occur less often at the points last mentioned, simply because perforations are there less common. It must be understood that if perforations do occur at these points, a splitting or fissure communicating with the joints is almost inevitable. A misunderstanding here would lead to a very fatal fracture in many cases. Prognosis. —In general it may be stated that gunshot fractures of the upper extremities do not demand amputation, and that similar injuries in the lower extremities do demand amputation. This statement is very broad, and cannot be understood except by a consideration of these accidents somewhat in detail. Thus: — Gunshot fractures of the clavicle, scapula, of the shaft of the humerus, of the shafts of the radius and ulna, and of the carpal, metacarpal and phalangeal bones, notwithstanding these bones have suffered extensive comminution, do not demand amputation: they will in most cases eventually unite, and give to the patients tolerably GUNSHOT FRACTURES. 741 useful limbs. If, however, at the same time that the shaft of the humerus, or of the radius and ulna, is thus broken, the large nervous trunks are torn asunder, so that the extremity is cold and insensible, the limb cannot probably be saved, nor, if it could be, would it be of any value. Destruction of the main artery supplying the limb diminishes the chance of its being saved, but does not, in the case of the upper extremity, necessarily demand amputation. Penetration of the shoulder-joint by a musket or rifle ball, producing a fracture of the head of the humerus or of the glenoid cavity of the scapula, demands amputation when either the axillary artery or axillary nerves are injured; but resection can generally be practised with a reasonable chance of success when the arteries and nerves are untouched. Resection is also made successfully at the shoulderjoint in some cases where larger missiles have traversed the joint, such as canister, fragments of shell, &c. Penetration of the elbow-joint by a large shot, or by a Minnie rifle ball, the missile fairly entering or traversing the joint, demands amputation when the main arterial and nervous supplies are cut off, and resection, generally, when both remain uninjured. Resection may be attempted at the elbow-joint, also, in some cases where, the nervous supply remaining good, only one of the principal arterial trunks is cut off. Frequently a ball strikes the outer or inner condyle of the humerus, making but a small opening into the joint, and producing only slight comminution, and in such cases we often save the limb with more or less anchylosis, and without resection. The remarks which we have made in reference to gunshot fractures of the elbow-joint apply, almost without qualification, to the same accidents at the wrist-joint; For gunshot wounds, with fracture of the carpal, metacarpal and phalangeal bones we seldom practise either resection or amputation, unless the soft parts are almost completely torn away. The prognosis which, as we have now seen, is so favorable in the upper extremities, will be found very different in the lower extremities; indeed it is almost reversed. Thus:— Gunshot fractures of the shaft of the thigh, of the shafts of the tibia and fibula, and of the tarsal bones, generally demand amputation; or, to be more precise, gunshot fractures of the head and neck of the femur almost always terminate fatally under amputation or excision, and equally under treatment as fractures, that is, where an attempt is made to save the limb without interference with the knife. The same accidents in the upper third or the shaft of the femur are generally fatal; but if the main artery, and the principal nerves are uninjured, the life is, in general, less hazarded by an attempt to save the limb than by amputation. In the middle third, under the same circumstances, the chances may be considered equal, as between amputation and the attempt to save the limb by apparatus; in the lower third the chances are in favor of amputation. The above statements in relation to fractures of the femur are based mainly upon my own experience, and have been carefully considered. 742 GUNSHOT FRACTURES. I have seen no resections of the knee-joint or of the shaft of the femur, after gunshot fractures, which have not terminated fatally; and I am convinced that they should never be attempted in fractures of the thigh, unless it be in that case which presents so little hope in any direction, viz., gunshot fracture of the head or neck of the femur. Gunshot fractures of the shafts of both tibia and fibula demand amputation where the comminution is extensive, or the pulsation of the posterior tibial artery is lost, or the foot is cold and insensible. We do not mean to say that some limbs thus situated have not been saved, but only that the attempt to save such limbs greatly endangers the life of the patient, while amputation at or below the knee is relatively safe. Amputation is the only safe expedient in deep penetrating wounds of the tarsal bones produced by missiles of the size of musket balls or larger. The only exceptions which can safely be made are in cases where balls have opened partially and superficially these articulations. Resections at the ankle-joint are much more hazardous than amputations, and scarcely to be preferred, in army practice, to attempts to save the foot without surgical interference. Treatment. —While considering the prognosis in these accidents, I have necessarily spoken of the treatment in certain cases; especially with a view to the propriety of amputation or resection. It remains only to speak briefly of the treatment of those cases in which we may attempt to save the limb without resection, properly so called; for we must not forget that pretty often we find it necessary to remove small, loose fragments of bone by the finger, or by the aid of the knife, or to resect sharp points with the saw or the bone-cutters, when we do not practise "resection," in the sense in which this term is usually employed by surgical writers. I shall take the liberty, in this connection, of reproducing what I have written elsewhere in relation to gunshot fractures, since it comprises nearly all that seems necessary to be added upon this subject. 1 " If an attempt is made to save a limb badly lacerated and broken, certain conditions in the treatment are necessary to success. " All projecting pieces of bone which cannot be easily replaced and are not firmly attached to the soft parts, must be at once cut or sawn away. " All foreign substances, such as fragments of balls or other missiles, pieces of cloth, wadding, dirt, &c, must be removed. " Any portion of integument, fascia, or muscles, which are entangled in the wound, and prevent a thorough exploration, or may obstruct the free escape of blood or of matter, must be freely divided. " Counter-openings must be made at once, or at an early period after the formation of matter, to prevent its easy escape. " The limb must be placed in an easy position, and not confined by tight bandages, or forcibly extended by apparatus. " The inflammation must be controlled by constitutional and local 1 A Practical Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol. 8vo. Published by Bailliere Brothers. New York, 1861. 743 GUNSHOT FRACTURES. means, and especially by the use of water lotions whenever its employment is practicable." If joints are implicated seriously, and an attempt is still made to save the limb, the joint surfaces must be laid freely open, so as to prevent all possibility of the confinement of blood, serum, or pus; and the joint must be placed perfectly at rest, without adhesive straps, bandages, or any apparatus which shall compress the limb or embarrass its circulation. I do not know that it is necessary to speak more particularly of the treatment of gunshot fractures, unless it be to say that I still give the preference, in fractures of the femur, to the straight splint, at least for the first few days, and if then the flexed position seems to be demanded, I prefer a suspending apparatus similar to that which has been recommended by Dr. George Shrady, of New York, in a previous part of this work, or the apparatus recommended by Dr. Nathan Smith, of Baltimore, the last of which I have seen much used in the TJ. S. Army hospitals during the present war, and with excellent results. INDEX. PART I.—FRACTURES. Abscess in fracture of the sternum, 162 Acetabulum, 327 Acromion process, 199 Amesbury's thigh splint, 393 Anatomical neck of humerus, "319, 221 Anaplasty in fractures of the septum narium, 95 Anchylosis after Colles's fracture, 239 after fractures of elbow, 254 excision for anchylosis of knee, 439 " Apparatus immobile," 53 in fractures of the leg, 460 Ashhurst, fracture of astragalus, 468 Astragalus, 466 Atlas, 158 and axis, 158 Axis, 155 Ayres, compound fracture of clavicle, 179 humerus, 227 Badly united fracture of leg, 464 Baker, fracture of maxilla superior, 103 Bartlett's apparatus for broken clavicle, 189 Barton's bran dressing, 60, 463 bandage for fractured jaw, 125 trephining vertebrae, 143 fracture of lower end of radius, 268 fracture-bed, 419 Base of acetabulum, 327 Bauer's wire splints, 461 Bending of bones, 69 Bigelow, fracture of axis, 156 stellate fracture of lower end of radius, 266 Boardman, fracture of zygoma, 105 perineal band, 414 Body of the scapula, 193 Bodies of the vertebra?, 146 Bond's elbow splint, 239 radius splint, 271 Box for leg, 463 Boyer's thigh splint, 394 Brainard, perforator, 68 fracture of anatomical neck of humerus, 206 Buck, lower jaw, 108 thigh splint, 402 Burges's thigh apparatus, 398 Galcaneum,466 Carpal bones, 312 Cartilages, 169 floating, 672, 682 Carved splints, radius, 278 48 Cervical ligaments, strains of, 152 vertebrae, bodies of five lower, 151 axis, 155 atlas, 158 atlas and axis, 158 Chapin's thigh apparatus, 404 Chronic rheumatic arthritis, 362, 363 Children, fracture of femur, 414, 420 Clark's case of fracture of pelvis, 321 Clavicle, 170 partial fractures, 171 repair of fractures, 177 Cline, trephining vertebrae, 143 fracture of atlas, 158 Coates, fracture-bed, 417 bran dressings, 60 Coccyx, 334 Colby, neck of femur within capsule, 357 Colles's fractures, examples, 262 Common signs of fracture, 33 Compress, pasteboard, for fractured jaw, 120 Compound fractures, 59 forearm, 312 thigh, Gilbert on, 410 patella, 432 tibia and fibula, 457, 463 Concussion of spinal marrow, 153 Condyles of humerus, 244 internal, 249 external, 251 base, 233 base and between condyles, 241 of femur, 423 external, 423 internal, 424 base, 426 between condyles, 426 Congenital, 30, 224, 439 Cooper, Sir Astley, fracture of olecranon process, 301 neck of femur within capsule, 343 patella, 436, 437 Coracoid process, 202 Coronoid process of ulna, 287 Liston's case, 290 Cotyloid cavity, 327 Counter-extension by adhesive plaster, 409 Cradle for leg, 462 Crandall, extension of fracture in leg, 458 Cricoid cartilage, 136 Cronyn, fracture of lumbar vertebrae, 149 Crosby, neck of femur within capsule, 365 external condyle, 423 746 INDEX —FRACTURES Dalton, John C, fracture of neck of femur, 346 Daniel's thigh apparatus, 401 fracture-bed, 419 Daniell, femur, 401 Deformities of legs, 465 Delayed or non-union, 60 humerus, 226 Dextrine, 54 Diagnosis, general, 33 Dieffenbach, tenotomy in fracture of olecranon process, 303 Dislocation of humerus, differential diagnosis, 218 Division of fractures, general, 27 Dorsal vertebras, 150 Dorsey, fracture of patella, 436 Dudley, treatment of fractures by bandages, 406 Dugas, sign of dislocation of humerus, 218 thigh apparatus, 401 Dupuytren's case of fracture of a dorsal vertebra, 150 body of a lower cervical vertebra, 151 dressing for fracture of fibula, 446 Elbow splint, Physick's, 238 Kirkbride's, 238 Rose's, 239 Welch's, 239 Bond's, 239 the author's, 240 Ellis, fracture of lower jaw, 109 Else, fracture of axis, 155 Emphysema in fracture of ribs, 167, 168, 169 Endless screw for extension of thigh, 415 Epicondyle of humerus, external, 248 internal, 244 Epiphyseal separations, 28 acromion, 200 humerus, upper end, 220, 222 lower end, 234 femur, upper end, 338 trochanter major, 378 Epitrochlea, 244 Etiology, general, 29 Eve, non-union of ribs, 166 patella, 432 Exciting causes, general, 29 Experiments on bending, 70 on partial fractures, 76, 77, 79 External epicondyle of humerus, 248 condyle of humerus, 251 femur, 423 Extension of thigh by adhesive plaster, 409 Fatjger, Colles's fracture, 273 Felt splints, 51 Femur, 335 neck, within capsule, 336 neck, anatomy of, George K. Smith, 360 differential diagnosis, 373 without capsule, within and without capsule, 375, 376 trochanter major and base of neck, 377 epiphysis of trochanter major, 378 shaft, 379 external condyle, 423 internal condyle, 424 between condyles, 426 base of condyles, 426 Fergusson's arm dressing, 238 Fibula, 442 Fingers, 316 Fissures, 83 neck of femur, 340 Forearm, 303 Fore's case of fracture of hyoid bone, 130 Flagg's thigh apparatus, 399 Flint, J. B., femur, 402 Floating cartilages, in knee-joint, 672, 682 Four-tailed bandage for broken jaw, 126 Fracture beds, 417 Jenks, 417 Hewson, 417 Barton, 417 Coates, 417 Daniels, 418 Burges, 398 Fracture-box, 463 Gangrene, after fracture at base of condyles of humerus, 237 Dupuytren's cases after fracture of radius, 280 Robert Smyth's cases, 280 Norris, 281 after fracture of forearm, 307 leg, from tight roller, 406 patella, 437 from tight bandages, 442 leg, from tight bandage, 454 from use of " apparatus immobile," 460 Gibson, bandage for fractured jaw, 125 fracture of clavicle, 180 of coracoid process, 202 Gilbert, apparatus for broken femur, 410 Glenoid cavity of scapula, comminuted, 198 Granger, fracture of epicondyle, 244, 246 Greater tubercle of humerus, 210, 219, 221 Greenwood, fracture of lower cervical vertebra, 151 Gunshot fractures, 739 treatment in, 742 Gross, fracture of sternum, 169 Gutta-percha splints, 52 Harris, separation of upper maxillary bones, 100 Harrold, lumbar vertebrae, 149 Hartshorne, thigh apparatus, 403 Hays, radial splint, 272 Hayward, lower jaw, 119 Head of femur, 337 of radius, 258 and anatomical neck of humerus, 204 and neck of humerus, longitudinal fracture, 210 Hewson, fracture-bed, 417 Hodge, thigh-splint, 411 Horner, thigh apparatus, 403 Humerus, 204 anatomical neck, 206 head and neck, 205 tubercles, 210 longitudinal fracture of head and neck, 210 surgical neck, 212 upper epiphysis, 213 differential diagnosis, 218 shaft, 224 base of condyles, 233 with splitting of condyles, 241 condyles, 244 747 INDEX —FRACTURES Humerus — internal epicondyle, 244 external epicondyle, 248 internal condyle, 249 external condyle, 251 delayed union, 228 dislocation of, 217 Hutchinson, leg splint, 456 Hyoid bone, 129 Ilium, 324 Immovable apparatus, 53 leg, 460 Impacted fractures, 28 head and neck of humerus, 205 tubercles, 210 neck of femur within capsule, 336 without the capsule, 369 Inferior maxilla, 107 Interstitial absorption of neck of femur, 361 Intra-uterine fracture, 30, 224, 439 fracture of tibia, 439 Internal condyle of humerus, 249 femur, 424 Interdental splints, 121 Ischium, 322 Jackson, acromion process, 200 Jarvis's adjuster, 456 Jenks, fracture-bed, 417 Johnson, neck of femur, 346, 351 Key, lumbar vertebrae, 149 Kimball, fracture of femur, 401 Kirkbride, elbow splint, 238 Lente, fracture of dorsal vertebra, 150 femur, 410 non-union, 65 pelvis, 320 Lewitt, patella, 432 Liston, thigh splint, 391 leg splint, 461 Lockwood, fracture of humerus at birth, 225 Long splints, 48 Lonsdale, extension in fracture of humerus, 227 patella, 438 Lower jaw, 107 Malar bone, 96 Many-tailed bandage, 45 March, acromial separations, 211 neck of femur, 367 Malgaigne, apparatus for fracture of leg, 464 Maxilla, superior, 99 inferior, 107 Mayo, neck of femur, 200 McDowell, remarkable displacement of head of humerus, 206 separation of upper epiphysis, 213 Metacarpus, 313 Metatarsus, 471 Metallic splints, 48 Monahan, fracture of astragalus, 466 Morbus coxae senilis, 363 Morland, statistics of fracture of tibia and fibula, 448 Mott, prognosis in Colles's fracture, 270 fracture of femur, 395 electricity in non-union, 65 Mussey, fracture of coracoid process, 202 Mussey, neck of femur, 349 Mutter's "clamp," 122 neck of radius, 256 Neck of femur, 335 within capsule, 336 prognosis, 342 G. K. Smith on, 360 without capsule, 369 Neck of humerus, anatomical, 205, 210 surgical neck, 212 Neck of lower jaw, 110 Neck of radius, 256 Neck of scapula, 198 signs of fracture, 218 Neill, maxilla superior, 103 coracoid process, 202 fracture of patella, 436 thigh, 399 leg, simple fracture, 455 compound fracture, 457 Nelaton, radial splint, 271 Non-union, 60 humerus, 229 lower jaw, 116 ribs, 166 Norris, delayed and non-union, 60 astragalus, 469 gangrene from bandages, 281 tibia, 442 Nose, fracture of, 88 Nott, wire splints, 48 thigh apparatus, 395 Odontoid process of axis, 156 Olecranon process, 295, 301 tenotomy, 303 Ossa nasi, 88 Partial fracture, 73 Patella, 428 Phalanges of toes, 472 Radius, 255 Radial splint, 272, 277 Radius and ulna, 303 Reduction of fractures : general considerations, 44 Refracture of badly-united legs, 464 Repair of fracture, 37 Resection for badly-united fractures, 465 Ribs, 164 cartilages of, 164, 169 Rim of acetabulum, 331 Rodet, neck of femur, 337 Rogers, trephining vertebrae, 144 Roller, 45 Rose, elbow splint, 239 Sacrum, 333 Sacro-iliac symphysis, 333 Salter's cradle for leg, 462 Sanborn, patella, 432 thigh, 401 Sargent, separation of upper maxillary bones, 99 Scapula, 193 body, 193 neck, 198 acromion process, 199 coracoid process, 202 Scultetus, bandage, 46 748 INDEX —FRACTURES Semeiology, general, 33 Septum narium, 93 Setting bones, 44 Seutin, dressing, 53 anaplasty, 95 Shaft of humerus, 224 radius, 260 ulna, 282 femur, 379 Shoulder-joint; differential diagonosis of accidents, 218 Shrady, radius splint, 284 thigh splint, 415 Side splints, 48 Sling for broken jaw, 126 Smith, E. P., radial splint, 271 Smith, H. H., fracture of neck of femur, 351 Smith, Nathan R., fracture of femur, 395 Smith Robert, head of humerus, 208 Smith, Stephen, fracture of lower jaw, 115 Smith, Geo. K., insertion of capsule of hipjoint, &c, 372 Spencer, fracture of humerus at base of condyles, 243 Spinal marrow, concussion, 153 Spinous processes : vertebrae, 138 ilium, 324, 325 Splints, 48 Starch bandage, 53 leg, 460 Sternum, 159 Stone, fracture of humerus, 227 base of condyles and resection, 243 Styloid process of radius, 267 Surgical neck of humerus, 212, 220, 222 Swan, neck of femur within capsule, 345 Swing box for leg, 462 Symphyses of pelvis, 319 pubes, 334 sacro-iliac, 334 Symphysis pubis, separation of, 334 Tarsus, 466 astragalus, 466 calcaneum, 467 Tenotomy in fractures of olecranon process, 303 Thompson,fracture of lumbar vertebrae, 49 Thyroid cartilage, 134 Thyroid and cricoid cartilages, 134 Tibia, 439 Tibia and fibula, 446 Toes, 472 Transverse processes of spine, 140 Treatment of fractures, general, 44 Trephining for fracture of vertebrae, 148 Trochanter major, 377 Trochlea of humerus, 249 Tubercles of humerus, 210, 220, 222 Ulna, resection of, 282 Ulna, 282 shaft, 282 coronoid process, 287 olecranon process, 295 Upper epiphysis, humerus, 220 femur, 339 Upper maxillary bones, 99 Van Buren, W. H., fracture of humerus, 224 Vanderveer, fracture in utero, 32 Vandeventer, fracture of vertebral arch, 141 Velpeau, mode of dressing fractures with dextrine and rollers, 54 Vertebral arches, 141 Vertebras, 138 spinous processes, 138 transverse processes, 140 vertebral arches, 141 bodies, 146 lumbar, 148 dorsal, 150 cervical, 151 axis, 155 atlas, 158 atlas and axis, 158 Waters, compound fracture of humerus, 224 Warren on anchylosis at elbow-joint, 254 Watson, fracture of lower jaw, 110 lower epiphysis of humerus, 234 patella, 431 Weber, plaster of Paris bandages, 58 Whittaker, pelvis, 335 Wells, internal condyle of femur, 424 Wire splints, 48 Wood, fraoture of patella, 436 Wooden splints, 49 Wrist, 312 Wire rack for fracture of leg, 463 Zygomatic arch, 104 749 INDEX — DISLOCATIONS. PART II. —DISLOCATIONS. Ancient luxations, 486 inferior axilla, 486 spine, 494 clavicle, outer end, 515 humerus, 539 head of radius forwards, 561 radius and ulna backwards, 571 thumb, 597 femur, 652 Andrews, inferior maxilla, 484 Ankle-joint, 674 Annan, dislocation of femur, 638 Anomalous dislocations of the hip, 647. See Femur. Atlas, dislocations of, 502 Ayres, dislocation of cervical vertebra, 499 Batchelder, head of radius, 559, 564 thumb, 601 Bard, H. H. Congen, dislocation of tibia, 737 Biceps, rupture or displacement of, 557 Blackman, ancient dislocations of humerus, 543 femur, reduced after six months, 653 Bloxham's dislocation tourniquet, 625 Brainard, reduction of ancient luxation of elbow, 576 reduction of femur by a novel method, 643 Canton, radius and ulna forwards, 584 Carpus, 585 backwards, 587 forwards, 590 congenital, 739 Carpal bones among themselves, 593 Carpo-metacarpal articulation, 595 Cartilages, of ribs from one another, 506 in knee-joint, 672 Clavicle, dislocations of, 506 sternal end forwards, 506 sternal end upwards, 510 sternal end backwards, 512 acromial end upwards, 513 acromial end downwards, 518 under coracoid process, 519 congenital, 724 Clove hitch, 482, 600 Compound pulleys, 482 Compound dislocations of the long bones, 701 reduction in, 707 non-reduction in, 710 amputation in, 710 tenotomy in, 711 resection in, 711 Congenital dislocations ; general observations and history, 716 general etiology, 718 inferior maxilla, 719 spine, 722 pelvic bones, 723 sternum, 723 clavicle, 724 Congenital Dislocations— shoulder, 724 radius and ulna backwards, 72S head of radius, 728 wrist, 729 fingers, 730 hip, 730 patella, 736 knee, 736 tarsus, 738 toes, 739 Cooper, Sir Astley, method of reducing dislocation of humerus, 538 Coxo-femoral dislocations, 609. See Femur. Crosby, dislocation of thumb, 602 ancient dislocation of elbow, 576 Damainville, statistics of dislocations of femur, 626 Direct causes of dislocations, 477 Dislocations, 475 Division and nomenclature of dislocations, 475 Double dislocation of lower jaw, 483 Dupierris, femur reduced after six months, 653 Dynamometer, 625 Elbow-joint, 568 Exciting causes, general, 477 Extension by a twisted rope, 482 Femur, dislocations of, 609 dislocation on dorsum ilii, 611 reduction by manipulation, 616 reduction by extension, 622 dislocation into great ischiatic notch, 634 dislocation into foramen thyroideum, 639 dislocation upon the pubes, 643 anomalous dislocations of the femur, 647 downwards and backwards upon the body of the ischium, 649 downwards and backwards into lesser ischiatic notch, 649 behind the tuber ischii, 649 directly up, 647 directly down, 650 forwards into perineum, 651 ancient dislocations, 616, 652 partial dislocations, 654 with fracture, 656 in children, 610 congenital, 730 Fenner, dislocation of femur on dorsum ilii, 613 Fibula, upper end forwards, 684 backwards, 685 lower end, 686 " Fifth," dislocation of femur, 649 Fingers, dislocations of first phalanx, 597,605, 606 second and third, 606 congenital, 730 Foot, dislocation outwards, 674. See Tibia. Fountain, dislocation of femur upon pubes, 645 750 INDEX —DISLOCATIONS Gazzam, rotation of patella on its inner margin, 664 General division, 475 General direct or exciting cause3, 477 General predisposing causes, 476 General prognosis, 480 General pathology, 479 General treatment, 430 General symptoms, 477 Gibson, ancient dislocation of humerus, 548 Gilbert, A. W., dislocation of lower jaw, 484 Graves, dislocation of dorsal vertebrae, 493 Gunn, dislocation of thigh on dorsum ilii, 613 Hartshorne, reduction of humerus by manipulation (note), 548 Head upon the atlas, 503 Hinckerman, cervical vertebrae, 498 Hodge, statistics of dislocations of the femur, 627 thigh splint, 422 Horner, partial dislocation of fourth cervical vertebra, 496 Howe, reduction of dislocation of the hip by manipulation, 619 Humerus, dislocations of, 520 downwards, 521 forwards, 547 backwards, 552 partial, 556 ancient, 539 with fracture, 546 congenital, 724 Humero-scapular dislocation, 520. See Humerus. Ilio-pubic dislocation of femur, 643 Indian "puzzle," 603 Inferior maxilla, 483 double dislocation, 483 single dislocation, 487 congenital dislocation, 719 Ingalls, reduction of dislocation of hip by manipulation, 621 Internal derangement of knee-joint, 672 Ischio-pubic dislocation of femur, 639 Ischiatic dislocation of femur, 634 Jarvis's adjuster, 482, 541, 625 Kirkbride, dislocation of the femur upon posterior part of the body of the ischium, 649 Knee, slipping of semilunar cartilages, 672, 679. See Tibia. Krackowitzer, dislocation of head of radius in delivery, 559 La Mothe, method of reducing dislocation of humerus, 535 Lehman, spontaneous dislocation of shoulder, 522 Lente, fifth cervical vertebra,with fracture, 496 fifth cervical vertebra without fracture, 496 femur directly upwards, 648 Levis, reduction of dislocation of thumb, 602 Ligamentum patellae, rupture of, 664 Long bones, compound dislocation in, 701 Lower jaw, 483 Lumbar vertebrae, 490 Markoe, on reduction of dislocation of femur, 613, 621 head of radius backwards, 564 femur with fracture, reduced, 658 Maxon, dislocation of cervical vertebrae, 499 May, reduction of old dislocation of humerus, 539 Mercer, on partial dislocations of humerus, 558 Metacarpus, 595 Metacarpo-phalangeal articulation, 597 Metatarsus, 698 Moore, on reduction of dislocation of femur. 613 Mussey, dislocation of thumb, 601 ancient dislocation of elbow, 576 Norris, ancient dislocations of the humerus, 546, 550 dislocation of humerus mistaken for a contusion, 550 compound dislocation of thumb, 604 partial luxation of patella, with fracture, 660 Occipito-atloidean dislocations, 503 Parker, head of humerus in sub-scapular fossa, 549 backwards, 553 head of radius backwards, 565 head of radius outwards, 566 femur into perineum, 651 Patella, outwards, 659 inwards, 661 on its axis, 662 on its inner margin, 662 upwards, 664 downwards, 664 congenital, 736 Pathology, general, 479 Pelvis, traumatic separations, 319 (Part I.) congenital, 723 Phalanges, thumb and fingers, 597 toes, 700 Pope, dislocation of femur into perineum, 652 Predisposing causes, general, 476 Prognosis, general, 480 Pseudo-luxations of inferior maxilla, 488 Pulleys, 482 Purple, dislocation of cervical vertebrae, 496 Radius, head dislocated forwards, 559 backwards, 564 outwards, 566 outwards and backwards, 578 inwards, 581 inwards and upwards, 581 congenital, 728 Radius and ulna, dislocation backwards, 568 congenital, 728 outwards, 577 inwards, 581 forwards, 583 Radio-carpal articulation, 585. See Carpus. Radio-ulnar articulation, inferior, 591 Rupture of quadriceps femoris, 664, 667 Reid, reduction of dislocation of femur by manipulation, 621 Ribs from vertebrae, 504 from sternum, 505 one cartilage upon another, 506 INDEX —DISLOCATIONS 751 Rochester, sternal end of clavicle upwards, 510 Rudiger, dislocation of dorsal vertebras, 494 Sacro-sciatic dislocation of femur, 634 Sanson, third cervical vertebra, 497 Schuck, dislocation of cervical vertebra , 498 Shoulder, dislocation of, 520. See Humerus. Single dislocation of lower jaw, 487 "Sixth" dislocation of femur, 647 Skey, method of reducing dislocation of humerus, 537 Smith, Nathan, on reduction of dislocation of the humerus, 534 reduction of femur by manipulation, 620 Smith, Nathan R., on reduction of humerus, 534 Smith, H. H., on reduction of humerus, 539 Spencer, dislocation of cervical vertebra, 497 Spine, 490. See Vertebrce. Squire, T. H., dislocation of radius and ulna inwards, 582 Sternum, diastasis, 159 (Parti.) congenital dislocations, 723 Subcoracoid dislocation of humerus, 547 Subclavicular dislocation of humerus, 549 Subcotyloid dislocations of femur, 650 Subluxation of the jaw, 488 Subglenoid dislocation of the humerus, 521 Subpubic dislocation of femur, 639 Subspinous dislocation of humerus, 552 Swan, dislocation of dorsal vertebra, 494 Symptomatology, general, 477 Tarsus, 686 astragalus, 686 astragalo-calcaneo-scaphoid, 693 calcaneum, 694 middle tarsal dislocation, 695 os cuboides, 695 • os scaphoides, 695 cuneiform bones 696 congenital, 738 Thigh, 509. See Femur. Thumb, first phalanx, 597 backwards, 597 forwards, 604 second phalanx, 608 Tibia, dislocation of upper end, 665 backwards, 665 forwards, 667 outwards, 669 inwards, 670 backwards and outwards, 671 congenital, 737 lower end, inwards, 674 outwards, 679 forwards, 680 backwards, 683 Tibia, dislocation of lower end, 674 Tibio-tarsal luxations, 674 Toes, 700 congenital, 739 Treatment, general, 480 Trowbridge, head of humerus backwards, 553 Twisted rope, extension, 482 Ulna, upper end backwards, 568 lower end backwards, 591 forwards, 592 Unilateral luxation of lower jaw, 487 Van Buren, W. II., dislocation of humerus backwards, 553 reduction of femur by manipulation, 629, 641 Vertebras, 490 lumbar, 491 dorsal, 492 six lower cervical, 495 atlas upon axis, 502 head upon atlas, 503 congenital dislocations, 722 Warren, humerus with fracture, 546 Watson, dislocation of patella outwards, 660 