i ,1-*,1 Stor^on General's Office ANNEX i 1 i\ DUE 3-?ft©M LAST .DATE SEP 29 1961 i/vw- 4 A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. BY FRANK HASTINGS JAMILTM, A.B., A.M., M.D, PROFESSOR OF THE PRINCIPLES OF SURGERY, MILITARY SURGERY AND HYGIENE, AND OF FRACTURES AND DISLOCATIONS IN BELLEVUE HOSPITAL MEDICAL COLLEGE ; SURGEON TO BELLEVUE HOSPITAL AND TO THE CHARITY HOSPITAL, NEW YORK: PROFESSOR OF MILITARY SURGERY, ETC., IN THE LONG ISLAND COLLEGE HOSPITAL; AUTHOR OF A TREATISE ON MILITARY SURGERY. THIRD EDITION, REVISED AND IMPROVED. ILLUSTRATED WITH TWO HUNDRED AND NINETY-FOUR WOOD-CUTS. PHILADELPHIA: H E K E Y' 0. L E A. 1866. Entered according to the Act of Congress, in the year 1866, by HENRY C. 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. i TO THE CIYIL AND MILITARY SURGEONS UNITED STATES OF AMERICA, BY WHOSE KINDNESS HE HAS BEEN PLACED UNDER MANY OBLIGATIONS, AND IN TESTIMONY OF HIS PERSONAL ESTEEM, j %\\% Volume IS RESPECTFULLY DEDICATED ; BY THE AUTHOR. PREFACE TO THE THIRD EDITION. In the preparation of this edition the author has studied carefully the cases and observations which have found a record since the date of the last edition; and in this labor he has been greatly assisted by that zealous student and thorough scholar, Dr. John Winslow, of this city. He has also added a considerable number of observations from his own private practice, but most of all from those ample fields of instruction, the Bellevue and Charity Hospitals, New York. Several changes have been made in the wood-cuts, and a few have been added. The frequency with which even surgical writers confound epiphyseal separations with fractures, has determined the author to select from Gray's excellent treatise upon anatomy a number of illus- trations, indicating the centres of ossification and the subsequent de- velopment of bones. Two or three illustrations of fractures, found in the same treatise, have been substituted for the less satisfactory wood- cuts of previous editions. The chapter on " Gunshot Injuries" has been enlarged by the addi- tion of a few statistics obtained from the published records of the United States and Confederate armies. FRANK H. HAMILTON. 64 Madison Avenue, N. Y. August, 1866. fr PREFACE TO THE FIRST EDITIOX. The English language does not at this moment contain a single com- plete 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 pro- perly 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 Lecons Orales of Dupuytren, translated in 1846, and the Trea- tise on Fractures in the Vicinity of the 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 trans- lation 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 vm PREFACE TO THE FIRST EDITION. that many valuable papers have been overlooked; indeed it is impos- sible 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 exclu- sion 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 illustra- tions 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, how- ever, 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 contriv- ance of useless apparatus. It is not in the discovery and multiplica- tion 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 H. HAMILTON. Buffalo, N. Y., December, 1859. CONTENTS. PART I. FRACTURES. CHAPTER I. General Division of Fractures .... CHAPTER II. General Etiology of Fractures . CHAPTER III. General Semeiology and Diagnosis CHAPTER IV. Repair of Broken Bones ..... CHAPTER V. General Treatment of Fractures CHAPTER VI. Delayed Union and Non-Union of Broken Bones CHAPTER VII. Bending, Partial Fractures, and Fissures of the Long Bones § 1. Bending of the Long Bones § 2. Partial fracture of the Long Bones § 3. Fissures . CHAPTER VIII. Fractures of the Nose . § 1. Ossa Nasi . § 2. Fractures and Displacements of the Septum Narium X CONTEXTS. CHAPTER IX, Fractures of the Malar Bone . CHAPTER X. Fractures of the Upper Maxillary Bones CHAPTER XI. Fractures of the Zygomatic Arch page 101 106 CHAPTER XII. Fractures of the Lower Jaw 109 CHAPTER XIII. Fractures of the Hyoid Bone .... 134 CHAPTER XIV. Fractures of the Cartilages of the Larynx . § 1. Thyroid Cartilage .... § 2. Thyroid and Cricoid Cartilages § 3. Cricoid Cartilage .... CHAPTER XV. Fractures of the Vertebra .... § 1. Fractures of the Spinous Processes § 2. Fractures of the Transverse Processes § 3. Fractures of the Vertebral Arches § 4. Fractures of the Bodies of the Vertebrae 1. Fractures of the Bodies of the Lumbar Vertebrae 2. Fractures of the Bodies of the Dorsal Vertebrae . 3. Fractures of the Bodies of the five lower Cervical Vertebrae 4. Treatment of Fractures of the Bodies of the Vertebrae . § 5. Fractures of the Axis ...... § 6. Fractures of the Atlas...... § 7. Fractures of the first two Cervical Vertebrae (Atlas and Axis) at the same time Fractures of the Sternum CHAPTER XVI CHAPTER XVII. Fractures of the Ribs and their Cartilages . § 1. Fractures of the Ribs .... § 2. Fractures of the Cartilages of the Ribs CHAPTER XVIII 139 139 139 141 143 143 145. 146 152 153 155 156 158 161 163 164 101 171 171 176 Fractures of the Clavicle 177 CONTEXTS. XI CHAPTER XIX. Fractures of the Scapula .... § 1. Fractures of the Body of the Scapula § 2. Fractures of the Neck of the Scapula § 3. Fractures of the Acromion Process § 4. Fractures of the Coracoid Process CHAPTER XX. Fractures of the Humerus ....... § 1. Fractures of the Head and Anatomical Neck .... § 2. Fractures through the Tubercles § 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of the Greater Tubercle ....... § 4. Fractures through the Surgical Neck (including Separations at the Upper Epiphyses) ....... § 5. Fractures of the Shaft below the Surgical Neck, and above the Base of the Condyles ....... § 6. Fractures at the Base of the Condyles (including Separations of the Lower Epiphysis) ....... § 7. Fractures at the Base of the Condyles, complicated with Fracture between the Condyles, extending into the Joint § 8. Fractures of the Internal Epicondyle ..... § 9. Fractures of the External Epicondyle ..... § 10. Fractures of the Internal Condyle ..... § 11. Fractures of the External Condyle ..... PAGE 200 200 205 206 209 212 213 217 218 220' 232 242 250 253 257 258 260 CHAPTER XXI. Fractures of the Radius 264 CHAPTER XXII. Fractures of the Ulna . § 1. Shaft of the Ulna .... § 2. Coronoid Process of the Ulna . § 3. Fractures of the Olecranon Process . CHAPTER XXIII. Fractures of the Radius and TJlna CHAPTER XXIV. Fractures of the Carpal Bones CHAPTER XXV. Fractures of the Metacarpal Bones . 293 293 297 306 314 323 324 CHAPTER XXVI. Fractures of the Fingers 327 Xll CONTENTS. CHAPTER XXVII. Fractures of the Pelvis, and Traumatic Separations at its Symphyses § 1. Pubes . § 2. Ischium § 3. Ilium . § 4. Acetabulum § 5. Sacrum § 6. Coccyx CHAPTER XXVIII. Fractures of the Femur ....... § 1. Neck of the Femur ....... (a.) Neck of the Femur within the Capsule (6.) Neck of the Femur without the Capsule (c.) Fractures of the Neck partly within and partly without the Capsule ....... § 2. Fractures through the Trochanter Major and Base of the Neck of the Femur ........ § 3. Fractures of the Epiphysis of the Trochanter Major . § 4. Fractures of the Shaft of the Femur ..... § 5. Fractures of the Condyles ...... (a.) Fractures of the External Condyle .... (6.) Fractures of the Internal Condyle .... (c.) Fractures between the Condyles and across the Base . Fractures of the Patella Fractures of the Tibia Fractures of the Fibula CHAPTER XXIX. CHAPTER XXX. CHAPTER XXXI. CHAPTER XXXII. Fractures of the Tibia and Fibula CHAPTER XXXIII. Fractures of the Tarsal Bones CHAPTER XXXIV. Fractures of the Metatarsal Bones CHAPTER XXXV. Fractures of the Phalanges of the Toes page 330 331 334 336 339 345 347 347 34S 349 383 390 390 391 393 437 437 438 440 442 CHAPTER XXXVI Gunshot Fractures 457 401 4>0 48 c 4S7 487 CONTENTS. Xlll PART II. DISLOCATIONS. CHAPTER I. General Considerations § 1. General Division and Nomenclature § 2. General Predisposing Causes § 3. Direct or Exciting Causes § 4. General Symptoms § 5. Pathology § 6. General Prognosis § 7. General Treatment CHAPTER II. Dislocations of the Lower Jaw § 1. Double or Bilateral Dislocations § 2. Single or Unilateral Dislocations § 3. Conditions of the Jaw simulating Luxations . CHAPTER III. Dislocations of the Spine .... § 1. Dislocations of the Lumbar Vertebrae . § 2. Dislocations of the Dorsal Vertebrae . § 3. Dislocations of the Six Lower Cervical Vertebrae § 4. Dislocations of the Atlas § 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dis locations ....••• CHAPTER IV. Dislocations of the Ribs ..•••• § 1. Dislocations of the Ribs from the Vertebrae . . • § 2. Dislocations of the Ribs from the Sternum § 3. Dislocations of one Cartilage upon another . CHAPTER V. Dislocations of the Clavicle . § 1. Dislocations forwards at the Sternal End § 2. Dislocations of the Sternal End of the Clavicle Upwards § 3. Dislocations of the Sternal End of the Clavicle Backwards § 4. Dislocations of the Acromial End of the Clavicle Upwards § 5. Dislocations of the Acromial End of the Clavicle Downwards § 6. Dislocations of the Acromial End of the Clavicle under the Coracoid Process . PAGE 497 497 498 499 499 501 502 502 505 505 509 510 512 513 514 517 524 525 526 526 527 528 529 529 533 534 536 541 542 XIV CONTENTS. CHAPTER VI. PAGE Dislocations of the Shoulder (Humerus at its upper Extremity) . . 543 § 1. Dislocations of the Shoulder Downwards (Subglenoid) . . 544 Dislocation, with Fracture of the Humerus near its Upper End . 568 § 2. Dislocations of the Humerus Forwards (Subcoracoid and Subclavicular) 570 § 3. Dislocations of the Humerus Backwards (Subspinous) . . 575 § 4. Partial Dislocations of the Humerus ..... 579 CHAPTER VII. Dislocations of the Head of the Radius ..... 582 § 1. Dislocations of the Head of the Radius Forwards . . . 582 § 2. Dislocations of the Head of the Radius Backwards . . . 5^7 § 3. Dislocations of the Head of the Radius Outwards . . . 589 CHAPTER VIII. Dislocations of the Upper End of .the Ulna Backwards . . . 590 CHAPTER IX. Dislocations of the Radius and Ulna (Forearm at the Elbow-Joi.nt) . 591 § 1. Dislocations of the Radius and Ulna Backwards . . . 591 § 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side) 6ul § 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side) . 605 § 4. Dislocations of the Radius and Ulna Forwards . . .608 CHAPTER X. Dislocations of the Wrist (Radio-Carpal Articulation) . . .609 §1. Dislocations of the Carpal Bones Backwards . . qh § 2. Dislocations of the Carpal Bones Forwards . . . ^4 CHAPTER XI. Dislocations of the Lower E.nd of the Ulna (Inferior-Radio Ulnar Articu- lation) .... § 1. Dislocations of the Lower End of the Ulna Backwards § 2. Dislocations of the Lower End of the Ulna Forwards . CHAPTER XII. Dislocations of the Carpal Bones (among themselves) CHAPTER XIII. Dislocations of the Metacarpal Bones (at the Carpometacarpal Articula- tions) .... CHAPTER XIV. DlSLOCAT.ONS OF THE FjRST PHALANGES OF THE THUMB AND F.NGERS (AT THE Metacarpophalangeal Articulations) § 1. Dislocations of the First Phalanx of the Thumb Backwards ' i 2. Dislocations of the First Phalanx of the Thumb Forwards § 3. Dislocations of the First Phalanx of the Fingers 615 615 616 617 619 621 021 029 630 CONTENTS. XV CHAPTER XV. PAGE Dislocations of the Second and Third Phalanges of the Thumb and Fingers 631 CHAPTER XVI. Dislocations of the Thigh (Coxo-Femoral) ..... § 1. Dislocations Upwards and Backwards on the Dorsum Ilii § 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch § 3. Dislocations Downwards and Forwards into the Foramen Thyroideum § 4. Dislocations Upwards and Forwards upon the Pubes § 5. Anomalous Dislocations, or Dislocations which do not properly belong to either of the four principal divisions before described 1. Dislocations directly Upwards ..... 2. Dislocations Downwards and Backwards upon the Posterior Part of the Body of the Ischium, between its Tuberosity and its Spine ........ 3. Dislocations Downwards and Backwards into the Lesser or Lower Ischiatic Notch • . 4. Dislocations directly Downwards 5. Dislocations Forwards into the Perineum § 6. Ancient Dislocations of the Femur § 7. Partial Dislocations of the Femur § 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur § 9. Voluntary Dislocations of the Femur . CHAPTER XVII. Dislocations of the Patella § 1. Dislocations of the Patella Outwards § 2. Dislocations of the Patella Inwards . § 3. Dislocations of the Patella upon its Axis § 4. Dislocations of the Patella Upwards . CHAPTER XVIII. Dislocations of the Head of the Tibia . § 1. Dislocations of the Head of the Tibia Backwards § 2. Dislocations of the Head of the Tibia Forwards § 3. Dislocations of the Head of the Tibia Outwards § 4. Dislocations of the Head of the Tibia Inwards § 5. Dislocations of the Head of the Tibia Backwards and Outwards § 6. Internal Derangement of the Knee-Joint CHAPTER XIX. Dislocations of the Lower End of the Tibia . § 1. Dislocations of the Lower End of the Tibia Inwards § 2. Dislocations of the Lower End of the Tibia Outwards § 3. Dislocations of the Lower End of the Tibia Forwards § 4. Dislocations of the Lower End of the Tibia Backwards 634 636 059 665 669 673 673 G74 675 676 677 678 681 682 6S5 686 686 689 689 691 692 693 695 697 698 699 700 702 702 707 708 712 XVI CONTENTS. CHAPTER XX. Dislocations of the Upper End of the Fibula . . . § 1. Dislocations of the Upper End of the Fibula Forwards § 2. Dislocations of the Upper End of the Fibula Backwards CHAPTER XXI. Dislocations of the Inferior Peroneo-Tibial Articulations . PAGE 713 713 714 715 CHAPTER XXII. Tarsal Luxations .... § 1. Dislocations of the Astragalus § 2. Astragalo-Calcaneo-Scaphoid Dislocations § 3. Dislocations of the Calcaneum § 4. Middle Tarsal Dislocations § 5. Dislocations of the Os Cuboides § 6. Dislocations of the Os Scaphoides §• 7. Dislocations of the Cuneiform Bones . CHAPTER XXIII. Dislocations of the Metatarsal Bones CHAPTER XXIV. Dislocations of the Phalanges of the Toes CHAPTER XXV. Compound Dislocations of the Long Bones CHAPTER XXVI. Congenital Dislocations .... § 1. General Observations and History § 2. Etiology ..... § 3. Congenital Dislocations of. the Inferior Maxilla § 4. Congenital Dislocations of the Spine . § 5. Congenital Dislocations of the Pelvic Bones . § 6. Congenital Dislocations of the Sternum § 7. Congenital Dislocations of the Clavicle § 8. Congenital Dislocations of the Shoulder (Upper End of the Humerus) § 9. Congenital Dislocations of the Radias and Ulna Backwards § 10. Congenital Dislocations of the Head of the Radius § 11. Congenital Dislocations of the Wrist § 12. Congenital Dislocations of the Fingers § 13. Congenital Dislocations of the Hip . § 14. Congenital Dislocations of the Patella § 15. Congenital Dislocations of the Knee § 16. Congenital Dislocations of the Tarsal Bones § 17. Congenital Dislocations of the Toes . 715 715 722 724 724 725 725 726 727 730 731 746 746 748 749 752 753 753 754 754 758 758 759 76U 760 766 767 770 770 LIST OF ILLUSTRATIONS. FRACTURES. FIG. 1. Perforating and longitudinal fracture 2. Impacted extra-capsular fracture of neck of femur 3. Union of fracture with the fragments widely separated 4. Fracture united with an oblique callus 5. Application of the roller, by circular and reversed turns 6. Many-tailed bandage .... 7. Application of the many-tailed bandage . 8. Bandage of Scultetus .... 9. Wood and leather splint .... 10. Starch- bandage applied for a broken thigh 11. Seutin's pliers ..... 12. Opening the apparatus with Seutin's pliers 13. Apparatus immobile, applied over a compound fracture 14. Clavicle, united by ligamentous bands 15. Hudson's splint, ununited fracture 16. Physick's first case, treated by seton—after 28 years 17. Dieffenbach's drill for ununited fracture . 18. Brainard's perforator for ununited fracture 19. Bone drill . 20. Gaillard's instrument for ununited fractures 21. Fergusson's case of permanent bending without fracture 22. Partial fracture of the femur without restoration of the bone to its form ....... 23. Partial fracture of the clavicle without spontaneous restoration 24. Partial fracture after union is consummated 25. Fracture of the lower jaw . 26. Beans' maxillary articulator 27. Beans' apparatus for broken jaw, applied . 28. Gibson's bandage for a fractured jaw 29. Barton's bandage for a fractured jaw 30. Four-tailed bandage or sling for the lower jaw 31. The author's apparatus for a broken jaw . 32. Fracture of the spinous process 33. Fracture of the vertebral arches . 34. Oblique fracture of the body of a vertebra 35. Key's case of fracture of the first lumbar vertebra 2 natural XV111 LIST OF ILLUSTRATIONS. FIG 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56, 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. Parker's case of fracture of the odontoid process of the axis Development of sternum ..... Fracture of ribs, with lateral union Oblique fracture, near the middle of the clavicle Fracture of the clavicle outside of the trapezoid ligament Complete oblique fracture of the clavicle at the outer end of the inner two-thirds .... Comminuted fracture of the clavicle united Velpeau's dressing for a fractured clavicle Figure-of-8 bandage, for a broken clavicle Keckerley's apparatus for a fractured clavicle Bartlett's apparatus for a fractured clavicle Fox's apparatus for a fractured clavicle . The author's apparatus for a fractured clavicle Fracture of angle of scapula Fractures of the body and acromion process of the scapula Comminuted fracture of the glenoid cavity Fracture of the neck of the scapula Scapula with epiphyses Fracture of the coracoid process . Fracture at the anatomical neck of the humerus 57. Pope's specimen of supposed fracture at the anatomical neck of the humerus, and reversion of the head—front and side views Humerus with epiphyses . Fracture of surgical neck of humerus Welch's shoulder splint Lonsdale's apparatus for extension, in fractures of the humerus Fracture of the humerus at the base of the condyles Separation of lower epiphyses ' Physick's elbow splint .... Kirkbride's elbow splint Rose's arm and forearm splint Welch's arm and forearm splint . Bond's elbow splint The author's elbow splint . Fracture at the base of the condyles of the humerus, and between the condyles .... Fracture of internal epicondyle of the humerus ! Fracture of external epicondyle . Fracture of the internal condyle of the humerus Fracture of external condyle Mutter's specimen of fracture of the neck of the radius Fractures of head of radius Fracture of the shaft of the radius Colles' fracture—radius near its lower end Bigelow's case of comminuted fracture of the lower end of the rad Nelaton's splint for fracture of the radius near its lower end Bond's splint for fracture of the lower end of the radius Hay's splint for fracture of the lower end of the radius E. P. Smith's splint for fractures of the lower end of the radius-fron view 282 LIST OF ILLUSTRATIONS. XIX FIG. 84. Same as above—back view ..... 85. Shrady's splint for Colles' fracture .... 86. The author's splint for fracture near the lower end of the radius 87. The author's dressing for a fracture of the radius near its lower end— complete .... 88. Radius, with epiphyses . 89. Fracture of the shaft of the ulna 90. Fracture of the coronoid process of the ulna 91. Ulna, with epiphyses 92. Fracture of the olecranon process at its base 93. Olecranon process united by ligament 94. Sir Astley Cooper's method of dressing a fracture of the olecranon process 95. The author's splint for a fracture of the olecranon process 96. The same applied .... 97. Fracture of the radius and ulna in the middle third 98. Fracture of the radius and ulna in the lower third 99. Radius and ulna united with displacement 100. Development of os innominatum 101. Clark's case of comminuted fracture of the pelvis 102. Development of femur .... 103. Fracture of the neck of the femur, within the capsule 104. Impacted fracture of the neck of the femur, within the capsule 105. Neck of unsound femur—case of Mr. S., reported by Mussey . 106. The same—vertical section . 107. Sound femur of Mr. S. . . 108. Neck of unsound femur ; case of Mr. N., reported by Dr. Mussey 109. Same as above—vertical section ..... 110. Sound femur of Mr. N. . 111. Neck of unsound femur; case of Mrs. M., reported by Dr. Mussey 112. The same—vertical section . 113. Vertical section of the neck of the femur, capsule and acetabulum—case of Mrs. Wakelee . ... 114. Section of the head and neck of the sound femur of an adult 115. Chronic rheumatic arthritis, in hip-joint 116. Crosby's specimen of fracture of neck of femur within the capsule— ununited . . . • • 117. Mayo's specimen of fracture of the neck of the femur within the cap sule, united by ligament . . • • ■ 118. Gibson's Modification of Hagedorn's thigh splints 119. Gibson's splint applied ...••• 120, 121, 122. Impacted, extra-capsular fracture 123. Fracture of the neck of the femur . . 124. Extra-capsular fracture of the neck of the femur—ununited . 125. Extra-capsular fracture of the neck of the femur—with excess of callus 120. The same—vertical section ...••• 127. Extra-capsular fracture of the neck of the femur—united with irregular callus . 128. Miller's splint for extra-capsular fractures 129. Sir Astley Cooper's mode of treating fractures of the trochanter major 130. Fracture of the femur at the base of the condyles 131. Physick's thigh splint . XX LIST OF ILLUSTRATIONS. FIG. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 150. 157. 15S. 159. 160. 161. 162. 163. 104. 165. 166. 167, 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. Liston's dressing of fractured femur with a straight splint Double inclined plane employed in Middlesex Hospital, London Amesbury's double inclined plane Amesbury's splint, applied Boyer's thigh splint applied Nathan R. Smith's suspending thigh splint, or double inclined plane Nott's double inclined plane N. R. Smith's anterior splint N. R. Smith's anterior splint, applied Burge's fracture bed and thigh splint The same in use ..... Neill's straight thigh splint, for extension and counter-extension Flagg's thigh apparatus—employed in the Massachusetts General Hos pital. Pelvic belt and perineal straps Same—footpiece and screw Same—lateral view of the apparatus, without the belt Same—front view, with folded sheets laid across Same—apparatus applied, front view Same—apparatus applied, side view Same—mode of applying adhesive plasters to leg Same—mode of making extension by adhesive plasters Same—perineal band secured with a padlock Sanborn's thigh splint .... Gurdon Buck's fracture apparatus Horner's thigh splint .... Joseph Hartshorne's thigh splint. George F. Shrady's thigh splint . Chapin's thigh apparatus Gilbert's thigh apparatus—mode of making extension and counter ex tension with adhesive straps . Same—applied in a case of fracture of both thighs H. L. Hodge's method of extension in fractures of the femur Lente's long, straight thigh splint, modified by Tiemann Lente's thigh splint, applied The author's single straight thigh splint, for children or adults The author's single straight thigh splint for children, or the straight splint in its simplest and elementary form The author's double straight thigh splint, for children or adults 168, 169. The same—endless screw ; front, side, and end views The same—front removed, showing the interior Fracture of femur just below trochanter minor . Jenk's fracture bed Daniels' fracture bed—descriptive diagram The same—complete The same—in use Crosby's specimen of fracture of the external condyle of the femur Sir Astley Cooper's case of fracture of the external condyle of the fern Transverse fracture of the patella Comminuted fracture of the patella Transverse fracture of the patella-exhibiting the relations of the mx cles to the fracture 443 LIST OF ILLUSTRATIONS. XXI FIG. 181. Fragments of a broken patella separated by flexion of the knee 182. Upper fragment of a broken patella drawn up very much by the action of the quadriceps femoris 183. The author's mode of dressing a fractured patella 184. Wood's apparatus for a fractured patella 185. Dorsey's patella splint .... 186. Sir Astley Cooper's method for broken patella by circular and parallel tapes ........ 187. Sir Astley Cooper's method by a leather band and counter-strap 188. Lonsdale's apparatus for fractured patella 189. Development of tibia . . . . . 190. Development of fibula ...... 191. Fracture of the fibula near its lower end 192. Dupuytren's splint for broken fibula—modified . 193. Same—improperly applied ..... 194. Dupuytren's splint, as originally made and applied by himself 195. Compound and comminuted fracture of the leg . 196. Long splint for fracture of the leg in Pott's position 197. Hutchinson's splint for extension in fractures of the leg 198. Neill's apparatus for fractures of the leg requiring extension and counter extension 199. Neill's apparatus for compound fractures of the leg 200. Gilbert's fracture box ...... 201. Crandall's apparatus for fractures of the leg requiring extension an< counter-extension—side view ..■••• 202. Same. Posterior view of the lower section . . 203. Same. Posterior view of the entire apparatus . 204. Immovable apparatus—applied to the leg 205. Liston's double-inclined plane, applied to the leg in a case of compound fracture . . . • 206. Bauer's wire splints, for the leg . 207. Swing box, for fractures of the leg 208. Salter's cradle for fractures of the leg 209. Fracture box for the leg, with movable sides 210. Wire rack, for fracture of the leg .... 211, 212. Malgaigne's apparatus for certain oblique fractures of the leg 213. Apparatus for fracture of the tuberosity of the calcaneum page 444 476 476 477 477 478 478 478, 479 485 DISLOCATIONS. 214. Clove hitch ....-•• 215. Compound pulleys and ring ... 216, 217. Double dislocation of the inferior maxilla . 218. Ayres' case of bilateral dislocation of the fifth cervical vertebra 219. Dislocation of the sternal end of the clavicle, forwards . 220. Sir Astley Cooper's apparatus for dislocated clavicle 221. Dislocation of the acromial end of the clavicle, upward and outward 222. Mayor's apparatus for dislocated clavicle 223, 224. Dislocation of the shoulder downwards into the axilla 225! New socket, in an ancient luxation of the shoulder downwards 504 504 507, 508 523 530 532 537 540 545, 546 XX11 LIST OF ILLUSTRATIONS. FIG. 226. 227. 228. 229. 230. 231. 232. 233. 234. 235. 236. 237. 238. 239. 240. 241. 242. 243. 244. 245. 246. 247, 249, 251. 252. 253. 254, 256. 257. 258. 259. 260, 262. 263. 204. 265. 266. 267. 268. 269, 271. N. R. Smith's method of reducing a dislocation of the shoulder La Mothe's method of reducing a dislocation of the shoulder—modified Sir Astley Cooper's method, with the heel in the axilla Sir Astley Cooper's method, with the knee in the axilla Iron knob employed by Skey, instead of the heel Skey's method in dislocations of the shoulder Sir Astley Cooper's method, by means of pulley Subcoracoid dislocation of the humerus . Subclavicular dislocation of humerus Subcoracoid dislocation . Subspinous dislocation of the humerus . Displacement of the long head of the biceps Dislocation of the head of the radius forwards—anatomical relations Dislocation of the head of the radius forwards . Dislocation of the head of the radius backwards Dislocation of the upper end of the ulna backwards Dislocation of the radius and ulna backwards . Sir Astley Cooper's method in dislocation of the radius and ulna back wards ........ Most frequent form of incomplete outward dislocation of the forearm Most frequent form of incomplete inward dislocation of the forearm Canton's case, dislocation of the radius and ulna forwards 248. Dislocation of the carpal bones backwards . 250. Dislocation of the carpal bones forwards—skeleton Dislocation of the first phalanx of the thumb backwards Clove hitch ....... Sir Astley Cooper's method of reducing dislocations of the thumb by the pulleys ..... 255. Levis's instrument for reduction of the phalanges Indian " puzzle"—employed in the reduction of dislocations of small joints ..... Backward dislocation of the first phalanx of the index finger—reduction by extension ..... Dislocation of the second phalanx backwards . Dislocation of the second phalanx forwards 261. Dislocation of the femur upon the dorsum ilii Nathan Smith's method of reduction of a dislocation of the head of the femur upon the dorsum ilii, by manipulation Hippocrates' mode of reducing dislocations of the hip by manipulation Reduction of a dislocation upon the dorsum ilii by pulleys Reduction of a dislocation upon the dorsum ilii by a twisted rope Jarvis's adjuster—applied in dislocation of the hip Bloxham's dislocation tourniquet—applied for reduction of a dislocation of the femur upon the pubes .... Reduction of a dislocation of the femur upon the dorsum ilii, by pulleys 270. Dislocation of the femur upwards and backwards into the great ischiatic notch ...... Reduction of a dislocation into the great ischiatic notch, by pulleys 273. Dislocation of the femur downwards and forwards into the foramen thyroideum ...... pace 557 558 559 560 560 561 562 571 572 573 577 580 5;S3 584 589 590 592 596 601 606 608 612, 613 614, 615 622 624 625 027 628 630 632 632 637, 639 645 647 648 649 650 650 657 659, 660 663 666 LIST OF ILLUSTRATIONS. XX111 FIG. 274. Sir Astley Cooper's mode of reducing recent luxations of the femur into the foramen thyroideum ...... 275. Specimen of dislocation upon the pubes, in St. Thomas's Hospital 276. Dislocation upwards and forwards upon the pubes 277. Reduction of dislocation upon the pubes by extension 278. Dislocation of the patella outwards 279. Dislocation of the patella inwards 280. Dislocation of the head of the tibia backwards 281. Dislocation of the head of the tibia forwards 282. Subluxation of the head of the tibia outwards 283. Subluxation of the head of the tibia inwards 284, 285. Dislocation of the lower end of the tibia inwards 286. Reduction of a dislocation of the ankle by pulleys 287. Dislocation of the lower end of the tibia outwards 288, 289. Dislocations of the lower end of the tibia forwards 290, 291. Dislocation of the lower end of the tibia backwards 292. Dislocation of the astragalus outwards—anatomical relations 293. Simple dislocation of the astragalus outwards . 294. Compound dislocation of the astragalus inwards PART I. FRACTURES. FRACTURES. CHAPTER I. GENERAL DIVISION OF FRACTURES. Fractures are divided into Complete and Incomplete, Simple, Comminuted, Compound, and Complicated. A Complete fracture is one in which the line of division completely traverses the bone. An Incomplete fracture is a partial separation of the bone: under which name are included Bending, Partial fractures, Fissures and Punctured or Perforating fractures, the last of which is almost pecu- liar to gunshot injuries. A Simple fracture is one in which the bone is broken at only one point. The term has no reference to the question of complications, but in its technical meaning, as employed by both English and Ameri- can surgeons, it has reference only to the number of fragments into which the bone is broken. It would be more correct, perhaps, to sub- stitute the word " single" for "simple,'' as has been done by Malgaigne and some other French writers, but I fear that to American surgeons the substitution would be rather a source of confusion than otherwise. A Comminuted fracture, called by Malgaigne "multiple," is a frac- ture in which the bone is broken at more than one point, and in which, consequently, the bone is divided into more than two fragments. It is used also in a technical sense, and by no means implies minute divi- sion or comminution of the fragments. A Compound fracture is technically one in which there exists also an external wound communicating with the bone at the point of frac- ture. It may be either partial or complete, simple or comminuted, or even complicated, while at the same time it is also compound. Complicated fractures are such as present additional complications, or complications for which no other specific term has been invented. Thus the fracture may be complicated with the lesion of an important bloodvessel or nerve, or with great contusion or laceration of the soft parts, with a dislocation, or with fractures of other bones, or even with some constitutional fault. Fractures are also divided into Transverse, Oblique, and Longitu- dinal, according as the direction of the line of separation is at a right 28 GENERAL DIVISION OF FRACTURES. angle with the axis of the bone at the point of fracture, or as it deviates more or less from this direction. But a fracture is called transverse when it does not traverse the bone precisely at a right angle; indeed, we usually apply this term whenever the obliquity is only moderate, not exceeding, perhaps, fifteen or twenty degrees, or when, in the examination of a limb, although we are unable to detect the precise line of the fracture, we ascertain that, without being impacted or ser- rated, the ends of the bones continue to rest upon each other, or being replaced, do not spontaneously become displaced. Longitudinal fractures occur generally in connection with oblique or transverse fractures; as when the lower end of the femur is split vertically into the joint, and the shaft of the bone is traversed hori- zontally by a fracture which intercepts the vertical or longitudinal fracture. A fracture of a condyle or of any projection from the body of the bone is called longitudinal if the direction of the line of fracture is parallel, or nearly so, to the axis of the shaft. Fig. l. Fig. 2. Perforata ng and longitudinal fracture. Impacted, extra-capsular fracture From Surg. General's Circular. of neck of femnr. A Serrated fracture is one in which the opposite surfaces denticulate, the elevations upon one fragment being reflected by correspondino- depressions upon the other. Impacted fractures are those in which the fragments are driven into each other, the lamellated structure of one fragment penetrating the cancellous structure of the other. Writers also occasionally speak of fractures en rave, en lee de flute, en lee de plume, spiroid, cuneate, &c; but we do not see the propriety of multiplying the divisions and encumbering our nomenclature by these fancied resemblances. For all useful purposes, the divisions above given are sufficient. Epiphyseal separations we shall not hesitate to class with fractures, and to submit them to the same rules of nomenclature. GENERAL ETIOLOGY OF FRACTURES. 29 CHAPTER II. GENERAL ETIOLOGY OF FRACTURES. The causes of fracture may be considered as predisposing and exciting. Predisposing Causes.—Partial fractures, with bending of the bones, are most frequent in infancy and childhood; but complete fractures occur most often during manhood; and if they are again less frequent in old age, it is because the exciting causes are less operative, since the fragility of the bones, as a general rule, increases with the age. It will be noticed, also, that somewhat in proportion as the bone is more brittle, its fracture will be more nearly transverse, so that very old persons have frequently what has been not inaptly termed the "pipe-stem fracture;" but we must except from this rule fractures occurring in children, which are also not unfrequently transverse, often denticulated or splintered, and but rarely oblique. In all of the intermediate periods of life, oblique fractures are by far the most common. Females are less liable to fractures than males, except in old age, when the law seems, in general, to be reversed. As to the season of the year, it has been generally observed by surgical writers, that fractures were more frequent in winter than in summer, and an explanation has been sought for in the greater rigidity of the muscles during the cold weather, and the greater liability to falls upon the ice and frozen ground. Some have affirmed that the bones themselves were more brittle; but aside from the improbability of this last explanation, it is a matter of question whether fractures are actually more frequent in the winter than in the summer. If, on the one hand, the rigidity of the muscles and falls upon slippery walks are active causes in the production of fractures in the one season, on the other hand, falls from buildings and accidents from a great variety of similar causes, are equally active agents in the other. Mollities ossium, fragilitas ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy, mercurialization, and, in short, all diseases dependent upon cachexias, more or less predispose to the occurrence of fractures. Inflammation of the periosteum, also, or of the bone itself, may predispose to fracture. It is said, moreover, that the bones of persons who have lain a long time in bed break easily. Exciting Causes.—The exciting, determining, or immediate causes of fractures are of two kinds: mechanical violence and muscular action. Of these two, mechanical or external violence is much the most frequent cause; and this violence may operate in two ways: by acting directly upon the bone at the point at which it separates, and then we say the fracture is "direct," or from "direct violence;" or by acting upon some point remote from the seat of fracture, and then we say the 30 GENERAL ETIOLOGY OF FRACTURES. fracture is "indirect," or from a "counter stroke." When a person falls from a height, alighting upon his feet, and the leg or thigh is broken, the fracture is indirect; so also if the bone is broken by flexion or torsion. Even direct pressure upon one side of a long bone in a child may produce a partial fracture upon the opposite side, which is properly an indirect fracture; or a direct blow upon the trochanter major may occasion a counter fracture through the neck of the femur. Fractures from muscular action occur most often in the patella, calcaneum, humerus, femur, tibia, and olecranon process of the ulna. These accidents imply generally some conditions of the bones them- selves which predispose them to fracture; but I have seen one example of a fracture of the shaft of the femur in a large and perfectly healthy man, occasioned by a twist of the leg in rolling tenpins. I have also known the tibia and patella to break from natural muscular action in persons of uncommon vigor. Fractures sometimes occur in the violent contractions of the muscles during convulsions, and where no abnormal condition of the bones could be assumed to exist. Parker, of New York, relates a case of fracture of the humerus in a negro preacher, which occurred in the act of gesticulation; also, a fracture of the clavicle occasioned by striking a dog with a whip; in another case the humerus was broken in attempting to throw a peach ; but the most singular case of all was a fracture of the humerus caused by an effort to extract a tooth.1 Lente, of Cold Springs, New York, has seen both femurs broken in epileptic convulsions, in a child twelve years of age. The left femur was broken April 10th, 1859, at the junction of the upper with the middle third, and the right femur was broken at the same point eight months after, and about six weeks later he died. The first fracture united with considerable bowing and shortening. The second did not unite at all. He had been subject to epilepsy since he was fifteen months old.2 Remarkable examples of fragility of the bones have been from time to time recorded. Gibson relates the case of a young man who at the age of nineteen had suffered twenty-four fractures. Arnott speaks of a girl who at the age of fourteen had suffered thirty-one fractures; and Esquirol had in his possession the skeleton of a woman in which were found traces of more than two hundred fractures. In most of these cases, so far as is known, union occurred rapidly.3 Nearly all of the cases of fractures occasioned by muscular contrac- tion seen by me were transverse, or nearly so, indicating, perhaps, also, the existence of some unusual fragility; and most of these have been unattended with shortening, the ends of the bones not becoming completely displaced from each other. The example of fracture of the shaft of the femur just mentioned, as having been broken in rolling tenpins, was, however, an exception. The bone shortened to the ex- tent of an inch or more, in consequence of overlapping, and in this position it has finally united. 1 Parker, New York Journ. Med., July, 1852. p. 95. 2 Ainer. Med. Times and Advertiser, July 21, 1860, p. 41. 8 Holmes' System of Surgery, vol. i. p. 745. GENERAL ETIOLOGY OF FRACTURES. 