Wells, dislocation of tibia, 672 Windlass for extension, 482 Wood, dislocation of cervical vertebras, 499 humerus, with fracture, 549 Wrist, 585. See Carpus. Youmans, J., congenital dislocation of knee, 737 THE END. BLANCHARD & LEA'S MEDICAL AID SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. The greatly enhanced cost of materials and labor has at length obliged us to make a small increase in the price of some of our books, and we have been forced in a few instances to change the style of binding from leather to cloth, in consequence of the increased difficulty of procuring a full supply of the superior quality of leather which we require for our publications. "We have made these changes with reluctance, and can only hope that we may not be forced to further modifications by a.continued increase of cost. BLANCHARD & LEA. Philadelphia, September, 1863. *** We have recently issued an Illustrated Catalogue of Medical and Scientific Publications, forming an octavo pamphlet of 80 large pages, containing specimens of illustrations, notices of the medical press, &c. &c. It has been prepared without regard to expense, and will be found one of the handsomest specimens of typographical execution as yet presented in this country. Copies will be sent to any address, by mail, free of postage, on receipt of nine cents in stamps. Catalogues of our numerous publications in miscellaneous and educational literature forwarded on application. OP The attention of physicians is especially solicited to the following important new work3 and new editions, just issued or nearly ready:— Bowman's Medical Chemistry, a new edition, See page 4 Barclay on Medical Diagnosis, second edition, " 5 Brande and Taylor's Chemistry, " 6 Dalton's Human Physiology, 2d edition, "11 Dunglison's Medical Dictionary, a revised edition, "12 Erichsen's System of Surgery, a revised edition, "14 Flint on the Heart, "14 Gross's System of Surgery, second edition, "16 Gray's Anatomy, Descriptive and Surgical, 2d edition, "17 Hamilton on Fractures and Dislocations, second edition, "18 Hodge on Diseases of Women, "19 Meigs' Obstetrics, fourth edition, "21 Parrish's Practical Pharmacy, a new edition, "25 Stille's Therapeutics and Materia Medica, "27 Simpson on Diseases of Women, "27 Sargent's Minor Surgery, new edition, "28 Watson's Practice of Physic, "30 Wilson on the Skin, filth edition, . "31 West on Diseases of Women, second edition, "32 NO INCREASE OF PRICE. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, Containing about Fifteen Hundred large octavo pages, FOR FIVE DOLLARS PER ANNUM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance, $5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - -100 or, both periodicals mailed, free op postage (as long as the existing rates are maintained), to any post-office in the United States, for Five Dollars remitted in advance. 2 BLANCHARD & LEA'S MEDICAL It will be observed that notwithstanding the great increase in the cost of production, the subscription price has been maintained at the former very moderate rate, which has long rendered them among the CHEAPEST OF AMERICAN MEDICAL PERIODICALS. The publishers trust that this course will be responded to by the profession in a liberal increase to the subscription list. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. 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In one very beautifully pritited octavo volume, of about 300 pages, extra cloth. $2 00. The most complete one we possess on the subject. Medico-Chirurgical Review. We are satisfied, after a careful examination of the volume, and a comparison of its contents with those of its leading predecessors and contemporaries, that the best way for the reader to avail himself of the excellent advice given in the concluding paragraph above, would be to provide himself with a c;)py of the book from which it has been taken, and diligently to con its instructive pages. They may secure to him many a triumph and fervent blessing Am. Journal Med. Sciences. ALLEN (J. MJ, M. D., Professor of Anatomy in the Pennsylvania Medical College, Jfcc. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting- ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, extra cloth. $2 25. We believe it to be one of the most useful works upon the subject ever written. It is handsomely Illustrated, well printed, and will be found of convenient size for use in the dissecting-room.— Med. Examiner. However valuable may be the "Dissector's Guides" which we, of late, have had occasion to notice, we feel confident that the work of Dr. Allen is superior to any of them. We believe with the author, that none is so fully illustrated as this, and the arrangement of the work is such as to facilitate the labors of the student. We most cordially recommend it to their attention.— Western Lancet. ANATOMICAL ATLAS. By Professors H. H. Smith and W. E. Horner, of the University of Pennsylvania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. BP" See Smith, p. 26. ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. $3 25. ASH WELL (SAMUEL), M. D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. The most useful practical work on the subject in The most able, and certainly the most standard the English language. — Boston Med. and Surg, and practical, work on female diseases that we have Journal. yet seen.— Medico-Chirurgical Review. The most able, and certainly the most standard and practical, work on female diseases that we have yet seen.— Medico-Chirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustrations. $2 50. BIRD (GOLDING), A. M., M. D., Sec. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the last and enlarged London edition. With eighty illustrations on wood. In one handsome octavo volume, of about 400 pages, extra cloth. $2 75. (Just Ready.) It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the results of those microscopical and chemical researches regarding the physiology and pathology of the urinary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our therapeutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful representation of the present state of scientific knowledge on the subject it embraces.— B ritish and Foreign Med.-Chir. Review. BENNETT (J. HUGHES), M. D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCULOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. $1 25. BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, &o. A P M ri^ A M L r, 0F f T HE , ( , P A AGTIGE 0F MEDICINE. With Additions by D. F. Condie, M. D., author of A Practical Treatise on Diseases of Children," (fee. In one handsome octavo volume, extra cloth, of over 600 pages. $2 75. We recommend Dr. Barlow's Manual in the warmeat manner as a moBt valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound.— Bos ton Med. and Surg. Journal, BLANCHARD to LEA'S MEDICAL 4 BUDD (GEORGE), M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third an& enlarged London edition. In one very handsome octavo volume, extra cloth, with four beautifully colored plates, and numerous wood-cuts. pp. 500. $3 00. Has fairly established for itself a place among the classical medical literature of England.— British and Foreign Medico-Chir. Review. Dr. Budd's Treatise on Diseases of the Liver is now a standard work in Medical literature, and during the intervals which have elapsed between the successive editions, the author has incorporated in So the text the most striking novelties which have characterized the recent progress of hepatic physiology and pathology: so that although the size of thebooic is not perceptibly changed, the history of liver disease* is made more complete, and is kept upon a level with the progress of modern science. It is the bezi work on Diseases of the Liver in any language.— London Med. Times and Gazette. BUCKNILL (J. C), M. D., and DANIEL H. TUKE, M. D., Medical Superintendent of the Devon Lunatic Asylum. Visiting Medical Officer to the York RetrcaS, A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages, extra cloth. S3 00. The increase ol mental disease in its various forms, and the difficult questions to which it is constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the roost perplexing branch of his profession. At the same time there has been for some years no work accessible in this country, presenting the results of recent investigations in tbe Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. To fil! this vacancy the publishers present this volume, assured tha'! the distinguished reputation and experience of the authors will entitle it at once to the confidence of both student and practitioner. Its scope may be gathered from the declaration of the authors that " their aim has been to supply a text book which may serve as a guide in the acquisition oi such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently modern in its views and explicit in its teaching to suffice for the demands of the practitioner." BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which is added, a Review of the present stale of Uterine Pathology. Fifth American, frora tbe third English edition. In one octavo volume, of about 500 pages, extra cloth. $S GO. BROWN (ISAAC BAKER), Surgeon-Acco«ehe»r to St. Mary's Ketspita}, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREATMENT. With handsome illustrations. One vol. Svo., extra cloth, pp. 278. $169. Mr. Brown has earned for himself a high repwta- tion in the operative treatment of sundry diseases;, addition to obstetrical literature. The operative suctions and contrivances which Mr. Brown de- scribes, exhibit much practical sagacity and skill, and merit the careful attention of eveTy euygeojiaccoucheur.—Association Journal. W 8 h a v r oh f itationinreeo m mendi B gtM S boo S Ji> t:te crnief*. attention of ail surgeons who mate fenate complaints a part of their study asd piactiee, J^rnal. BOWMAN (JOHN E.>, M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited hj C. L. Bloxam. Third American, from the fourth and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp.301. $175. (WowReady, May, 1863.) Of this well-known handbook we may say that it retains all its old simplicity and clearness of arrangement and description, whilst it has received from the able edit ir those finishing touches which the progress of chemistry has rendt red necessary.— London Med. Times and Gazette, Nov. 29, 1862. Nor is anything huiried over, anything shirked ; open the book where you will, you find the same careful treatment of the subject manifested, ana the best process for the attainment of the particular object in view lucidly detailed and explained. And this new edition is not merely a repriat of the last. With a laudable desire to keep the book up to the scientific marl! of tfee present age, every improvement in analytical method has been introduced. In conclusion, we would only »ay that, familiar from long acquainlaaee with each paire of the former issues of this little book, we gladly place beside them another presenting so many acceptable improvements and addition*.— Dublin, Mtdisal Press, Jan. 7, 1863. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Second American, from the second and revised London edition. With numerous illustrations. In one neat vol., royal 12mo., extra cloth, pp. 2V8. $1 25. BEALE ON THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal 12mo., extra cloth, pp. 296. 80 cents. flUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp.234 . 80 cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF FIBRO-BRONCHl* TIS AND RHEUMATIC PNEUMONIA. la one 8vo. volume, extra cloth, pp.150, fl 25. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWIOK. One thick volume, royal 12mo., extra cloth, witli plates, pp. 460. $1 25. BRODIE'S CLINICAL LECTURES ON SURGERY. 1 vol. 8vo. cloth. 350pp. 0125. AND SCIENTIFIC PUBLICATIONS. 5 BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Physicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. In one very handsome octavo volume, of nearly 700 pages, extra cloth; $3 75. By far the most valuable contribution to this particular branch of practice that haB seen the light within the last score of years. His clear and accurate descriptions of the various forms of venereal disease, and especially the methods of treatment he proposes, are worthy of the highest encomium. In these respects it is better adapted for the assistance of the every-day practitioner than any other with which we are acquainted. In variety of methods proposed, in minuteness of direction, guided by careful discrimination of varying forms arid complications, we write down the book as unsurpassed. It is a work which should be in the possession of every practitioner.— Chicago Med. Journal. Nov. 1861. The foregoing admirable volume comes to us, embracing the whole subject of sy philology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completest, fullest monogiaph on this subject in our language. As far as the author's labors themselves are concerned, we feel it a duty to say that he has not only exhausted his subject, but he has presented to us, without the slightest hyperbole, the best digested treatise on these diseases in our language. He has carried its literature down to the prestnt moment, and has achieved his task in a manner which cannot but redound to his credit.— British American Journal, Oct. 1S61. We believe this treatise will come to be regarded as high authority in this branch of medical practice, and we. cordially commend it to the favorable notice of our brethren in the profession. For our own part, we candidly confess that we have received n.any new irieas from its perusal, as well as modified many views which we have long, and, as we now think, erroneously entertained on the subject of syphilis^ To sum up all in a few words, this book is one which no practising physician or medical student can very well afford to do without.— American Med Times, Nov. 2, 18(51. The whole work presents a complete history of venereal diseases, comprising much interesting and valuable material that has been spread through medical journals within the last twenty years —the period of many experiments and investigations on the subject—the wh"le carefully digested by the aid of the author's extensive personal experience, and offered to the profession in an admirable form. Its completeness is secured by good plates, which are especially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that may fairly be jailed original.