31 Intra-uterine fractures are not yet fully explained, but it is probable that they, like extra-uterine fractures, may be ascribed sometimes to external violence, and at other times to simple muscular contraction, both perhaps acting upon bones already somewhat predisposed by a peculiar constitutional cachexy. Lawrence Proudfoot, of New York, has related a case of compound fracture in utero occurring in the practice of Dr. Freeman, which was apparently caused by external violence. Mrs. F., set. 38, always having enjoyed good health, during the sixth month of gestation, while attempting to pass through.a very narrow passage, was severely pressed upon the abdomen, and immediately experienced a severe pain in that region, accompanied with nausea and faintness. The following day, uterine hemorrhage with pain, commenced; and these symptoms continued at intervals, in a form more or less severe, up to the period of her delivery, which occurred at full time, and was perfectly natural. At birth, the right foot of the child, a female, was found to be much distorted, and in a condition of valgus with equinus, the outer side of the foot being laid against the side of the leg above the external mal- leolus. The tibia, also, of the same limb, near its middle, seemed to have been the seat of a compound fracture; the two ends of the bone having united at an angle slightly salient anteriorly, and the skin presenting over the point of fracture an old cicatrix. The soft tissues adjacent were considerably thickened. Seventeen months after birth, when the child was seen by Drs. Proudfoot, Van Buren, and Isaacs, of New York, the foot, although much improved by the means employed by Dr. Freeman, was still considerably deformed in consequence of the contraction of the tendo-Achillis ; on cutting which, the limb was found to be of the same length with the other.1 Dr. Aristide Rodrigue, of Hollidaysburg, Pa., has communicated a case of fracture with dislocation, which he ascribes to a similar cause. The woman, when about four months with child, fell on her left side, striking upon a board, and hurting herself severely. At the full period she was delivered of a well-grown male child. Its left humerus was found to be dislocated into the axilla, and both the radius and ulna of the same limb had been broken through their lower thirds, but were now united by bony callus at an angle of about 45°, and slightly overlapped. In all other respects the child was perfect. It does not appear that anything was done to the fracture, and the attempt to reduce the humerus was unsuccessful. Four years later Dr. R. saw the lad and found him strong and hearty, the dislocated humerus having grown nearly at the same rate with the opposite, but the forearm remained " short and deformed as at birth." The hand was of the same size as the hand of the sound limb.2 Devergie has given an account of a woman, who, when seven months with child, struck her abdomen against the corner of a table. Intense pain followed, lasting some time. She went her full period, however, and the child was then found to have a fracture of the left ' Proudfoot, New York Jouru. Med., Sept. 1840, p. 199. 2 Rodrigue, Ainer. Jouru. Med. Sci., Jan. 1&54, p. 272. 32 GENERAL ETIOLOGY OF FRACTURES. clavicle, the fragments being overlapped somewhat, and united in this position by a firm and large callus.1 A woman also six months gone met with a similar accident, and at the full time she gave birth to a feeble child, having in one leg a separation of the shaft of the tibia from its lower epiphysis. The end of the shaft was necrosed and projected through a wound in the integument. This child died on the thirteenth day.2 Schubert reports the case of a female delivered before her term, of twins, one of whom was born with a fracture of the left thigh, which had occurred in utero; the fractured bone had pierced the flesh, through which it projected more than an inch, and it was carious. The mother stated that about six weeks before the accouchement, during a movement of the foetus, she had heard a noise like that produced by breaking a stick, and from that moment she had felt pricking pains in her belly.3 It is probable that in this instance the fracture was the result of a muscular action, although it is possible that it was occasioned by the thigh having become entangled between the legs of the twin. Similar cases have been recorded by Ploucquet, Kopp, Devergie, Carus, Schubert, Sachse, Moffat, and Brodhurst.4 In many other examples upon record3 the explanation is plainly enough to be sought for in the abnormal or rachitic condition of the bones. Monteggia saw, in a newly born infant, twelve ununited frac- tures. Chaussier, who has published a memoir upon this subject, mentions two very extraordinary cases, in one of which the child pre- sented forty-three fractures, and in the other, one hundred and twelve.8 I myself was permitted to see, on the 29th of June, 1853, with Drs. Hawley and White, of Buffalo, an infant only four days old, who was born at the full time, of a healthy mother, in whom nearly all of the long bones were separated and movable at their epiphyses, the motion being generally accompanied with a distinct crepitus. The bones were also much enlarged in their circumference; the bones of the forearm and the femur were greatly curved; the fontanelles unusually open, and the clavicles were entirely wanting. The child was of full size, but looked feeble. It died in a condition of marasmus six months after birth; at which time some degree of union had taken place at several of the points of separation, the limbs having been supported constantly with pasteboard splints and rollers. I have also seen one example of complete separation of the tibia and fibula near the middle of the leg, which I was disposed to regard as defective development rather than as an instance of intra-uterine fracture: and a gentleman in Michigan has sent me an account of another which I am inclined to think belongs to the same class of deformities, although he thought it might be a case of intra-uterine iracture. ' Devergie, Rev. Mel., 1825. * Malgaigne, from Archiv. Gen. de Med., t xvi p "«8 ■ Chaa«u», Ball,,, a. la Facult. a. Mad. de Pads' 1813° p 301. ' °"- 186°- GENERAL SEMEIOLOGY AND DIAGNOSIS. 33 Fractures occurring from violence inflicted upon the child by the accoucheur, or from contractions of the neck of the womb while the child is in transitu, are more common occurrences, and do not require a separate consideration. I shall mention several in connection with the various bones in which they have taken place; among which, one of the most interesting is that published by Dr. Jacob H. Vanderveer, of Long Branch, N. J. The mother came to bed on the 18th of January, 1847, after a labor of more than twelve hours. It was a foot presentation; the child weighed fourteen pounds, and was perfectly healthy, but one of the thighs had suffered a complete fracture, occa- sioned probably by the strong contractions of the cervix uteri. With careful splinting and bandaging, the bone was finally, but not without some difficulty, kept in position and made to unite, so that at the date of the report one would not discover that the bone had been broken, except by close inspection.1 CHAPTER III. GENERAL SEMEIOLOGY AND DIAGNOSIS. Fractures are liable to be confounded with contusions, and with various other local injuries, but most often with dislocations; and especially when the fracture has taken place near one of the articu- lations, is the differential diagnosis sometimes rendered exceedingly difficult. It is with particular reference, therefore, to the general points of distinction between fractures and dislocations, that I now propose to speak. The special signs or points of difference which belong to each individual case, will be considered in their proper places. ,, The most important general, or common signs of a fracture—and by "common" signs I mean those which are common to most fractures- are crepitus, mobility, and an inability on the part of the fragments to maintain their positions when reduced; indeed, in many cases, this constantly recurring displacement is due to the fact that the surgeon is unable to accomplish a complete reduction. While, on the other hand, dislocations are almost as uniformly characterized by the absence of crepitus, by preternatural immobility, and by the fact that when reduced the bones do not usually require support to retain them in place, or indeed, we may say, by the fact that they are generally reducible. . .. Let us study these phenomena a little more in detail. Crepitus, occasioned by the chafing of the broken surfaces upon each other, when actually present, is almost positive evidence oltbe existence of a fracture. It is possible, however, to confound the chal- i Vanderreer, Amer. Journ. Med. Sci., May, 1847, p. 378. 34 GENERAL SEMEIOLOGY AND DIAGNOSIS. ing of engorged tendinous sheaths, or of inflamed joints upon which fibrinous effusions have occurred, or of emphysema even, for the true crepitus of a fracture; but to the experienced ear and well practised touch these sensations are seldom a source of error. The one is rough, crackling, or even clicking sometimes, while the other is more sub- dued, and imparts a more uniform sensation to the hand, and but rarely conveys an actual sound, unless the ear is directlv applied or the stethoscope is employed. It is only when the crepitus is trans- mitted obscurely through a great mass of soft tissues, or sufficient time has elapsed for the ends of the fragments to become softened by inflammation, and partially covered with a plastic material, or when indeed a dislocation is actually coincident with the fracture, that the surgeon is left in doubt. Occasionally, also, the existence of caries or of necrosis, in connection with a dislocation, might lead to the sup- position of a fracture; but the history of the case, aside from the remaining common signs, and the special symptoms hereafter to be enumerated, would prevent any possibility of error. In a few cases the diagnosis may be facilitated by the application of the ear or of the stethoscope, as first recommended by Lisfranc.1 It must not be forgotten, moreover, that a fracture at one point may transmit the sensation of crepitus distinctly enough, but in such a direction, owing to the relations of other bones to the one broken, as to mislead the surgeon, and induce him to locate the fracture in the wrong bone. Several examples of this species of deception I shall hereafter have occasion to mention. Valuable and important as is crepitus in its relations to differential diagnosis, unfortunately it is not always present, and for reasons which must be plainly stated. First; we cannot, in a pretty laro-e proportion of cases, bring the broken ends again into apposition U hatever mere theorists may say to the contrary, and notwithstand- ing surgeons up to this time have rarely ventured to allude to this subject, the fact is so that we do not usually " set" broken bones We do not even at the first, bring them into complete apposition, unless it is as the exception I speak of bones once completely displaced bv overlapping, and these constitute the majority of examples which come under the surgeon's observation. Second; in transverse frac- tures of the patella, and in fractures of the olecranon and coronoid process of the ulna, of the coracoid and acromion process of the scapula, and in all similar detachments of processes and apophyses the action of the muscles by displacing the fragments, prevents creS from being readily produced. Third; in a few cases, such as cer ah fractures of the neck of the femur, of the neck aVdl^rf the hu™ &c the broken ends are impacted, or so driven into each other as to forbid the production of motion and crepitus; or they may be simnlv "Tb" ttlame" ^ C°™^*> S0 ^ - * 1 ~nT$ Finally, in very many incomplete fractures, crepitus does not exist and even when it is present the sensation is feeble, or very much 1 New England Med." Journ., 1824, p. 220. GENERAL SEMEIOLOGY AND DIAGNOSIS. 35 modified, sometimes resembling the chafing of lymph, and at other times giving only a faint and single click. Under the head of crepitus we may properly include the sharp crack sometimes felt, or even heard by the patient at the moment of fracture. Preternatural mobility, less valuable as a means of diagnosis than crepitus, is nevertheless more constantly present, being never absent, in some degree, in all complete, non-impacted, and non-denticulated fractures ; but its presence does not, like crepitus, render the existence of a fracture quite certain. Whenever the bony lesion takes place in the vicinity of a joint, it may be difficult or impossible to determine whether the mobility of the limb is due to motion in the joint or to motion at the supposed seat of fracture. While on the other hand, the preternatural immobility so generally observed in dislocations, may give place to preternatural mobility, as when the ligaments and tendons surrounding the joint are extensively torn, or the system itself is laboring under the shock of the accident, or when from any other cause there exists great general prostration. As to the third common sign mentioned, namely, that in the case of fractures the bones do not generally support themselves, but de- mand for this purpose the interposition of splints, bandages, and even of extending and counter-extending forces, its authority rests upon the same evidence as does the assertion already made that bones once separated entirely, cannot generally be "set," that is, placed again end to end in such a manner as to be made effectually to support each other. It rests upon the evidence of my own personal experience; to which I am permitted to add, also, the personal experience of Mal- gaigne, who, with a frankness which does him great credit, and which, I am sorry to say, has hitherto found few imitators, remarks: "Second. That overlapping is' the most stubborn of all. Here I will add a dis- agreeable truth, which classical authors have kept too much out of sight, namely, that it is so stubborn that in an immense majority of cases the efforts of art are unable to overcome it."1 And it must be observed further, that if we shall often find it possible to bring the broken surfaces sufficiently into contact to develop crepitus, they may still be unable to maintain themselves in this position, owing to the obliquity of the line of fracture. The other common signs of fracture may be briefly stated. Pain at the seat of fracture ^swelling; ecchymosis; deformity, produced by either an angular, transverse, or rotatory displacement of the frag- ments, and which is quite as often due to the direction and force of the impulse which occasioned the fracture as to the action of the mus- cles ; separation of the fragments, as in fractures of the patella and olecranon process; and inability to move the limb, a phenomenon due in part to the breaking of the bony lever upon which the muscles acted, and in part to the intense pain caused by any such attempts. This latter symptom is, however, often entirely absent. It is not generally present in impacted fractures, in serrated and partial frac- ' Malgaigne, Traite des Fractures et des Luxations, Paris ed., t. i. p. 102. 36 GENERAL SEMEIOLOGY AND DIAGNOSIS. tures, or in many other fractures in which the periosteum has not yet completely given way. Velpeau was the first, I think, to call attention to the fact that patients with broken clavicles could very generally raise the arm above the shoulder and even to the head, and I have repeatedly veri- fied the observation, notwithstanding the separation of the fragments has been complete, and the overlapping considerable. In fractures of the neck of the femur and of the tibia it is no uncommon thing for the patient to walk some distance after the receipt of the injury. I cannot dismiss this subject without calling attention to the neces- sity of exercising care and gentleness as well as skill in the examina- tion of broken limbs. Nothing, in my opinion, betrays a lack of judgment as well as of common humanity on the part of the surgeon, so much as a rude and reckless handling of a limb already pricked and goaded into spasms by the sharp points of a broken bone. It is not enough to say that such rough manipulation is generally unneces- sary, it is positively mischievous, provoking the muscles to more violent contractions, increasing the displacement which already exists, and sometimes producing a complete separation of the impacted, den- ticulated, transverse, or partial fractures, which can never afterwards be wholly remedied; augmenting the pain and inflammation, and not unfrequently, I have no doubt, determining the occurrence of suppu- ration, gangrene, and death. ^ In proceeding to establish the diagnosis in any case, the surgeon should sit down quietly and patiently by the sufferer, so as to inspire in him from the first a confidence that he is not to be hurt, at least unnecessarily. He ought then to inquire of him minutely as to all the circumstances immediately relating to the accident, in order that he may determine as nearly as possible its cause, which alone, to the experienced surgeon, often affords presumptive, if not conclusive evi- dence as to the nature and precise point of the injury. From this he should proceed to examine the disabled limb; removing the clothes with the utmost care by cutting them away rather than by pulling- and, when completely exposed, he should notice with his eye its posi- tion, its contour, the points of abrasion, discoloration, or of swelling • and not until he has exhausted all these sources of information ouo-ht the surgeon to resort to the harsher means of touch and manipulation ^or will his sensations guide him to the point of fracture by any other method so accurately as when, the patient being composed and his muscles at rest he moves his fingers lightly along the surface of the limb, pressing here and there a little more firmly, according as a triflin* indentation or elevation may lead him to suspect this or that to be thS point of fracture If the skin is more than usually tender, a few drops of sweet oil or of fresh lard laid upon its surface, or even moistenk^ the skin with tepid water, will render this examination less painful whilst it will facilitate the diagnosis, by rendering the tactile sensat on somewhat more acute. MUUU The limb in case of a supposed fracture of a long bone mav now be measured with a tape line, and compared with the opposite limb[ REPAIR OF BROKEN BONES. 37 having first marked with a soft pencil or with ink the several points from which the measurements are to be made. Finally, if any doubt remains, the limb must be firmly but steadily held while the necessary manipulations are performed, for the purpose of ascertaining the existence of mobility and of crepitus. Mobility is most easily determined by giving to the limb a lateral motion, but in general, crepitus is most effectually developed by gentle rotation. If the place of fracture is already pretty well declared by the previous examinations, the surgeon should place one finger over the suspected point, during this manipulation, by which means the crepitus will be more certainly recognized. I do not often find it necessary to resort to anaesthetics for the pur- pose of insuring quietude and annihilating pain in making these examinations, since it is seldom that the patient need to be much dis- turbed ; but if the examination is not satisfactory, and the diagnosis is important, I do not hesitate to render the patient completely insen- sible, after which the questions in doubt may be more thoroughly investigated and perhaps definitely settled. The surgeon ought not to forget, however, that while the patient is under the influence of an anaesthetic violent manipulations are no less liable to rupture bloodvessels, and to lacerate other tissues, than if employed when the patient is conscious. Surgeons have not seemed always to understand this, and the result has been that in too many instances they have inflicted serious and irreparable injury; in one instance tetanus and death has been the consequence. It is scarcely necessary to say that the earlier the examination is entered upon, the more readily will the diagnosis be made out; and if, unfortunately, some time has already elapsed before the patient is seen by the surgeon, and much swelling has taken place, the exami- nation is still not to be omitted, and whatever doubts remain we must endeavor to remove by repeated examinations made from day to day until the subsidence of the tumefaction has brought the surfaces of the bone again within the reach of our observation. CHAPTEE IY. REPAIR OF BROKEN BONES. It is not my intention to enter very fully into a consideration of the process of repair in fractures, preferring to leave this subject where it more properly belongs, to the general treatises on surgical pathology. And especially am I disinclined to this topic, because of the discrep- ancy of opinion which has all along existed upon many of the points involved, and which differences still continue to exist, even among the best informed pathologists, and to the final settlement of which I 3S REPAIR OF BROKEN BONES. confess I have not brought, except perhaps in relation to one single point, any new observations or labors. I only propose to state very briefly a few practical, and I trust I may now say, pretty well established facts, such as the manner or position in which this reparative material, whenever it is employed, is applied to the broken bones, the length of time which is usually required for the completion of the process of repair, and the causes which may impede or prevent bony union. If I think it necessary to say anything more upon this subject, it will be simply to announce my belief that the reparative material, consisting origiually of a plastic lymph, is poured out from the vessels of the" medullary membrane, the periosteum, the broken ends of the bone, and more or less from all of the lacerated tissues which are immediately adjacent to the seat of fracture; that after a period, longer or shorter, this lymph becomes organized, and begins to receive from the same sources particles of bony matter, through which the con- solidation is finally effected; that the transition from the original plastic material to bone is almost constantly through the interposition of a fibrous tissue, rarely, unless in the case of children, through a cartilaginous tissue, and sometimes through both consentaneously or consecutively; that, perhaps, in a few fortunate examples bones unite directly or immediately, without the intervention of a reparative material: and finally, that granulations, or inflammatory exudations become transformed into bone, or perhaps we are only authorized to say that they immediately precede ossification, in certain cases of compound fractures, or of fractures in which the process of inflamma- tion exceeds certain limits. This last proposition, in reference to the agency of granulations in the production of callus, or their mutual pathological relations, is at the present more in debate than either of the others; but, with this exception, it will be seen that I have carefully avoided all of those points upon which the observations and opinions of pathologists are still greatly at variance. 8 Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel Camper, and Haller, declared that "nature never accomplishes the immediate union of a fracture save by the formation of two successive deposi s of callus ;' one of which is derived from the periosteum and from the adjacent tissues and from the medulla; while the other de rived perhaps, from the broken extremities of the bone itself, is found at a later period directly interposed between these surfaces The material or callus derived from the tissues outside of the bone and which Ga en compared to a ferule, but which Mr. Paget caHs "en sheathing," together with the material derived from the medSlla com pared often to a plug, and by Mr. Paget named interior" callus Tp by Dupuytren spoken of as the "provisional," or temporary call" s by which the fragments are supported, and maintainedTnVontact until the permanent callus is formed. This temporary splint 's com eri^^ the character 5 compact bo^uS ^od ^ylX^Tyl REPAIR OF BROKEN BONES. 39 to six months, has elapsed; after which it is gradually removed by absorption. The second process, by which the ends of the bone are definitively or permanently united, commences when the provisional callus has arrived at the stage of spongy bones, and is not completed usually within less than eight, ten, or twelve months, " when," says Dupuytren, " it acquires a solidity greater than the original bone." While it is certain that this eminent surgeon and most accurate observer has described faithfully the various phenomena which usually accompany the repair of bones in those animals which were the subjects of his experiments, and that his conclusions have a certain degree of application to the human species, it is equally certain that he erred in assuming that in man simple fractures always unite by this double process; yet, such is the power of authority, these doctrines were accepted from the first without hesitation or debate, and for nearly half a century they have occupied the minds of surgeons to the almost complete exclusion of every other theory. Mr. Stanley was among the first to question the solidity of the doctrines of Dupuy- tren, but it remained for Mr. Paget to fully expose their many falla- cies; nor has Malgaigne, although not strictly a disciple of Paget, failed to detect certain of these errors. I should also do injustice to myself were I not to mention that at the very moment when Mr. Paget was making his observations upon the specimens in "the large collection of fractures in the museum of the University College," I was myself employed in similar researches both among cabinet specimens and in the hospitals of this country and of Europe; and that the conclusions to which I had arrived were nearly identical with, although the inferences were far from being so complete in their detail, as those to which this distinguished patholo- gist was himself brought.1 I do not, however, wish to make Mr. Paget responsible for any of the opinions upon this subject which I shall hereafter express, except so far as they may be found to agree with his own published views.2 I think it may now be fairly stated that the repair of bones by the double process described by Dupuytren, is, in man, only an exception to a very general rule; and that fractures may unite by either one of the following modes:— First. Immediately, or in the same manner that the soft tissues sometimes unite, by the direct reunion of the broken surfaces, and without the interposition of any reparative material. This happens probably sometimes in the spongy bones, and in the extremities or spongy portions of the long bones, especially when one portion of bone is driven into another and becomes impacted; as in certain fractures of the neck of the humerus or of the femur. Second. By interposition of a reparative material between the broken ends; as when the fragments remain in exact apposition, but immedi- ate union fails. This is especially apt to occur in superficial bones, 1 Paper on " Provisional Callus," by Frank H. Hamilton. Buffalo Medical Journal, Feb. 1853. 2 Lectures on Surgical Pathology, by James Paget, Phila. ed., 1854, Chapter XI. 40 REPAIR OF BROKEN BONES. such as the tibia; or upon those sides of the bone which are most superficial. It is not an unusual circumstance to find the shaft of the tibia during the process of union presenting no exterior callus upon its anterior and inner surface, whilst the posterior and outer section of its circumference is covered with an abundant deposit. In other cases, however, of fractures of the shaft as well as of the epiphyses, the intermediate callus secures a prompt union, but no ensheathing callus is ever formed. Third. Bones broken and not separated, unite occasionally by the process described by Dupuytren, namely, by the formation, first, of an ensheathing callus, whilst at the same moment the cylindrical cavity becomes closed by a spongy plug or a compact septum of bone; and second, by definitive callus deposited between the broken ends. It is probable that this happens generally in children, and it is a common mode of union in the ribs, which bones, during the whole progress of the union, are necessarily kept in motion. My cabinet furnishes many illustrations of ensheathing callus in ribs; and also a few in fractures of the tibia and fibula. Fourth. Under similar circumstances, where no displacement exists, the fracture may unite by ensheathing and interior callus alone, no in- termediate callus ever being formed between the broken ends; in which case it may be properly said that the bone itself has never united, and the ensheathing callus instead of being provisional is permanent or definitive. This was essentially the doctrine of Galen, Haller, and Duhamel before Dupuytren added his " fifth period," or the formation of definitive callus; and by these older surgeons it was held to be of universal application, except perhaps in the case of children. To this doctrine also Malgaigne has returned—at least to the question " Is there always a definitive callus, or complete union of the fragments ?" he has made this laconic reply : " Galen admitted its occurrence, but only in young subjects; it has been obtained in animals, where there had been no displacement. I would willingly believe that such is sometimes the case in human adults; but I must confess I have seen only the instance above cited, which might just as well be used to prove the compact ossification of the provisional callus." He accepts, therefore, the doctrine of Galen as having not merely an occasional application, but as explaining the process of union in the large ma- jority of cases; and in support of this extreme view he finds that the exterior callus, which Dupuytren called provisional or temporary, is actually permanent unless removed by the absorption consequent upon pressure. To all of which we can only say that an examination of five or six specimens in our own cabinet, after having carefully divided them with a saw, has furnished only one illustration of union by ensheathing and interior callus alone. In each of the other specimens the union was completed by definitive or intermediate callus. We cannot therefore, avoid the conclusion that Malgaigne has been deceived as to the relative frequency of these different modes of union, and that union without intermediate callus is exceptional. Fifth. When bones are broken and overlap, they may unite by the REPAIR OF BROKEN BONES. 41 interposition of a callus between the opposing surfaces, that is, by an intermediate callus, but which will differ from that described as the second method, inasmuch as the new material will be deposited upon the sides of the fragments and not upon their extremities. The limb being kept perfectly at rest, and all other circumstances proving favorable, this union may take place without any excess or irregularity in the deposit. The surfaces will unite firmly where they are in actual contact, and smooth and well-formed buttresses will fill up all the spaces between the bones where they are not in actual contact, suffi- cient generally to give the requisite strength to this new bond of Fig. 3. Fig. 4. Fracture of the thigh of a turkey ; united with the frag- ments widely separated. From a specimen in the author's cabinet. union. This mode of union will be completed sometimes when the two ends of the bones are separated later- ally an inch or more from each other. I have in my collection the bone of a turkey's thigh (Fig. 3) thus united by a transverse bony shaft, although sepa- rated more than one inch; and what is less common, I possess also a specimen of the adult human thigh (Fig. 4), in which an oblique shaft of solid callus has, after many months, and while no splints were employed, bound together firmly the two opposite extremities of the broken bone. Sixth. The fragments being overlap- ped more or less, and suffering unusual disturbance, or the adjacent tissues having been much torn, or much blood being effused so that considerable in- flammation is caused, the amount of cal- lus will exceed what is necessary for the complete union of the bones; and this redundancy may be deposited around and upon the broken ends of the bones, or anywhere in their immediate vicinitv, in layers, or in masses of irregular shape and size. Even the bones which are not broken, but which are near, as in the case of the fibula after a fracture of the tibia, may become inflamed, or their coverings may inflame, and they may also contribute to the general mass of bony callus. 4 Fracture of the shaft of the femur; united with an oblique callus. From a specimen in the author's cabinet. 42 REPAIR OF BROKEN BONES. Compound fractures, or rather, we ought to say, fractures accom- panied with granulations and- suppuration, obey no uniform law of repair, so far as the manner and position of the deposit are concerned; but they come together finally with more or less irregular distributions of ossified matter, according to the varying circumstances of imperfect coaptation, mobility, &c, in which they may chance to be placed-. Occasionally the amount of callus is less than occurs in simple frac- tures, and at other times the excess is very great. In short, we conclude that fractures of adult human bones, whether placed end to end or overlapped, unite most naturally and most promptly either immediately or mediately, and in the same manner that soft tissues unite; that is to say, without the interposition of any reparative material, or through the medium of an intermediate, permanent callus; and that all deviations from these simple methods are accidential, or the result of disturbing influences. That was, no doubt, a beautiful thought, which ascribed the form- ation of provisional callus to an intelligent efficient cause, which in this manner sought to support the fragments until a reunion of their divided ends was accomplished. But the beauty of a conception supplies no evidence of its truth; and we have grave doubts whether Nature ever allows any interference with her laws even in an exigency, unless by the substitution of a miracle. Provisional callus is, in our opinion, just as much the necessary result of natural laws, as is defini- tive. It is formed because in that condition of the parts and of the general life its formation was inevitable. Whether useful for the purposes of repair or not, it will, under certain circumstances, exist. In the repair of certain fractures, provisional callus, it is conceded, seldom occurs. Thus it is with the cranium, the acromion, coracoid and olecranon processes, the patella, and with all those portions of bones which are immediately invested with a synovial capsule. Will it be affirmed that in the examples just named this callus is not formed because it is not required? To us it seems that nowhere could it prove more useful, since, with the single exception of the cranium, it is in these very cases that the obstacles to a reunion are the most serious. In fractures of the patella, olecranon, &c, the action of the muscles tends constantly and powerfully to displace the fragments, and gladly would the surgeon avail himself of the assistance of a tem- porary callus, but it is rarely present, at least in any useful degree. So also in fractures of the neck of the femur within the capsule, and in other similar cases, we cannot say that temporary callus would not be advantageous in facilitating the retention of the fragments, yet the " intelligent efficient agent" neglects to furnish it. The only satisfactory reason which, as we think, can be assigned for the absence of callus in these cases, is found in the doctrines we now advocate; that is to say, it is usually absent because that amount of excitement and irritation is usually absent which alone determines its formation. In the case of the olecranon, patella, &c, the fragments being separated from each other by muscular action, so that no painful pinchings or chafings occur, and their rough surfaces or sharp points being rather drawn away from, than protruded into the flesh, no REPAIR OF BROKEN BONES. 43 sufficient provocation exists for the production of inflammation and effusion. Hence the failure of provisional callus, but wherever the frac- ture occurs, and however moderate the action, definitive callus does not fail; still the broken surfaces of the patella and olecranon are softened, and smoothed, and covered over with a new matter, which, if contact could have been secured and preserved, would certainly have served to consolidate and repair the breach. The natural reparative process proceeds, but only the accidental process is omitted. This latter, however, is seen again even here, when from other and unusual causes a sur-excitement is established. Temporary callus is not formed upon bones invested with synovial membranes, because here, too, as in the neck of the femur, there are not so many structures lacerated and irritated, and the supply of this effusion must be the less not only in proportion to the less intensity of the inflammation, but also to the less amount of structures impli- cated. Possibly other and more satisfactory reasons may be assigned why provisional callus is not formed usually when the neck of the femur is broken within the capsule; but we certainly can never admit the common, and, as here applied, the too palpably absurd explanation, that it is not wanted. It is wanted, and in no case so much as in the one now supposed. Provisional callus has, therefore, no final purpose, but it is the unavoidable result of certain abnormal conditions. It still occurs everywhere when against and in the vicinity of the bone there is the requisite lesion and action, and it will occur as certainly when there is no fracture at all, but only a caries, a necrosis, or a simple bony or periosteal inflammation; and whilst it is doubtless true that in fractures it sometimes renders valuable aid to the surgeon, it is equally true that it often proves a source of hindrance. From these remarks I choose to except fractures occurring in chil- dren, in relation to which the observations are not yet sufficiently numerous to determine absolutely the laws of repair. If, however, I were to venture an opinion based upon a few examinations, I should say that in children we may accept with but little qualification the doctrine of Dupuytren as already explained. Dupuytren, in determining the limits of his " third" period, or of that in which a provisional callus is formed of sufficient strength to support the fragments, has given what has been usually quoted as the natural period within which bones may be said to be united, that is, " from the twentieth or twenty-fifth day, to the thirtieth, fortieth, or sixtieth." But this depends so much upon the age of the patient, his general condition of health, the condition and position of the broken ends, as well as upon the bone itself, and the point at which it is broken, with many other circumstances, that it would be unsafe to establish any absolute laws in reference to this point. In very early infancy, union is accomplished in half the time re- quired in adult life, and it is generally thought to be still more re^ tarded in advanced age, but Malgaigne has not found this latter observation confirmed by his own experience. Various constitutional 44 GENERAL TREATMENT OF FRACTURES. causes, as we shall hereafter explain more fully, retard bony union. Motion, also, sometimes delays consolidation: fragments which are overlapped do not unite as speedily as those which are placed end to end, and other complications interfere in a similar manner, such as lesions of nerves, of bloodvessels, comminution of the bone, the inter- position between the ends of the fragments of a blood-clot, a portion of muscular, tendinous, or other tissue, &c. It is affirmed, moreover, that in general the bones of the lower extremities, independently of their size, unite more slowly than the bones of the upper extremities. Epiphyses, when separated, unite by the same process as fractures of the bone. It is affirmed, however, that, when certain epiphyses unite with much displacement, the shafts from which they have been sepa- rated cease to grow, and the limb becomes atrophied. For a more complete consideration of the causes which retard the union of bones, I beg to refer the reader to the chapter on " Delayed Union, and Non-Union of Bones." CHAPTER V. GENERAL TREATMENT OF FRACTURES. All that has been said in relation to the propriety of handling a broken limb gently when the surgeon is examining the position and character of the fracture, is equally applicable to the liftingiand trans- porting of the patient to his bed, to the removal of the clothing, and to the general management of the limb before it is dressed. Eude or awkward manipulations, by which needless pain is inflicted, are not simply acts of wanton cruelty, but they are sources, and I think I may say frequent sources, of inflammation, suppuration, and gangrene. Here, as in all the subsequent handlings, everything should be°done slowly, thoughtfully, and systematically. Yet it is difficult to state the precise manner in which the surgeon ought to proceed. Much will depend upon the circumstances of the case, something upon one's natural tact, and upon the amount of experience, but more, I think upon natural kindness of heart, and social education. The man of refinement and sensibility will know instinctively how to proceed and needs no instruction. They who lack these qualities can never learn, and it would be quite useless to undertake to teach them I sincerely wish such men as these latter would find some more suitable employment than the practice of a humane art. Nearly all fractures present three principal indications of treatment namely: to restore the fragments to place as completely as possible • to maintain them in place; and to prevent or to control inflammation spasms, and other accidents. ' It ought to be regarded as a rule, liable only to rare exceptions that broken bones should be restored to place, or to the position in GENERAL TREATMENT OF FRACTURES. <±5 which we hope to maintain them, as soon as possible after the occur- rence of the accident. If the patient is seen within the first few hours, or before much swelling has taken place, we scarcely know the cir- cumstance which would warrant an omission to adjust the fragments either end to end or side by side, as the one or the other might be found to be practicable. We have before sufficiently explained the general impossibility of again restoring to place, end to end, and fibre to fibre, fragments which have been made to override. We are there- fore in no danger of being understood to say that bones should in all cases be immediately "set," in the popular sense of this term. They ought to be "set," no doubt, if this can be accomplished through the application of a prudent amount of force; but if they cannot be thus placed end to end, they may at least be laid in such a manner side by side as to restore, in some measure, the natural axis of the limb, and prevent the points of the bone from pressing unnecessarily into the flesh. Experience has indeed furnished us with four or five very good reasons why broken bones should be reduced as soon as possible. When the injury is recent, the muscles offer less resistance; their resistance being increased after a time not only by the reaction which ensues upon the shock, but also by actual adhesion between their fibres; effusions distend both the muscles and the skin, and compel the limb to shorten; the constant goading of the flesh by the sharp points of the broken bones increases the muscular contractions; the patient will submit readily to manipulation and extension at first, but after the lapse of a few days, it is very seldom that he will permit the limb to be in any manner disturbed, even if he is assured that his refusal entails upon him a great deformity. If it is true that no callus or bony structure is deposited earlier than the seventh or tenth day, it is also true that the renewed attempt to adjust the bones at this period, by chafing and tearing again the tissues, reduces the fracture, in some degree, to the same condition in which it was at first, and, consequently, the time which has elapsed, or, at least, a portion-of it, may be regarded as lost. We cannot, therefore, understand the argument by which Brom- field, South, and a few other surgeons have persuaded themselves that reduction should never be attempted before the third or fourth day; nor, indeed, do we fully appreciate the refinement which Mal- gaigne has given to this question in itself so simple. To affirm that we ought not to reduce the bones to their original positions during the period of intense inflammation, or of great swelling, or while the muscles are acting spasmodically, is only to affirm that we may not do what is impossible; and the attempt to do which, therefore, can only be mischievous; but to authorize their restoration to a better position, by such manipulation, extension, and lateral support as they may comfortably bear, is warrantable under any circumstances. The practice is not only defensible but imperative, and we do not think any really sound and practical surgeon ever intended to teach the contrary. We say still, if bones can be easily reduced, or the position of the fragments improved at any moment or under any circumstances, 46 GENERAL TREATMENT OF FRACTURES. Fig. 5. Fig. 6. Application of the versed turns. ' roller " by circular and re- Many-tailed bandage. it ought to be done; and if we fail in accomplishing all that we wish to do in the first instance, we must remain incessantly watchful to seize the earliest opportunity which presents, to complete the adjustment. No doubt our efforts will prove fruitless very much in proportion to the amount of swell- ing, inflammation, or muscular spasm which exists, and also in proportion to the time which has elapsed, but this will not excuse us for omitting to do all which the circumstances permit. It has been the practice of most surgeons, for a long period, to cover the broken limb with some form of a bandage or roller before apply- ing the lateral splints. Of these primary dressings there are two principal varieties: first, the "roller," or simple bandage, applied to the limb in circular and reversed turns; and, second, the " many-tailed bandage," consisting of a piece of muslin, or other cloth, torn down from each side into a suitable number of strips, leaving the centre, which is to be applied to the back of the limb, entire. A modification of this latter bandage consists of a number of separate strips, so laid upon one another, commencing from above, as that each strip shall overlap the other by one-third or one-half of its breadth. This is called the bandage of Scultetus, and it possesses one advantage over the many-tailed bandage just described, especially in the case of compound fractures, in the facility with which each separate piece may be removed and another substituted. Some surgeons prefer to form the bandage of separate strips, and having overlaid them in the manner directed, to unite them again into one by running a thread through the whole mass along the centre. Whichever of these several varieties of strips are employed, the mode of applying them is the same. They are folded alternately GENERAL TREATMENT OF FRACTURES. 47 around the limb, being made to overlap and cross upon each other in front, and only the last strip or two is fastened with a pin. Fig. 7. Fig. 8. Application of the many-tailed bandage. Bandage of Scultetus. The object proposed in the use of the roller or of the many-tailed bandage is twofold: first, to compress and support the muscles, by which°their tendency to contraction is in some measure controlled; and second, to protect the limb against the direct pressure of the side A moment's consideration will convince us that the first of these objects is in most cases fully attained by the lateral splints themselves, and by the bandages by which they are retained in place; and that the second can be as well accomplished by a single fold of cloth, or by the compresses, which ought generally, even when the roller is used to underlie the splints. Nevertheless we should hardly feel authorized to reject these primarv dressings solely because the splints and com- presses furnish a convenient substitute, especially since we are com- pelled to admit that they are occasionally useful unless objections of a more serious nature could be brought against them. Unfortunately this latter supposition is actually true. By ligating the limb com- pletely, leaving no point of the tegumentary surface to which the pressure is not applied, they too often occasion congestion, inflamma- tion and gangrene. It is not until lately that the attention of surgeons nas been Lfficiently called to this subject; but the records of^ngery are to-day filled with these terrible accidents, formerly attributed to 43 GENERAL TREATMENT OF FRACTURES. the original injury or to the splints themselves, but now understood to be plainly traceable to the too common employment of the primary bandage. The roller is by far the most dangerous dressing of the two, since it does not yield to the swelling so readily as the bandage of strips, and it is more objectionable also on account of the inconve- nience of applying and removing it; but even the bandage of strips may be so confined as to produce the same consequences, as I have myself seen in more than one instance. It is also all the more dan- gerous in the hands of the inexperienced surgeon, because he feels a confidence that it will not cause ligation. Except in rare cases and for especial reasons, which we shall attempt to indicate in their appropriate places, we cannot recommend the em- ployment of any kind of bandages next to the skin. In order to fulfil the second indication, namely, to maintain the fragments in place, we employ usually what are called short, side, or coaptation splints, and long or extending splints, or the weight and pulley. Side splints may be constructed from various materials, according to the size and circumstances of the limb, or according to the convenience of the surgeon ; and as the surgeon cannot be expected to have always on hand, at the bedside of the patient, such splints as he might prefer to use, it is well for him to understand how to avail himself of such materials as may be within his reach, in order that he may make the most of his sometimes imperfect resources. Lead, sheet iron, zinc, and other metals have been occasionally em- ployed, but especially tin and copper, which possess all of the requisite firmness and malleability to allow them to be hammered and thus moulded to the limb. In general, however, they are unnecessarily heavy, and demand too much labor to be wrought into shape. I have sometimes employed tin splints perforated with large fenestra? to diminish their weight and increase their flexibility, and found them to answer an excellent purpose. The light perforated zinc splints, introduced into the U. S. Army by the Sanitary Commission, through the agency of Dr. E. Harris, of New York, were found exceedingly useful. Iron wire splints, made from wire cloth or coarse gauze, were first publicly mentioned, so far as I can learn, in a communication to the Memphis Medical Recorder, made by Dr. J. C. Nott, of Mobile; but they have been brought more particularly into notice, and their construction perfected by Louis Bauer, of New York.1 These splints are moulded upon " gypsum or wooden casts," of different sizes, and surrounded with a stout iron wire frame in order to give them the requisite de°ree of firmness, and to preserve their forms; after which they are tinned by galvanism, and varnished, to prevent them from becoming rusted. When applied, Dr. Bauer recommends that they shall be filled with loose cotton, and that they shall be held in place by rollers. It is claimed for these splints that they are light, flexible, permeable to air and to the perspiration, and that they permit the application of cool- » Nott and Bauer, Buf. Med. Journ., vol. xii., April, lb57. GENERAL TREATMENT OF FRACTURES. 49 ing lotions without impairing their firmness; the last of which is a quality of questionable value, since lotions applied to permanent dressings of any kind are only warm fomentations, and do not, there- fore, in this respect serve the purpose for which they were intended; besides that they render the skin tender, and disposed to vesicate, they give rise to a sensation of scalding, which is sometimes almost intolerable; they soak into the bed, and in many other ways render the patients uncomfortable. Cooling lotions are only applicable where the dressings are open, loose, and temporary. The same objections hold also to this as to all other forms of moulded metallic or carved wooden splint, namely, that they seldom exactly fit the limb, even when the supply of assorted sizes is com- plete, and that they are not sufficiently flexible to adapt themselves to anything but the slightest irregularity of surface. They are not, however, without merit, and they deserve at least a qualified recom- mendation in many cases. I shall refer to them again when speaking of fractures of the thigh and leg. Horn and whalebone may be employed in thin plates, or in the form of narrow strips quilted into cloth; but they are expensive and pos- sess no special value except in an emergency. Beeds, the coarse rank grass which grows in swamps, flags, willow branches, and unbroken wheat straw, may be quilted between two thicknesses of cloth in the same manner, and form very excellent temporary splints. I have especially found it convenient to use wheat straw in the form of junks. Gathering up a bundle of unbroken straws of the size of my arm, I roll them snugly in a broad piece of cotton cloth, cut off the projecting ends, and then stitch up the cloth neatly. We have thus a splint of considerable firmness, and one which is cool and especially adapted to the summer, allowing the perspiration to evaporate freely. Straw splints were employed sometimes by Ambrose Pare*, by J. L. Petit, Larrey, and I have several times seen them in the wards of certain European hospitals, although I am unable now to say under whose direction. Mr. Tuffnell, of Dublin, has especially recommended them in the form of junks.1 Wooden splints, made of pine, willow, white or linden wood, or of some other light and easily wrought timber, are probably of more universal application, and possess greater intrinsic value than splints constructed from any other material; but I wish at once, and for all, to disclaim any intention of giving even a qualified approval of any of those carved, polished, and generally patented wooden splints, which are manufactured and sold by clever mechanics, and which one may see suspended in almost every doctor's office, whether m the city or in the country. Constructed with grooves and ridges, and variously inclined planes, for the avowed purpose of meeting a multitude of indications, such as to protect a condyle, to press between parallel bones, to follow the subsidence of a muscular swelling, &c, they never meet exactly a single one of these indications, whilst they seldom fail to defeat some other indication of equal importance. They deceive » Tuffnell, New York Journ. Med., March, 1847, p. 264. 50 GENERAL TREATMENT OF FRACTURES. especiallv the inexperienced surgeon into the belief that he has in the splint itself a provision for all these wants, and consequently lead him to neglect those useful precautions which he would otherwise have adopted. If carved wooden splints are employed, they ought to be made especially for the case under treatment. But this requires time and some more mechanical skill than can always be commanded; and when accurately fitted, it is quite probable that the subsidence or increase of the swelling will, within the next forty-eight hours, render some change in the form of the splint necessary, or compel the surgeon to throw it aside. We much prefer to use plain, straight strips of wood, of the requisite width and length, which may be cut at any moment from a shingle or a thin piece of board. In order that these splints may adapt themselves to the inequalities of the limb, and properly support the fragments, they may be under- laid with pads or junks of a suitable thickness; or, what is still better, they may be covered with a muslin sack, open at both ends, into which, and on the side of the splint which is to be placed against the limb, bran, wool, cotton batting, or curled hair may be pressed, until it is made to fit accurately. . I generally prefer cotton batting. Bran is liable to get displaced, and curled hair does not pack firmly enough. When the sack is sufficiently filled, the two ends must be stitched up. This mode of constructing the splint is simple and easy of accomplish- ment ; the splint can be fitted very accurately; the pad never becomes displaced; and when the bandages are applied, they may be pinned or sewed to the cover in such a way that they shall not slide or loosen. If pads are employed separate from the splint—and for this purpose, also, I generally prefer the cotton batting—they ought to be made and fitted with the same care, and neatly stitched together at their ends, rather than pinned. Cotton batting laid loosely next to the skin, or underneath the splints at any point, will not keep its place so well as when it is inclosed in covers—it is more liable to get into knots, and it has altogether a slovenly appearance. The pads may be stitched to the roller, and in this way secured effectually in place, but loose cotton is subject to no control. When I speak of pads, it must not be understood that I intend to recommend them for compresses, or for the purpose of pressing frag- ments into place. Nothing could be a greater source of mischief in the dressing of a broken limb. I have only directed their employ- ment as a means of adaptation, and to protect the skin against the direct pressure of the splint. Dr. Jacobs, of Dublin, says that he has seen an excellent splint made from the " fresh bark of a tree taken off while the sap is rising" " It fits admirably," says Dr. Jacobs, "just like pasteboard soaked inwater."1 Dr. C. C. Jewett, of the 20th Mass. Vols., recommends for the same purpose the bark of the liriodendron, or tulip tree. Undressed sole-leather, cut into shape and soaked a few minutes in ' Jacobs, New York Journ. Med., March, 1S47, p. 265, from Dublin Med. Press. GENERAL TREATMENT OF FRACTURES. 51 water, adapts itself easily to the limb and is sufficiently firm. It is especially applicable to fractures of the larger limbs. At Bellevue Hospital it has of late taken the place of almost all other materials. A splint is also occasionally made of thin calf skin veneered with some light timber, such as linden or white wood, the latter being sub- sequently split into strips of from half an inch to one inch in width, so as to combine a certain degree Fis- 9- of flexibility with the requisite firmness. The Turks use, according to Sedillot, in a similar manner, the " nervures" of palm laid upon sheep- skin and fastened with wooden thongs ;* and Dr. Packard mentions that he has seen narrow slips of some light wood glued in the same way upon soft pieces of buckskin, and then fastened together with two strips of buckskin, which were also glued to the Splints.2 Wood and leather splint. Common, unpolished pasteboard, cardboard, or the stout millboard used by bookbinders, constitute invaluable do- mestic resorts, since they can generally be found in the house of the patient; and if in no other way, pasteboard may generally be had at the expense of some paper box or of the loose cover of some old book. For small bones, the thinner sheets afford a sufficient support; but for large bones the thick binders' board is necessary. In preparing the latter for use, it ought to be moistened with water; but if soaked too much it will separate and fall into pieces, or lose its firmness when dry, in consequence of having parted with some of its paste. This splint may be applied to the limb without the interposition of anything but a few folds of muslin cloth, or a piece of flannel; or we may use instead a single sheet of cotton wadding. It must be bound to the limb by the roller while it is moist, and as it dries speedily it forms a smooth, firm, and reliable splint. . Felt, made of wool saturated with gum shellac, and pressed into sheets, makes an excellent moulding tablet for splints. This may be obtained at any hat manufactory. They are now manufactured, and moulded into a great variety of forms by Dr. David Ahls, at York, Pennsylvania. A much cheaper material, however, and which has nearly all of the qualities of the real felt, may be made from old pieces of broadcloth, or from any similar closely woven texture by saturating it thoroughly with gum shellac, the gum being dissolved in alcohol m the proportions of one pound of the former to two quarts of the latter. Thus prepared, it is to be spread upon both surfaces o the cloth with a common paint brush. When this first coat is well dried by suspending the cloth where the air will have free access to both surfaces, a second must be spread upon one of the surfaces; and then a third ; the cloth being allowed to dry after each successive coat. Finally, the sheet is to be folded upon itself so as to bring the most thickly covered surfaces together, and pressed with a hot flat. ■ Amer. Journ. Med. Sci., vol. xxiii., Feb. 1839, p. 481. 2 Packard's edition of Malgaigne, vol. i. p. 1<3. 52 GENERAL TREATMENT OF FRACTURES. If it is necessary to have greater strength, more gum may be laid upon the cloth, and it may be again folded and pressed. When used, it is to be dipped into boiling water or held near the fire until it becomes flexible. It hardens very rapidly in cooling, and demands, therefore, some quickness in its application; but once ap- plied and fitted, it forms a hard but smooth splint well adapted for all the purposes for which it is designed. It is well to mention, if one wishes to keep any portion of the solu- tion which is not used, that in order to prevent evaporation the vessel in which it is contained must be closely covered. I have used this material for many years, both in hospital^ and pri- vate practice, and I can safely recommend it for all cases in which splints are required. The principal objection to all of those forms of splints which contain gum shellac is, that they harden so rapidly after being made flexible by exposure to heat, that it is often found difficult to give them an accurate mould to the limb. Dr. Jacobs says he has sometimes found an old hat to furnish a very efficient splint in the small fractures of children. It has been objected to the felt splint occasionally, that it is imper- vious to air and moisture, and that it confines the insensible perspira- tion ; an objection which may be obviated in some measure by rubbing the surface which is to be laid against the limb, with pumice-stone until it is roughened or until a short nap is raised. But as I never use splints of any kind without underlaying them with compresses which act sufficiently as absorbents, I have never been aware of any inconvenience from this source. Within a few years, sheets of gutta percha have been brought into the market, varying in thickness from one-sixteenth to one-quarter of an inch: the use of which for side splints, was first suggested and prac- tised by Oxley, of Singapore. For fractures of the thigh, and for the large bones generally, I prefer a thickness of about one sixth or one- fifth of an inch; but for the fingers or toes, it need not be more than one-sixteenth of an inch in thickness. In its natural state, and at the ordinary temperature of the body, it is nearly as hard and as inflexible as bone; but when immersed in hot water it almost immediately softens, and would become too soft to be conveniently handled unless soon removed. It can therefore be adapted to any surface, however irregular, and its form may be changed as often as may be necessary. It does not harden as rapidly as felt, and it possesses, therefore, in this respect an advantage, since it allows the surgeon more time for adjust- ment; while, on the other hand, it hardens much more rapidly than either starch, paste, or dextrine. Ten or twenty minutes is all the time usually required for gutta percha to acquire that degree of firm- ness which will prevent it from yielding under the pressure of a bandage. To use it skilfully requires some experience, and I have known surgeons to reject it after a single trial; but by those who have ac- quired the necessary skill it is generally regarded as an invaluable resource. When constructing from this material a thigh splint, we should GENERAL TREATMENT OF FRACTURES. 53 order a very large tin pan, or some open, flat tray, in which we may lay the splint at full length. If the splint is required to be twelve inches long, and six inches wide, we must cut it about sixteen inches long by eight wide, so as to allow for the contraction which always takes place more or less when the hot water is applied. It is then to be laid upon a sheet of cotton cloth of more than twice the width of the splint, in order that the cloth may envelop it completely when it is folded upon it; and the cloth should be enough longer than the splint to enable us to handle and lift it by the two ends without immersing our fingers in the hot water. Beside, if the gum is not thus covered and supported, it will adhere to the vessel, to the fingers, to the surface of the limb, and indeed to whatever else it comes in contact with; it may even fall to pieces, or become very much stretched and distorted by its own weight. The cloth cover will generally adhere to the splint, and may be permitted to remain upon it permanently. Place the splint, thus covered, in the basin, and pour on the water slowly. As soon as it is sufficiently softened, lay it over the limb, moulding it carefully with the hands, or by pressing it against the limb with a pillow. If it does not harden rapidly enough, this process may be hastened by sponging the outer surface with cold water; and as soon as it has acquired sufficient firmness to support itself it may be removed and immersed in a pail of cold water or placed under a Irydrant; after this, it is to be neatly trimmed and wiped dry, when it is ready for use. When gutta percha remains a long time exposed to the air, it gradually oxidizes, its colour becomes darker, it loses its tenacity and flexibility. This may be prevented by keeping it constantly immersed in cold water. The same objection has been made also to gutta percha which is occasionally made to felt, namely, that it confines the perspiration, but to this we have already sufficiently replied. There is scarcely any fracture demanding the use of a splint in which I have not demonstrated its utility, but it is especially valuable, as I shall have occasion to mention again, as an interdental splint in fractures of the jaw, and as a moulding tablet in all fractures occur- ring in the vicinity of joints. Sheets of gutta percha of any required thickness may be obtained in this city, of Mr. Samuel C. Bishop, the manufacturer, at 113 Liberty Street. One pound will make about four thigh splints: the present price is about one dollar fifty cents per pound. Benjamin Welch, of Lakeville, Conn., has contrived a very ingenious application of gutta percha to the purposes of a splint, by veneering a thin plate of the gum with equally thin plates of elastic wood. The veneering is laid upon both sides, and then it is pressed into form in moulds. The elasticity of the wood, together with the plasticity of the gum, enables the surgeon to change its form somewhat at pleasure, by dipping it into hot water. Its form cannot, however, be changed to any great extent, and by frequent immersion in hot water the veneering is apt to loosen from 5-1 GENERAL TREATMENT OF FRACTURES. the gutta percha. Fi«. 10. Nevertheless it is a most excellent splint, and in very many respects it is superior to any of the carved wooden splints which we have ever seen. The moulding tablet of Alfred Smee, composed of gum Arabic and whiting, spread upon cloth,1 has nothing special to recommend it, any more than the cloth splints, hardened with the whites of eggs and flour, used by Larrey.2 Starch and alum, glue, pitch, and vari- ous other materials of a similar character deserve only to be mentioned as having been occasionally employed, but which have never succeeded in securing for themselves the confidence of surgeons. In 1834, Seutin, of Brussels, intro- duced the use of starch as a means of hardening the bandages; his method of using which is essentially as follows: a dry roller is first applied to the skin, and then smeared with starch; all of the bony prominences and irregularities of the limb are filled up or covered with cotton batting, charpie, down, etc.; strips of pasteboard, or of binders' board, moistened and covered also with starch, are now laid alongside the limb, over which again are turned in succession one, two, or three layers of the starched roller; the number of rollers and the thickness of the pasteboard being proportioned to the size of the limb or to the required strength of the splint. The whole is com- pleted by starching the outside of the last bandage. This dressing will generally become dry within from thirty to forty hours; which process may be expedited by exposing its sides as much as possible to the air, or by the application of artificial heat with bao-s of dry sand, or with hot bricks. As a temporary support until the drying is completed, some surgeons lay upon each side of the limb additional splints, securing them in place with tapes As soon as the bandages are dry they are to be cut along the front to a sufficient extent to permit of an examination of the limb and then closed with an additional roller. For the purpose of opening the bandages both at this period and subsequently, Seutin uses a pair of strong scissors or pliers, such as are represented in Fig 11 # On the third or fourth day, or as soon as the subsidence of the swell- ing may render it necessary, the bandages should be cut open through 25,' iSt J°™' MCd- S0i" V°L XXVL P' 22°> M^> 1840 i ^om London Lancet, Jan. i Amer. Journ. Med. Sci, vol. ii. p. 216, May, 1828 ; from Journal des Progres, vol. iv. Starch bandage, applied for a broken thigh. GENERAL TREATMENT OF FRACTURES. 55 their whole extent, the edges pared off and brought together ao-ain snugly with an additional roller. Fig. 11. Seutin's pliers. Erichsen, who uses the starch bandage in all fractures and from the first day, advises that the limb shall be completely enveloped with cotton wadding before the first roller is applied; in consequence of which he does not think it necessary to apply the first roller dry. Velpeau prefers dextrine (" British gum") a kind of glue or jelly obtained by the continued action of diluted sulphuric acid upon starch at the boiling point. It is prepared for use by dissolving it in alcohol or tincture of camphor, or camphorated brandy, until it has acquired about the consistence of honey; at this point hot water should be added, reducing its consistence to that of thin treacle, when, after one or two minutes' shaking, it is ready for application. According to F. D'Arcet, the proportions most favorable to the drying and solidifying of the apparatus are, one hundred parts of dextrine, sixty of cam- phorated brandy, and fifty of water. Malgaigne, to whom I am in- debted for this observation of D'Arcet, says, also, in a note, " as regards dextrine, an important point was recently brought practically under my notice, viz., that as sold in the shops, it is often unfit for making an agglutinative mixture; it forms lumps with alcohol, as starch does with cold water, without cohering; and twice in succession I have been obliged to change the supply at the Hopital Saint Antoine. The dextrine thus deteriorated is whiter and less saccharine; it crepitates more in the fingers; and on pouring a few drops of tincture of iodine into the solution, there is produced a violet tint, indicating the pre- sence of fecula; while true dextrine, treated with iodine, gives a vinous red, or the color of onion peel." Velpeau soaks his bandages with the dextrine before applying them, but like Seutin, he applies his first roller dry. He uses but one band- age, which he carries first from below upwards and then from above downwards; and he rarely thinks it necessary to employ the pasteboard as a collateral support. For myself I am quite as much in the habit of using wheat flour paste as either starch or dextrine, and if properly made, it dries about as quickly as the starch, and is equally as firm. Whatever material is used in the construction of what is now usually termed the "immovable apparatus," or, as Seutin has more lately called it, the "movable immovable apparatus" ("movo-amobile"), in reference to his practice of opening it at an early period, it is still the same apparatus in effect, and is liable to the same judgment—a judgment 56 GENERAL TREATMENT OF FRACTURES. which we shall find it very difficult to declare, since, from the day in which this practice was first recommended by Seutin, to the present moment, it has been constantly experiencing the most extraordinary vicissitudes in the public favor. At one time, and bythemost ex- perienced surgeons, extolled as a method unequalled in its simplicity, efficiency, and safety, and at another, and by surgeons of equal experi- ence, denounced as eminently lacking in all of the true essentials of an apparatus for broken limbs. These conflicting opinions, which it is impossible to reconcile, have nevertheless some foundation in truth. The immovable apparatus, of whatever materials constructed, is under some circumstances a very simple, safe, and efficient dressing, while under other circumstances it is, as we think, eminently unsafe and ineffi- cient. Thus, in all of those fractures which are accompanied with such injury to the soft parts as to render subsequent inflammation inevitable or probable, this form of dressing exposes to congestion, strangula- tion, and gangrene. Whatever its advocates may say to the contrary, the simple fact is before us, that the number of accidents resulting from this practice is out of all proportion with any other yet introduced. I have met with them myself in all parts of my own country, and the journals abound with records of disasters from this source.1 Nor is it a sufficient reply to this statement, that, with proper care and pru- dence, such accidents may be avoided. We think they could not always be avoided. But admitting that they could, it is still undenia- ble that in certain cases the immovable apparatus demands extraordi- nary attention; and what is the need of multiplying our cares when already they are more than sufficient? Many circumstances, over which he has no control, may prevent the surgeon from giving to the limb the full amount of attention which is required; and for this rea- son that apparatus is the best which, whilst it answers the indications equally well, exacts the least amount of skill and attention on the part of the surgeon. Fig. 12. Opening of the apparatus with Seutin's pliers. Immovable dressings are not only liable to become too tight as the swelling augments, but, on the other hand, the surgeon may omit to 1 Amer. Journ. Med. Sci., vol. xxv. p. 460, Feb. 1840; also vol. xxxi. p. 212. GENERAL TREATMENT OF FRACTURES. 57 Fig. 13. notice that as the swelling has subsided it has become loose. Portions of the limb may vesicate, ulcerate, or even slough, without the know- ledge of the surgeon. If, however, the bandages are frequently opened and all the proper precautions are taken, it is possible that these acci- dents may also be avoided; but unfortunately experience has shown that they have not been avoided in too many instances. The cases, then, to which this apparatus seems to be adapted, are a few examples of transverse or serrated fractures in which the bones have not become displaced, and in which little or no swelling is anti- cipated ; and certain fractures which were origi- nally more complicated, but in which a partial union, and the subsidence of the inflammation, have reduced them to a more simple condition; and especially is it adapted to cases of delayed union. If now the dressings are applied care- fully, the bandage being only moderately tight; and a portion of the extremity of the limb is left uncovered so that we may observe con- stantly its condition, and at proper intervals the apparatus is opened completely, in order that we may subject the whole limb to a thorough examination; in such cases as we have now indicated and with such precautions, we admit that the "apparatus immobile" constitutes an invaluable surgical appliance, and one of which no surgeon can well afford to be deprived. I have even met with examples of compound fractures in which it has seemed proper to ap- ply this dressing; but only when a sufficient time had elapsed to render it probable that there would be no sudden accession of swelling in the limb. In such cases I have preferred generally to lay the several turns of the roller directly over the suppurating wound in the same manner as if no wound existed, and to make a valvular opening, or window, with the scissors on the following day in order to allow the matter to escape, after which the valve may be laid down and stitched, or the piece may be removed entirely, and a new piece of bandage drawn closely around the limb at this point. This may be repeated once or twice daily. If an opening is left by the roller, and no additional bandage is laid over it, the margins of the wound soon become ©edematous and protrude, making an ugly-looking and ill-conditioned sore. , Plaster of Paris moulds, employed occasionally frorn a very early period, and more lately recommended by Hendnksz, Hubenthal, Keyl, and Dieffenbach, are not entitled to serious consideration Heavy stone coffins, they might serve well enough the purposes of interment, but they are wholly unsuited to the purposes of a splint. ^ Plaster of Paris has, however, been of late employed m another form, and in relation to which our judgment must be much more 5 "Apparatus immobile" ap- plied over a compound frac- ture. 58 GENERAL TREATMENT OF FRACTURES. favorable. I allude to the so-called " plaster of Paris bandages," which were first introduced to notice by Mathiesen and Van der Loo, of Holland, but the value of which has been more especially brought to notice by Prof. Nicholas Pirogoff, of St. Petersburg, Surgeon-in-chief at Sebastopol, during the Crimean war. The manner of using the gypsum bandages is as follows: A dry roller is first applied to the limb, or it may be covered with a single piece of cloth of any kind, and the irregularities are filled up and pro- tected with cotton wool, the same as we have directed when about to apply the starch bandage. The remaining dressings being now at hand and ready for use, we proceed to mix the plaster. For this pur- pose we must select the fine, fresh, well dried, white powder. The gray does not solidify well, nor that which has been a long time ground, or is moist. The proportions of water and plaster usually required are about equal parts by weight. For the thigh it may re- quire, perhaps, seven or eight pounds of plaster, and for the leg or arm much less. It is probably a better rule to direct the gypsum to be added to the water until it is of about the consistence of cream. The water should be cold and the gypsum thrown in not too rapidly, at least not more rapidly than it can be thoroughly mixed, otherwise we shall not be able to determine precisely its consistence. If, while ap- plying the paste, it begins to harden in the bowl, we must not add more water, as this will again interfere with its final solidification upon the limb. It must be thrown away and some fresh immediately prepared; or the crystallization may be retarded by throwing in a few drops of carpenters' glue, or a little starch or dextrine; but the plaster is apt to be brittle after the addition of these articles. When the plaster is good, and it is properly mixed, we may allow ourselves from five to eight minutes in the application. A large paint brush is the most convenient thing for spreading it, but the hands will do very well in an emergency. Everything being ready, the limb is to be seized by assistants at both of its extremities and held in a position of steady extension until the dressing is completed, and for one or two minutes longer, or until the plaster is hard. It will be sufficiently hard to support itself even when the dressings are quite moist. The surgeon then proceeds to lay a long piece of linen—old sack will answer as well as any—folded three or four times, and saturated with the paste, parallel to the two sides of the limb, around which are to be immediately placed horizon- tally and at several points, short and wide strips of the same material. These latter are intended to iacreas-e the strength of the apparatus, and to bind on the side strips. Finally, the whole may be painted with the solution. It is very well, however, not to cover the front of the limb, or a narrow strip somewhere in the line of the axis of the limb, with the plaster, as this will not diminish materially its strength, and !t will enable the surgeon to open it more easily with the scissors. Pirogoff accomplishes the same purpose by laying a piece of narrow tape, soaked in oil, along the line through which he wishes to make the section of the splint.1 ■iter of Paris Bandage, New York Journ. Med., May, 1855, p. 341. GENERAL TREATMENT OF FRACTURES. 59 Another mode of applying the gypsum is to employ common rollers, made of unglazed, open calico. The cloth, being torn into strips of a suitable width and length, is laid upon a table, and the dry plaster rubbed into it for several minutes, until its meshes are well and evenly filled. Each bandage is then rolled up closely, and immediately before being applied a little water must be dropped into the extremities of the roll to moisten the plaster, but not enough to soak through the plaster and thereby wash it out. Thus prepared, the gypsum roller is applied to the limb in circular turns, until the whole is completely en- cased with one or .two layers. Reversed turns must be avoided as far as possible, and when they become necessary, the fold should not be made over a projecting ridge of bone.1 At Bellevue Hospital we occasionally apply the plaster of Paris by a method which is very simple. The limb being carefully shaven is enveloped with one single sheet of coarse woollen cloth, which is pre- viously thoroughly saturated with the plaster. Dr. E. Harris, of this city, has ascertained that by mixing the plaster in the following proportions the weight will be considerably dimin- ished, namely, water 100 parts by weight, gypsum 75 parts, clear- boiled starch 2 parts. By this method the process of crystallization is retarded, and all the water, except about twenty per cent., is per- mitted to escape. For the use of the surgeons in the U. S. Army the Sanitary Com- mission furnished the plaster in tin cans hermetically sealed, but at a period too late to enable us to give it a fair trial in field practice. It is my impression, however, that this material is not well suited to the service of campaigns in this country, and that the opinions of foreign army surgeons as to its value must be taken with some allowance.2 Professor B. W. Dudley, of Lexington, Ky., one of the most suc- cessful surgeons in this country, but especially distinguished as a lithotomist, has for many years employed in the treatment of fractures nothing but a roller, regarding both side splints and extending ap- paratus as not only useless but absolutely pernicious.3 This practice, which seems to have originated with Radley, of England, has not found, hitherto, in this country or elsewhere, many imitators; and although one ought in general to speak very cautiously of a practice which he has never seen tried, and especially when it brings with it the authority of so distinguished a surgeon as Dr. Dudley, I do not hesitate to pronounce it irrational, and to declare my belief that it is in no way entitled to the confidence of the profession. Still more unscientific, and absurd even, is the practice of Jobert, of Paris who employs neither side splints nor bandages, but only extension, in the treatment of all, or of nearly all fractures of the long- bones. ' Gamgee's Researches, London, 1856, p. 154. ,•*„,„ * Practical Lectures on Military Surgery, by Isidor Gluok, of New \ork, chief sur- geon to the Hungarian (Vilmos) Hussars, &c. &c, during the late war m Hungary. Arner. Med. Monthly, Dec. 1855, p. 449, &c, vol. iv. New \ork Med. Lines, Dec. ,, '» Dudley, Trans. Amer. Med. Assoc, vol. iii., 1850, p. 349. 