— Berkshire Med. Journal, Dec. 1861. One thing, however, we are impelled to say, that we have met with no other book on syphilis, in the English language, which gave so full, clear, and impartial views of the important subj-ds on wuich it treats. We cannot, however, refrain from expressing our satisfaction with the full and perspicuous manner in which the subject has been presented, and the careful attention to minute details, so useful—not to say indispensable—in a practical treatise. In conclusion, if we may be pardoned the use of a phrase now become stereotyped, but which we here employ in all seriousness and sincerity, we do not hesitate to express the opinion that Dr. Burastead'l Treatise on Venereal Diseases is a work without which no medical library will hereafter be considered complete."— Boston Med. and Surg. Journal, Sept. 5, 1861. BARCLAY (A. W.), M. D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Second American from the second and revised London edition. In one neat octavo volume, extra cloth, of 451 pages. $2 25. The demand for a second edition of this work shows that the vacancy which it attempts to supply has been recognized by the profession, and that the efforts of the author to meet the want have been successful. The revision which it has enjoyed will render it better adapted than before to afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For this latter purpose its complete and extensive Index renders it especially valuable, offering facilities for immediately turning to any class of symptoms, or any variety of disease. The task of composing such a work is neither an easy nor a light one; but Dr. Barclay has performed it in a manner which meets our most unqualified approbation. He is no mere theorist; he knows his work thoroughly, and in attempting to perform it, has not exceeded his powers.— British Med. Journal. We venture to predict that the work will be deservedly popular, and soon become, like Watson's Practice, an indispensable necessity to the practitioner—N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.— Nashville Med. Journal. We hope the volume will have an extensive circulation, not among students of medicine only, but practitioners also. They will never regret a faithful study of itspages.— CincinnatiLancet. An important acquisition to medical literature. It is a work of high merit, both from the vast importance of the subject upon which it treats, and also from the real ability displayed in 't« elaboration. In conclusion, let us bespeak for this volume that attention of every student of our art which it so richly deserves — that place in evsry iiieuical library which it can so well adorn.- -Peninsular Medical Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS ° f F D T HE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof, ol Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. Price $3 00. It is a work of great practical value and interest, containing much that is new relative to the several diseases of which it treats, and, with the additions of the editor,is fully up to the times. Thedistinctlve features of the different forms of fever are plainlv and forcibly portrayed, and the lines of demarcation carefully and accurately drawn, and to the American practitioner is a more valuable and safe guide than any work on fever extant.— Ohio Med. and ourg. Journal. This excellent monograph on febrile disease, has gtood deservedly high since its first publication. It will be seen that it has now reached its fourth edition under the supervision of Prof. A. Clark, a gentleman who, from the nature of his studies and pursuits, is well calculated to appreciate and discuss the many intricate and difficult questions in pathology. His annotations add much to the interest of the work, and have brought it well up to the condition of the science as it exists at the present day in regard to this class of diseases.— Southern Med. and Surg. Journal. 6 BLANCHARD & LEA'S MEDICAL BRANDE (WM. T.) D. C. L., and ALFRED S. TAYLOR, M. D., F. R. S. Of her Majesty's Mint, &c. Professor of Chemistry and Medical Jurisprudence in Guy's Hospital. CHEMISTRY. In one handsome 8vo. volume of 696 pages, extra cloth. $3 50. (Now Ready, May, 1863.) " Having been engaged in teaching Chemistry in this Metropolis, the one for a period of forty, and the other for a period of thirty years, it has appeared to us that, in spite of the number of books already existing, there was room for an additional volume, which should be especially adapted for the use of students. In preparing such a volume tor the press, we have endeavored to bear in mind, that the student in the present day has much to learn, and but a short time at his disposal for the acquisition of this learning."—Authors' Preface. In reprinting this volume, its passage through the press has been superintended by a competent chemist, who has sedulously endeavored to secure the accuracy so necessary in a work of this nature. No notes or additions have been introduced, but the publishers have been favored by the auihors with some corrections and revisions of the first twenty-one chapters, which have been duly inserted. In so progressive a science as Chemistry, the latest work always has the advantage of presenting the subject as modified by the results of the latest investigations and discoveries. That this advantage has been made the most of, and that the work possesses superior attractions arising from its clearness, simplicity of style, and lucid arrangement, are manifested by the unanimous testimony of the English medical press. It needs no great sagacity to foretell that this book will bo, literally, the Handbook in Chemistry of the student and practitioner. For clearness of language, accuracy of description, extent of information, and freedom from pedantry and mysticism of modern chemistry, no other text-book comes into competition with it. The result is a work which for fulness of matter, for lucidity of arrangement, for clearness of style, is as yet without a rival. And long will it be without a rival. For, although with the necessary advance of chemical knowledge addenda will be required, there will be little to take away. The fundamental excellences of the book will remain, preserving it for years to come, what it now is, the best guide to the study of Chemistry yet given to the world.— London Lancet, Dec. 20, 1862. Most assuredly, time has not abated one whit of the fluency, the vigor, and the clearness with which they not only have composed the work before us, but have, so to say, cleared the ground for it, by hitting right and left at the affectation, mysticism, and obscurity which pervade some late chemical treatises. Thus conceived, and worked out in the most sturdy, common sense method, this book gives, in the clearest and most summary method possible, all the facts and doctrines of chemistry, with more especial reference to the wants of the medical student.— London Medical Times and Gazette, Nov. 29, 1862. If we are not very much mistaken, this book will occupy a place which none has hitherto held among chemists; for, by avoiding the errors of previous authors, we have a work which, for its size, is certainly the most perfect of any in the English language. There are several points to be noted in this volume which separate it widely from any of its compeers—¦ its wide application, not to the medical student only, nor to the student in chemistry merely, but to every branch of science, art, or commerce which is in any way connected with the domain of chemistry.—Zo»> donMed. Review, Feb. 1863. BARWELL (RICHARD,) F- R. C. S., Assistant Surgeon Charing Cross Hospital, &c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engravings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $3 00. At the outset we may state that the work is worthy of much praise, and bears evidence of much thoughtful and careful inquiry, and here and there of no slight originality. We have already carried this notice further than we intended to do, but not to the extent the work deserves. We can only add, that the perusal of it has afforded us great pleasure. The author has evidently worked very hard at his subject, and his investigations into the Physiology and Pathology of Joints have been carried on in a manner which entitles him to be listened to with attention and respect. We must not omit to mention the very admirable plates with which the volume is enriched. We seldom meet with suchstrik- ing and faithful delineations of disease.— London Med. Times and Gazette, Feb. 9, 1861. This volume will be welcomed, as the record of much honest research and careful investigation into the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bond, fide work it contains. It is no slight matter for a volume to show laborious investigation, and at the same time original thought, on the part of its author, whom we may congratulate on the successful completion of his arduous task.— London Lancet, March 9,1861. CARPENTER (WILLIAM BJ, M. D., F. R. S., 8cc, Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix containing the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 50. The great importance of the microscope as a means of diagnosis, and the number of microscopists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's firevious writings on Animal and Vegetable Physioogy, will fully understand how vast a store of knowledge he is able to bring to bear upon bo comprehensive a subject as the revelations of the microscope; and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette.] The additions by Prof. Smith give it a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. Indeed, we know not where the student of medicine will find such a complete and satisfactory collection of microscopic facts bearing upon physiology and practical medicine as is contained in Prof. Smith's appendix; and this of itself, it seems to us, is fully worth the cost of the volume.— Louisville Medical Review. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM BJ, M. D., F. R. S., Examiner in PhyBiology and Comparative Anatomy in the University of London PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsylvania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 75, For upwards of thirteen years Dr. Carpenter's work has been considered by the profession generally, both in this country and England, as the most valuable compendium on the subject of physiology in our language. This distinction it owes to the high attainments and unwearied industry of its accomplished author. The present edition (which, like the last American one, was prepared by the author himself), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medicine in this country, it will amply repay the practitioner for its perusal by the interest and value of its contents.— Boston Med. and Surg. Journal. This is a standard work—the text-book used by ali medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Physiology. Nothing need be said in its praise, for its merits are universally known ; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.— Western Lancet. The most complete exposition of physiology which any language can at present give.— Brit, and For. Med.-Chirurg. Review. The greatest, the most reliable, and the best book on the subject which we know of in the English language.— Stethoscope. To eulogize this great work would be superfluous. We should observe, however, that in this edition the author has remodelled a large portion of the former, and the editor has added much matter of interest, especially in the form of illustrations. We may confidently recommend it, as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the science in our language Am. Med. Journal. The most complete work now extant in our language.—N. O. Med. Register. The best text-book in the language on this extensive subject.— London Med. Times. A complete cyclopaedia of this branch of science. —iV. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Physiology in all our medical schools, and its circulation among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere announcement of its appearance will afford the highest i pleasure to every student of Physiology, while its I perusal will be of infinite service in advancing I physiological science.— Ohio Med. and Surg. Journ. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIOLOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $5 25. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and comprehension of those truths which are daily being developed in physiology— Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.— Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect physiological study.— Ranking's Abstract. This work stands without its fellow. It is one few men m Europe could have undertaken; it is one no man, we believe, could have brought to so successful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneoub materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable marner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucidity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to is high reputation.— Medical Times. by the same author. (Preparing.) P 5SSF LES 0F GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal tungdom. In one large and very handsome octavo volume, with several hundred illustrations. BY THE SAME AUTHOR. A am¥SM S JL AT 0N THE USE OF ALCOHOLIC LIQUORS IN HEALTH j r NeW edition > with a Preface by D. F. Condie, M. D., and explanations of •cientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 8 BLANCHARD & LEA'S MEDICAL CONDIE (D. FJ, M. D., Sec. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., extra cloth, of over 750 pages. $3 25. In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect "a complete and faithful exposition of the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been thoroughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. A few notices of previous editions are subjoined. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.— Br. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the greatest satisfaction.— Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Children in the English language.— Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy of this work.— N. Y. Journal of Medicine. A veritable psediatric encyclopaedia, and an honoi te American medical literature.— Ohio Medical and Surgical Journal. We feel persuaded that the American medical profession will soon regard it not only as a very good, but as the very best "Practical Treatise on the Diseases of Children."