60 GENERAL TREATMENT OF FRACTURES. The side or coaptation splints bring the fragments intomore com- plete apposition, and secure a more prompt and certain union. They ouo-ht, therefore, never to be omitted unless the condition of the limb precludes their application. As to the question of permanent extension in fractures, and the means by which it may be most effectually accomplished, nothing need be said at this time, inasmuch as it relates only to the fractures of certain bones, and to certain forms of fractures; we must therefore refer its consideration to those chapters which treat of individual bones. In the treatment of comminuted fractures, no pains ought to be spared to bring the fragments as nearly as possible into apposition; and if there exists at the same time an external wound, and the frag- ments are small and loose, they ought to be removed carefully. Nor, indeed, should we be deterred from the attempt to remove them by finding that they are adherent, if still they are easily moved about with the finger. In compound fractures, not unfrequently the end of one of the frag- ments protrudes from the wound, and its reduction may be attended with considerable difficulty. My practice is usually in such cases to attempt the reduction first, by simple extension and counter-exten- sion ; but if this fails, I introduce my finger into the wound, and endeavor to stretch the skin over the sharp point of bone; or I make use of a spatula formed from a piece of shingle, or of any suitable piece of metal which may be at hand; finally, but not until all other expedients have failed, I enlarge the wound sufficiently to insure its return. There are some cases, however, in which the surgeon may feel justified in sawing off the projecting end; as when the periosteum is completely torn from it by its having penetrated a boot, or even some- times when its extremity is very sharp, and there is reason to suppose that it would prick and irritate the tissues. In a few of these cases, also, surgeons have proposed to secure the fragments in apposition by metallic ligatures or sutures. In a few instances the practice has been attended with success, but in most cases the wires have failed utterly of their purpose, and have only proved sources of additional irritation.' If arteries bleed freely and for a long time, we may make some effort to find the open mouths in the wound, but in this we rarely succeed, nor is it prudent always to tie the main branch which supplies the limb. Fortunately, this bleeding, although at first profuse, gene- rally ceases in a few hours under the steady employment of cold lotions, moderate compression, and rest. If it does not, the chances are that the case will call for amputation. The rule generally laid down by surgeons that we should at once close the wound m compound fractures, with sutures and adhesive straps if necessary or with bandages, is far too absolute. This prac- tice will do when there is no great contusion or extravasation of blood, ■ de Mtd., i;75, and Laloy, Paris, 1839, from Holmes's Surgery. DELAYED AND NON-UNION OF BROKEN BONES. 61 but if blood is flowing, it is much better to leave the wound open so as to permit it to escape freely; and if the severity of the injury war- rants the supposition that much inflammation is to ensue, the danger of gangrene is greatly lessened by thus allowing the opening to remain as a channel of exit for the inflammatory effusions. Many years since Dr. J. Rhea Barton introduced into the Pennsyl- vania Hospital what has since been called the " bran dressing" for the treatment of compound fractures of the leg; the limb being made to repose in a box filled with this material.1 I have used it very fre- quently in Bellevue and in other hospitals, and can speak of it as possessing many qualities of excellence, especially as a summer dress- ing. The particular mode of using this apparatus I shall describe more minutely when treating of fractures of the leg. The treatment of inflammatory symptoms, and of the later accidents, such as suppuration, oedema, gangrene, tetanus, &c, must be left mainly to the good judgment of the surgeon. Gentle manipulation, uniform support, rest, and sometimes cooling lotions constitute the most impor- tant means by which inflammation is to be controlled. Bleeding is rarely necessary, and in a large majority of cases it might prove injurious by lowering too much the vital forces, which need to be husbanded in view of the requirements of the process of repair and of the long and exhausting confinement. Cathartics should also be administered cautiously for the same reason, and because they are liable, especially in fractures of the lower extremities, to occasion a serious disturbance of the limb. CHAPTER VI. DELAYED UNION AND NON-UNION OF BROKEN BONES.2 Most surgical writers concur in the statement that non-union of broken bones is an uncommon event. Walker, of Oxford, affirms that of not less than one thousand fractures which have come under his treatment at some period of the repair, he does not recollect more than six or eight instances. According to Lonsdale, not more than five or six cases of false joint, excepting those within a capsule, have occurred out of nearly four thousand fractures treated at the Middle- sex Hospital. In a table of 367 cases, collected and arranged by W. W. Morland, from the books of the Massachusetts General Hospital, 1 Paper on Bran Dressings, by Reynell Coates, of Philadelphia. Amer. Journ. Med. Sci., April, 1842, p. 515 ; from the Med. Examiner, Nos. 9 and 11, vol. i., New Series. 2 I shall, in this chapter, avail myself freely of the labors of George W. Norris, of Philadelphia, whose paper, entitled "On the Occurrence of Non-union after Fractures, its Causes and Treatment," published in the American Journal of Medical Sciences for Jan. 1842, constitutes the most complete and reliable monograph upon this subject contained in any language. 62 DELAYED AND NON-UNION OF BROKEN BONES. extending through a period of nineteen years, only one example of false joint is recorded; but as only seventy-four days had elapsed when this patient was discharged, it is doubtful whether this mio-ht not have proved to be a case of delayed union simply.1 In 946 cases of recent fracture treated in the Pennsylvania Hospital between the years 1830 and 1840 there was no instance of false union.2 Sir Stephen Hammick, Mr. Liston, and Malgaigne affirm also the infrequency of these accidents in the cases which have come under their personal treatment. I have myself seen a considerable number of examples of non-union, but in not one of my own patients, whether in hospital or private practice, except in cases involving joints, has the bone re- fused finally to unite; and my opinion is, that in proportion to the number of fractures everywhere, these cases are very rare, perhaps not in a larger proportion than one in five hundred. Amesbury alone seems to have entertained a contrary opinion, his own experience having supplied fifty-six examples of what he has called "fractures of long standing." I notice, also, that at a later period Mr. Amesbury's experience in false joint extended to ninety cases The humerus and femur would appear to be the bones most liable to non-union, as shown by Norris's statistics; in which forty-eight be- longed to the humerus, forty-eight to the femur, thirty-three to the leg nineteen to the forearm, and two to the jaw. In my own experience' I have found the humerus ununited much more often than the femur Berard has shown that in the growth of the long bones the period at which the epiphyses are united to the diaphyses depends upon the direction of the nutritive artery; for example, "it is found that in the humerus, where the direction of this vessel is from above downwards, consolidation takes place soonest at its inferior extremity In the fore- arm, the course of the nutrient vessels is from below upwards, and here consolidation of the epiphyses is found to occur at the elbow sooner than at the wrist. In the inferior members, on the contrary, the epiphyses composing the knee are the last which become firm wf'f?h iG TUr the ;utnti0US arteJT ™s upwards, and in the bones of the leg it courses from above downwards.'' A knowledge of unon the cotobd'tetin *? "^ lnt° the influence of *«» arteri^ upon the consolidation of fractures; and the cases collected by him the ar^ and T ^ \*?*J° ^^ W*e* the dlctin of the artery and the union of the bone; that is to say, the examples of non-union were chiefly found where the frant^J^ aTi P thit side nf thp nntT.it'L f wnere the fracture had taken place on if to imnlftba 2 .1 f°ramenfrom which the artery entered, as fee nutrl of' tW? T™ ^"J S°me measure due *> *e imper- tect nutrition of this extremity of the bone. In thirtv-five cases of non-union analyzed by Gueretin, ten belonged to that porlion of the portion BuTaVanir86" ft*6 *"***' ^ twent^fi/e tt he othe sPe0em°to ^^K^^?8? "^ * ^ doM ^ mib ooservation of Gueretin, since twenty-seven were May^l^cT FraCtUre3' b7 A' L" Peir30a> read before the Massachusetts Med. Soc. 2 Norris, loc. cit. DELAYED AND NON-UNION OF BROKEN BONES. 63 in the direction of the nutritious arteries, and only fourteen in the opposite portion, or in that which is supposed to be less nourished. Another observation, made by Curling, that in fractures of the long bones the portion below the entrance of the nutrient artery, or on that side of the nutrient foramen towards which the blood flows, being defrauded of its proper supply, is subjected to a species of atrophy, presenting a larger medullary canal, with thinner walls, and a spongy tissue less dense, also needs confirmation. Malgaigne has not noticed this fact in any of the specimens contained in the public museums of Paris; and we do not know that any other writer has made the ques- tion a subject of especial inquiry. According to Norris, there are four principal kinds of false joint:— In the first, the bones are united and completely enveloped in a car- tilaginous mass or callous tumor, but in consequence of some retarda- tion in the process bony matter is not deposited, and, as a consequence, it wants solidity, the part continuing easily movable. This may be regarded as a proper example of delayed union, as distinguished from complete non-union, or false joint. In the second, there is entire want of union of any sort between the fragments, the ends of which seem to be diminished in size and extremely movable beneath the integuments. The limb in these cases is found wasted and powerless. In the third and most common class, the medullary canal is oblite- rated in both fragments, and the ends are more or less absorbed, rounded, ^ and covered, in part or in whole, with a dense tissue resembling the periosteum. A connection also exists . Clavicle united by ligameatousbandJ between the opposing fragments in the form of strong ligamentous or fibro-ligamentous bands, which, if of any length, are quite flexible, and allow of considerable motion at the seat of fracture. In the fourth, "a dense capsule without opening of any kind con- taining a fluid similar to synovia, and resembling closely the complete ligaments, is found." In these cases the points of the bony fragments corresponding to each other, are rounded, smooth, and polished, in some instances eburnated, and in others covered with points or even thin plates of cartilage, and a membrane closely resembling the syno- vial of the natural articulation. It is in this kind of cases, Norris remarks, that the member affected may still be of use to the patient, the fragments being so firmly held together as to be displaced only upon the application of considerable force. The existence of these newly-formed joints, or true diarthroses, has been called in question by Boyer, Hewson, Chelius,1 and others; but the observations of Sylvestre, Brodie, Beclard, Home, Howship, Otto, Kuhnholtz, Houston, Cooper, Langenbeck, and Breschet prove that such examples are occasionally found.2 ' Malad. Chirurg.,t. iii. p. 103, Paris, 1831; North Amer. Med. and Surg. Jouru., No. ix. p. 7, 1828 ; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris oc. cit ) _ 2 Nouvelles de la Repub. des Lettres de Bayle, p. 718, 1685 ; Lond. Med. Gaz., xm. 64 DELAYED AND NON-UNION OF BROKEN BONES. Norris is a disciple of Dupuytren, and accepts his doctrine of the formation of callus without reservation; consequently he finds no ne- cessity for but one form of delayed union, namely, that which we have described as belono-ing' to the first class. In all of this class he assumes the existence of a cartilaginous ring or ferrule ; but we think the error of this exclusive theory has been sufficiently shown by the observa- tions of Paget and others, and we should be warranted therefore in affirming the existence of as many varieties of delayed union as there are varieties in the manner and position of the deposit of callus, even if their actual existence had not been repeatedly demonstrated by dissections. The causes of delayed union and of non-union are either constitu- tional or local. The constitutional causes are chiefly those conditions of the general system which manifest themselves by anaemia, debility, or some pecu- liar dyscrasy. Sanson, Beulac, Condie,1 and many others have mentioned cases in which the existence of syphilis in the system has seemed to prevent the formation of callus: but on the other hand Lagneau and Oppeu- heim2 incline to the opinion that syphilis exerts in this respect but little influence; and even Bdrard, who admits the pertinence of one case observed by Nicod, concludes, after numerous researches, that it has been very rarely shown to affect the formation of callus.3 Pregnancy and lactation have been known to interfere with the union of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, of New York, and Condie, of Philadelphia,4 have all reported examples, in some of which the process of union was resumed and brought to a rapid completion so soon as the period of pregnancy was closed, or when lactation ceased ; but three cases reported by Sir Stephen Love Hammick would seem to show, what, indeed, other evidences render probable, that the delay was less due to the fact of the pregnancy and the lactation than to the debility occasionally consequent upon these conditions.5 As to the question whether cancer ever causes a delay in the union of bones, Norris declares, that after a very careful examination of what has been written upon this subject, it is his opinion that where the fracture arises in consequence of a true cancerous deposit around, or in the interior of the bones, producing absorption of their tissue, no union p. 57,1833; Beelard, Gen Anal; trans, by Hayward, pp. 149,248 ; Transac. Med.-Chir. Soc. of Edinburgh, i. p. 233, 1793; Med.-Chir. Trans., viii. p. 517, 1M7- Otto's Path Anat., trans, by South, i. p. 138 ; Journ. Complement., iii. p. 291 ; Dub 'Med Journ ' yni. p. 493; Cooper on Frac. and Disloc, fourth London ed., p. 508 ; Recherch sur les Formation du Cal, 1M9, p. 34. (Norris, loc. cit.) "ecnercn. sur ies 'Diet, de Med. et Chir Prat., iii. p. 492 ; Journ. de Med. Chir. et Pharm., t. xxv. p. ^16. (Norris, loc. cit.) ' (NonSToltit )JmP' ^ ^ mal' V6n'' P' 525 ! °PPenheim on False Joints, 1837. 3 Op.'cit., p. 21. « Cooper's Die., ed. 1838 p 546 ; Opera Hild , 1681 ; Wilson on the Human Skele- ton, p. 214; Bib. Choisie de Med., xxiv. p. 595- Med Obs and Irw,,,;..;. T i--f Philosoph. Trans., xlvi. p. 397, 1750. (Norris, loc.oil'.) In *, 1« '2 ; s Practical Remarks on Amputations, Fractures, &c, p. 121. (Norris, loc. cit.) DELAYED AND NON-UNION OF BROKEN BONES. 65 takes place; but where, as is usually the case, the fracture is due to a fragility of the bones, occasioned by what Mr. Curling has denominated eccentric atrophy, it will be found to unite readily. Parker, of New York, relates the case of a girl only fifteen years of age, in whom the femur was broken from a very trivial cause; and in which case the autopsy, made at the end of five months from the time of the accident, furnished some confirmation of these views. The place of fracture was occupied by an irregular encephaloid mass. It is curious, how- ever, that in this case, the callus was actually formed at first, and the bone seemed to be well united at the end of five weeks; but at the time of the autopsy no callus existed.1 Scurvy, fevers of a low type, and, on the other hand, fevers of a highly inflammatory character, profuse uterine and vaginal discharges, and rachitis, conduce to the same result. The withdrawal of a habitual stimulus, and especially a change from a good to a low diet, or copious bleedings may either of them delay the deposit of ossific matter, or prevent it altogether.2 Bonn has furnished two cases in which advanced age seemed to have retarded the formation of callus, but Horner saw a fracture of the humerus in a woman ninety years old, unite in five weeks.3 I have myself noticed a good many similar examples in advanced life, and it is now rendered quite probable that surgeons have generally over- estimated the influence of age upon the formation of callus. The local causes are, arrest of the arterial circulation by bandages, splints, &c, a perineal band, or an axillary pad may accomplish the same result; paralysis or impairment of the nervous circulation, the occurrence of the fracture within a capsule, obliquity of the fracture, overlapping of the fragments, interposition of a piece of bone, of a tendon, muscle, or of a clot of blood, or separation of the fragments from any cause whatever, erysipelas, acute phlegmonous inflammation, suppuration, necrosis, too much motion, compression, exclusion of light and air inducing local scurvy, wet and especially cold and moist dressings, too early use of the limb, &c. In order to hasten the consolidation when it is simply delayed, we resort to all of those expedients which are calculated to invigorate the general system; and for this purpose the employment of a nutritious diet and the use of mineral or vegetable tonics may not be properly omitted; but in our experience nothing has proved so efficient as encouraging the patient to leave his bed and get out into the open air; for which purpose, if the fracture is in the lower extremities, crutches will be necessary. , As local means we may enumerate first the removal ot those local causes which seem to have interfered with the consolidation or with the union. If the fragments have been officiously disturbed, it may be sufficient to impose upon the limb absolute rest for a certain length of time; and the fragments may be more closely pressed against each other; in other cases it will be found necessary to remove the bandages, ' Parker, New York Journ. Med., July, 1852, p. 97. ^ ^ 1 Norris, loc. cit. •> V- - (Jlj DELAYED AND NON-UNION OF BROKEN BONES. Fig. 15. expose the limb freely to the light and air at least once or twice daily, and to rub it gently with the dry hand or with some moderately stimu- lating oil, so as to'induce a more healthy condition of the'soft parts, and encourage the natural circulation. Moving the fragments freely upon each other, sufficient to determine a degree of excitement in the adjacent tissues, and upon the opposing surfaces of the bones, and then confining them during one or two weeks in firm and well-fitting splints, will often succeed when other means have failed. Indeed I may say that by one or another of the simple methods now enumerated I have never failed sooner or later to effect consolida- tion, in recent fractures; and it has only been in fractures of at least four, six, or eight months' standing that I have been compelled to re- sort to more extreme measures. As a means of combining immobility with compression and health- ful exercise, the "apparatus immobile," in many of its forms, is pecu- liarly adapted. White, of Manchester, employed a firm leather sheath for the thigh. H. II. Smith, of Phila- delphia, recommends a more complex artificial support, upon which the limb may be allowed to rest while in the act of progression.1 With some surgeons the object of allowing the patient to walk in fractures of the thigh or leg, is chiefly to excite in the tissues adjacent to the seat of fracture some degree of inflammatory action, but which, as the result in one of White's patients has sufficiently shown, may be carried too far, and even determine a suppuration. Dr. E. R. Hudson, artificial-limb maker, of New York, has applied in similar cases an apparatus of his own construction, made of willow, and secured in place by leather straps. In case the purpose of the apparatus is to encourage bony union, no motion is allowed at the knee-joint. Blisters, mustard cataplasms, the tincture of iodine,2 caustics,3 &c, applied externally over the seat of fracture, can have no other effect than to increase moderately the congestion of the tissues, and in so far they may aid in the accomplishment of the bony Hudson's splint for ununited fractures of femur, accompanied with shortening of the limb. 1 H. H. Smith, Amer. Journ. Med. Sci., Jan. 1855. 2 Hartshorne, Eclectic Rep., vol. iii. p. 114, 1813.' » Willoughby, Am. Journ. Med. Sci., Aug. 1834, p. 444. DELAYED AND NON-UNION OF BROKEN BONES. 67 Fig. 16. union; but in this respect they are inferior to the violent twistings, flexions, and rubbings of the broken ends of which we have already spoken. Electricity was first employed by Mr. Birch, of London, but Dr. Mott obtained no effect from it in two cases where he seems to have given it a fair trial.1 Lente, of the New York Hospital, has more re- cently furnished an account of three cases treated in that institution by electricity in connection with acupuncturation; the mode of using which was to pass a needle down to the periosteum on each side of the bone, and to attach the poles of the battery to these opposite points. Lente thinks that electricity employed in this way is much more effi- cient than when the poles are merely applied to the surface. He informs us also that other cases than these now reported have been treated suc- cessfully in this hospital by means of electricity.2 Mercury, urged to ptyalism, will no doubt prove serviceable occasionally by virtue of its powers as an anti-syphilitic, but its beneficial influence in other cases is far from having been established. The seton is said to have been first suggested by Winslow, in 1787; but what is of much more consequence, the credit of its first successful ap- plication and its general introduction into practice, is due to Dr. Philip Syng Physick, of Philadel- phia, by whom it was employed in 1802.3 Physick used for his seton, generally, silk rib^ bon, or French tape; and this he introduced by means of a long seton needle, between the ends of the fragments. He recommended that the seton should remain in place four or five months, and longer if necessary, and it was his opinion that the failures were generally due to its being removed too early. At the present day, however, surgeons who employ the seton think it serves its purpose better when it remains in place but a few days, not longer, perhaps, than ten or fifteen, always taking care that it is removed before ex- cessive suppuration is induced. It has been found especially valuable in fractures of the inferior maxilla, clavicle, and upper extremity generally ; but in the case of the femur, it has so frequently failed that Dr. Physick himself did not recom- mend its use. In case the seton cannot be passed directly between the opposing fragments, as recommended by rhysicfc,, we may adopt the practice suggested by Oppenheim, and carry two seton,, one on each side, close to the bone. ' Mott, Med. and Surg. Rep., p. 21, p. 375 » Lente, New York Journ. Med., Nov. 1850, p. 317. » Physick, Med. Repository of New York, vol. l. lbltt. Physick's first case, after 28 years. (From Am. Journ. Med. Sci.) GS DELAYED AND NON-UNION OF BROKEN BONES. Fig. 17. Somme*, of Antwerp, preferred a loop of wire to the silk seton Employed by Physick.1 Seerig passed a ligature around the liga- mentous mass connecting the two fragments, and then proceeded to tighten the ligature until it fell off.2 Dr. Hulse, of the U. S. Navy, employed stimulating injections with success in a case of non-union, accompanied with an external and fistulous opening.3 In 1848, Dieffenbach recommended that ivory pegs be introduced into holes previously made in the bone,4 by means of a gimlet or drill, and Mr. Stanley has succeeded once by this method.5 Malgaigne, in 1837, tried to introduce acupuncture needles between the ends of an united fracture, but although he thrust the needle down to the bone thirty-six times, he was unable to make it pass once between the ends of the fragments.6 Wiesel succeeded better. In a case of ununited fracture of the ulna of nine weeks' standing, having passed two needles between the fragments, at the end of six days, the needles being removed, con- solidation rapidly ensued.7 This practice does not differ essentially from the metallic loop of Sommd. It is only a modification of the seton. Brainard, of Chicago, has attempted to show that setons of any kind, whether of wood, ivory, or metal, placed in contact with the bone, occa- sion absorption, caries, and necrosis, but that they never directly give rise to bony callus; and that the occasional success of the seton, which success he believes to have been greatly exag- gerated, has not resulted from any tendency to favor the formation of callus, but from the indu- ration and tenderness of the soft parts produced by it; circumstances which, by conducing to rest, indirectly favor the consolidation.8 In May, 1848, Miller, of Edinburgh, reported five cases treated successfully by subcutaneous puncture. The operation consisted in passing the point of a needle or small tenotomy bistoury, down upon the ends of the bone, and freely irritating the surfaces at several points.9 George F. Sandford, of Davenport, Iowa, has successfully imitated this practice in two cases.10 In 1850 Dr. William Detmold, of New York, performed the opera- tion of drilling or perforating the fragments in a case of ununited 1 Amer. Journ. Med. Sci., vol. vii. p. 497. 2 Norris, loc. cit., p. 46. 3 Hulse, Amer. Journ. Med. Sci., vol. xiii. p. 374, 1 Malgaigne, trans, hy Packard, op. cit., p. 258, note 6 Stanley, New York Journ. Med., Nov. 1854, p. 441, from Dublin Pre 'v-aa„ p Surgery to Illinois State Med. Soc, May, lPUO. ' * E&s,ay' PiePort on 9 Miller, New York Journ. Med., July', 1*48, p. 134. 10 Sandford, Trans. Amer. Med. Assoc, vol.' iii. p. 355, 1850. ' Dieffenbach's drill for un united fracture. DELAYED AND NON-UNION OF BROKEN BONES. 69 fracture of the tibia, employing for this purpose a large gimlet. He first bored two holes between the opposing fragments, and then, intro- ducing the gimlet one and a half inches below the fracture, he pene- trated the tibia upwards and inwards until he had traversed, also, the upper fragment to the extent of an inch. In three weeks the bone appeared firm, but from this time the patient was not seen.1 Brainard employs for this same purpose a strong metallic perforator, consisting of a handle, into which points of different sizes may be in- serted, and which have been hardened so as to penetrate the hardest bone or even ivory in every direction easily. The points are "some- what awl-shaped; but more pointed in the middle rather than like a drill, which leaves chips.'' His manner of using this instrument is as follows: " In case of an oblique fracture, or one with overlapping, the skin is perforated with the instrument at such a point as to enable it to be carried through the ends of the fragments, to wound their sur- faces, and to transfix whatever tissue may be placed between them. After having transfixed them in one direction, it is withdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as often as may be Fig. 18. Brainard's perforator, reduced one-half. desired." Dr. Brainard, who has already succeeded by this procedure in a number of cases of ununited fracture, thinks it is better to com- mence in most cases with not more than two or three perforations, in Fig. 19. Bone drill. order that the effect produced shall not be too severe. It is scarcely necessary to add that, after the punctures have been made, the limb should be put completely at rest in appropriate splints, or in apparatus of some kind. » New York Med. Gazette, Oct. 12, 1850. 70 DELAYED AND NON-UNION OF BROKEN BONES. Mr. Tieman has made for me a bone drill which is rotated by the movement of a handle upon a rod, or shaft, composed of twisted wire, and which possesses the advantage of being worked with great facility and rapidity. Perforators of any size or shape may be fitted to the shaft at pleasure. (Fig. 19.) Scraping or rasping the ends of the bones is a practice which dates from a very early period. Mr. Brodie scraped the ends of the bones, and then interposed a bit of lint.1 Mayor, in 1S28, contrived to intro- duce an iron, previously heated in boiling water, through a canula, and thus brought the heat to bear directly upon the ends of the frag- ments; and by repeating the application several times a cure was effected.2 Resection of the ends of the bones, first brought into notice by White, of Manchester, in 1760,3 and opposed by Brodie4 as dangerous, and by Malgaigne regarded as generally useless or unnecessary, has still been practised a great number of times with more or less success. It is especially applicable to superficial bones, and in cases where the bones overlap. Roux practised resection in one instance, and then managed to en- gage the point of one of the fragments in the medullary canal of the other.5 White, of Manchester, Henry Cline, of London, Hewson, Barton, and Norris of Philadelphia, have applied caustics directly to the ends of the fragments, after having exposed them by a free incision.6 Petit applied the actual cautery.7 Tying the fragments together by means of metallic ligatures, is as old as the days of Hippocrates; but in 1805 Horeau adopted the same procedure in a case of ununited fracture.8 J. Kearney Rodders Mott and Cheeseman, of New York, Flaubert, of Rouen,9 and K R. Smith, of Baltimore,10 have repeated the operation with complete success. 1 he operation is, however, not without its hazards. Norris has seen one case m which a broken patella was wired together, and a fatal result followed on the fourth day. # E S. Gaillard, of Richmond, Va., proposes to secure the fragments in place by means of a metallic pin. The instrument which he employs is composed of a steel shaft with a handle, a silver sheath, and a brass nut. For.a broken femur, the shaft is six inches long, its ower extremity being constructed like a gimlet, while two and a half ot?rfti;!\UPPer eftremulty f6 CUt f°r a male screw' beinS tended to carry the brass nut. The sheath is three inches long d^r^f a\r wn made °Ver the seat of f™ctSre the sheath, Da sed throTh** if Vif ^ ?°Wn t0 the W The s^ft is then Fr^fen? of ™ I ™* "^ t0 PGnetrate and transfix ** two fiagments, as soon as this is accomplished the nut is turned down 1 Brodie, Lond. Med. Gaz., July, 1834 t v . , » Diet, de Med., vol. xiii. p 503 iSorns, loc. cit., p. 48. « Brodie New York Journ. Med.," vol. viii. lst ser t, 133 5 IS orris, loc. cit., p. 49. s T, A ' P- • Rodger. New York Journ. M,d., vol. i f,er n 343 iVif' $ Ibid' » Note to Packard's Trans, of Malgaigne, p. 255* ' DELAYED AND NON-UNION OF BROKEN BONES. 71 firmly upon the top of the sheath and apposition of the fragments is thus secured. The whole instrument is permitted to remain until bony union is effected.1 Fig. 20. Gaillard's instrument fur ununited fractures. Finally, having thus brought rapidly before us all of the various modes of treatment which have been suggested and practised for non- union of broken bones,-we are prepared to affirm the following con- clusions, or summary of what has been our own practice, and of what we believe ought to be the general course of procedure in these cases:— First. Improve the condition of the general system. Second. Remove as far as possible the local impediments, such as a separation of the fragments, local paralysis, local scurvy resulting from long exclusion from light and air, congestions, &c. Third. Increase the action of the tissues immediately adjacent to the fracture, upon which tissues rather than upon the bone, as Mal- gaigne thinks, the formation of callus depends. A theory which, as applied to old and ununited fractures, we are not prepared to deny. This may be accomplished by frictions, and violent flexions of the limb at the seat of fracture; possibly in some measure by the applica- tion of vesicants or of other stimulants, to the skin itself. Fourth. Employ again compression and rest for a period of from two to four or eight weeks. Fifth. Resort to the methods recommended by Brainard or by Gail- lard. Sixth. If in the lower extremity, allow the patient to walk about with the fragments well supported. Seventh. If the fracture is not in the femur, and as an extreme measure, employ the seton. Eighth. Resection is applicable only to superficial bones, and in cases of overlapping. Where these measures have'failed, after a fair trial, we should either abandon the case as hopeless, only supporting the limb by such appa- ratus as may be found most serviceable, or we should recommend amputation. 1 E. S. Gaillard, New York Journ. Med , Nov. 1865. 72 BENDING OF THE LONG BONES. CHAPTEE YII. INCOMPLETE FRACTURES. BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG BONES. § 1. Bending of the Long Bones. Strictly speaking, no bone can be much bent without being also more or less broken, and that whether it immediately and spontane- ously resumes its position or not; for, if the bending and straightening of the bone be repeated a sufficient number of times, the yielding of the fibres will become apparent, and at length the separation will be complete. The first of this series of flexions was quite as much re- sponsible for this result as the last, and, no doubt, performed its share in the production of the complete fracture. There could be no impropriety, therefore, in speaking of a bending of the bones as a variety of incomplete fractures, as I have done in the first section of my " Report on Deformities after Fractures," made to the American Medical Association in 1855.1 They have been called, not inappropriately, interperiosteal fractures, since in these cases the periosteum is not broken; M. Blandin thinks that the outer and semi-cartilaginous laminae of the bone also do not break, while the deeper laminae suffer an actual disruption.2 But it is quite as probable that in a majority of cases the true pathological condition is a compression of the bony fibres upon one side, with a corresponding expansion upon the opposite side, with only a slight interstitial fracture, too trivial to be easily recognized even in the dis- section. Sometimes, as I have several times observed in my experi- ments on the bones of chickens, when the bones are small, and the bending is near the centre of the shaft, the whole of the lamina? on the side of the retiring angle produced by the bending are doubled in, or indented toward the hollow of the bone, so that the fibres on the side of the salient angle are not even stretched, and much less broken. In such cases, the interstitial disruption, if it exists at all, and I think it does, first takes place in the deeper layers of the retiring angle. I might, therefore, feel justified in continuing to call *these cases partial fractures, or, perhaps, interstitial fractures, but I believe that the whole subject will be rendered more intelligible if I call them simply bending of the bones, as distinguished from those other and more palpably partial fractures of which I shall speak presently. 1 Op. cit., pp. 421—422. J*i?w\f^if °D the SUrg' Pl'aCtice °f Paris> Lotldon Med.-Chir. Rev., vol. BENDING OF THE LONG BONES. 73 1. Bending with an immediate and spontaneous restoration of the lone to its original form.—The possibility of this accident, to which, however, surgical writers have hitherto made no distinct allusion, is rendered certain by the following experiments:— Experiment 1.—July 16, 1857. I bent the tibia of a Shanghai chicken, four weeks old, at about the middle of the bone. It was bent to an angle of quite twenty-five degrees, but it was not felt or heard to break. It immediately and spontaneously resumed the straight position. July 18, two days after the bending, I dissected the limb, and found no trace of the injury, either within or without the bone, unless I except a very minute blood-clot in the centre of the shaft. Experiment 2.—I bent the leg of a chicken, four weeks old, at the same point and to the same degree. It immediately resumed the straight position. Dissection after two days. Nothing abnormal except a small blood- clot in the centre of the bone, and a slight disorganization of the medulla. Experiments 3 and 4.—Bent both legs of a chicken, four weeks old, at the same point, and in the same manner. They immediately re- sumed their positions. Dissection after two days. No lesions or morbid appearances which I could detect. Experiments 5 and 6.—Bent both wings of a chicken four weeks old. Bent the right wing to an angle of thirty-five degrees. I did not feel them break. Both resumed their positions spontaneously. Dissection after two days. No lesions or other morbid appearances. Experiment 7.—July 16,1857,1 bent the leg of a Shanghai chicken, five weeks old, below the knee, and at about the middle of the bone. It was bent to an angle of about twenty-five degrees, but the bone was not felt or heard to break. It immediately and spontaneously resumed the straight position. July 20, four days after the bending, I dissected the leg, but could not discover the slightest trace of the injury, unless it be that there was a very minute ossific deposit in the centre of the bone, at the point at which I suppose it to have been bent. Experiment 8.—July 16, 1857, I bent the right leg of a Shanghai chicken, five weeks old, at the same point as in the first experiment, and to the same extent. The bone did not seem to break, but it immediately and spontaneously resumed the straight position. Dissection after four days. Nothing appeared to indicate the seat of the bending except a small clot of blood in the centre of the shaft. Experiment 9.—Bent the leg of a chicken, six weeks old, in the same manner, and to the same degree, as in the other examples. It resumed its position spontaneously. Dissection after ten days. No evidence of injury of any kind; the bone being sound and straight. These experiments were made in connection with others, which I shall take occasion hereafter to mention. They are selected, and con- 6 71 BENDING, PARTIAL FRACTURES, AND FISSURES. stitute the whole number of those in which I did not feel the bone break or crack under my fingers. In every instance the bone sprung back immediately and spontaneously to its natural form. In no in- stance could I afterward discover any trace of lesion, or sign indicating the point at which the bone had been bent before dissection; nor did dissection itself disclose anything but the most inconsiderable marks; and that in but three examples. I infer, therefore, not forgetting the caution with which the conclu- sions from all such experiments ought to be applied to similar acci- dents upon the human skeleton, that whenever the bones of healthy infants have been slightly bent and not broken, they will, probably, in most cases, unless prevented by causes foreign to the bones them- selves, spontaneously and immediately resume their position ; and that no sign will remain to indicate that a bending has occurred. The accident will not be recognized; and, as a farther inference, this bending does not belong to that class of cases of which I shall next speak. 2. Bending without immediate and spontaneous restoration of the lone to its original form.—" Dethleef, believing that he had broken the two bones of the leg of a dog, found the fibula bent without a fracture. Similar results were obtained by Duhamel upon a lamb; by Troja upon a pigeon; and I have myself twice succeeded in bending the fibula while breaking the tibia. The possibility of simple curvature is then not contestable" (the writer means to say that the possibility of a simple curvature remaining permanently bent, is not contestable), " but we must observe that they have never been obtained except upon young animals, and that they have been unable to maintain themselves permanently except through the aid of a fracture and dis- placement of a neighboring bone; and there is a wide difference between these and those pretended curvatures which some believe they have seen in man, in which the curved bone maintains itself, and resists perfect reduction until the fracture is complete."1 In this single paragraph Malgaigne seems to have given a fair sum- mary of the testimony upon this point. With the exception of these and a few other similar examples, some of which I think I have ob- served myself, where one of the bones of the forearm has been broken and the other bent, I know of no well-attested cases of a permanent bending; using the term bending in a sense distinguished from a par- tial fracture. If, in numerous cases mentioned by surgical writers, there has seemed to be probable evidence that the permanent bending was unaccompa- nied with fracture, there has always been wanting, so far as I know the positive evidence of dissection. The example of partial fracture mentioned by Fergusson, and represented by a drawing, is described as having also, "toward the lower extremity, a slight indentation and curve. * This was the radius of a child; but how long the child survived the accident, and what was the condition of the ulna we ' Traits des Frao., etc., par L. F. Malgaigne, torn. i. p 48 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. BENDING OF THE LONG BONES. to Fig. 21. Case mentioned by Fergusson. are not informed. The observations made by Jurine, of Geneva, in Switzerland,1 by Barton2 and Norris,3 of Philadelphia, all fail to fur- nish any such conclusive evidence of the correctness of their own views. Norris says that " Thierry, of Bordeaux, Martin, and Chevalier, had all met with and published cases of this kind prior to the appear- ance of Jurine's paper (in 1810), the former of whom asserts that Haller, in experimenting upon the subject, had been able satisfactorily to produce the same acci- dent in young animals." For myself, I cannot say how much confidence we ought to place in these assertions of Thierry, Martin, and Chevalier, having never seen the papers referred to; but since Dr. Nor- ris has neglected to inform us whether any dissections were ever made, we shall not be expected to.regard their testimony as conclusive. With the qualifications now made, Gibson was more nearly right when he said, " Dupuytren and Dr. John Rhea Barton have each furnished accounts of lent bones. There are no such injuries, however, in my opinion; such cases being, in reality, partial fractures, from which deformities result upon the same principle that a piece of tough wood, like oak or hickory, if broken half through, may be inclined to one side and shortened, although still held together by interlocking of fibres. Many specimens in my cabinet, and in the Wistar Museum, attest the accuracy of this assertion."4 In my own experiments upon the chicken, the bones uniformly resumed their original position as soon as the restraining force was removed, unless a fracture occurred, and this notwithstanding the bones were bent quite abruptly and to an angle of twenty-five de- grees. Certainly, if the bones of children may be bent during life and be made to retain this position without a fracture, then the same thing might be done upon the bones of children recently dead, and by suc- cessful experiments, this long agitated question might be easily and forever put to rest. It will be understood that our observations are confined to the long bones. That the flat bones, and especially the bones of the cranium, in childhood, may be indented by blows, and remain in this condition, is undeniable. Scultetus says he had seen "the skull pressed down in children, without a fracture, so that those who touch or look upon it can perceive a small pit,"5 and it has been mentioned by many wri- ters since, and perhaps before his day. I have myself published two examples of it in the second volume of the Buffalo Medical Journal. 1 Journ. de Corvisart et Boyer, torn. xx. p. 278, etc. 2 Phila. Med. Recorder, 1821. » Phila. Med. Journ., vol. xxix. p. 233, 1842. « Institutes and Practice of Surgery, by Wm. Gibson, Plnla., 1841,.vol. l. p. ^54. 5 The Chirurgeon's Storehouse, by Johannes Scultetus, 1674, p. 126. 6 Op. cit., p. 347, 1846, Cases 1 and 2. 76 BENDING, PARTIAL FRACTURES, AND FISSURES. § 2. Partial Fracture or the Long Bones. 1. Partial Fracture with immediate and spontaneous restoration of the lone to its original form.—-No writer seems to have given any special attention to the form of fracture now under consideration, although its existence appears to have been occasionally recognized. In the case reported by Camper, in 1765, of a partial fracture of the tibia, the bone had regained its natural form, but whether immediately after the accident occurred, or at a later period, I am not able to learn.1 Jurine, Gulliver, and others, have noticed a gradual straighteniug of the bone after a partial fracture, so that its complete restoration has been accomplished after several weeks or months; but this, although partly due to the same cause which produces occasionally an immediate restoration, namely, its elasticity, is in part also due to other causes, and will be more properly considered under the next division of par- tial fractures. Says Malgaigne: "Finally, at other times the fracture takes place without opening and without curvature; the only sign which one can recognize is a yielding of the bone under the pressure of the finger, at the point of fracture; yet upon the living subject, we may see the same symptom pertain to complete and simple fractures without dis- placement."2 Blandin has described the accident a little more distinctly: "In some cases of fracture of the clavicle occurring about the middle of the bone in young subjects, displacement of the fragments does not immediately take place, thus giving rise to a risk of an error in diagnosis, by which the ultimate probability of a cure is diminished. A lad seventeen years of age, was recently admitted into the Hotel Dieu, under the care of M. Blandin, having, a few days previously, fallen upon one of his comrades while playing with him, when he instantly experienced pain and a cracking sensation about the middle of the left clavicle, where there soon formed a tumor, which increasing induced him to enter the hospital. On examination, the swelling was found to occupy the middle of the clavicle; it was about as large as half a hen's egg, ovoid in shape, well circumscribed, colorless, and hard, but sensible to pressure. There was not any deformity of the shoulder, nor any abnormal modification of the axis of the bone, to indicate the existence of a fracture; and although the different move- ments of the arm caused pain in the shoulder, yet they could be made without much difficulty. " The symptoms in this case would lead to the belief that it was a case of simple periostitis, caused by external violence; but M. Blandin at once decided that there existed a fracture of the bone, having seen a similar case previously at the hospital Beaujon, where the tumor was treated as traumatic periostitis, the patient merely carrying his arm in a sling, until, by a sudden movement of the limb, displacement of the fragments was produced, and clearly demonstrated the existence 1 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh vol iii d 537 2 Op. cit., torn i. p. 50. 5 ' ' " v' PARTIAL FRACTURE OF THE LONG BONES. 77 of a fracture. A second case occurring soon afterward, M. Blandin profited by the experience gained from the preceding, and by moving the fragments of the broken clavicle on each other, obtained motion and crepitus. Still these indications were not so clear, that M. Mar- jolin could diagnosticate a fracture; he was of opinion that the case was one of exostosis, probably syphilitic, and the crepitus, he believed, depended on an erosion of the osseous surface. In consequence, the patient was left to himself, until a movement of the arm gave proof of the fracture by the displacement of the broken portions of the bones. " Two other cases occurring in young subjects have been admitted since into the Hotel Dieu, under the care of M. Blandin, one of whom was purposely left without surgical assistance, while Desault's bandage was applied to the other. The former soon showed evidence of con- secutive displacement; the latter was cured without any deformity following. "The surgeon may diagnose a fracture, without displacement of the middle portion of the clavicle, when a circumscribed tumor forms in that part of young subjects, consecutive on a fall on the shoulder, and motion of the fragments, with crepitus, can be detected, there not being any syphilitic taint in the constitution."1 Prof. Green, of Geneva Med. Col., N. Y., has furnished me the fol- lowing account of a case which came under his observation^ "December 21, 1847, I was called to dress what was considered to be a fractured clavicle, of George Stone, a lad eight years of age. One of his playmates had tripped him in such a manner that he fell on his side, striking on the extremity of the left shoulder. I found that he was unable to raise the hand to the head. On examination I discovered on the posterior edge of the clavicle, at the inner extremity of the external curvature, a point which was swollen, tender, and painful. The anterior edge of the clavicle was continuous, and there was neither crepitus nor displacement. Considering the age of the patient, and the appearance of the parts, I diagnosticated bending of the clavicle forward, with a splitting out of the posterior edge, and that the bone, by its elasticity, had resumed it ordinary direction. In order to be safe, however, I dressed the shoulder as for actual fracture of the clavicle, lest the fracture might have extended nearly through the bone, and there be subsequent displacement. The swelling subsided in four or five days, and as all seemed secure, I removed the dressings, and heard no more of the matter until the 11th of May, ult., when I was called to see the patient again, and found that he had met the day before, with precisely the same accident, at the old point, and by the same cause, being tripped down by a playmate. This time the swell- ino- and other symptoms of inflammation, were greater than before The anterior edge of the clavicle was entirely continuous, but he could not raise the arm. I merely directed him to keep to his bed until the swelling and inflammation should in a measure subside. In three or . Am. Journ. Med. Sci., vol. xxxi. p. 473, from Journ. de Med. et Chirurg. Prat., July, 1842. 78 BENDING, PARTIAL FRACTURES, AND FISSURES. four days he was about. The callus left is not large, still it is quite evident." The following examples which have come under my own observation, will illustrate more completely their usual history and symptoms:— A. B., aged three years, fell from the sofa upon the floor, striking, it is thought, on her right shoulder. Two days after this, she fell again, and then, for the first time, Mr. B. noticed the deformity. She was brought to me three days after the second fall. There existed then a round, smooth projection at the outer end of the middle third of the clavicle. It felt hard, like bone. The line of the clavicle was not changed. I advised a handkerchief sling, simply to steady and support the arm. Seven months after the accident, she fell sick and died. The projection continued at the time of death, only slightly diminished. H. S., aged six years, was thrown from a horse, partially breaking his left clavicle, near its middle. Dr. Sprague, of Buffalo, was em- ployed. The projection in front was for several days very apparent, and was examined by myself at Dr. Sprague's request. The bone cfid not seem to be out of line. Five years after the accident, I examined the lad, and could not find any trace of the original injury. September 25, 1855. Mrs. T. C. brought to me her infant child, then but two weeks old. Upon the left clavicle, at a point a little nearer the acromion process than the sternum, was an oblong swelling-, three-quarters of an inch in length, smooth and hard like callus; the skin was not reddened, nor tender. There was no motion or crepitus, and the line of the axis of the bone was perfect. The mother, who had been put to bed by a midwife, thinks the injury occurred in the act of birth, although she did not notice the swelling until a week after. October 20. Nearly one month later, I found no change in the con- dition of the bone ; the hard lump remained, but it was still entirely free from tenderness. I have not seen the child since. An infant boy, three years old, fell, August 12,1857, from the hands of the nurse. The child cried, but the point of injury was not de- tected until the third or fourth day, although the mother examined the shoulders and neck carefully at the time. She is quite certain that if any swelling or discoloration had been present she would have seen it then, or on the subsequent days, while washing and dressing the child When first seen it was very distinct, but not so large as at present. August 19. The child was brought to me. A little to the sternal side of the middle of the right clavicle there was an oblong node-like swelling of the size of the half of a pigeon's egg, hard, smooth, and feeling like bone; there was no discoloration or swelling of the integu- ments; no crepitus or motion; the line of the clavicle°seemed nearly or quite unchanged. J I have not noticed this variety of accident in any other bone except the clavicle, yet it is not improbable that it happens occasionally and perhaps quite as often, m other long bones, but that its existence is not elsewhere so easily recognized. Of one hundred and five fractures of the clavicle, recorded by me PARTIAL FRACTURE OF THE LONG BONES. 79 twenty-two were partial fractures; and of these six were spontaneously and immediately restored to their natural axis. In explanation of the fact that hospital surgeons have not observed so large a proportion of partial fractures of the clavicle, it must be stated that nearly all these cases of partial fracture were drawn from private practice. Accidents of this class may be often met with in dispensaries, but they are seldom found in hospitals. Experiment.—In fourteen experiments upon the bones of chickens, a partial fracture, with immediate and spontaneous restoration, has occurred but once. In nine of these cases the bones were only bent, and in five they were partially broken; an immediate restoration has occurred, therefore, in one case out of five of partial fracture; while in my reported examples of partial fracture of the clavicle it has been noticed about once in every three or four cases. The following is the experiment to which I have referred:— I produced a partial fracture of the tibia in a chicken six weeks old. The fracture was near the middle of the bone. I felt it break under my finger; but on removing the pressure, it immediately and spon- taneously resumed the straight position. I dissected the limb on the tenth day. The line of the axis of the bone was perfect; but on the fractured side was a node-like enlarge- ment, sufficient to be distinctly felt and seen before the soft parts were removed. Pathology.—In no case, except in my single experiment upon the bone of a chicken, has the actual condition been determined bydis- section, and if any question has existed heretofore as to the possibility of an immediate and spontaneous restoration after a partial fracture, this experiment ought to decide it in the affirmative; but then the first nine experiments already quoted have shown that a mere bending with immediate restoration leaves no such traces or signs as have been de- scribed as following these accidents. We have, therefore, the negative argument that, since a bending with restoration leaves no signs, these examples reported by myself and others as having occurred, and as having been followed by a node-like swelling, etc., must have been partial fractures. Moreover, in one of the cases of immediate resto- ration reported by Blandin, there was a feeble crepitus; and in another, the subsequent displacement proved the correptness of his diagnosis. , „ . . „ -, . We conclude, then, that these are examples of partial fracture, but that the number of bony fibres which have given way are too incon- siderable, as compared with those not broken, to affect materially the elasticity of the bone. , , . Diaqnosis.-The diagnosis will depend somewhat upon the history of the accident as well as upon the present symptom* In no instance, where I could ascertain the cause, have I known an incomplete frac- ture of this variety produced by any other than an indirect blow and where the clavicle has been the seat of the °™*™^™^£ has been received upon the end of the shoulder T^« &«'P^8^ therefore, equal significance in its relation to either of the^varieties^ot partial fracture: but in the case of a partial fracture with a permanent 80 BENDING, PARTIAL FRACTURES, AND FISSURES. curvature, the diagnosis would be complete without the history, while in this case it might not be, and a knowledge of the manner in which the accident occurred would, therefore, be of great importance. The signs, then, after a knowledge of the fact that a blow has been received upon the shoulder, are a node-like swelling upon the anterior or upper face of the clavicle, generally in its middle third, this swell- ing being hard, smooth, oblong; the skin only slightly or not at all swollen or tender, and in no way discolored, as it would have been had the swelling upon the bone been the result of a direct blow, and the line of the axis of the bone unchanged. I have never detected motion or crepitus at the point of injury, yet we have seen that Blan- din was able to detect both in one instance; nor has it ever occurred to me to see the swelling upon the bone until two or three days after the injury was received. We are not likely, therefore, to recognize this accident immediately after its occurrence. Treatment.—In the case of the clavicle, neither bandages, slings, compresses, nor lotions can be of much service. Yet no harm can arise from employing a simple sling and roller to confine the arm; and it is always proper to enjoin some degree of care in using the arm of the injured side. The consolidation will be speedily accomplished, and after a time the ensheathing callus will wholly disappear. If a similar accident should occur in any other of the long bones, as retentive and precautionary means, splints ought to be applied, at least for a few days. 2. Partial Fracture without immediate and spontaneous restoration of the lone to its natural form.—The causes of this accident are the same with those which produce simple bending, or partial fracture with im- mediate and spontaneous restoration, from which latter they differ probably in the greater extent of the bony lesion. Perhaps, also, they differ sometimes in the peculiar form and degree of the denticulation at the seat of the fracture; in consequence of which an antagonism of the fibres takes place, preventing a restoration of the bone to its original form. They constitute a large majority of those examples of partial frac- ture which come under our observation in the various long bones. In one hundred and five fractures of the clavicle, it has been observed by me sixteen times. In two hundred and nine fractures of the radius and ulna, it has occurred twelve times. It has not happened to me to meet with this fracture in any other bone; but examples have been mentioned as having occurred in the humerus, ribs, femur, tibia, and fibula. Very few surgeons have spoken of partial fractures in the clavicle, while Jurine, Syme, Liston, Miller, Norris, and many others, have declared that it is much more frequent in the bones of the forearm than elsewhere. This does not agree with my experience, according to which it occurs oftener in the clavicle than in the forearm; a discrepancy which I cannot very well explain, except by supposing that, in the case of the clavicle, the accident has either been over- looked entirely or misapprehended. Blandin, who, we have seen, has PARTIAL FRACTURE OF THE LONG BONES. 81 reported five cases of partial fracture of the clavicle with immediate restoration, states distinctly that in two of these cases distinguished Fig. 22. Fig. 23. Partial fracture with- out restoration of the bone to its natural form. Partial fracture of the clavicle without spontaneous restoration. From nature; taken three weeks after the accident. surgeons of Hopital Beaujon and Hotel Dieu failed to recognize it. Says Turner: "The next I shall descend to is that of the clavicle or collar-bone, which I have found the most frequently overlooked, I think, of any other, till it has been sometimes too late to remedy, especially among the children of poor peo- ple ; for, though they find these little ones to wince, scream, or cry, upon the taking off or putting on their clothes, yet, seeing that they suffer the handling of their wrists and arms, though it be with pain, they suspect only some sprain or wrench, that will go away of itself, without regarding anything further or looking out for help; whereas, this fracture discovers itself as easily as most others. For not only the eye, in examining or taking a view of the part, may plainly perceive a bunching out or protuberance of the bones when the neck is bared for that purpose, with a sinking down in the middle or on one side thereof, which will be still more obvious on comparing it with its fellow on the other side: but when it is more obscure, and the bone, as it were, cracked only—a semi-fracture, as we say—yet, by pressing hard upon the part, from one extremity to the other, you will find your patient crying out when you come upon the place; and by your fingers, so examining, sometimes perceive a sinking farther down, with a crackling of the bone itself."1 Erichsen, who regards all of these cases as mere bendings of the bones, remarks that it "most commonly occurs in the long bones, especially the clavicle, the radius, and the femur."* He says, more- ' Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 255. 8 Science and Art of Surgery, Phila. ed., 1854, p. 180. 82 BENDING, PARTIAL FRACTURES, AND FISSURES. over, "Fracture of the clavicle in infants not unfrequently occurs, and is apt to be overlooked. The child cries and suffers pain whenever the arm is moved. On examination, an irregularity, with some protuberance, will be felt about the centre of the bone."1 The reader will not fail to recognize, in these symptoms the incomplete fracture of which we are now speaking, although Erichsen evidently believes them to be examples of complete fracture. In addition to this testimony as to the frequency of these fractures in the clavicle, I will only mention that Johnson, in his review of Markham's Olservations on the Surgical Practice of Paris, says that " many surgeons have noticed the incomplete fracture of the clavicle, as of other bones, which takes place in the young."2 Pathology.—The following experiments will assist in the elucidation of this point of our subject:— Experiment 1.—I bent the leg of a chicken five weeks old. It cracked under my fingers, and remained bent. Having waited a few seconds, and finding that it was not restored to position, I pressed upon it and made it straight. The chicken walked off without any limp. On the fourth day, before dissection, the bone looked as if it was still bent; but on removing the soft parts, the line Flg- 24« of the axis of the bone was found to be straight. The areolar tissue under the skin was infiltrated with lymph, which was most abundant near the fracture, and gradually diminished towards each extremity of the limb. This effusion was confined almost entirely to the front of the limb, or to that side which had been broken, and constituted the greater part of the enlargement which I had noticed before the dissec- tion was commenced, and which then felt-like bone. On the front of -the bone, also, underneath the pe- riosteum, there was a loose, honeycomb deposit of ensheathing callus, about one line in thickness, and extending upward and downward about half an inch. This callus surrounded the bone in three-fourths of its circumference; but there was no callus on its posterior surface. It was also deficient exactly along the line of fracture, in front and on the sides, in con- sequence of which an oblique groove remained, indi- cating the seat of the fracture. Experiment 2.—I produced a partial fracture at the same point, in a chicken five weeks old. The bone was felt to crack, and, as it would not straighten spon- taneously, I immediately bent it back to its place. On the eighth day I dissected the limb. The ap- pearances, before and after dissection, were the same as in Experiment 1. No ensheathing callus on the posterior surface. The furrow over the line of fracture Partial fracture after union is con- summated. 1 Science and Art of Surgery, Phila. ed., 1854, p. 205. 2 Lond. Med.-Chir. Rev., vol. xxxiv. p. 474, 1841. PARTIAL FRACTURE OF THE LONG BONES. 83 was not quite so deep as in Experiment 1. On opening into the centre of the shaft I found the canal nearly filled with bony matter opposite the fracture, and the broken ends were completely united. Experiment 3.—This was made upon the opposite leg of the same chicken, and with the same results. Experiment 4.—Same as Experiment 1, except that I supposed at first the bone was broken completely off. The dissection showed, however, that such was not the fact. The posterior wall was a little thickened, but the ensheathing callus was only in front and on the two sides. The medullary canal was closed with bone. So early as the year 1673, a dissection made by Grlaser demon- strated incontestably the existence of partial fractures in the shaft, and in the direction of the diameter of long bones.1 Camper, in 1765, again described a specimen which he had seen;2 and Bonn, in 1783, added a third positive observation.3 M. Gimele is, therefore, in error when he ascribes to Campaignac the credit of having first proven by dissection their existence, in a paper communicated to the Academy of Medicine at Paris, in 1826. Campaignac, however, seems to have been the first who described very particularly the condition of this fracture. He has recorded the history and dissection of two cases, one of which occurred in the fibula, and one in the tibia. The first of these cases was a girl twelve years old, who survived the accident just eight weeks. The fracture had occurred near the middle of the bone, and upon the anterior and internal side; in which direction, resting against the tibia, the bone was found inclined. " The bony fibres had been broken at different lengths, almost exactly like what takes place in the branch of a tree which has been partially broken; and, as we see sometimes in this latter case, the bundles of splintered bony fibres abutted upon them- selves, and did not take their places when we endeavored to restore them ; so the abnormal angle which the fibula represented could not be effaced, the ends of the divided fasciculi not restoring themselves to their respective places. This disposition might be especially seen toward the anterior part of the internal face, where a packet of fibres coming from below, was braced against the upper lip of the division, which it thus held open. This opening at first made me think that the fragments could not have been well consolidated; but I assured myself that it was, and the fact was subsequently confirmed by the Academy of Medicine; all the points which were in contact were found intimately united."4 Diagnosis.—The diagnosis is not difficult. The distortion indicates sufficiently the existence of a fracture, while the complete absence of crepitus in nearly all cases, and of either overlapping or lateral dis- placement, must, generally, especially where the accident has occurred in a child, sufficiently indicate that the fracture is incomplete. It will 1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn. iii. p. 424. 2 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, 1771, vol. iii. p. 537. 5 Malgaigne, op. cit., p. 44, from Descript. Thes. Ossium Morb. Hoviani, 1783. 4 Des Fractures Incompletes et des Fractures Longitudinales des Os des Membres ; par J. A. J. Campaignac. Paris, 1829, pp. 9-10. 84 BENDING, PARTIAL FRACTURES, AND FISSURES. assist the diagnosis also to notice that these accidents are almost con- fined to the middle third of the long bones; and they are produced usually by a bending of the bones, the forces operating upon the extremities, and not directly upon the point which is broken. In complete fractures, also, preternatural mobility is so constant a sign as to be regarded as diagnostic, while here there is almost always a great degree of immobility at the seat of fracture. The angle made by the projecting extremities is usually rather gentle and smooth ; at other times it is abrupt, indicating a greater amount of fracture, or that the outer fibres are broken more irregularly. The power of using the limb is generally sensibly impaired, but not completely lost. Treatment.—Jurine, Murat, Campaignac, Gulliver, Malgaigne, with some others, have noticed the fact that it is often difficult, and some- times quite impossible, to restore these bones to position; a cir- cumstance which they have justly ascribed to that condition of the fragments described by Campaignac. The broken extremities of the fasciculi become braced against each other, and effectually resist all efforts to straighten the bone; unless, indeed, so much force is used as to render the fracture complete: a result which, if it should chance to happen, need not occasion any alarm, since, while it enables us at once to restore the bone to line, does not much increase the danger of lateral displacement and overlapping. That the fracture has become com- plete we may know by a sudden sensation of cracking, by the increased mobility, and by the crepitus which is now easily developed. But we need not, on the other hand, be over anxious to straighten the bone completely, since experience has shown that after the lapse of a few weeks or months the natural form is usually restored spon- taneously. I am not now speaking of those cases in which the resto- ration occurs immediately, where it is probable that the splintered fibres offer no resistance to the restoration; but only of those in which the bone straightens so gradually as to induce a belief that the broken ends are the cause of the resistance. To this variety of accident belong cases one, five, six, seven, and eight, published in my Beport on De- formities after Fractures;1 in one of which the natural axis was resumed in less than four weeks. In a case mentioned by Gulliver, it required about the same time to render the bones of the forearm perfectly straight; and in one case mentioned by Jurine, at the end of six months it was "difficult to say which arm had been broken, and at the end of one year it was impossible." Jurine attributes this restoration to " muscular action, or more especially to the reaction of the compressed bony plates;" but while it is easy to understand how the reaction of the compressed fibres may accomplish the gradual restoration, I am unable to understand in what manner muscular action contributes to this result, since most of the muscles attached to the long bones operate so much more ener- getically in the direction of their axes than in the direction of their diameters. Indeed we have often seen these bones bent after com- plete fractures, and before the union was consummated, by muscular action alone. 1 Trans. Am. Med. Assoc, vol. viii., 1855, pp. 392-5. FISSURES. 85 I repeat, then, that the gradual restoration of these bones is due to the same circumstance which produces at other times an immediate restoration, namely, the elasticity of the unbroken fibres, but which elasticity, in this latter instance, is, for a time, effectually resisted bv the bracing of the broken fibres. At length, however, in consequence of the gradual absorption of the broken ends, this resistance is removed, and the bone becomes straight. If this absorption refuses to take place, and the fibres continue pressed forcibly against each other, as in the case described by Campaignac, then the bone remains perma- nently bent. Having straightened the bone as far as is practicable, it only remains to secure the fragments in place by suitable bandages or splints. If the restoration is incomplete, these means may assist the efforts of nature in accomplishing a gradual restoration. It is scarcely necessary to say that extension and counter-extension avail nothing in partial fractures. § 3. Fissures. These constitute the second principal form of incomplete fractures, or those in which the fracture is accompanied with no appreciable bending, which occur almost exclusively in inflexible bones, such as the compact bones of adults, and more often in the direction of their axes than of their diameters. They are complete so far as they extend, but they do not completely sever the bone so as to form two distinct fragments. They have been most frequently observed in the flat bones, such as the bones of the skull, and in the upper bones of the face; occasionally in the long bones, both in their diaphyses and epi- physes, and rarely in the short bones. ■M. Gariel has reported, in the Bulletins de la Societe Anat., for 1835, a case of fissure of the inferior maxilla, occurring in a lad sixteen or eighteen years old. Palletta found a fissure extending partly through the third dorsal vertebra, in a man who had fallen upon his back eleven days before; and M. Lisfranc has mentioned a remarkable case of fissure and partial fracture, with bending of five ribs in the same person.1 Malgaigne believes that he has seen one example of this variety of incomplete fracture of the scapula, occurring through a portion of the infra-spinous region. I have myself elsewhere recorded another, as having been found in the skeleton of Nimham, an Oneida Indian, 'who was a great fighter, and who died when about forty-five years old, in consequence of severe injuries received in a street brawl; but his death did not occur until four or five months after the receipt of the injuries. In addition to this fracture of the right scapula, five of his ribs were broken, and both legs, all of which, except the scapula, had united completely by intermediate and ensheathing callus. The scapula was broken nearly transversely, the fracture com- 1 Des Fract. Incomplet. et des Fissures, par J. A. J. Campaignac, 1829, p. 20. 86 BENDING, PARTIAL FRACTURES, AND FISSURES. mencing upon the posterior margin at a point about three-quarters of an inch below the spine, and extending across the body of the bone one inch and three-quarters, in a direction inclining a little upwards, being irregularly denticulate and without comminution. The frag- ments were in exact opposition, and, throughout most of their extent, in immediate contact. They were, however, not consolidated at any point, but upon either side of the fissure there was a ridge of en- sheathing callus, of from one to three or four lines in breadth, and of half a line or less in thickness along the broken margin, from which point it subsided gradually to the level of the sound bone. The same was observed upon the inner as well as upon the outer surface of the scapula. This callus had assumed the character of complete bone, but it was more light and spongy than the natural tissue, and the outer surface had not yet become lamellated. Its blood-canals and bone-cells opened everywhere upon the surface. Directly over the fracture, and between its opposing edges, no callus existed, but as the bone had lain some time in the earth before it was exhumed, it is probable that a less completely organized intermediate callus had occupied this space, and that, owing to the less proportion of earthy matter which it contained, it had become decomposed and had been removed. M. Voillemier found the head of the humerus penetrated by two or three fissures;1 and M. Campaignac has reported the case of a lad ten or twelve years old, who was compelled to submit to amputation of his arm at the shoulder-joint, in consequence of a severe injury, in which the humerus was found fissured from the insertion of the del- toid to near the condyles, extending through the entire thickness of the bone, and the edges of the fissures so much separated toward its lower extremity as to admit the blade of a knife.2 Chaussier has related a case in which a criminal, who died soon after having sub- mitted to the torture, was found to have a nearly longitudinal fissure of the radius in its upper fourth, and which penetrated half way through the thickness of the bone.3 Gulliver saw a fissure in the pelvis of an infant.1 Malgaigne has seen two specimens of this frac- ture in the iliac bones, both of which belonged, as he thinks, to adults; in one, the fissure was limited to the internal table;5 and in the case of the lad reported by Gariel, as having a fissure of the inferior maxilla, there was also found a fissure of the left ilium, but which was limited to the outer table.6 M. J. Cloquet has mentioned a case of fissure of the shaft of the femur passing through the condyles and extending upward to near the middle of the bone. The fissure was produced by a bullet, which had completely traversed the bone from behind forward, a little above the condyles.7 M. Malgaigne has also represented, in one of his plates, 1 Malgaigne, op. cit., p. 35. 2 Campaignac, Des Fract. Incomplet., &c, p. 24. 3 Med. Legale, p. 447 et seq. * Gazette M6d., 1835, p. 472. 5 Op. cit., p. 34. B Bulletins de la Soc. Anat., 1835, p. 24. i Tbese du Concours de Pathol. Externe, 1831, pi. xii., fig. 7. Also, Des Frac, etc., par Campaignac, 1829, p. 19. FISSURES. 87 a fissure of the femur extending along the front of the bone, some- what irregularly, from a point a little below the trochanter minor to near the condyles.1 The bone was presented to the Museum of Val- de-Grace, by M. Fleury; but it is to be regretted that we have no farther account of this remarkable specimen. Certainly, in the com- plete absence of any farther history of the case, one might be justified in expressing a doubt whether it was not a fissure occasioned by the contraction consequent upon exposure and drying after death. The following account of a fissure of the neck of the femur, of the same character with those which now occupy our attention, is copied from the proceedings of the " Boston Soc. for Med. Improvement," at its regular meeting in September, 1856 :— " Partial Fracture of the Neck of the Femur in a man set. 44 years. Specimen shown by Dr. Jackson.—The fracture, which appears as a mere crack in the bone, commences anteriorly just above, but very near to, the insertion of the capsular ligament, runs along this inser- tion for about an inch, and then extends directly upward to the mar- gin of the head of the bone. From this last point it crosses the upper surface of the neck almost in a straight line, and at a little distance from the margin of the head, but afterward approaches very closely to this margin posteriorly; it then turns downward and obliquely forward, and stops at a point about half way between the small tro- chanter and the head of the femur, and two thirds of an inch or more anteriorly to the line of this trochanter. The fracture then involves about three-fourths of the neck of the bone ; the inner-anterior portion only being spared. There is considerable motion between the neck and the shaft, and the fracture could, undoubtedly, be completed with- out the application of any extraordinary force. Dr. J. referred to other cases of partial fracture; but a fracture of this sort, as occurring in this situation, and in a fully adult subject, he believed had never before been described. There was, also, in this case, a transverse frac- ture of the same femur midway, with a split extending upward nearly to the neck of the bone; and still further, a fracture of the spine. The patient, a laboring man, fell through two stories of a building and down upon a hard floor. On the same day he entered the Massachu- setts General Hospital, and on the 18th day from the time of the acci- dent he died. The femur is perfectly healthy in structure, and no changes are observable in the bone about the fracture."2 _ Whatever doubts may have been thrown upon the possibility of this accident, as applied to the neck of the femur, by the ingenious argu- ments of Robert Smith, of Dublin,3 the question is now at least deter- mined by an incontestable fact. Dr. Smith had rendered it quite pro- bable that both Colles and Adams were mistaken, and that the cases described by them were examples of impacted fracture, and not of partial fracture; but, in arguing the improbability of its occurrence, • Op. cit., p. 37, pi. 1, fig. 1. _, , _ . 