— American Medical Journal In the department of infantile therapeutics, the work of Dr. Condie is considered one of the best which hus been published in the English language. — The Stethoscope. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.— Medical Examiner. The value of works by native authors on the diseases which the physician is called upon to combat, will be appreciated by all; and the work of Dr. Condie has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.— N. Y. Med. Times. This is the fourth edition of this deservedly popular treatise. During the interval since the last edition, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said before, we do not know of a better book on diseases of children, and to a large part of its recommendations we yield an unhesitating concurrence.— Buffalo Med. Journal. Perhaps the most full and complete work now before the profession of the United States; indeed, we may say in the English language. It is vastly superior to most of its predecessors.— Transylvania Med. Journal. CHRISTISON (ROBERT), M. D., V. P. R. S. E., AVc. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Actions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and improved, with a Supplement containing the most important New Remedies. With copious Additions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, extra cloth, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. in one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRACTURES OF THE JOINTS —Edited by Bransby B. Cooper, F.R.S., &c. With additional Observations by Prof. J. C. Warren. A new American edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellaneous and Surgical Papers. One large volume, imperial 8vo., extra cloth, with 252 figures, on 36 plates. $2 50. COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., extra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. C.LYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. In one octavo volume, leather, of 600 pages. 81 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, leather, with numerous wood-cuts. pp. 720. $3 50. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMATIC CORD, AND SCROTUM. - Second American, f rom the second and enlarged English edition, In one handsome octavo vo ume, extra cloth, with numerous illustrations, pp. 420. $2 00 AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 illustrations. In one very handsome octavo volume, leather, of nearly 700 large pages. $3 75. This work has been so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation for the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received. Having had the benefit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been thoroughly brought up with the latest results of European investigation in all departments of the science and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now contains fully one-half more matter than the last American edition, with nearly one-half more illustrations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal .to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction; the opinion of all writers of authority is given on questions of difficulty, as well as the directions and advice of the learned author himself, to which lie adds the result of statistical inquiry, putting statistics in their pro per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It appears to be written with the true design of a hook on medicine, viz: to give all that is known on the subjectof which he treats, both theoretically and practically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Churchill's is admirably suited for a book of reference for the practitioner, as well R3 a text-book for the student, and we hope it may be extensively purchased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press. To bestow praise on a book that has received such marked approbation would be superfluous. Weneed only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much interest and instruction in everything relating to theoretical and practical midwifery.— Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obstetric practitioner.— London Medical Gazette. Few treatises will be found better adapted as 6 text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. Were we reduced to the necessity of having but tne work on midwifery, and permitted to choose, Are would unhesitatingly take Churchill.— Western Med. and Surg. Journal. It is impossible to conceive a more useful and slegant manual than Dr. Churchill's Practice of Midwifery.— Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.— N. Y. Annalist. No work holds a higher position, or is more deserving of being placed in the hands of the tyro, the advanced student, or the practitioner.— Medical Examiner. Previous editions have been received with marked favor, and they deserved it; but this, reprinted from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of remedial science.— N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric scienco which we at present possess in the English language.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the greatamountof statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. This is certainly the most perfect system extant, ft is the best adapted for the purposes of a textaook, and that which he whose necessities confine aim to one book, should select in preference to all Hhers.— Southern Medical and Surgical Journal. BY THE same author. (Lately Published.) ON THE DISEASES OP INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages, f3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, white every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar f™u ri y aS mig , have escaDed the attention of the author, and the whole may, theref • pr ° n « Uneed ? ne of the most complete works on the subject accessible to the AmeaUeration eration in the size of tbe page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. r?u XI 2?xS?J PUERPERAL FEVER, AND OTHER DISEASES PEt£ Vu W ° 4 MEN -, Selected from the writings of British Authors previous to the close of we Century. In one neat octavo volume, extra cloth, of about 450 pages, f2 50. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., Stc. ON THE DISEASES OF WOMEN; including those of Pregnancy and Childbed. A new American edition, revised by the Author. With Notes and Additions, by D. Francis Condie, M. D., author ot "A Practical Treatise on the Diseases, of Children." With numerous illustrations. In one large and handsome octavo volume, extra cloth, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustrations introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as appeared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most exact and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.— Am. Journ. Med. Sciences. This work is the most reliable which we possess on this subject ; and is deservedly popular with the profession.— Charleston Med. Journal, July, 1857. We know of no author who deserves that approbation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and students as a masterpiece in its particular department. — Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject frosa the British press.— Dublin Quart. Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Therapeutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume, ol 750 pages, extra cloth. $3 75. The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority everywhere acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life devoted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRU ITT (ROBERT), M.R. C.S., 8tc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 75. A work which like Druitt's Surgery has for so many years maintained the position of a leading favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about onfe-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived hi the mechanical and artislical execution of the work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive work on surgery, has undergone many corrections, improvements, and additions, and the principles and the practice of the art have been brought down to the latest record and observation. Of the operations in surgery itis impossible to speak toohighiy. The descriptions are so clear and concise, and the illustrations so accurate and numerous, that the student can have no difficulty, with instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected departmentof medical education. — British and Foreign Medico-Chirurg. Review, Jan. 1960. In the present edition the author has entirely rewritten many of the chapters, and has incorporated the various improvements and additions in modern ¦urgery. On carefully going over it, we find that nothing of real practical importance has been omitted ; it presents a faithful epitome of everything relating t) surgery up to the present hour. It is deservedly a popular manual, both with the student and practitioner.— London Lancet, Nov. 19, 1859. In closing this brief notice, we recommend as cordially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote himself to the study of more lengthy volumes. — London Med. Times and Gazette, Oct. 22,1859. In a word, this eighth edition of Dr. Druitt'fl Manual of Surgery is all that the surgical studenl or practitioner could desire. — Dublin Quarterly Journal of Med. Sciences, Nov. 1859. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Imbibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is intended. It will be Been, therefore, that Dr. Dalton's best efforts have been directed towards perfecting his work. The additions are marked by the same features which characterize the remainder of the volume, and render it by far the most desirable textbook on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intended, satisfied as we are that it is better adapted to their use than any other work of the kind to which they have access.— American Journal of the Med. Sciences, April, 186L. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the current year. It states in comprehensive but concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical p Dints. Herein it is unique; and these characteristics render it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physiology thus presented that lies at the foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics; so that pathalogy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. —Cincinnati Lancet, May, 1801. Dr. Dalton needs no word of praise from us. He is universally recognized as among the first, if not the very first, of American physiologists now living. The first edition of his admirable work appeared but two years since, and the advance of science, his own original views and experiments, together with a desire "to supply what he considered some deficiencies in the first edition, have already made the present one a necessity, and it will no doubt be even more eagerly sought for than the first. That it is not merely a reprint, will be seen from the author's statement of the following principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admirable tor their clearness in expressing exactly what their author intended.— Boston Medical and Surgical Journal, March 28, 1861. It is unnecessary to give a detail of the additions; suffice it to say, that they are numerous and important, and such as will render the work still more valuable and acceptable to the profession as a learned and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.— St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceedingly useful, as the mosf complete expose of a science, of which Dr. Dalton is doubtless the ablest representative on this side of the Atlantic.— New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the Bhort space of two years, the author has supplied deficiencies, whicn existed in the former volume, and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text- book, and one which we consider the best outline on the subject of which it treats, in any language.— N. American Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine •xtant; or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it is above all price to every practitioner Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a workfor ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.— Medical Examiner The editors are practitioners of established reputation, and the lisi of contributors embraces many of the most eminent professorsand teachers of London, Edinburgh, Dublin, and Glasgow. It is, indeed, the great merit ol this work that theprincipal articles have been furnished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.— American Medical Journal. °SSp 0 v MP ,P ensive system of MIDWItERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of 600 pages 8320 OEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD REN. The last edition. In one volume, octavo, extra cloth, 518 pages. $2 80 DEVVEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. $3 00. 12 BLANCHARD & LEA/S MEDICAL DUNGLISON (ROBLEY), M. D. , Professor of Institutes of Medicine in the JefTerson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concis® Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, 6rc. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary "to make it a satisfactory and desirable—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, rendering the whole number of definitions about Sixty Thousand, to accommodate which, the number of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the page. The medical press, both in this country and in England, has pronounced the work indispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care has been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of which, it has become our duty and pleasure to announce,is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the preceding editions, where we have never failed to find a sufficiently full explanation of ever) medical term, that in this edition ''about thousand subjects and terms have been added," wii.h a careful revision and correction of the entire work. It is only necessary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.— Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the American profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than a*hy other with which we are acquainted, and of a character which places it far above comparison and competition.