2 Bost. Med. and Surg. Journ., vol. lv. p. 351. See, also, Amer. Journ. Med. Sci. for 1857, p. 306 ; with engraving. » Treatise on Fractures in the Vicinity of Joints, etc., by Robert Wm. Smith, Dublin, 1854, p. 44 et seq. 88 BENDING, PARTIAL FRACTURES, AND FISSURES. from the infrequency of fractures of the neck of the femur in early life, he overlooked the fact that there were two forms of incomplete fractures, and that it was only the " green stick" fracture which be- longed mostly to childhood; " fissures" being found most often in the bones of adults. Indeed, I think the example recorded by Tournel in the Archives de Medecine, had already, so early as the year 1837, established the possibility of a "fissure" in the neck of the femur; al- though by Malgaigne this case has been mentioned as an example of that other variety of partial fractures which is almost peculiar to childhood, and in which the bones yield quite as much by bending as by breaking. But the man was eighty-five years old, and, having died three months and a half after the accident, a long crevice was found, extending nearly through the neck of the femur, partly within and partly without the capsule. I have seen, in Dr. Mutter's valuable collection of bones at Phila- delphia, a specimen of fissure of the trochanter major, which, it is believed, occasioned the death of the patient by hemorrhage. Gulliver says there is an example of a fissure in a patella belonging to the museum of the Edinburgh College of Surgeons; the fissure tra- versing its articular face only.1 The first example of a fissure of the tibia is recorded by Corn. Stal- part Vander-Wiel, in 1687; and indeed this is, according to Cam- paignac, the first exact observation of this species of fracture which our science possesses, although its existence had been recognized by the most ancient authors. A servant had been kicked by a horse, and after a time, pain continuing in the limb, his surgeon, Dufoix, suspected a fissure of the tibia, and having cut down to the bone, a cure was soon effected.2 In the Dupuytren Museum, at Paris, there are two tibise with linear fractures; one without history, and the other presented by MM. Mar- jolin and Bullier, " and which had been broken by a ball."3 In the example related by Campaignac, a woman, having leaped from a second-story window, died immediately, and upon examination she was found to have three fissures in the upper portion of the left tibia, one only of which entered the articulation.4 The soldier spoken of by Became, having been struck upon the middle of the tibia, continued to march for some distance; but serious complications ensuing, he finally died. A fissure was found, after death, near the middle of the shaft of the tibia.5 LeVeille relates that an Austrian soldier had his leg penetrated by a ball at the battle of Marengo; from thence he marched several miles and then was transported to Pavia. Although the wound at first seemed very simple, graver symptoms soon followed, and it became necessary to amputate the thigh. Dissection showed that the ball had occasioned several oblique and longitudinal fissures, which extended nearly the whole length of the shaft of the bone.6 1 Malgaigne, op. cit., page 35. 2 Campaignac, op. cit., p. 17. 3 Malgaigne, op. cit., p. 36. 4 Campaignac, op. cit., p. 21. s Abrege des Maladies qui attaquent la Substance des Os. Toulouse, 1775, p. 134. h Malgaigne, op. cit., p. 39. See, also, Chapter ou Gunshot Fractures in this volume. FISSURES. 89 Many similar examples of fissure from "perforating" gunshot wounds of the bone have been observed during the late war in this country ; but as these examples belong peculiarly to military surgery, they will be discussed more at length in the chapter on gunshot frac- tures. Duverney saw a priest who had fallen and bruised the middle of his left leg; the swelling and pain consequent upon which were subdued after a few days. The patient believed himself cured, and acted ac- cordingly. Suddenly, in the night, he was seized with an acute pain in the limb; and on cutting down to the bone, a bloody serum escaped from between it and the periosteum, and the bone was discovered to be fissured longitudinally. Subsequently the tibia was trephined, but the fissure did not reach the marrow. He recovered completely in less than two months. The same writer mentions another case in which a soldier received the kick of a horse in the middle of his left leg which was followed immediately by great pain, and subsequently by much inflammation, and even gangrene of the skin. The wound, however, cicatrized kindly, but after three months he was seized suddenly with a severe pain in the limb; and, after the trial of many remedies, resort was finally had to the knife, when the tibia was seen to be discolored, and cracked longitudinally. On the following day the bone was opened over the course of the fissure with a chisel and mallet, and the patient was at once relieved by the escape of a yellowish and very offensive matter. At the next dressing, the bone was opened more freely by several applications of the trephine, and an abscess was exposed in the centre of the bone. The patient finally recovered after about four months.1 M. Campaignac saw, also, at the hospital La Charite', the tibia of a woman, set. 38 years, upon which were found four fissures; the report of which case is accompanied with a wood-cut illustration.2 Fissures may occur probably at all periods of life, but they are more frequently found in the bones of adults. Campaignac, however, men- tions a fissure of the humerus in a child ten or twelve years old, and Gulliver has seen a fissure in the pelvis of an infant. Etiology.—They may be occasioned by most of those causes which produce fractures in general, such as direct or indirect shocks; but they are occasioned much more often by direct blows, especially when inflicted upon bones imperfectly covered by soft parts, such as the tibia. Bullets, having violently struck or penetrated the bone, have frequently occasioned fissures. Their course may be parallel with the axis of the bone, oblique or transverse; they are often multiple; some merely enter the outer laminee, others open into the cellular tissue, and others still divide both surfaces of the bone through and through; and, according as they penetrate more or less deeply the bone, their lips will be found to be more or less separated. They frequently extend into the joint surfaces. Diagnosis.__The signs which indicate the existence of a fissure must, in a large majority of cases, be insufficient to determine fully the ' Malgaigne, op. cit., p. 39 et seq. 2 Campaignac, op. cit., pp. 21-22. 7 90 FRACTURES OF THE NOSE. diagnosis during the life of the patient. It is not probable that such fissures could ever be clearly made out by the touch alone, where the skin is not broken, since the pain, swelling, suppuration, etc., are only characteristic of inflammation of the bone or of its coverings, and might be equally present whether a fracture existed or not. In those rare cases only in which the flesh is torn off* and the surface of the bone is brought directly under the observation of the eye, will the diagnosis become certain. Treatment.—Fortunately, an error in judgment in this matter will not materially, if at all, prejudice the interests of the patient; since whatever may be the fact in other respects, if the bone, or its perios- teum, or its medullary membrane, is inflamed, and rest, with anti- phlogistics, does not accomplish its speedy resolution, incisions and perforations become inevitable, if we would give either safety or relief to the sufferer. Accordingly, in the inflammation and suppuration consequent upon these fractures, we have seen that it has been occa- sionally found necessary to lay open the soft tissues freely, and even to trephine the bone at one or more points. Fissures in Cartilage.—I have once met with a fissure in the thyroid cartilage, which constitutes, so far as I know, the only example upon record of a fissure in cartilage.1 CHAPTER VIII. FRACTURES OF THE NOSE. § 1. Ossa Nasi. Of twenty-four cases of fracture of the ossa nasi recorded by me only fourteen were seen by a surgeon in time to afford relief. It seemed to me necessary, therefore, that the student should be in- structed how frequently the nature of this accident is overlooked by the friends, and even by the surgeon himself, to the end that he might be thus admonished of the necessity of always instituting, in such cases, careful and thorough examinations. In some of the cases recorded in my notes, where surgeons were called in time, and a de- formity remains, it is not improbable that the accident was not recog- nized. The rapidity with which swelling ensues after severe blows upon the nose, concealing at once the bones, and lifting the skin even above its natural level, explains these mistakes. The nose, also, is remarkably sensitive, and the patient is often exceedingly reluctant to submit to a thorough examination. It ought, however, not to be forgotten that the omission on the part of the surgeon to do his duty 1 See Buffalo Med. Journ., vol xiii. Article entitled Fracture of the Thyroid Car- tilage. OSSA NASI. 91 will not always be excused, even though the patient himself has pro- tested against his interference, especially where an organ so prominent, and so important to the harmony of the face, is the subject of his neglect or mal-adjustment; since the most trivial deviation from its original form or position, even to the extent of one or two lines, becomes a serious deformity. When the ossa nasi are struck with considerable force, from before and from above, a transverse fracture occurs usually within from three to six lines of their lower and free margins, and the fragments are simply displaced backwards, or if the blow is received partially upon one side, they are displaced more or less laterally. This is what will happen in a great majority of cases, as I have proven bv examinations of the noses of those persons who have been the subjects of this acci- dent, both before and after death, by repeated experiments upon the recent subject. These fragments are generally loose and easily pressed back into place by the use of a proper instrument. A silver female catheter, which we have seen recommended by surgeons, may answer well enough in a few instances, but it will more often fail. The diameter of the meatus at the point where the instrument must touch in order to make effective pressure upon the ossa nasi, is on the average not more than two lines, and when the membrane which lines it is injured, it becomes quickly swollen, and reduces the breadth of the channel to a line or less. Under these circumstances, any instrument of the size of a female catheter could only be made to reach and press against the nasal process of the superior maxilla, which is too firm and un- yielding to allow it to pass without the employment of unwarrantable force. In this way it happens that the operator is occasionally sur- prised to find how much resistance is opposed to his efforts to lift the bones, and after repeated unsuccessful attempts the case is not unfre- quently given over. If, however, he had used a smaller instrument, he would have found almost no resistance whatever. A straight steel director, or sound, or sometimes even a much smaller instrument, if possessing sufficient firmness, is more suitable than the catheter. For the same reason, also, one ought never to wrap the end of the instru- ment with a piece of cotton cloth as some have, I suspect, without much consideration, recommended. What I have said of the facility with which these bones may be' replaced, when a proper instrument is employed, is true only when the treatment is adopted immediately, or at most within a few days after the accident. Boyer, Malgaigne, and others have noticed the fact that these frac- tures are repaired with great rapidity. Hippocrates thought the union was generally complete in six days; and in a case which has come under my own observation, the fragments were quite firmly united on the seventh day. Nor has Malgaigne, whose observations are always very accurate, overlooked the fact, also, that their repair is effected without the in- terposition of provisional callus, but, as it were, "par premiere inten Hon" My own observation confirms this statement. Among all the 92 FRACTURES OF THE NOSE. specimens which I have seen in the various college and private col- lections illustrating fractures of the ossa nasi, and amounting in all to over forty, in no instance has there been detected, after a careful ex- amination, the slightest trace of provisional callus. I am not certain that it will always be found so easy to retain these loose fragments in place, as it is to replace them. The very swelling which takes place so promptly under the skin tends to depress the fragments, unsupported as they are by any counter force; a tendency which, possibly, is in some instances increased by attempts on the part of the patient to clear his nostrils by snuffing and hawking. I have, in one instance, noticed very plainly a motion in the fragments when such efforts were made. How we are to remedy this I am not prepared to say. None of the plans which I have seen suggested possess, in my estimation, very much practical value. Few patients will consent to the introduction of pledgets of lint, or of stuffed bags, or, indeed, of anything else, sufficiently far up into the nostrils to answer any useful purpose. The membrane is too sensitive and too intolerant of irritants to enable us to have recourse generally to such methods. Then, too, it would require, on the part of the surgeon, more than ordinary tact to accomplish so nice and delicate an adjust- ment of the supports from below as these cases demand, where the slightest excess of pressure, or the least fault in the position of the compress must defeat the purpose of the operator. Yet, if one were disposed to make the attempt in certain cases where the comminution was very great, or where, for any other rea- son, the fragments would not remain in place, I think there could be no better plan than to push up in succession a number of small pledgets of patent lint, smeared with simple cerate, to each one of which there has been attached a separate string, so arranged as that their relative position may be recognized, and that they may at a suitable time be removed in the order of their introduction. The employment of canulas, as recommended by Boyer, B. Bell, and others, allows of the nostrils being stuffed without interfering materially with the breathing; a provision, however, which is quite unnecessary with a majority of persons, so long as there exists no impediment to the free admission of air through the fauces. With nicely adjusted compresses made of soft cotton or lint, and secured upon the outside of the nose with delicate strips of adhesive plaster or rollers, we shall be better able to prevent the fragments from becoming displaced outwards than by moulds of wax, of lead, or of gutta percha, under which it is impossible to see from hour to hour what is transpiring. The complicated apparatus devised by Dubois and recommended by Malgaigne, to lift the bones and retain them in place, seems to me indeed very ingenious, but destitute of a single practical advantage. A more considerable force than that which I have first supposed will break, generally, the ossa nasi transversely and a little above their middle, while, at the same time, the nasal processes of the supe- rior maxillary bones may suffer slightly. With neither of these accidents is the cribriform plate of the eth- OSSA NASI. 93 moid likely to be broken or disturbed. Indeed, in numerous experi- ments made upon the recent subject, and in which the force of the blow was directed backwards and upwards, breaking and comminuting the nasal bones above and below their middle, with also the nasal processes of the superior maxillary bones, and the septum nasi, the cribriform plate of the ethmoid was, without an exception, uninjured. The exceeding tenuity and flexibility of the septum nasi at certain points prevents effectually the concussion from being communicated through it to the base of the brain. If, therefore, after these accidents, cerebral symptoms are occasionally present, as I have myself twice seen,1 they must be due rather to the concussive effects of the blow upon the very summit of the nasal bones, where they rest immediately upon the nasal spine of the os frontis, or to some direct impression upon the skull itself. The amount of force requisite to break in the nasal bones, at their upper third, is very great; no less, indeed, than is requisite to fracture the os frontis. If they do finally yield at this point, then no doubt the base of the skull must yield also. Nor do I think patients could often be expected to recover from an accident so severe. To this class of fractures belongs the specimen contained in my museum, in which not only both of the nasal bones are sent in—the nasal spine being broken at its base—but also the os frontis is depressed, the nasal pro- cesses of the upper maxillary bones are broken and greatly displaced, and the anterior half of the cribriform plate of the ethmoid is forced up into the base of the brain. If it is meant that in these cases the patient is in danger from injury done to the base of the skull through the fracture and depression of the ossa nasi, we can appreciate the value of the opinion; but we do not understand how this danger can exist when the nasal spine of the os frontis is not broken, and the upper ends of the nasal bones are not displaced backwards. But, ad- mitting that it were possible in this way to force up the base of the skull, it does not seem to me that we ought to attach any value to the advice occasionally given, to attempt to restore the broken ethmoid by seizing upon the septum and pulling downwards. A force suffi- cient to break the base of the skull never fails to comminute and detach almost completely the septum nasi. We are to proceed in such a case as we would in a case of broken skull. We must lay open the skin freely, and with appropriate instruments seek to elevate and remove, if necessary, the fragments. Indeed, after such accidents, we shall generally see plainly enough that death is inevitable, and that our services will be of no value. Occasionally, I have observed, the bones are neither broken at their lower ends nor through their central diameters, but only at their lateral, serrated, or imbricated margins. This is rather a displace- ment, or dislocation, than a fracture. It is more likely to happen, I think, in childhood than in middle or old age, as in the following example:— Thomas Kelley, aged four years, was kicked by a horse. 1 wo 1 Report on Deformities after Fractures, Cases 16 and 18. 94 FRACTURES OF THE NOSE. hours afterwards, when he was first seen by a surgeon, the nose and face were much swollen, and the fracture was overlooked. One year after the accident, I found both nasal bones depressed through nearly their whole length, and especially in their lower halves, The right nasal process was also much depressed, and the right nostril obstructed. The lachrymal canals upon this side were closed. Sometimes the lower ends of the nasal bones are bent backwards, or laterally, constituting a partial fracture. A lad, aged ten years, was hit by one of his mates accidentally with his elbow, upon the left side of his nose. I was immediately called, and found the lower end of the left os nasi displaced laterally and backwards, so that it rested under the lower end of the right os nasi. There did not appear to be any fracture beyond that which was in- evitable by the mere separation of its serrated margins from the bone adjoining. The angle formed by the bone at the point where the bending had occurred was smooth and rounded, and not abrupt as in a complete fracture. With a steel instrument, introduced into the left nostril, I attempted to lift the bone to its place. The membrane was very sensitive, and the patient very restless under my repeated efforts. I pressed up- wards with considerable force, and succeeded at length in bringing the bone nearly into position. It' there is more complete displacement, the upper ends are not usually forced backwards, but rather a very little forwards, from their articulations with the os frontis, and the bones then swing, as it were, upon the lower ends of the nasal spine, as upon a pivot. In this con- dition they are very firmly locked, and it requires considerable force, applied under their lower extremities, to restore them to place. Such seemed to be the position of the bones in the case of the lad Kelley, already mentioned, and also in a German, whose nose was flattened by a severe blow when he was eleven years old, whom I saw, thirteen years after the accident, in the Buffalo Hospital. In this last example the bones were very much displaced backwards. In children, also, the nasal bones may be spread and flattened, the lateral margins not being depressed or displaced, but only the mesial line or arch forced back, so as to press aside the processes of the supe- rior maxilla; which deformity may become permanent. A block of wood fell upon a child three weeks old, as she was lying in the cradle. The nature of the injury was not understood by the parents, and no surgeon was called. The ossa nasi are now, twelve years after the accident, much wider than is natural, and depressed; the nasal processes of the superior maxilla appearing to have been spread asunder. Jacob Kibbs, a German, aged seven years, fell from a height of forty feet, striking on his face. His parents did not suspect the injury, and no surgeon was called. Twenty-four years after this, I found the nose almost flat. The nasal bones appeared unusually wide, and were sunken between the processes of the upper maxillary bones, which latter might be recognized by two parallel ridges on each side, slightly rising above the level of the ossa nasi. FRACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 95 Benjamin Bell and others have spoken of tedious ulcers, polypi, necrosis, fistula lachrymalis, abscesses, impeded respiration, and im- pairment of the sense of smell and of speech, as circumstances apt to result from these injuries, and it is certain.that such consequences have occasionally followed; but they must sometimes be regarded as acci- dents due to the state of the general system, and as having no connec- tion with the fracture, except as this injury served to awaken certain vicious tendencies. Two years ago, a gentleman, then twenty-five years old, was struck accidentally upon the right side of his nose by a board, and the ossa nasi were displaced to the left. A surgeon made an attempt to reduce them, but did not succeed, and they have remained displaced ever since. The nose for a time was much swollen. A few months after the accident, a purulent discharge commenced from the right nostril, and at length an abscess formed in the right cheek. The abscess is now healed, but the nose continues to discharge pus, and occasionally it bleeds freely. There is a perforation of the septum, of the size of a three-cent piece, which is continuing to enlarge. No hereditary maladies exist in the family, except that, on his father's side, it has been generally observed that wounds do not heal kindly. The same is the fact with him. When a child, he was also very sub- ject to epistaxis; at sixteen, a pulmonary difficulty began, and he had more or less cough, with haemoptysis, for two years. Since then, his health has been good. He is a lawyer by profession, but of late he has lived in the country, upon a farm, and has accustomed himself to much out-door exercise. As to the prognosis in these fractures, I can only say that either owing to the ignorance and carelessness of the patients themselves, who neglect to call a surgeon in time, or to the difficulty of diagnosis, or to the greater difficulty in maintaining an adjustment of the frag- ments, it has hitherto happened that, after a fracture of the ossa nasi, more or less deformity has usually remained. I have seen but five which could be said to be perfectly restored. § 2. Fractures and Displacements of the Septum Narium. Fractures or displacements of the septum narium must occur to some extent in all fractures of the ossa nasi accompanied with depres- sion ; but they are also occasionally met with as the results of a blow upon the nose, which has been insufficient to break the bones, and in which only the cartilaginous portion of the nose has been bent inward upon the septum. Of these simple, uncomplicated accidents, I have seen eight; in four of which no surgeon was employed, or surgical treatment of any kind adopted, and it is quite probable that only in a small proportion of all the cases was the nature of the accident recognized. Such, at least, has been generally the statement of the patients themselves. The same causes will explain this which have been invoked to explain 96 FRACTURES OF THE NOSE. similar oversights in cases of broken ossa nasi. To which we may add, as an additional reason why it may be overlooked, the frequency of lateral distortions or deviations in the natural development of this septum. The cartilaginous portion of the septum is that which is most fre- quently displaced by violence, and then it is usually at the point of its articulation with the bony septum. Next, in point of frequency, the perpendicular nasal plate is broken, and especially where it ap- proaches the vomer. We omit in this enumeration, of course, those cases where the nasal bones themselves are broken down, in most or all of which, as we have already said, the perpendicular plate is more or less fractured and displaced. We cannot say how_ often the vomer is broken, since it is beyond our observation, except in autopsies. It is probable, however, that the force of the concussion rarely reaches it, the cartilage or the perpendicular plate giving way first and easily. Where the deviation is only lateral, the results are less serious, yet sufficiently so, in a few instances, to demand our attention. Lateral obliquity of the lower portion of the nose follows generally, but not uniformly, a lateral displacement of the cartilage, and when it does exist, it is not always proportioned to the amount of displacement existing in the septum, so that the septum is then made to project obliquely across the nasal passage, causing often a serious obstruction and permanent inconvenience. In one instance, also, I have known it to occasion a chronic catarrh. A lad, get. 15, was struck violently on the nose, which became im- mediately much swollen, but no surgeon was called. Eight years after, I found the septum displaced laterally, and to the left side, pro- ducing also a slight lateral inclination of the end of the nose. He was unable to breathe freely through the left nostril, and from the same side a catarrhal discharge had continued from the time of the accident. The following example, in which the accident has been followed by a morbid condition of the cutaneous glands, is of more difficult ex- planation:— . ,111 A young man, ast. 23, called upon me, supposing that he had a polypus nasi. I found that in consequence of a fall upon the ice, seven years before, the septum narium had been displaced to the right so as to almost completely close this nostril. In very cold weather, when the vessels of the membrane are contracted, the passage is more free. The left nostril is proportionably wide. During the last four or five years, the right side of his face has been subject to profuse perspiration. It is almost constant in summer, and only occasional in winter. The line of division between the perspir- in°- and non-perspiring portions of the face passes perpendicularly from the top of the centre of the forehead, along the ridge of the nose, and down to the centre of the chin. The phenomenon is due, perhaps, to an increased vascularity in the right side of the face; possibly to some peculiarity in the condition of the nervous trunks, occasioned by the nasal obstruction. A depression of the cartilage forming a portion of the ridge of the FRACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 97 nose is necessarily accompanied with a corresponding degree of late- ral displacement, with or without fracture, of its perpendicular portion, and produces, therefore, not only great deformity, sometimes a com- plete flattening of the end of the nose, but, also, in some instances, complete obstruction of the nostrils. We conclude, from all that we have seen, that fractures and displace- ments of the septum narium are generally followed by permanent deformity, and occasionally with still more serious results. We sug- gest, therefore, a more careful examination in recent injuries, with a view to the ascertainment of its lesions, and it would be well, cer- tainly, if we could devise some reliable mode of treatment. It is doubtful whether a partition so thin and unsupported can ever be well adjusted and supported by artificial means. We possess, how- ever, one advantage in the treatment of this accident which we do not in the treatment of broken ossa nasi, viz: facility of observation and of approach, and if we can do little with plugs and supports in the one case, we may possibly do more in the other. Nothing seems more rational, then, than to plug carefully and equally each nostril, with pledgets of lint, while we cover the outside of the nose completely with a nicely moulded gutta-percha splint or case, which ought to be made to press snugly upon the sides, and permitting these to remain for several weeks, or until the cure is completed. The papier mache of Dzondi, employed by him in cases of broken ossa nasi, would be equally applicable here; but the gutta percha, as being more plastic, and hardening more quickly, ought to be preferred. Attempts to remedy the deformities of the nose at a later period, belong to the department of anaplastic surgery, and the modes of pro- cedure must be varied according to the circumstances of the case. The following example will serve as an illustration of what may sometimes be accomplished in these cases:— A young man fell from a two-story window, striking upon his face, A surgeon was called, but he did not discover the nature of the injury to the nose. One year after the accident he called upon me for relief. The car- tilaginous portion of the septum was broken just at the ends of the nasal bones, and forced backwards about three lines, producing a strik- ing depression at this point of the ridge of the nose, while at the same time the end of the nose was thrown up. The deformity was very unseemly, and annoying both to himself and to his friends, who at first could scarcely recognize him. I introduced a narrow, sharp-pointed bistoury through the skin of the nose on the right side, and resting its edge upon the ridge at the junction of the cartilage with the ossa nasi, I cut the cartilaginous sep- tum directly backwards about three lines, and then making a gradual curve with my knife, I cut downwards about eight lines towards the end of the nose. The intercepted portion of cartilage could now be easily lifted with a probe, and the line of the ridge of the nose com- pletely restored. It was at once apparent, also, that lifting the cartilage ■would depress the tip of the nose and restore its symmetry. To retain the cartilage in place, I constructed a gutta-percha splint 98 FRACTURES OF THE MALAR BONE. of the length and shape of the nose, but so formed along its middle as that it would not press upon the cartilage which I had lifted, resting well upon the ossa nasi, but not touching the ridge from the lower ends of these bones to the tip of the nose, at which latter point it again received support. I now passed a needle, armed with a stout ligature, through the upper end of the uplifted cartilage, transfixing, of course, the skin on both sides of the nose, and this I tied firmly over the splint. This accomplished the important object of pressing backwards and downwards the tip of the nose, and thus tilting up the upper part of the ridge and septum, and of more effectually securing the cartilage in place by lifting it directly with the ligature. On the second day the ligature was removed, but the splint was continued two weeks, during most of which time a band was kept drawn across the lower end of the splint, and tied behind the neck. To prevent the cartilage from falling back when final cicatrization occurred, I pressed the sides of the splint firmly towards each other, just below the incision, so as to force as much as possible the walls of the nares into the fissure of the septum, made by lifting it up. The result is a complete and perfect restoration of the nose to its original form. CHAPTEKIX. FRACTURES OF THE MALAR BONE. I have been unable to find any records of a simple fracture of the malar bone, that is to say, of a fracture unconnected with a fracture of other bones of the face. It is probable, however, that it sometimes occurs, but that not being accompanied with much displacement, it is overlooked. I have myself seen a fracture of the upper margin, or of that portion which constitutes a part of the orbital border, in two or three instances, while I was unable to detect any other fracture among the bones of the face; but it is by no means certain that other fractures did not exist, perhaps in some of the bones which form the socket, or in the superior maxilla, as mere fissures, or as fractures with only slight displacement. The prominence of the malar bone, and especially the sharpness of its orbital margin, would enable the surgeon to detect easily the smallest displacement, or even a fissure, while a much more extensive displacement elsewhere would escape detection. The two upper maxillary bones form, as they are placed opposite to each other, an irregular arch, one end of which rests upon its fellow, at the intermaxillary suture, and the other end rests upon the nasal and frontal bones; while over the centre of the arch is situated the malar bone. The force of a side blow upon the malar bone will ex- pend itself therefore chiefly upon the base of the maxillary apophysis, as being in the line of the direction of the force. The force continuing FRACTURES OF THE MALAR BONE. 99 to act, after the apophysis is broken, the portion of the superior maxilla above the floor of the nares will fall inward toward the septum, while the portion below will tilt outward and open the intermaxillary suture along the roof of the mouth. This suture will also open more widely in front than behind, owing to the greater depth of the suture in front. These observations I have verified by several experiments made with a hammer upon a clean skull. One might suppose that it would be a very easy matter to restore these bones to place upon the naked skull, after such an accident. Certainly it would be very desirable to do so, were this accident to occur to any patient, since the malar bone is slightly depressed, the nostril upon this side is nearly closed, and the line of the teeth is disturbed, and it is possible also that an opening might be established between the nose and mouth immediately back of the incisors. In fact, however, I found the restoration impossible. It could not be accomplished by an instrument within the nose pressing outward, nor by pressing inward upon the teeth and alveoli; not certainly without very great and unwarrantable force. The difficulty consisted simply in the antagonisms of the serrated margins of the intermaxillary suture, which projecting one or two lines on each side, could not be made to interlock again, but were firmly braced against each other. I shall not find it necessary to report in detail the results of the experiments, but shall content myself with stating that by the second blow, in the last experiment, the skull was also found broken at its base through the lesser wings of Ingrassias; the force of the blow having been conveyed, apparently, along the orbital plate of the supe- rior maxilla and os planum. This is the only example from four experiments in which the frac- ture extended through the dental arcade, and it was the result of the first blow. The fracture of the base of the skull by the second blow indicates the possibility of producing a fatal lesion of the brain or of its bloodvessels by a blow upon the malar bone. General Summary.—A fracture of the superior maxilla has occurred in every instance; and twice when the malar bone was not broken : in each of the two last cases the antrum alone was broken, and the depression of the malar bone was scarcely noticeable. In the second of these cases, the fracture extended also through the dental arcade. In three cases the nasal apophysis has broken near the base, and in one case at two points. One of the three fractures of the nasal apo- physis was accompanied with a diastasis of the superior maxilla through its intermaxillary suture. The malar bone has been broken twice by the first blow, and always when the blow has been repeated. The orbital margin and orbital plate have been fissured twice, the outer portion of the orbital plate being pushed a little into the socket. Once this plate has been pushed downwards. The zygoma has been broken three times, and always transversely, a little beyond its centre, or where the bone is the most slender and most convex. 100 FRACTURES OF THE MALAR BONE. The ethmoid has been broken three times, and always longitudinally through the orbital plate. The sphenoid has been broken once, at the base of the skull. In addition to these observations upon the naked skull, I have seen at least four examples, which illustrate the relative infrequency of fractures of the malar bone, as compared with fractures of the superior maxilla and of the other bones of the face, even when the blow is received directly upon the malar bone. Pat. Maloney, aet. 55, fell about twenty feet and struck upon his face. Six weeks after the accident, while an inmate of the Buffalo Hospital of the Sisters of Charity, I found the right malar bone de- pressed, but I could not trace any line of fracture in the malar bone. I think the antrum of the superior maxilla was broken and the malar bone forced in upon it. Thomas Crotty, aet. 20, was struck with a hoop, August 15, 1855. He was seen immediately by a surgeon in Canada, but the fracture was not recognized. Five days after he called at my office. I found the outer portion of the right malar bone lifted slightly and the lower and anterior angle depressed about three lines, as if this portion had been forced in upon the antrum. The third case will be found reported under fractures of the superior maxilla, and the fourth has recently been brought under my notice in the practice of Dr. Wadsworth of this city, the fracture having been occasioned by collision with the head of another man. Prognosis.—The malar bone may be depressed, as we have seen, to the extent of two or three lines, without being broken. This accident will be more properly considered under fractures of the upper maxilla. A fracture of the malar bone implies, therefore, generally, that great force has been applied, and that other fractures exist as complications. This may not be true, however, when only the orbital margin of the socket is broken. If the orbital plate is broken, and a portion of it is pushed into the socket, it may occasion a slight protrusion of the ball, as in two cases related by Dr. Neill as fractures of the upper maxilla, and as has been noticed in the experiments already referred to. This protrusion of the eyeball will probably continue in some degree, as long as the bones remain displaced. It is quite probable, however, that in some cases, after severe injuries of the face, a moderate pro- trusion of the eyeball is due entirely to extravasation of blood in the socket; a circumstance which would be likely to follow a fracture of the bones of the socket, and to increase temporarily the protrusion of the eye. If the body of the bone is broken entirely through, and coma super- venes upon the accident, there is some reason to fear that the skull is fractured at its base, and the prognosis ought to be grave. Treatment.—If there is only a fissure of the orbital margin, it will not require attention; but if the fissure extends through the orbital plate and at the same time the anterior and inferior margin of the bone is depressed, in consequence of which the orbital plate is tilted upward and made to push forward the eyeball, the propriety of surgical interference may be considered. If this protrusion is con- FRACTURES OF THE UPPER MAXILLARY BONES. 101 siderable, and evidently due to the displaced bone, an attempt should be made to lift the body of the malar bone and thus to restore to position its orbital plate. The method of accomplishing this I shall describe particularly when speaking of fractures of the superior maxilla with depression of the malar bones. CHAPTER X. FRACTURES OF THE UPPER MAXILLARY BONES. These fractures assume so great a variety in respect to form, situa- tion and complications, that it would be impossible to speak of them systematically or to establish anything but very general rules as to treatment and prognosis. They may be broken, or loosened from each other or from the other bones with which they are articulated, with or without any farther fracture; the nasal processes may be broken, and generally this acci- dent is accompanied with a fracture of the nasal bones also; the malar bones may be forced in, carrying with them a portion of the outer wall of the antrum; the alveoli may be broken and more or less completely detached; and either of these several fractures may be complicated with fractures of the other bones of the face or of the base of the skull even. Treatment.—When the harmonies of the upper maxillary bones are only slightly disturbed, nothing but a retentive treatment is necessary. A man was thrown backward from a loaded cart, one wheel of the cart passing over his face. He was taken up unsconscious, but when I saw him on the following morning, his consciousness had returned. The right malar bone was broken and forced down upon the antrum about three lines. Both superior maxillae were loosened from their articulations, and could be moved laterally, the motion producing a slight grating sound. The same motion and grating occurred when- ever he attempted to swallow. No effort was made to elevate the malar bones, nor did I find any means necessary to retain the maxil- lary bones in place, the amount of displacement being very incon- siderable, and never sufficient to be observed by the eye. Cool lotions were applied constantly to the face, and the patient was sustained by a liquid diet. On the ninth day all motion of the fragments had ceased, and on the twenty-seventh day the patient was completely recovered, with only the depression of the malar bone remaining. Sargent, of Boston, reports a similar case, in which a slight separa- tion of the maxillary bones united promptly and without any reten- tive apparatus.1 But in a case in which the superior maxillary bones had been more completely torn from their connections, complicated with other severe 1 Boston Med. and Surg. Journ., vol. Iii. p. 378. 102 FRACTURES OF THE UPPER MAXILLARY BONES. injuries, I found it necessary to support the fragments by closing the lower jaw upon the upper, and by suitable bandages. The patient died, however, on the twelth day.1 Graefe recommends, where the bones are thus extensively separated and displaced, an apparatus made of steel, and suitably covered, which is to be applied against the forehead and buckled under the occiput. From the two sides descend a couple of steel plates, which, having arrived at the free border of the upper lip, are reflected upon them- selves, and are made to support upon their extremities long silver gutters, intended for the reception of not only the displaced teeth and alveoli, but also those teeth which are firm.2 Wiseman having been summoned to a child with his whole upper jaw forced in, by the kick of a horse, "beating the ethmoides quite in from the os cribriform," and forcing the palate bone against the back of the pharynx, found great difficulty in securing a permanent read- justment. At first he attempted to introduce his finger back of the bone, but failing in this he bent an instrument into the form of a hook, and passing it between the bone and the pharynx, he easily replaced the fragments. But, on removing the instrument, they were again displaced. Immediately he had constructed an instrument by which the bones could be not only easily reduced, but also retained in place, extension being made by the hands of the child, his mother and others, alternately. In this way the reunion was finally effected, and " the face restored to a good shape, better than could have been hoped for."3 Harris, of New York, mentions a case in which a child, two years old, having fallen from a height of fifty feet upon the pavement, was found to have a diastasis of both the superior maxillary and palate bones; the separation being sufficient to admit the little finger, and extending from between the alveoli which supported the central in- cissors, to the soft palate. It is not said whether any efforts were made to reduce the bones, but six weeks after the injury was received, they were still open, and it was proposed to close the space by a plastic operation as soon as the condition of the patient would warrant such a procedure.4 I suspect that in this example, as in my experiments referred to under fracture of the malar bone, it was found impossible to adjust the bones and close the intermaxillary suture, and for the same reasons. If, in consequence of a blow received upon the ossa nasi, the nasal processes of the superior maxillae are broken down, they may be lifted and adjusted in the same manner as the ossa nasi. I have seen several examples of this accident, and I have in my cabinet a specimen, in which the nasal bones being driven in by the kick of a horse, the nasal process upon the left side is broken off just above the root of the cuspid tooth, and its upper end inclined inward 1 Report on Deformities after Fracture. Trans. Amer. Med. Association, vol. viii. p. 375, Case IV. 2 Traite des Frac, etc., par. L. F. Malgaigne, p. 373. 3 Cliirurgical Treatises, by Richard Wiseman, 1734, p. 443. \ 4 New York Journ. Med., vol. xiii., 2d ser., p. 214. \ FRACTURES OF THE UPPER MAXILLARY BONES. 103 toward the nasal passage and backward, until it is completely buried. In this situation it has become firmly united to the bony and soft tissues into which it was brought in contact. The following example will illustrate some of the complications and difficulties connected with a depression of the malar bone, and conse- quent fracture of the antrum maxillare. M. P., of Colesville, aged about 34 years, was thrown from a height, striking upon his face, forcing the right malar bone down upon the antrum of the superior maxilla. Dr. L. Potter, of Varysburg, and myself were called. The deformity produced by the sinking of the malar bone was very striking, and both the patient and myself were very anxious to have it remedied if possible. We found some of the teeth upon the side of the fracture loose, and we determined to extract them, and press up the bone with an instrument introduced through the empty sockets. The first attempt to extract a molar tooth, however, brought down several teeth, and the whole floor of the antrum. The detach- ment of this fragment was also now so complete that we believed it necessary to remove it entirely, a labor which was accomplished with infinite difficulty, and with no little hazard to the patient, as dissection had to be extended very far back into the throat, and in the end it was not effected without bringing out, attached to the fragment of maxillary bone, a considerable portion of the pyramidal process of the os palati. The time occupied in this operation was at least one hour, during which we were every moment in the most painful apprehensions lest we should reach and wound the internal carotid, which lay in such close juxtaposition to the knife that we could distinctly feel its pulsa- tion. After its removal the hemorrhage was for an hour or more quite profuse, and could only be restrained by sponge compresses pressed firmly back into the mouth and antrum. When the hemorrhage was sufficiently controlled, we proceeded to examine the antrum, the floor of which being removed entire, per- mitted the finger to enter freely. The restoration of the malar bone was now accomplished without much difficulty, and with only mode- rate force. Two years after the accident the face presented, externally, no traces of the original injury. The malar bone seemed to be as promi- nent as upon the opposite side, and there was no perceptible falling in where the teeth and alveoli were removed. During several months after the removal of the bone, the antrum continued to discharge pus, but at length a semi-cartilaginous production closed in the cavity below, entirely reconstructing its floor, and the discharge ceased. Since then he has experienced no further inconvenience. I wish to propose two or three expedients for lifting the malar bone when it has been thrust down, which may in certain cases be substi- tuted for the mode which has been heretofore generally adopted. In many instances, no difficulty will be experienced in resorting to the usual method. The recent loss of one or more teeth opposite the floor of the broken antrum, or the complete displacement of a tooth, 104 FRACTURES OF THE UPPER MAXILLARY BONES. by the accident itself, will give an opportunity for the perforation of the antrum through the open socket, and for the introduction of a suitable instrument for lifting the depressed bone. Unless, however, the opening is quite large, the instrument employed must be so small, such as a straight steel sound or a female catheter, as to expose the parts against which its end is made to press, to some risk of being broken and penetrated. It is even possible in this way to penetrate the socket of the eye, and thus inflict serious injury upon the eye itself. Yet, with some care, such accidents may be avoided, and it is probable that in the cases supposed, where the sockets of the teeth opposite the base of the antrum are open, this method will continue to have the preference. But if the teeth remain firm in their places, or if they have been some time removed, and the sockets are filled up, and we wish to enter the antrum at its base, we must either drill through its anterior wall above the roots of the teeth, or we must proceed to extract a tooth. The first method gives an inconvenient opening, and one through which it will be necessary to use a curved instrument; but yet it is a method far less objectionable than the extraction of a tooth which is firm, or which is even tolerably firm in its socket, and which may require the forceps for its removal. The objections to this latter pro- cedure were suggested by the tedious and painful operation already detailed. The first attempt to extract a tooth brought down the whole floor of the antrum, with all its corresponding teeth, and the pyramidal process of the palate bone. The tooth was already loose, and we thought it might easily be taken out, but it had not occurred to us that it was loosened by the comminuted condition of the walls of the antrum, and of the dental arcade. The experiments made upon the dead sub- ject would seem to show that this fracture and comminution of the alveoli is not a very frequent result of a fracture of the antrum pro- duced by a blow upon the malar bone, yet it may happen, and when- ever it does, the attempt to extract a tooth must always expose the patient to the same hazards. Certainly it is no trifling matter to pull away all of a man's upper teeth upon one side, and to open freely into a broad cavity which might never close again, and which, in this event, must always serve as a place of lodgment for particles of food, and for foul secretions, to say nothing of the external deformity which it is likely to produce, and of the severity and even danger of the operation. I wish, then, to suggest certain procedures, the value of which I have not yet had an opportunity to determine by any experiment upon the living subject, but which I have carefully and frequently tested upon the dead. First, we ought to attempt to lift the bone by putting the thumb under its zygomatic process and body within the mouth. If the bone is thrown directly downward, or downward and backward, this method can scarcely fail; and even when it is thrown downward and forward so as to press into the antrum, it is likely to succeed. If, however, for any reason, the thumb cannot be brought to bear upon its under surface, we may make a small incision upon the cheek over the ante- FRACTURES OF THE UPPER MAXILLARY BONES. 105 rior margin of the masseter muscle, where its insertion into the malar bone terminates, and pushing a strong blunt hook under the bone, we may lift it with ease. Where the depression of the malar bone is in the direction of the anterior and superior angle these means may not be found available, and we may then employ a screw elevator, an instrument which I find already constructed in a case of trephining instruments made for me by Mr. Liier, of Paris, and which I have often used and constantly recommended to my pupils, in certain cases of fractures of the skull. The instrument ought to be made of the best steel, and with a broad, sharp-cutting thread. A slight incision being made through the skin' and down to the centre of the malar bone, the elevator is then screwed firmly into its structure, and now its elevation and adjustment may be accomplished with the greatest ease. Malgaigne remarks: "In all complicated fractures of the upper jaw, there is one principle which surgeons cannot too much study, namely, that all fragments, however slightly adherent they may be, ought to be most carefully preserved, and they will be found to unite with wonderful ease. This remark had already been made by Saviard. Larrey insists strongly upon it, and we have seen that M. Baudens, so great an advocate for the removal of loose fragments, has declared for these fractures a special exemption."1 Malgaigne has here especial reference to fractures of the dental arcade, and to fractures implicating the alveoli and extending more or less into the body of the bone. It would be an error, however, to suppose that a reunion will in these cases uniformly take place. Exceptions have occurred in my own practice, the fragments becoming loosened and completely de- tached after the lapse of several weeks. In the case related by Miller, the whole floor of the antrum having been broken off* in an unskilful attempt to extract the second right upper molar, it was found impos- sible to make it unite, and it was subsequently removed.2 Such unfortunate results certainly may sometimes be reasonably anticipated. Yet they occur so seldom as to justify the opinions and practice advocated by Malgaigne. In some instances, where fragments are displaced carrying with them several teeth, while others in the same row remain firm, it will be sufficient to close the mouth and apply a bandage as for fracture of the inferior maxilla; in others, the teeth and their alveoli ought to be fastened with silk, or gold or silver thread; or gold or silver clasps may be applied, or gutta percha moulded to the teeth and jaw. In a case of fracture of the right superior maxilla, reported by Baker, of Norwich, N. Y., complicated with a fracture of the inferior maxilla, the alveoli were retained in place very perfectly by a mould of gutta percha.3 Neill, of Philadelphia, has also reported three cases of fracture of the bones of the face, involving the superior maxilla, 1 Op. cit., vol. i. p. 376. Paris ed. 2 News Letter, April, 1854. Also, Bost. Med. and Surg. Journ., vol. li. p. 246. 9 New York Journ. of Med., vol. i., 3d ser., p. 362. 8 106 FRACTURES OF THE ZYGOMATIC ARCH. in two of which the eyes were made to protrude more or less from their sockets.1 The loosened alveoli were made fast by wire. The subsequent deformity was inconsiderable, yet in no instance was the restoration complete.* The same method was adopted successfully by a surgeon in Virginia, in the case of a negro fifty years old, where most of the teeth of the left upper jaw were forced into the mouth, carrying with them their corresponding alveolar processes. The teeth remained firm in their sockets, but the separation of the bone was complete, the fragment being held in place only by the mucous membrane of the mouth. On the eighth day the surgeon found that the negro had removed the wire, and also the cork from between his teeth, and the maxillary bandage; but the soft parts had already united, and the bones showed no tendency to displacement. His recovery was speedy, and it was accomplished without any farther treatment.3 Our experience during the war of the rebellion in this country con- firms most of the observations heretofore made in relation to these fractures. Owing to the extreme vascularity of bones composing the upper jaw the fragments have been found to unite, after the most severe gunshot injuries, with surprising rapidity; the amount of necrosis and caries being usually inconsiderable, compared with the amount of comminution. The same anatomical circumstances, namely, the vascularity, has rendered these accidents peculiarly liable to troublesome hemorrhages, both primary and secondary. The Surgeon-General reports that of 4167 wounds of the face tran- scribed from the reports from the beginning of the war to October, 1864, there were 1579 fractures of the facial bones, and of these 891 re- covered, 107 died—the terminations are still to be ascertained in 581 cases. He further remarks that secondary hemorrhage has been the principal source of fatality in these cases, and that frequent recourse has been had to ligation of the carotid, with the result of postponing for a time the fatal event.4 CHAPTER XI. FRACTURES OF THE ZYGOMATIC ARCH. The zygoma, strictly speaking, is formed in a great measure by the body of the malar bone, and it is broken whenever the malar bone is completely separated through any portion of its body; but I propose to confine my remarks to that portion only which is composed of the 1 See " Observations," under Fractures of the Malar Bone ; in which the orbital plate of the malar bone was pushed into the sockets. « Phil. Med. Exam., vol. x., new ser., pp. 455-8. s Amer. Med. Gazette, vol. viii., new ser., p. 106. • Circular No. 6, Washington, Nov. 1, 1865, p. 20. FRACTURES OF THE ZYGOMATIC ARCH. 107 two processes, called respectively the zygomatic processes of the malar and temporal bones. Duverney relates a case in which a young child, having in his mouth the end of a lace spindle, fell forwards and thrust the spindle through the mouth from within outwards, breaking the zygoma in the same direction, and leaving the fragments salient outwards.1 To which case of outward displacement Packard, in a note to Malgaigne's work on fractures, &c, has added a second.2 I know of no other examples in which the fragments have been thrust outwards. A reference to my experiments upon the naked skull will, however, show that the zygoma may be broken and dis- placed in the same direction, by any force which shall fracture the superior maxilla, and depress the anterior margin of the malar bone. In my experiments this has happened three times, and always at the same point, viz., a little beyond the middle of the zygoma, near where the suture which joins the two processes terminates below. The fractures were always transverse, and not in the line of the suture. They wrere therefore fractures of that portion of the zygoma which belongs to the temporal bone. I suspect, also, that to this class of cases belongs the example related by Dupuytren, in which the patient having died on the fifth day, from the effects of the cerebral concussion, the autopsy disclosed "a fracture through the zygomatic arch; and that part of the superior maxillary bone which constitutes the antrum was driven in."3 In another case mentioned by Dupuytren, produced by a direct blow, the fracture was compound and comminuted, and although the fragments were raised easily by an elevator, suppuration ensued be- neath, and the matter was discharged within the mouth.4 Tavignot reports a case of fracture of this arch which was not dis- covered until after death, the fragments not being at all displaced.5 Dr. John Boardman, one of the surgeons to the Buffalo Hospital of the Sisters of Charity, informs me that he has met with a fracture of the zygoma in a man about thirty years of age, occasioned by a blow from a cricket ball. Dr. Boardman saw him on the fourth day, and ascertained that immediately on the receipt of the injury he felt slightly stunned, and that he soon recovered from this, but was unable to open his mouth except by pulling it open with his hand; neither could he close it except in the same manner. This immobility of the jaw continued several days with only very slight improvement; at the end of five weeks, however, when last seen, the mobility was nearly, but not quite restored. The depression, a little in front of the centre of the zygoma, was discovered by the patient himself imme- diately after the receipt of the injury, and he says he tried at once to ascertain whether he could not push the fragments back by moving the jaw. He was unable to make any impression upon them by this 1 Bulletin de la Societe Anatomique, p. 138, 1810. 2 Op. cit., p. 289, vol. i. 3 Injuries and Diseases of Bones, by Baron Dupuytren. Syd. ed., London, 1847, p. 336. « Op. cit., p. 335. 5 Bulletins de la Soc. Anat., 1810, p. 138. 108 FRACTURES OF THE ZYGOMATIC ARCH. manoeuvre. The depression still remains, but it is not so distinct as it was when first seen. Symptoms.—An irregular projection or depression of the fragments is the only sign which can be relied upon to indicate the existence of this accident; and this must often be concealed by the swelling which follows so rapidly wherever the integuments are severely bruised over a superficial bone. This displacement can scarcely occur in but two directions, either outwards or inwards; since the attachments of the temporal aponeurosis above, and of the masseter muscle below, must effectually prevent its descent or ascent. Neither motion nor crepitus will often be present. In some few cases the difficulty in opening or shutting the mouth, occasioned by the projection of the fragments towards or into the tendon of the temporal muscle may assist in the diagnosis. Prognosis.—If the fracture has been produced indirectly by a de- pression of the malar bone, the prognosis must depend upon the amount of injury done to the other bones of the face; in itself, the fracture of the zygoma cannot be a matter of any moment. The same remark might apply also to any fracture of the zygoma in which the angles were salient outwards. If, on the contrary, the angle is salient inwards, the fracture having been produced by a blow inflicted directly upon the zygomatic arch, from without, or by a blow upon the outer portion of the malar bone, it may, perhaps, occasion some embarrass- ment to the action of the temporal muscles. If the force which produces the fracture has acted more upon the temporal portion of the arch, near where the process arises from the temporal bone, it may be accompanied with a fracture of the skull, and with serious cerebral lesions, as in one of the cases already alluded to as having been noticed by Dupuytren. The abscess which followed in the case of the compound, comminuted fracture, quoted from the same author, indicates the danger of this complication; but it must be noticed that its evacuation resulted in a rapid cure, and that no deformity or difficulty in moving the jaw re- mained. Treatment.—A fracture, accompanied with an outward displacement, and occasioned by a depression of the malar bone, will be adjusted by a restoration of the malar bone in the manner already described, when speaking of fractures of the superior maxillary, &c. If the fragments are displaced outwards, in consequence of a direct blow from within, then they may be replaced by pressing upon the projecting angle. In this way Duverney easily reduced the bones in the case which I, have cited. When the fragments, in consequence of a direct blow from without, have been driven inwards, and, as a consequence, serious embarrass- ment to the motions of the temporal muscle ensues, an attempt ought to be made at once to replace them; if, however, no impediment to the action of the muscle exists, it is scarcely necessary to say that no sur- gical interference will be required. It is quite probable, indeed, that a slight amount of embarrassment may be the result of the direct in- jury to the muscle inflicted by the blow, without reference to the dis- FRACTURES OF THE LOWER JAW. 109 placement of the bone, and that a few days will suffice to remedy this evil entirely ; and, moreover, experience teaches that in the case of a fracture in other bones, where the fragments actually penetrate the muscles and remain thus displaced, the points are gradually absorbed, and rounded, so that after a time they constitute no impediment to the action of the muscles. It is proper to infer that the same thing will occur here. The surgeon may be reminded, also, that it is not the muscle but only its tendon which is liable to be penetrated, and that even this is usually protected somewhat by a plate of soft adipose tissue. If to these considerations wre add the difficulties which we shall be likely to encounter in the reduction, we shall expect to find but few cases in which a resort to surgical interference will be necessary. Duverney says that he restored a fracture of this arch, accompanied with depression, by pressing against the zygoma from within the mouth; but an examination of the interior of the buccal cavity will convince us that this is impossible when the fracture is at any point near the middle of-the zygoma, and that it can be only when the frac- ture is at or near the junction of the zygoma with the body of the malar bone that any effective pressure can be made from this direction. In such a case, we may, perhaps, lift the portion of the zygoma re- maining attached to the malar bone, by the same means which have already been suggested for lifting the bone itself. If the bone is driven toward the tendon of the temporal muscle at or near its centre, as happens almost always, then if its restoration be- comes necessary, it can be accomplished only by approaching the bone from without. Dupuytren found an external wound through which, by the aid of a levator, he easily restored the fragments to place. M. Ferrier, however, of the Hospital of Aries, in a case brought before him, made an incision through the integuments down to the bone, and then attempted to slide underneath the small extremity of a spatula; but the aponeurosis would not yield, and he was obliged to cut it also. He was now able to lift the fragments easily. The wound healed rapidly, and the patient was dismissed without any deformity.1 CHAPTEE XII. FRACTURES OF THE LOWER JAW. Division.—Of 33 examples of fracture of this bone which have come under my observation and been recorded by me, not including gunshot fractures, 31 were broken through some portion of the body. 1 Bulletin des Sciences Med., torn. x. p. 160. HO FRACTURES OF THE LOWER JAW. Of the whole number 13 were broken completely asunder at two or more points, constituting double and triple fractures; and of the re- maining 20, 5 were accompanied with detachment of portions of the alveoli, and 1 with the detachment Fig. 25. 0f a considerable fragment from the body. From this analysis it will be seen that 19 of the 33 were comminuted fractures. 12 were compound; not to include in this enumeration several examples in which the partial or complete dislodgment of a tooth might entitle them to be called com- pound. Four fractures through or near the symphysis were nearly or quite vertical, and 18 of the remainder were known to be oblique. Malgaigne has remarked, also, that in fractures of the body of the bone the direction of the obliquity is generally such that the anterior fragment is made at the expense of the internal face of the bone, and the posterior fragment at the expense of the external face: this latter overriding the former. Buck, of New York, has seen the fragments in an opposite condition, requiring the use of the knife and the saw for their extrication.1 I have myself recorded one similar example, but in which the fragments were easily replaced. In twenty examples of fractures through the body, not including fractures of the symphysis, the line of fracture has been observed to be fourteen times at or very near the mental foramen; twice between the first and second incisor; three times behind the last molar, and once between the last two molars. Syme, Liston, and Miller have remarked, also, the greater fre- quency of fracture near this foramen, but Mr. Erichsen thinks he has seen it most frequently broken near the symphysis, between the lateral incisors or between these teeth and the canine. Boyer observes that it is generally somewhat in front of the foramen; for which reason, as he thinks, the dental nerve is rarely torn. Says Boyer, in his Traite des Maladies Chir urg kales, " A fracture never takes place in the central point of the length of the jaw, called the symphysis of the chin; but when the solution of continuity occurs towards the middle of the bone, it is upon one or the other side of the symphysis, which remains always upon one of the fragments." An opinion which, however, he does not seem always to have entertained, since Eicherand, in a report of his lectures, has made him say that a fracture sometimes takes place "near the chin, but seldom so as to produce the division of the symphysis of that part, though it be not impossible." But many surgeons since his time have noticed this fracture, and Malgaigne assures us that J. Cloquet has demonstrated 1 New York Journ. Med., March, 1847. Proceedings of N. Y. Med. and Surg. Soc. Sept. 19, 1846. FRACTURES OF THE LOWER JAW. Ill its existence upon an anatomical specimen. In the two following cases the evidences were so complete that I do not myself entertain much doubt as to their character:— An Irish laborer, aged seventeen years, was thrown from a wagon, breaking the inferior maxilla on both sides through the body, and, also, exactly in the centre, vertically, between the central incisors. I dressed the jaw with a four-tailed bandage, but found great diffi- culty in bringing up the left fragment to a line with the right. I therefore closed the jaws; but finding that the left side still fell three lines below the right, I placed a pine wood wedge between the teeth on the right side, and drew the inferior maxilla up firmly. It now lacked only about half a line of being in place. There did not appear to be, after this, much difficulty in maintaining quiet and apposition of the fragments; and I supposed, from repeated examinations, that they were in exact line, until four weeks after the fracture had occurred, when I discovered that the central fragments were lifted about two lines above the lateral, and, also, slightly carried. back; and although union had not taken place, yet they could not be replaced by any moderate force. The bones united with this slight deformity. Four days later no motion was perceptible, and the dis- placement seemed to be rather less. From this time the dressings were discontinued. A gentleman, aged twenty-five years, had his inferior maxilla broken by the kick of a horse. The left lateral incisor was completely dis- placed, and a large piece of the dental arcade detached. Dr. S. G. Ellis, of Gowanda, N. Y., dressed the fracture, securing the loosened fragment by the main-spring of a watch, made fast to the teeth by a silver wire, and closing the mouth completely, without any interdental splint. Upon the outside he placed a pasteboard splint and bandages. On the fourth week a fragment exfoliated, and came out under the chin. The union was delayed some six or eight weeks. I examined the jaw ten years after it was broken, and found the line of a vertical fracture exactly through the symphysis menti. The left half of the chin was slightly elevated, and the whole of that side of the shaft was smaller than the right. He could not close his teeth perfectly, yet he could close them sufficiently for the purposes of mastication. Stephen Smith, of New York, has seen two examples,1 Lonsdale mentions three,2 and Gibson has seen one.3 One ought not to be too confident, however, of the exact line of the fracture unless its existence can be demonstrated upon the naked bone, since a slight deviation to the one side or the other of the symphysis might not be easily detected in the living subject. Velpeau, Fergusson, Gibson, Henry Smith and others, have re- marked that a separation at the symphysis takes place usually in in- fancy or childhood. But in the eight examples in which I find the ' New York Journ. Med., Jan. 1857, Hospital Reports. * I'ractical Treatise on Fractures. By Edward F. Lonsdale. London, 18.38, p. ^b. " Institutes and Practice of Surg. By Wm. Gibson. Philadelphia, 1841, p. 2bl. 112 FRACTURES OF THE LOWER JAW. ages reported, only one, a case mentioned by Lonsdale, occurred in a person as young as ten years; in one of the cases seen by myself the patient was seventeen years old, and the remainder have ranged from twenty-five years to sixty: and the average age of all is thirty-two years. I have seen one example of a fracture of the ramus, in a man twenty- three years old, who had been struck by a wooden block on the side of his face. The ramus was broken just above the angle, and the body was broken, also, obliquely near the symphysis. The intercepted fragment was carried inwards.1 Ledran mentions the case of a child, ten or twelve years old, in whom the fracture was double also; one fracture having taken place through the body, and one extending obliquely from the root of the coronoid process to the neck of the condyle. The intercepted fragment was, however, so little displaced that the fracture of the ramus was not discovered until after death.3 Malgaigne refers to this 'as the only example recorded; but Stephen Smith, of the Bellevue Hospital, has met with it four. times; in one case the ramus was broken on both sides; in two cases one ramus only was broken; and in one the body was broken on the right side and the ramus on the left.3 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 pro- cesses, and of the symphysis.4 "With this single exception, I am not able to find a recorded exam- ple 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 Berard, one by Houzelot, one by Bichat, one by Packard, of Philadelphia, and two by Watson, of N. 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 pro- cesses and at the symphysis. The man also whom Watson saw in ' Trans. Amer. Med. Assoc. Report on "Deformities after Fractures," vol. viii. p. 385, Case 17. 2 Malgaigne, op. cit., p. 337, from Led"ran, Observ. Chirursr., torn. i. obs. viii. 8 New York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports. * Malgaigne, op. cit., p. 400. FRACTURES OF THE LOWER JAW. 113 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 sore- ness ceased to trouble him; but the shape of the jaw and difficulty of opening the mouth to any great extent, still remained unaltered."1 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 maxilla from indirect blows have, however, been mentioned by other surgeons, the angles of the bone being pressed together by the pas- sage of a wheel, and the fracture taking place usually towards the symphysis. We have already alluded to the observation of Malgaigne, that frac- tures 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, set. 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. 1 New York Journ. of Med., Oct. 1840. Hospital Reports. Ill FRACTURES OF THE LOWER JAW. Led ran 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 de- pressed; 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 upon 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. 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 frac- ture 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 occasion- ally 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 greater in proportion as the line of fracture is farther back. 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 pro- bably 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 suffi- ciently explain the fact that it is not now so easily depressed below the level of the posterior fragment; while the separation of the frag- 1 Trans. Amer. Med. Assoc, vol. viii. p. 380, 1855, Case 6. * Ibid., Cases 1 and 10. FRACTURES OF THE LOWER JAW. 115 ments along the line of the base when an attempt is made to close the jaw forcibly, is probably due to the loosening and partial dislodg- ment 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 ex- clusive, since the fragments may have become displaced in any direc- tion 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, in simple fractures, no doubt, exceptional, and in such examples as I have seen, it was very trivial. It occurred in case " three" of my " Beport," 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 over- lapping exceed two or three lines, and it was always easily overcome. The mobility of the fpagments 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 paint 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 con- stant 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, how- ever, 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 116 FRACTURES OF THE LOWER JAW. myself never seen any extraordinary suffering distinctly attributable to an injury of the dental nerve after fracture, nor any degree of facial paralysis. Kossi relates a case in which convulsion 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 confirma- tion. 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; at other times .the point of fracture has not been noted with such accuracy as to enable me to say whether it was in front of or behind 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 gene- rally 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 in- ternal 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 mus- cles were paralyzed, in consequence of which there was a slight con- tortion 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 1 Malgaigne, from Gazette des Hopitaux, 10 Aout, 1841. FRACTURES OF THE LOWER JAW. 117 To these signs now enumerated, we may add as occasional compli- cations, 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 indi- cated 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 re- ceived the kick of a horse exactly upon the centre of the chin, break- ing the bone on both sides, and who, in consequence, bled freely from his ears j1 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.2 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 one line. In a case mentioned by Syme there was scarcely any dis- placement.3 Liston remarks that it is usually slight. Erichsen and B. Cooper have observed the same. 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 in- wards towards the mouth. I have noticed, also, that owing probably to the loosening and partial dislodgment of the last molar, it is some- times 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 1 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 pam 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, bv mobility and displacement. The upper fragment, if disengaged from the lower, is drawn for- wards, upwards, and inwards, by the action of the pterygoideus exter- nus; and it is felt not to accompany the movements of the lower fragment. ' Malgaigne, pp. 383 and 386, from Journ. de Med., 1789, torn, lxxix. p. 246. * Ibid., p. 386, from Alix, Observata Chir., fascic. 1, obs. 1U. 3 Amer. Jouru. Med. Sci., vol. xviii. p. 243. 118 FRACTURES OF THE LOWER JAW. The lower fragment is at the same time drawn upwards, in conse- quence of which the lower part of the face is distorted: a circumstance first noticed by Kibes, and which supplies an important diagnostic mark between a fracture of one condyle and a dislocation. In dis- location, 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.1 Dupuytren mentions a case which had existed three years.2 Stephen Smith, of New York, reports a case of fracture of both the body and the ramus, in a man forty-five years old. The severity of the injury, with the supervention of delirium tremens, prevented the application of dress- ings 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 days, and was finally dis- charged, the fragments not having yet united.3 I have seen one example of fibrous union in the case of a man who broke the body of the jaw by a fall upon his chin. Malgaigne says that Boyer has seen several examples, but I know of no other cases unless as the result of gunshot injuries which have been recorded. In no instance of a simple fracture which has come under my personal care, has the bone refused finally to unite, although I have seen the union delayed six, seven, ten, and even eleven weeks or more.4 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 condiiion of the system, and in part, perhaps, to neglect of proper treatment. Since the commencement of the late war I have met with several examples of non-union, and of fibrous union after gunshot fractures: but so far as I can remember in all of these cases necrosis existed, or some portions of the bone had been carried away. The infrequency of non-union after this fracture, is a fact worthy of especial attention, because of the extreme difficulty, if not actual im- possibility, in many cases, of wholly 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 deg- lutition, or to speak, even, without inflicting some slight 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 im- movable at the seat of fracture, on the seventeenth day, and, perhaps, » Phila. Med. and Surg. Journ., vol. v. 2 Lemons Orales. » Smith, New York Journ. of Med. and Surg., Jan. 1857. « My Report on Deformities alter Frac, Cases 2, 14, 15, 18. FRACTURES OF THE LOWER JAW. 119 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. Only eight of the united fractures, seen and recorded by me, 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 fall- ing 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 dif- ficult 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 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 ordi- narily 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 frag- ments in apposition, and sometimes it may be found to be impossible. Bicherand mentions the case of a man, who, having been three months in the " Hopital de la Charite"," for a double fracture of the lower jaw, one fracture being near the middle, and the other near the right con- dyle, left before the cure was complete. Seven or eight months after, he called upon Boyer, who extracted from a fistula in the meatus audi- torius externus, a bony mass which had evidently the form of the condyle.1 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 notwith- standing 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 occa- sion contraction of the ligaments about the joint; and a degree of 1 Boyer, Lectures on Dis. of Bones, p. 53, Phila. ed., 1805. 