— Am. Journ. Med. Sciences, Jan. 1858. We need only say, that, the addition of 6,000 new terms, with their accompanying definitions, may be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indispensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.— Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, are the most labor-saving contrivances which literary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author tells us in his preface that he has added about six thousand terms and subjects to this edition, which, before, was considered universally a3 the best wori of the kind in any language.— Silliman's Journal, March, 1858. He has razed his gigantic structure to the foundations, and remodelled and reconstructed the entirs pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placecf before the profession a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. — Nashville Journ. of Med. and Surg., Jan. 1853. It is universally acknowledged, we believe, that this work is incomparably the best and most complete Medical Lexicon m the English language. The amount of labor which the distinguished author has bestowed upon it i3 truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commendation are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.— St. Louts Med. and Surg. Journ., Jasi. 1858. It is the foundation stone of a good medical library, and should always be included in the first list of books purchased by the medical student.— Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly tha most perfect in the English language.— Med. and Surg. Reporter, Jan. 1858. It is now emphatically the Medical Dictionary of the English language, and for it there is no substitute.— N. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medical library wanting a copy of Dunglison's Lexicoa must be imperfect.— Cin. Lancet, Jan. 1853. We have ever considered it the best authority published, and the present edition we may safely say has no equal in the world.— Peninsular Med. Journai, i Jan. 1858. ! The most complete authority on the subject to h* i foundin any language.— Va. Med. Journal, Feb. '53. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and Th* rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $8 35. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, extra cloth, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological sciencp, to which the student and man of science can at all times reter with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more complete repertory of faets upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility ttnd ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.— Boston Med. «nd Surg. Journal. The most complete and satisfactory system of Physiology in the English language.— Amer. Med. Journal . The best work of the kind in the English language.—Silliman's Journal. The present edition the author has made a perfect mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.— Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every physician's library.— Western Lancet. BY the same author. (A nevj edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., extra cloth, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have iso words of commendation to bestow upon a work Whose merits have been heretofore so often and bo justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judieious analysis, and clearness of expression, is fully sustained by the numerous additions he has made to the work, and the careful revision to which he has subjected the whole.— N. A. Medico-Chir. Review, Jan. 1858. The work will, we have little doubt, be bought and read by the majority of medical students; its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of reference. The young practitioner, more especially, will find the copious indexes appendtd to this edition of great assistance in the selection and preparation of suitable formulas.— Charleston Med. Journ. and Review, Jan. 185b. BY the same author. (A new Edition.) NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, extra cloth, of 770 pages. $3 75. One of the most useful of the author's works.— Ecuihem Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of reference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to ftnhaace its value.— New York Med. Gazette. The great learning of the author, and his remarkable industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.— The American Journal of Pharmacy. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe, .together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one volume, 8vo. (Preparing for early publication.) This work has been allowed to remain for some time out of print, awaiting the appearance of cae new U. b. IVharnneopaeia. Immediately on the publication of the latter it will be issued, and 11 u? u desirous of procuring it may rely upon obtaining an edition thoroughly brough t up with all that has appeared of value since the last edition was issued, and fully worthy to maintain the reputation ot this old and favorite work. 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), ProfeBBor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $5 00. The very distinguished favor with which this work has been received on both sides of the Atlantic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange that just such books are notoftener produced by public teachers of surgery in this country and Great Britain. Indeed, it is a matter of great astonishment, but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even approximates to the fulfilment of the peculiar wants of young men just entering upon the study of this branch of the profession.— Western Jour .of Med. and Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard i; the most serviceable guide which he can consult. He will find a fulness of detailleadinghim through every step of the operation, and not deserting him until the final issue of the case is decided.— Seihoscope. Embracing, as will be perceived, the whoie surgical domain, and each division of itself almost complete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, profusely illustrated, are rich in physiological, pathological, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.—JV. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point, both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.— Buffalo Med. Journal. A work of original observation of thehighest merit We recommend the treatise to every one who wishee to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidence of careful study and discrimination upon every page. It does credit to the author, and, through him, to the profession in this country It is, what we cannot call every book upon auscultation, a readable book.— Am. Jour. Med. Sciences This volume belongs to a class of works which confer honor upon their authors and enrich the domain of practical medicine. A cursory examination even will satisfy the scientific physician that Dr. Flint in this treatise has added to medical literature a work based upon original observation, and possessing no ordinary merit.—JV. Y. Journal of Med. This is an admirable book, and because of its extraordinary clearness and entire mastery of 'he subjects discussed, has made itself indispensable to those who are ambitions of a thorough knowledge of physical exploration.— Nashville Journ. of Med. The arrangement of the subjects discussed is easy, natural, such as to present the facts in the most forcible light. Where the author has avoided being tediously minute or diffuse, he has nevertheless fully amplified the more important points. In this respect, indeed, his labors will take precedence, and be the means of inviting to this useful department a more general attention.— O. Med. and Surg. Journ. We hope these few extracts taken from Dr. Flint's work may convey some idea of its character and importance. We would, however, advise every physician to at once place it in his library, feeling assured that it may be consulted with great benefit both by young and old Louisville Review. BY the same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. We do not know that Dr. Flint has written anything which is not first rate ; but this, his latest contribution to medical literature, in our opinion, surpasses all the others. The work is most comprehensive in itt, (scope, and most sound in the views it enunciates. The descriptions are clear and methodical; the statements are substantiated by facts, and are made with such simplicity and sincerity, that without them they would carry conviction. The style is admirably clear, direct, and free from dryness With Dr. Walshe's excellent, treatise before us, we have no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language. — Boston Med. and Surg. Journal. We have thus endenvored to present our readers with a fair analysis of this remarkable work. Pre- ferring to employ the very words of thedistinguished author, wherever it was possible, we have essayed to condense into the briefest space a general view of his observations and suggestions, and to direct the attention of our brethren to the abounding stores of valuable matter here collected and arranged for their use and instruction. No medical library will hereafter be considered complete without this volume; and we trust it will promptly find its way into the hands of every American student and physician.— N. Am. Med. Chir. Review. With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list of textbooks for our schools, and is, tor the practitioner, the most valuable practical work of its kind.— N. O. Med. News. AND SCIENTIFIC PUBLICATIONS. 15 FOWNES (GEORGE), PH. D., &c. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo. volume, of 600 pages, extra cloth, $1 65. The death of the author having placed the editorial care of this work in the practised hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the department of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed within the convenient and portable limits of a moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. Dr. Fownes'excellent work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generally adopted, we believe, as the standard text-book in all ( ur colleges, both literary and scientific.— Charleston Med. Journ. and Review. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author has achieved the difficult task of condensation with masterly tact. His book is concise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreciated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Grnelin, but we say that, as a work for students, it is preferable to any of them.—London Journal of Medicine. A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.— Edinburgh Journal of Medical Science. FISKE FUND PRIZE ESSAYS —THE EFFECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lee, M. R. C. S , London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By I Edward Warren, M.D., of Edenton.N. C. Together in one neat 8vo. volume, extra cloth. SSI 00. FRICK ON RENAL AFFECTIONS; their Diagnosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents. FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 50. Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be had separate, cloth backs and paper sides. Price $2 50. From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to rae, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. No reader of English works on this science can afford to be without this edition of Prof. Graham's Elements.— Silliman's Journal, March, 1858. From Prof. Wolcott Gibbs, N. Y. Free Academy. The work is an admirable one in all respects, and its republication here cannot fail to exert a positive influence upon the progress of science in this country. GRIFFITH (ROBERT E.), M. D., Stc. A UNIVERSAL FORMULARY, containing the methods of Preparing and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of 650 pages, double columns. $3 25. It was a work requiring much perseverance, and when published was looked upon as by far the best work of its kind that had issued from the American press. Prof. Thomas has certainly "improved," as well as added to this Formulary, arid has rendered it additionally deserving of the confidence of pharmaceutists and physicians.— Am. Journal of Pharmacy. We are happy to announce a new and improved eumon of tins, one of the most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found m daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensatolits.—Southern Med. and Surg. Journal. Itisoneofthe mostnseful books a country practitioner can possibly have.— Medical Chronicle. This is a work of six hundred and fifty-one pages, embracing all on the subject of preparing and administering medicines that can be desired by the physician and pharmaceutist.— Western Lancet. The amountof useful, every-day matter.for a practicing physician, is really immense.— Boston Med. and Surg. Journal. This edition has been greatly improved by the revision and ample additions of Dr Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the recent improvements. A work of this kind appears to us indispensable lo the physician, and there is none we can more cordially recommend — IV. Y. Journalof Medicine. 16 BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, Ac. Enlarged Edition. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by Twelve Hundred and Twenty-seven Engravings. Second edition, much enlarged and carefully revised. In two large and beautifully printed octavo volumes, of about twenty-two hundred pages ; strongly bound in leather. Price $12. The exhaustion in little more than two years of a large edition of so elaborate and comprehensive a work as this is the best evidence that the author was not mistaken in his estimate of the want which existed of a complete American System of Surgery, presenting the science in all its necessary details and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale of the work, but also by the very favorable manner in which it has been received by the organs of the profession in this country and in Europe, and by the fact that a translation is now preparing in Holland—a mark of appreciation not often bestowed on any scientific work so extended in size. The author has not been insensible to the kindness thus bestowed upon bis labors, and in revising the work for a new edition he has spared no pains to render it worthy of tbe favor with which it has been received. Every portion has been subjected to close examination and revision ; any deficiencies apparent have been supplied, and the results of recent progress in the science and art of surgery have been everywhere introduced; while the series of illustrations has been enlarged by the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated works ever laid before the profession. To accommodate these very extensive additions, the work has been printed upon a smaller type, so that notwithstanding the very large increase in the matter and value of the book, its size is more convenient and less cumbrous than before. Every care has b?en taken in the printing to render the typographical execution unexceptionable, and it is confidently presented as a work in every way worthy of a place in even the most limited library of the p actitioner or student. Has Dr. Gross satisfactorily fulfilled this object? A careful perusal of his volumes enables us to give an answer in the affirmative. Not only has he given to the reader an elaborate and well-written account of his o»vn va3t experience, but he has not failed to embody in his pages the opinions and practice of surgeons in this and other countries of Europe. The result has been a work of such completeness, that it has no superior in the systematic treatises on surgery which have emanate, from English or Continental authors. It has been justly objected that these have been far from complete in many essential particulars, many of them having been deficient in some of the most important points which should characterize Buch works Some of them have been elaborate—too elaborate—with respect to certain diseases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross has avoided this error, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly speaking, a Dictionary of Surgery, but it gives to the reader all the information that he may require for his treatment of surgical diseases. Having said so much, it might appear superfluous to add another WJrd; but it is only due to Dr. Gross to state that he has embraced the opportunity of transferring to his pages a vast number of engravings from English and other authors, illustrative ot the pathology and treatment of surgical diseases. To these are added several hundred original wood-cuts. The work altogether cornmenus itself to the attention of British Burgeons, from whom it cannot fail to meet with extensive patronage.— London Lancet, Sept. 1, 1860. Of Dr. Gross's treatise on Surgery we can say no more than that it is the most elaborate and complete work on this branch of the healing art which has ever been published in any country. A systematic work, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge of the classical style of the author, and the exhausting way in which each subject is treated.— Bub Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recommend it as the best work of the kind to be taken home by the young practitioner.— Am. Med. Journ. With pleasure we record the completion of this long-anticipated work. The reputation which the author has for many years sustained, both as a surgeon and as a writer, had prepared us to expect a treatise of great excellence and originality; but we confess we were by no means prepared for the work which is before us—the most complete treatise upon surgery ever published, either in this or any other country, and we might, perhaps, safely say, the most original. There is no subject belonging properly to surgery which has not received from the author a due share of attention. Dr. Groes has supplied a want in surgical literature which has long been felt by practitioners; he has furnished us with a complete practical treatise upon surgery in all its departments. As Americms, we are proud of the achievement; as surgeons, we are most sincerely thankful to him for his extraordinary labors in our behalf.— N. Y. Review and Buffalo Med. Journal, , BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original extra cloth. $4 75. The very rapid advances in the Science of Pathological Anatomy during the last few years have rendered essential a thorough modification of this work, with a view of making it a correct exponent of the present state of the subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say that " with the many changes and improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. We most sincerely congratulate the author on the successful manner in which he has accomplished his proposed object. His book is most admirably calculated to fill up a blank which has long been felt to exist in this department of medical literature, and as such must become very widely circulated amongst all classes of the profession. — Dublin Quarterly Journ. of Med. Science, Nov. 1857. We have been favorably impressed with the general manner in which Dr. Gross has executed his task of affording' a comprehensive digest of the present state of the literature of Pathological Anatomy, and have much pleasure in recommending his work to our readers, as we believe one well deserving of diligent perusal and careful study.— Montreal Med. Ckron., Sept. 1857. EY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume 3 extra cloth, with illustrations, pp.468. 82 75. AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eightyfour illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth, $4 75. Philosophical in its design, methodical in its ar- rangement,ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so important a subject.— Boston Med. and Surg Journal. Whoever will peruse the vast amount of valuable practical information it contains, will, we think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal.—iV. Y. Journal of Medicine. a volume replete with truths and principles of the utmost value in the investigation of these diseases American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, &c. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D.,Iate Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and execution have been found to present superior practical advantages in facilitating the study of Anatomy. In presenting it to the profession a second time, the author has availed himself of the opportunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first edition of a scientific work on so extensive and complicated a science is liable. These improvements have resulted in some increase in the size of the volume, while twenty-six new wood-cuts have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition has been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all respects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired. With little trouble, the busy practitioner whose knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and not to the student alone, that this work will ultimately tend to be of most incalculable advantage, and we feel satisfied that the library of the medical man will soon be considered incomplete in which a copy of this work does not exist Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and enlarged, and contains several new illustrations by Dr. Westmacott. The volume is a complete companion to the dissecting-room, and saves the necessity of the student possessing a variety of" Manuals."— TheLon- , don Lancet, Feb. 9, 1861. The work before us is one entitled to the highest praise, and we accordingly welcome it as a valuable addition to medical literature. Intermediate in fulness of detail between the treatises of Saar pey and of Wilson, its characteristic merit lies in the number and excellence of the engravings it contains. Most of these are original, of much larger than ordinary size, and admirably executed, lhe various parts are also lettered after the plan adopted in Holden's Osteology. It would be difficult to over-estimate the advantages offered by this mode of pictorial illusiration. Bones, ligaments, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names ; thus enabl ing thestudent to comprehend, at a glance what would otherwise often be ignored, or at any rate, acquired only by prolonged and irksome apwnrt l'? ivr n^° nclusion ' we hp artily commend the rfrofe BK ,n M r ? ray to the at,e »ti"n of the medical 11 nZ r tl Wng Ce , rtain ttlat il Bhould be regarded to ed It n Tvl va ! uable contributions eve? made Dec 1859 literature._IV. Y. Monthly Review. faJVeUwLdTA tS W the Work of Mr ' Grav as and eg pecia th° Wants of the Profession, vet ZM,£ e S tu £ nt > than an y treat '«e on unaiomy yet published in this country I t is destinrd o^dis^ student of *en„r n 1 a Btai | dard of reference to the siuaent ot general or relative anatomv JV Y Journal of Medicine, Nov 1859 y to exist in this country. Mr. Gray writes throughout with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to the parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After describing the bones and muscles, he gives a concise statement of the fractures to which the bones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and accurate. Not only is the surgical anatomv given to every important vessel, with directions for its ligation, but at the end of the description of each arterial trunk we have a useful summary of the irregularities which may occur in its origin, course, and termination.— N. A. Med. Chir. Review, Mar. 1659. Mr. Gray's book, in excellency of arrangement and completeness of execution, exceeds any work on anatomy hitherto published in the English language, affording a complete view of the structure of the human body, with especial reference to practical surgery. Thus the volume constitutes a perfect book of reference for the practitioner, demanding a place in even the most limited library of the physician or surgeon, and a work of necessity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.— The Dublin Quarterly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present volume cannot but present many ad vantages to the studgntof anatomy. To the zealous disciple of Vesalius, earnestly desirous of real improvement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simply desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of their development. The study of these parts is thus made one of comparative ease, if not of positive pleasure: and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.— Am. Journ. Med. Sci., July, 1859. BLANCHARD & LEA'S MEDICAL 18 GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth edition, improved and altered. With thirty-four plates. In twohandsome octavo volumes, containing about 1,000 pages, leather, raised band t. $6 50. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal l'imo. vol., cloth, pp. 396, with wood-cuts. 81. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Addi- tions. by Joseph Leidy, M. D. In one volume, very large imperial quarto, extra cloth, with 320 copper-plate figures, plain and colored, $5 00. HUGHES' INTRODUCTION TO THE PRACTICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS. IN DISEASES OF THE LUNGS AND HEART. Second edition 1 vol. royal 12mo., ex. cloth, pp. 304. $1 00. HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. Second edition, revised and improved. In one large and handsome octavo volume, of over 750 pages, with nearly 300 illustrations, extra cloth, $4 75. (Just Ready, May, 1863.) The early demand for a new edition of this work shows that it has been successful in securing the confidence of the profession as a standard authority for consultation and reference on its important and difficult subject. In again passing it through the press, the author has taken the opportunity to revise it carefully, and introduce whatever improvements have been suggested by further experience and observation. An additional chapter on Gun-shot Fractures will be found to adapt it still more fully to the exigencies of the time. Among the many good workers at surgery of whom America may now boast, rot the least is Frank Hastings Hamilton; and the volume before us is (we say it with a pang of wounded patriotism) the best and handiest book on the subject in the English language. It is in vain to attempt a review of it; nearly as vain to seek for any sins, either of commission or omission. We have seen no work on practical surgery which we would sooner recommend to our brother surgeons, especially those of " the services," or those whose practice lies in districts where a man has necessarily to rely on his own unaided resources. The practitioner will find in it directions for nearly every possible accident, easily found and comprehended ; and much pleasant reading for him to muse over in the after consideration of his cases.— Edinburgh Med. Journ. Feb.1861. This is a valuable contribution to the surgery of most important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatise on Fractures and Dislocations in the English language. It has remained for our American brother to produce a complete treatise upon the subject, and bring together in a convenient form those alterations and improvements that have been made from time to time in the treatment of these afTections. One great and valuable feature in the work before us is the fact that it comprises all the Improvements introduced into the practice of both English and American Burgery, and though far from, omitting mention of our continental neighbors, the author by no means encourages the notion—but too prevalent in some quarters—that nothing is good unless imported from France or Germany. The latter half of the work is devoted to the consideration of the various dislocations and their appropriate treatment, and its merit is fully equal to that of the preceding portion.— The London Lancet, May 5, 1860. • It is emphatically the book upon the subjects of which it treats, and we cannot doubt that it will continue so to be for an indefinite period of time. When we say, however, that we believe it will at once take its place as the best book for consultation by the practitioner, and that it will form the most complete, available, and reliable guide in emergencies of every nature connected with its subjects; and also that the student of surgery may make it his textbook with entire confidence, and with pleasure also, from its agreeable and easy style—we think our own opinion may be gathered as to its value.— Boston Medical and Surgical Journal, March 1, I860. The work is concise, judicious, and accurate, and adapted to the wants of the student, practitioner, and investigator, honorable to the author and to the profession.— Chicago Med. Journal, March, 1860. We regard this work as an honor not only to its author, but to the profession of our country. Were we to review it thoroughly, we could not convey to the mind of the reader more forcibly our honest opinion expressed in the few words—we think it the best book of its kind extant. Every man interested in surgery will soon have this work on his desk. He who does not, will be the loser.— New Orleans Medical News, March, 1860. Dr. Hamilton is fortunate in having succeeded in filling the void, so long felt, with what cannot fail to be at once accepted as a model monograph in some respects, and a work of classical authority. We sincerely congratulate the profession of the United States on the appearance of such a publication from one of their number. We have reason to be proud of it as an original work, both in a literary and scientific point of view, and to esteem it as a valuable guide in a most difficult and important branch of study and practice. On every account, therefore, we hope that it may soon be widely known abroad as an evidence of genuine progress on this side of the Atlantic, and further, that it may be still moire widely known at home as an authoritative teacher from which every one may profitably learn, and as affording an example of honest, well-directed, and untiring industry in authorship which every surgeon may emulate.— Am. Med. Journal, April, 1860. HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the " American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.— Charleston Med. Journ. We know of no dictionary better arranged and adapted. It is not encumbered with the obsolete terms of a bygone age, but it contains all that are now in use ; embracing every department of medical scienco down to the very latest date.— Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. HOLLAND'S MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. $3. HORNER'S SPECIAL ANATOMY AND H1S- TOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than 1000 pages, with over 30* illustrations. $6 00. AND SCIENTIFIC PUBLICATIONS. 19 HODGE (HUGH L.), M. D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c. ON DISEASES PECULIAR TO WOMEN, including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 pages, extra cloth. $3 25. We will say at once that the work fulfils its object capitally well: and we will moreover venture the assertion that it will inaugurate an improved practice throughout this whole country. The secrets of the author's success are so clearly revealed that the attentive student cannot fail to insure a goodly portion of similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work of the highest order of merit; and it will take rank as such immediately.— Maryland and Virginia Medical Journal, Feb. 1861. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favorable reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscui ity ; the amount of malaise and even of actual suffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to recur—these, taken in connection with the entire competency of the author to render a correct account of their nature, their causes, and their appro- priate management—his ample experience, his matured judgment, and his perfect conscientiousness— invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim— Am. Journ. Med. Sciences, Jan. 1861. Indeed, although no part of the volume is not eminently deserving of perusal and study, we think that the nine chapters devoted to this subject, are especially so, and we know of no more valuable monograph upon the symptoms, prognosis, and management of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one of the most original and m jst practical works of the day ; one which every accoucheur and physician should most carefully read; for we are persuaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering female, who may have placed her health in his hands.— British American Journal, Feb. 1661. Of the many excellences of the work we will not speak at length. We advise all who would acquire a knowledge of the proper management of the maladies of which it treats, to study it with care. The second part is of itself a most valuable contribution to the practice of our art.— Am. Med. Monthly and New York Review, Feb. 1861. The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, OESOPHAGUS, STOMACH, CAECUM, AND INTESTINES. With illustrations on wood. In one handsome octavo volume of 312 page*, extra cloth $1 75. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised Lendon edition, with additions by Edward Hartshorne, M. D., Surgeon to Walls' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. SI 50. JONES (C. HANDFIELD), F. R. S., &. EDWARD H. SI EVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OP PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, extra cloth. $3 75. Asa concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our literature. Heretofore the student of pathology was obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.— Western Lancet. KIRKE5 (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OP PHYSIOLOGY. A new American, from the third and 19«,^, i London edition. With two hundred illustrations. In one large and handsome royal volume, extra cloth, pp. 586. $2 00. D¦ KiiW , Very much edition of It comhtne* well " knOWn Handbook of Physiology, therefore .Srf' With com Pleteness, and is, consultation by the ousy practitioner.— Bubhn Quarterly Journal! One of the very best handbooks of Physioloev we eneraslhe'studelt jUSt BUCh , an """ine of K Sliffi?lS" d ? Hng his f lectures, or for reference whilst prepanng for examination.- Am. Medical Journal. Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkesand Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know.— Boston Med. and Surg. Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.— Charleston Mtd. Journal. 20 BLANCHARD ' a 'ii? t !rhtful 'u and "a&acious physician. Dr. Kf n , ,i erS ° n e di8eases of the external or- SSnviZ nZ m * ny > lnter <*ting and rare cases, and of DT wHK bS t rV t ti0^ S - We take our leave original g th n a - h ! g , h ° 1)inion of his talents and B ™ md Medico-Chitio^Tudtt^h 8 - replete Y ith Practical instruc- EftSfifj? ? me " me 3accuTacTin h£"dt •cription of symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the reader.— Ranking's Abstract. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of many years.— Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.— St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warmheartedness infecting the effjrt of Dr. Meigs, which is entirely captivating, and which absolutely hurries the reader through from beginning to eud. Besides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is presented. We know of no better test of one's understanding a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader.— Tk$ Charleston Med. Journal. BLANCHARD & LEA'S MEDICAL 22 MEIGS (CHARLES D.),.M. D., Lately Professor of Obstetrics, &c, in Jefferson Medical College, Philadelphia. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and interesting author of this work, whose previous labors have placed his countrymen under deep and abiding obligations, again challenges their admiration in the fresh and vigorous, attractive and racy pages before us. It is a de- lectable book. * * * This treatise upon childbed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns tolag in the rear,— Nashville Journal of Medicine and Surgery. BY THE SAME AUTHOR J WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style ol art. In one handsome octavo volume, extra cloth. $4 50. MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto- With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Containing one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $11 00. Gentlemen preparing for service in the field or hospital will find these plates of the highest practical value, either for consultation in emergencies or to refresh their recollection of the dissecting room. *„.* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.— British American Medical Journal. No practitioner whose means will admit should fail to possess it.— Banking's Abstract. Too much cannot be said in its praise; indeed, we have not language to do it justice.— Ohio Medical and Surgical Journal. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.— Buffalo Medical Journal. It is very rare that so elegantly printed, so well Illustrated, and so useful a work, is offered at so moderate a price.— Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medital Examiner. Country practitioners will find these plates of immense value.— N. Y. Medical Gazette. A work which has no parallel in point of accuracy and cheapness in the English language.— N. Y. Journal of Medicine. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unrivalled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.— The Net* Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Anatomy that has come under our observation. We know of no other work that would justify a student, in any degree, for neglect of actual dissection. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.— The Western Journal of Medicine and Surgery. MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.; including the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome octavo volume, of over 600 pages, extra cloth. $3 75. We congratulate the author that the task is done. We congratulate him that he has given to the medical public a work which will secure for him a high and permanent position among the standard authorities on the principles and practice of obstetrics. Congratulations are not less due to the medical profession of this country, on the acquisition of a treatise embodying the results of the studies, reflections, and experience of Prof. Miller.— Buffalo Medical Journal. In fact, this volume must take its place among the standard systematic treatises on obstetrics; a posi- tion to which its merits justly entitle it.— The Cincinnati Lancet and Observer. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country praotitioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope to see this American production generally consulted by the profession.— Va. Med. Journal. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. Sec. A PRACTICAL TREATISE ON DISEASES AND INJURIES OP THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and Enlarged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, extra cloth, with plates and numerous wood-cuts. $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases of the Eye, We consider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language upon the diseases of the eye.— Med. Times and Gazette. AND SCIENTIFIC PUBLICATIONS 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, extra cloth, of 700 pages, with two hundred and forty illustrations on wood. $3 75. BY THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, extra cloth, of nearly 700 pages. $3 75. No encomium of ours could add to the popularity Of Miller's Surgery. Its reputation in this countryis unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which noconscieritious surgeon would be willing to practice his art.— Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensible, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.— Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Aliller's, as we regard it as superior to all others.— St. Louis Med. and Surg. Journal. The author has in this and his w Principles," presented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, energetic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding theattention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommended.—Southern Journal of Med. and Physical Sciences. MORLAND (W. W.), M. D. f Fellow of the Massachusetts Medical Society, &c. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, oi about 600 pages, extra cloth. $3 50. Taken as a whole, we can recommend Dr. Morland's compendium as a very desirable addition to the library of every medical or surgical practitioner.— Brit, and For. Med.-Chir. Rev., April, 1859. Every medical practitioner whose attention has been to any extent attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some full, yet concise recent compendium to which he could refer. This desideratum has been supplied by Dr. Morland, and it has been ably done. He has placed before us a full, judicious, and reliable digest. Each subject is treated with sufficient minuteness, yet in a succinct, narrational style, such as to render the wortc one of great interest, and one which will prove in the highest degree useful to the general practitioner.— N. Y. Journ. of Medicine, BY THE SAME AUTHOR. THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11, 1861. In one small octavo volume, 83 pages, extra cloth. 75 cents. MONTGOMERY (W. F.), M. D., M. R. I. A., &c, Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. $3 75. A book unusually rich in practical suggestions.— Am. Journal Med. Sciences, Jan. 1857. These several subjects so interesting in themselves, and so important, every one of them, to the most delicate and precious of social relations, controlling often the honor and domestic peace of a lamiiy the legitimacy of offspring, or the life of its parent, are all treated with an elegance of diction, iuiness of illustrations, acuteness and justice of rea- SnSSSj ""Peeled in obstetrics, and unsurpassed in medicine. The reader's interest can never flag, so fresh, and vigorous, and classical is our author's style; and one forgets, in the renewed charm of every page, that it, and every line, and every word has been weighed and reweighed through years of preparation; that this is of all others the book of Obstetric Law, on each of its several topics ; on all points connected with pregnancy, to be everywhere received as a manual of special jurisprudence ; at once announcing fact, affording argument, establishing precedent, and governing alike the juryman, advocate, and judge. — N. A. Med.-Chir. Review. MOHR (FRANCIS), PH.D., AND REDWOOD (TH EOPH I LU S). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, , ILLIAM Procter, of the Philadelphia College of Pharmacy. In one handsomely primed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75 PEUTICAL R™^mm£ R £™ A i* D THERA- Practical Porfn7i M . BRA^ CRR - With ever y Pharmaconffi Z T**, 1 ? J he three British FormVilm nf th. tt « ol Wlth the addition of the «aiFFiTH M r> U by R. E. *siffit Hj M.D 112mo.vol.ex.cl.,300pp. 75c. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Tranalated ted from the French By Frederick Brittan, A. B.,M. D. Withnumerousillustrationson wood! In one handsome octavo volume, extra eloth, of nearly six hundred pages. $2 85. 24 BLANCHARD