2 Desault, Treatise on Fractures and Luxations, Phila. ed., 1805, p. 3. 3 Malgaigne, op. cit., p. 402. 4 Ibid., p. 402. 5 Fountain, New York Jour. Med., Jan. 1860. 120 FRACTURES OF THE LOWER JAW. embarrassment to the motions of the jaw has followed in the expe- rience of Desault and others, even when the cure has been most com- plete; but this has usually remained only for a short period. Sanson asserts that when the coronoid process is broken, the frac- ture never unites; but that mastication is performed very well, the masseter and pterygoid muscles then fulfilling the office of the tem- poral.1 Treatment.—The few attempts which I have made to restore a com- pletely 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 bring- ing 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 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 in a longitudinal direction, 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 gene- rally 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 frag- ments 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.2 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 1 S. Cooper's First Lines, Amer. ed., 1844, vol. ii. p. 311. 2 Malgaigue, op. cit., p. 3U6. FRACTURES OF THE LOWER JAW. 121 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 ter- minated 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 main- tained by wiring them together, the wire passing out through the lower angle of the wound. Sutures and adhesive straps, with a band- age, 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."1 Dr. R. A. Kinloch, of Charleston, S. 0., has reported a similar case, in which he employed successfully the wire.2 In May, 1858, while trephining at the angle of the jaw for the pur- pose of cutting out a portion of the dental nerve in a patient suffering from 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 appo- sition, and in three weeks the union was accomplished, the wire sepa- rating and falling out of itself. No splints were ever used.3 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 frac- ture, 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—(Oelsus advised the use of horsehair)—has been applied to the two teeth on the opposite sides of the fracture, or if these have not been 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 Mal- gaigne, 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.4 ' New York Journ. of Med., &c, March, 1847, p. 211. 2 Kinloch, Am. Journ. Med. Sci., July, 1859, p. 67. 8 Buffalo Med. Journ., vol. xiv. p. 148. * Trans. Amer. Med. Assoc. My report on " Defor.," &c, vol. vm. p 383, Case 14. 9 122 FRACTURES OF THE LOWER JAW. Dr. George Hay ward, 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 suc- cess, 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."1 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 cor- responding teeth of the upper jaw;2 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 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 im- bedded, the flesh had closed over it until it rested like a seton through the middle of the tongue.3 None of these various methods recommend themselves very satis- factorily 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 unfrequently, after having been made fast with much labor, they soon become disarranged or break. They require, therefore, almost always the additional pro- tection afforded by bandages, interdental splints, &c. Alone they are usually insufficient, and if properly constructed bandages, slings, in- terdental splints, &c, are employed, they are not needed. Sometimes, moreover, they are actually mischievous, as when they loosen a sound 1 Boston Med. and Surg. Journ., vol. xix. p. 133, 183S. 2 Malgaigne, op. cit., p. 392. 8 Journ. Univer. des Sci. Med., torn. xix. p. 77. FRACTURES OF THE LOWER JAW. 123 tooth or press upon and inflame the gums. A. Be"rard passed a silver wire twice around tbe 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 liga- ture in the same manner. On about the third day this also was dis- arranged; 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.1 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 sub- stitute a loss of the tongue for an ununited fracture of the jaw. Splints have been employed in various ways. First, simple inter- dental splints, laid along the crowns of the teeth and only sufficiently grooved to be easily retained in place; Second, clasps, which are ap- plied over the crowns and sides of the teeth, operating chiefly by their lateral pressure, or made fast by screws; Third, splints applied to the outer and inferior margin of the jaw; Fourth, interdental splints com- bined 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 be- tween 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.2 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 ' Lond. Med. and Phys. Journ., Nov. 1822, p. 401. 2 Loud. Med.-Chir. Rev., vol. xx. p. 470. 124 FRACTURES OF THE LOWER JAW. 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 jawr renders the two corresponding arcades unequal and irregular, and prevents our making use of the upper 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 in- dispensable. 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 recommended to the profession in 1849/ and also again in my report to the Ameri- can Medical Association, made in the year 1855. I have employed this method repeatedly myself, and my suggestions have been followed by Stephen Smith, of the Bellevue Hospital, New York, and by many others with, as they affirm, the most satisfactory results. Dr. Smith declares indeed 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 hot water, and when they are softened, mould them into wedge-shaped blocks, and carry them to their appropriate places between the back teeth on each side of the mouth; taking care, of course, that on the fractured side the splint extends sufficiently far forward to traverse thoroughly the line of fracture. Now 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 well hardened. Mean- time, 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 hardened, remove the splints for the purpose of determining more precisely that they are properly shaped and fitted. It is scarcely necessary to say that in carrying the long wedge- shaped block into the mouth, the apex of the wedge is to be intro- duced first. 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. It possesses this advantage, also, that in case more or less of the teeth are gone in either the upper or 1 Buffalo Med. and Surg. Journ., vol. v. p. 144, Aug. 1849. FRACTURES OF THE LOWER JAW. 125 lower jaw, it fills up the vacancies, and renders the support uniform and steady. 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, and N. R. Smith, of Baltimore, employ for this purpose a plate of silver, folded snugly over the tops and sides of two or more teeth adjacent to the fracture. 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 thumb-screw, 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 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. J. B. Gunning, Dentist, of New York, has substituted for all these materials vulcanized India rubber, which he employs both as a clasp and as an interdental splint; and according to Dr. Covey1 the same material has been used with excellent results by J. B. Beans, Dentist, of Atlanta, Ga. The following is Dr. Beans' plan of procedure. An impression is taken in wax of the crowns of the teeth of the uninjured jaw, and of each fragment separately of the broken jaw. When, in doing this, the ordinary "impression cup" used by dentists cannot be introduced, one composed of a thin metallic plate, which is covered with wax and stiffened by a rim of wire, may be substituted. "From these impressions are made casts of plaster of Paris, very carefully prepared, so as to produce a smooth, hard surface, and giving as perfect a representation of the teeth as possible. These plaster models are then adjusted, properly antagonized in their normal posi- tion, and placed in the ' maxillary articulator.' " The fragments of the model representing the broken jaw are held in their proper position by wax, being secured thus one to the other, and to the" remaining plate of the articulator." * * * The model jaws are now opened from three to five lines, and a wax model of a splint is built up between the molars, covering also the inner and outer surfaces of the teeth. A connecting band of wax is laid from one side to the other behind the upper front teeth, leaving thus an opening in front for the reception of the food. This wax and plaster model now com- 1 Beans, Richmond Med. Journ., Feb. 1866. 126 FRACTURES OF THE LOWER JAW. Maxillary Articulation. 1, 1. Upper and lower plates. 2, 2. Adjustable rods. 3, 3 Adjustable hinge. Fig. 27. posing one piece, is then removed from the articulator, and placed in a dentist's "flask," and a complete mould of the model is again formed from plaster laid on in sections, in a manner which those accus- tomed to make plaster moulds will readily understand. The plaster having fairly set, the flask and mould are opened, the wax carefully removed, and the spaces thus left in the mould at once filled with the rubber rendered soft by heat. The mould is again closed, replaced in the flask, and by heat the rubber is thoroughly vulcanized. The flask is again opened, the plaster removed, and an interdental splint of rubber remains, which is fitted accurately to all the surfaces of the teeth both above and below. The splint is now placed in the mouth, adjusted to the teeth and the lower jaw secured in position by the apparatus represented in the accompanying wood cut. Dr. Covey says, that during the late war Dr. Beans was placed in charge of a hospital at Macon, Geor- gia, devoted exclusively to the re- ception of this class of injuries, and that over forty cases were treated, and with eminent success. My own judgment of this appara- tus is, that so far as the substitution of vulcanized rubber for gutta percha is concerned, it is wholly unnecessary in the great majority of simple frac- tures of the jaw. Gutta percha is applied with great facility, and with equal accuracy to all the dental sur- faces, and it speedily hardens suffi- ciently for all practical purposes. In gunshot fractures, however, and in certain other badly comminuted fractures, I can well understand how the surgeon may advantageously avail himself of vulcanized rubber, which being somewhat harder may be made to grasp the teeth attached to the several fragments more firmly; and indeed may, in a few cases, allow of the teeth being made fast to the splint by screws. It will be observed that these are the cases which Dr. Beans has had chiefly under treatment. An examination of the cases reported by Dr. Covey, will also show that the apparatus was never applied earlier than the tenth day, even Beans' apparatus for broken javr, applied. FRACTURES OF THE LOWER JAW. 127 when the patients were under the charge of Dr. Beans from the first, and that in most cases the application of the apparatus was delayed to a much later period. Indeed it is apparent that there may be the same reasons for occasional delay in the application of vulcanized rub- ber, as in the application of gutta percha, or any other mode of sup- port and dressing. In reference to the head apparatus, or sling, as used by Dr. Beans, we have only a single remark to make. It is a modification of the apparatus employed for many years by myself—the modification con- sisting in the use of a horizontal piece of wood supporting a cup which is placed under the chin, the purpose of which is to prevent the lateral pressure usually made by the maxillary bands. The necessity of this modification has long been recognized by myself and others in certain fractures; and it is especially important in all com- minuted and gunshot fractures. To the attainment of this purpose, namely, the prevention of lateral pressure, I have employed usually a firm gutta-percha splint under the chin, to the projecting lateral ex- tremities of which the maxillary bands have been attached; and I think it much better than Dr. Beans' piece of wood. In a great majority of cases, however, occurring in civil practice, that is to say, in most simple fractures, this submental splint is unnecessary, since the lateral pressure is harmless, especially when the interdental splints of gutta percha or of vulcanized rubber are employed. In short, while I am prepared to admit that Dr. Beans has by his appareil and by the application of great mechanical skill, talent, and industry, treated successfully many cases which by other appliances and in other hands might have resulted most unfortunately, yet it is plain that his method will find its field of usefulness in civil practice limited to exceptional cases. Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very ingenious mode of employing the interdental splint and wire ligature conjointly, and which method, at my request, he adopted recently in a case under my care at Bellevue Hospital. A plate of gutta percha was placed upon the top of the teeth across the line of fracture, and this was secured in position by silver wire, which had been made to grasp firmly the crowns of the adjacent teeth and was then brought over the horizontal gutta percha plate. In this case it accomplished all that was desired. 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 band- ages or the sling. As before stated, 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 essential service, and may properly enough be dispensed with. 128 FRACTURES OF THE LOWER JAW. Whatever objections hold to the use of metallic clasps, must apply 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 band- ages or slings, the mouth being permitted to open and close freely during the whole treatment. Motion of the jaw cannot be permitted in any case where the fracture is far back, since it is then impossible to grasp the posterior fragment between the two parallel splints. Nothing but complete immobility of the jaw will now insure immo- bility to the fracture. They are liable, moreover, to additional objec- tions, which will be readily suggested by an explanation of their mode of construction. Chopart and Desault originated this idea as early as 1780, for frac- tures occurring upon both sides; in which cases they advised "band- ages 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 Rutenick, a German surgeon, in 1799, and improved by Kluge, is thus described by Dr. Chester: " It con- sists, 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 vurious 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 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,a 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 1 London Med.-Chir. Rev., vol. xx. p. 471, from Monthly Archives of the Medical Sciences, 1834. 2 Malgaigne, op. cit., p. 395. FRACTURES OF THE LOWER JAW. 129 and with complete success.1 Rutenick succeeded with his apparatus in a case where the displacement persisted in spite of all other means.2 Jousset was also successful in two cases.3 Wales, Asst. Surg. U. S. Navy, succeeded with an instrument of his own invention.'1 But others have not been equally fortunate; or if they have suc- ceeded 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 every- thing, and the patient was transferred to Bicetre. The second patient complained immediately of an intense pain under the chin and a pro- fuse 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 derange- ment. 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. Neu- court 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 ap- plied 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 submaxil- lary 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 sym- physis, 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 cer- tain but that it would be better to reject it altogether; and I should scarcely have thought it worth while to notice these modes of treat- ment 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 com- press, of moderate thickness, reaching from the angle of the jaw nearly to the chin, is placed beneath and held by an assistant, while the sur- geon 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 1 Lonsdale: Practical Treatise on Fractures ; Loudon, 1838, p. 234. 2 Malgaigne, op. cit., p. 396. 3 Ibid., p. 396. 4 Wales, Am. Journ. Med. Sci., Oct. 1860. 130 FRACTURES OF THE LOWER JAW sides of the face and over Gibson's bandage for a fractured jaw. 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 chang- ing its position, a short 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 extremity 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 zy- gomatic 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. 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 frag- ments 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 pre- vent 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, with or with- Barton's bandage for a fractured jaw. FRACTURES OF THE LOWER JAW. 131 Four-tailed bandage or sling, for the lower jaw. out the interdental splint, that surgeons have generally given the prefer- ence. The sling is known, also, by the name of the four-headed or the four-tailed roller or bandage. B. Bell, Boyer, Skey, S. Cooper, B. Cooper, Sy me, 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, ad- hesive 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 suffi- ciently to receive the chin. The middle 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 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 tendeney of the sling, as ordinarily constructed, and of Gibson's roller, to carry the anterior fragment backwards, especially in double fracture where the body of the bone is broken upon both sides, I devised, some years since, an apparatus intended to obviate this objection, and which I have used now many 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 counter-straps, made of strong linen webbing, called, respectively, the occipito-frontal and the vertical. The occipito-frontal is looped upon the maxillary at a point a little above the ears, and may be elevated or depressed at pleasure. The occipital portion of the strap is then carried back- wards and buckled under the occiput, while the frontal portion is buckled across the forehead. The vertical strap unites the occipital to the maxillary across the top of the head, and prevents the upper B52 FRACTURES OF THE LOWER JAW. part ot the latter from becoming displaced forwards. At each point where a buckle is used, a pad must Fig. 31. be placed between the strap and the head. The maxillary strap is narrow under the chin "to avoid pressure upon the front of the neck, but im- mediately becomes wider so as to cover the sides of the inferior maxilla and face, after which it gradually di- minishes to accommodate the buckle upon the top of the head. The an- terior margin of this band, at the point corresponding to the symphy- sis 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 ap- paratus is in place, shall cross in front of the chin, and prevent the The author's apparatus. maxillary strap from sliding back- wards 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 down- wards 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 degreee of immobility is usually obtained when the apparatus is only moderately tight. 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, in general, 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 dress- ing 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. FRACTURES OF THE LOWER JAW. 133 Occasionally, indeed, as often as every two or three days, the appa- ratus 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 ap- plicable 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 com- pound fractures where it became necessary to allow the pus to dis- charge 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 thick- ness, 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. As has been already explained, the gutta percha, if sufficiently thick, and if the lateral wings are allowed to project a little on either side, will serve effectually to protect the sides of the face against pressure from the bandage; and being more easily moulded to the base and front of the chin than any other material which has yet been employed, must have the preference. The necessity for its use, however, is only occasional. 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 re- placement is difficult, and the retention uncertain. Ribes 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 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 prac- ticability of a method of which he had as yet only conceived the idea. Malgaigne thus describes his procedure: " With the left hand seize the 134 FRACTURES OF THE IIYOID BONE. 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 for- wards 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 a sling." The frag- ments 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 con- venient. CHAPTEE 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 Eeldomadaire, for March, 1833, a case which occurred in a marine, sixty-seven years old, " who, in a quarrel, had his throat violently clenched by the hand of a vigorous adversary. At the moment there was very acute pain, and the sensa- tion 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 1 Traite" de Med. legale, troisieme ed., torn. ii. p. 423. 2 Cazauvieilh, du Suicide, etc., p. 221. FRACTURES OF THE HYOID BONE. 135 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 re- duced. The position of the head inclined a little back; rest, absolute silence, diet, and some saturnine fomentations, composed the after- treatment. 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 re- main 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 Dieffenbach has also recorded a fracture of the great right horn, pro- duced 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:— "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 1 Amer. Journ. Med. Sci., vol. xiii. p. 250. 2 Medic. Vereinszeitung fur Preussen, 1833, No. 3 ; Gazette Med., 1834, p. 187. s Revue Med., July, 1835. 13G FRACTURES OF THE HYOID BONE. 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. Crepitus was distinctly felt on pressing the bone between the thumb and finger; or when the pa- tient 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 wholy 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.2 Dr. Grander reports the following :— " A laborer, set. 63, fell from a wagon on his face, and discharged a large quantity of blood by the mouth. He found he could not swal- low, and when seen twelve hours afterward, complained of severe pain in the neck and nape, with inability to turn his head, though no in- jury 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 direc- tions, and pressing it down with a spatula caused no inconvenience. The hyoid seemed to possess its continuity. No crepitation or abnor- mal 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; a hectic cough, from which he had long suffered, alone remaining. After continuing, however, to go on thus well for six days, the cough in- creased ; 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 1 Western Lancet; also N. Y. Journ. Med., vol. xv. p. 152. 2 Medic. Vereinszeitung, fur Preussen, 1833, No. 15 ; Gazette Medicale, 1833, p. 354. FRACTURES OF THE HYOID BONE. 137 cornua was broken, and had become firmly imbedded between the epiglottis and rima glottidis, inducing the raised position of the epi- glottis, 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 d'Angers."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 Olli- vier, 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 amount- ing 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 incor- rect, since although a large proportion of these subjects are submitted to dissection both in this and 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 pre- sent, however, in the examples mentioned by Dieffenbach 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 deglu- tition, and by loss of voice in others ; with great pain in moving the 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 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. 10 138 FRACTURES' OF THE HYOID BONE. a later period, cough, expectoration, hoarseness, &c. The circum- stances 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 dis- tinctly felt in a careful examination of the pharynx. In the case related by Gruner, 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 de- tected, 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 re- lated by Marcinkovsky, or such as to bury the fragment deep in the tissues about the rima "glottidis as in the case mentioned by Gruner, 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 frac- ture 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, 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. FRACTURE OF THE CARTILAGES OF THE LARYNX. 139 CHAPTEE XIY. FRACTURE OF THE CARTILAGES OF THE 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 hand- kerchief 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 suffoca- tion.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 Habicot operated successfully, in 1620, by introducing a leaden tube into the trachea in a case in which the thyroid was " damaged." Gibb, Norris, Nelaton, and Kenderline, have each reported examples of fracture of this cartilage alone." § 2. Thyroid and Cricoid Cartilages. Plenck saw a fracture of both the thyroid and cricoid cartilages pro- duced by falling upon the rim of a pail.4 Morgagni also says that he had seen fractures of the larynx; and Reiner mentions a fracture of the larynx found in a person who had been hanged ;6 but in neither case is it said in which cartilage the fracture occurred, or whether it had not occurred in both. ' Gazette M6dicale, 1838, p. 698. 2 Archives Generates de Medecine, tome ii. p. 307. 3 Marjolin, Cours de Patholog. Chir., p. 396. * Hunt, Frac. of Larynx, &c. Am. Journ. Med. Sci., April, 1866. 5 Mais;., op. cit., p. 409. 6 Morgagni, de Sedibus, etc., Epist. 19, num. 13,14, et 16; Remer, Annates d hygiene, tome iv. p. 171 ; from Malg. 140 FRACTURE OF THE CARTILAGES OF THE LARYNX. Dr. O'Brian, of Edinburgh, reports in vol. xviii. of the Edinburgh Med. and Surg. Jmn-n., a case of fracture of both cartilages, involving the trachea also, in a woman who had received a kick under the jaw, and who died on the following day. Hunt has collected other cases, some of which involved the arytenoid cartilages, the hyoid bone, the trachea, &c. I am able to furnish, from my own observation, another example of fracture of both the thyroid and cricoid 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 car- tilage 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, deter- mined 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 carti- lage 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 CRICOID CARTILAGE. 141 pomum Adami was depressed to the level of the cricoid cartilage, and the left ala, being completely detached, was thrown inwards and up- wards several lines. Underneath the perichondrium, especially upon the inner side, there was pretty extensive bloody infiltration. Ossifi- 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 carti- lage 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 ex- tending 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 exam- ple of this fracture, without fracture of the thyroid cartilage; and Weiss has found the cricoid cartilage broken into numerous frag- ments, and at the same time separated from the trachea.' General Etiology of Fractures of the Laryngeal Carti- lages.—As a predisposing cause, advanced age, with its usual con- comitant, partial or complete ossification of the cartilages, has been thought to occupy a prominent place. 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 experi- ments have satisfied me that the adult laryngeal cartilages are quite as brittle as bone, and, consequently, that ossification in no way in- creases their liability to fracture. Hunt ascertained the age in fifteen cases, and but one of the whole number was over 45 years; five occurred in children, one of whom was only four years old. 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. 1 Malg., op. cit., p. 408. 142 FRACTURE OF THE CARTILAGES OF THE LARYNX. General Symptomatology, etc.—The signs of this accident are such as may attend any severe injury of this organ, whether accom- panied with a fracture or not, such as pain, swelling, difficult degluti- tion, embarrassed respiration, 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 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 pro- bable 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 suffo- cation 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 k • 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 lace- ration, and is followed by great swelling, emphysema, very difficult respiration, complete aphonia, impossibility of deglutition, &c, the prognosis cannot but be unfavorable. General Treatment.—In examples of simple, uncomplicated frac- ture, "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. Indeed, one of these operations ought, we think, to be resorted to in all cases in which emphysema is prominent. Dr. William Hunt, of the Pennsylvania Hospital, in his excellent paper on " Fractures of the Larynx and Ruptures of the Trachea," in which he has arranged a tabular synopsis of twenty-nine cases, says that of twenty-seven cases ten recovered and seventeen died. Of eight cases in which tracheo- tomy was performed, but two died. In the four cases in which recovery took place without an operation no mention is made of bloody expec- toration or of emphysema.1 1 Hunt, Amer. Journ. Med. Sci., April, 1S66. FRACTURES OF THE VERTEBRAE. 143 As to a " reduction" of the fragments by manipulation, I believe it will be found generally, if not always, impracticable. Whatever dis- placement 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 median line, and after stanch- ing the bleeding, proceeding at once to divide the larynx itself in its whole length and then replacing the broken cartilages.1 The pro- cedure has an aspect of severity, but I can well conceive of circum- stances 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 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. CHAPTEE XV. FRACTURES OF THE VERTEBRAE. It will be convenient to divide fractures of the vertebrae into frac- tures of the spinous processes, transverse processes, vertebral arches and bodies. § 1. Fracture of 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 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; hy the swelling, ten- i System of Surgery, Philadelphia ed., vol. i. p. 581, 1847. 144 FRACTURES OF THE VERTEBRAE. derness 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 dis- Fjg- 32. placement. Nor would it be surprising if the displacement was absent in a ma- jority 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 more or less torn. Sir Astley mentions a case in which, however, such lacerations did occur, and the lateral de- formity was quite conspicuous. A boy had been endeavoring to sup- port a heavy weight upon his shoulders, when he fell, bent double. Immediately Fracture of the spinous process. 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 corresponding muscles 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 rup- ture of the supra-spinous ligaments, or of the ligamentum nuchae, 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 frac- ture of a spinous process of the arch, or of the body itself of the ver- tebra. 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 1 Sir Astley Cooper, op. cit., p. 459. FRACTURES OF THE TRANSVERSE PROCESS. 145 process, as proved by dissection, has been carefully stated, the frag- ment 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.1 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 mentions a similar example.2 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 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 of 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 second- ary hemorrhage occurred, of which he ultimately died. The autopsy showed that the vertebral artery had been injured, and that the inflam- mation of its coats being followed by a slough, caused his death.3 I have also elsewhere reported the case of Charles Harkner, of Buffalo, N. Y., 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 ' A. Cooper, op. cit., p. 459. 2 Malgaigne, op. cit., p. 412. 3 Dupuytren, Diseases, &c, of Bones, Syd. ed., p. 360. 146 FRACTURES OF THE VERTEBRA. no pain. He gradually sank, without hemorrhage, and died in thirty- six 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 con- siderable 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 com- plications, 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. 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 re- garded 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 Fig- 33> upon the spinous process; but generally it is the lamellar portion, or the " ver- tebral 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 balus- trade fell from the top of a high build- ing, 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 Fracture of the vertebral arch. again move his feet or legs, although he never lost his consciousness until he died. I found the bladder paralyzed also, and his left arm, but his FRACTURES OF THE VERTEBRAL ARCHES. 147 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. Vandeventer, 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 vertebras were not broken. It was our opinion, there- fore, 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. 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 Erie County, N. Y., 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 1 Prout, Amer. Journ. Med. Sci., Nov. 1837, vol. xxi. p. 276, from Western Journ. of Med. and Phys. Sci. 148 FRACTURES OF THE VERTEBRAE. 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 vertebras. 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 deter- mine that the plates were broken; but we should be still unable to say that the bodies of the vertebrae were not broken also. 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 vertebras 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 con- vince 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 indica- tion 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 pre- sents 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 FRACTURES OF THE VERTEBRAL ARCHES. 149 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 ope- ration 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 deter- mine much inflammation of the cord, then it would seem possible that an operation might save the patient. Paulus JEgineta 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 para- lysis of his lower extremities. Of course nothing could be more ra- tional or simple than this procedure, adopted by Louis, in any case of 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 JEgineta, namely, to attempt the removal of the fragments in a case of simple fracture. He made an incision upon the depressed bones as the patient was lying upon his face, raised the muscles covering the spinal arch, removing by means of a circular saw, chisel, mallet, and trephine, &c. the spinous processes of the eleventh and twelfth dorsal vertebrae, and the arch of one of the vertebrae. The patient was in no manner relieved, and died on the 4th day after the receipt of the injury and the 3d after the opera- tion.2 Mr. Oldknow repeated this operation in 1819 in a case of fracture of the arch of the seventh vertebra. The patient died on the 6th day.3 In 1822, Mr. Tyrrell operated at St. Thomas's Hospital on a man who had been injured four days previously, removing the spinous processes of the twelth dorsal and first lumbar vertebra. The opera- tion was accomplished with considerable difficulty, and resulted in only a partial return of sensibility. He died on the 13th day after the operation.4 In 1827, Tyrrell operated a second time, and death resulted on the eighth day.5 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. 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 effusion existed along the whole length of the spinal canal.6 The patient whom Laugier trephined at 1 Chelius's Surgery, Amer. ed., note by South, vol. i. p. 592. ! Cline, Chelius's Surgery, Amer. ed., vol. i. p. 590. 3 Sir A. Cooper, on Disloc. and Frac, Amer. ed., 1851, p. 479. 4 Sir A. Cooper's Loc, by Tyrrell, 3d Amer. ed., 1831, vol. ii. p. 17. 6 Med.-Chir. Rev., vol. x. p. 601. 6 Barton, Goduian's ed. of Sir A. Cooper on Disloc, &c, p. 421. 150 FRACTURES OF THE VERTEBRAE. the base of the spinous process of the ninth dorsal vertebra, died on the fourth day.1 The operation has been repeated unsuccessfully by Wickham, Attenburrow, Holscher, Heine, and Roux.2 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. This man died on the eighth day.3 In 1854, Dr. Blackman, of Cincinnati, operated, his patient dying on the fourth day. During the same year also, Dr. B. removed a por- tion of the sacrum for an injury of four years' standing, with no benefit.4 In 1858, Dr. Stephen Smith, of Bellevue, removed the arch of the tenth dorsal vertebra, death occurring soon after.3 December 29th, 1857, ten days after the receipt of the injury, Dr. J. C. Hutchinson, of Brooklyn, operated upon a man at the City Hospital, Brooklyn, removing the spinous processes of the eighth, ninth, and tenth dorsal vertebras, with the posterior arch of the latter. This patient survived the operation ten days.6 Ballingall says, a Dr. Blair has operated successfully, but no particulars are given. Dr. H. A. Potter, of Geneva, N. Y., informs us that he has operated three times. In the first case he states that he removed the posterior portion of the three lower cervical vertebras. The patient died on the fourth day. In the second case the doctor removed the spinous pro- cesses of the fifth and sixth cervical vertebras, and the entire posterior arch of the fifth. The sheath was not broken, " but the cord was much injured." There was almost complete paralysis of the extremities, and this condition was not remedied by the operation. Three years later, the patient being still alive, but only a very slight improvement having taken place, Dr. Potter " removed the fourth, sixth, and seventh cervical vertebras." (We presume he intends to say the " posterior arches.") At the time of the report, Jan. 1863, there was no further improvement. Finally, the doctor reports a completely successful case. The injury was of "five months' standing."7 Packard says, in a note to his translation of Malgaigne, that Dr. Potter operated on a case of three months' standing, and the patient died on the eighteenth day. I suppose this to be the same case. These are all of the cases of which we have any information in which this operation has been made, and they have all, excepting the two cases reported by Potter and the one by Blair, 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 1 Malgaigne, Amer. ed., p. 341. 2 Chelius's Surgery, Amer. ed., vol. i. p. 590. Also, Velpeau's Op. Surgery, 1st Amer. ed., vol. ii. p. 737. 3 Rogers, Amer. Journ. Med. Sci., May, 1835. * Velpeau's Surgery, Blackmail's ed., vol. ii. p. 392; also, Dr. Hutchinson's Paper, Trans. N. Y. St. Med. Soc, 1861. s New York Journ. Med., 1859, p. 87. 6 Hutchinson, Trans. N. Y. Med. Soc , 1861, p. 93. ' Amer. Med. Times, Jan. 10, 1863. FRACTURES OF THE VERTEBRAL ARCHES. 151 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."1 So unique a case would certainly have found before this an ample confirmation. Indeed we must say that none of the cases reported as successful give any evidence of authenticity. Experience, then, seems to have shown that we have little or nothing to expect from this surgical expedient; and noth withstand ing 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 scarcely 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, Alexander Shaw, 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 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 fractures of the vertebral arch 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 ver- tebra. 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 vertebras. The observation is interesting, and, I think, has not before been made. As to the therapeutical treatment of the various symptoms belong- ing 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. ' Edwards, British and Foreign Med. Rev., 1838, p. 162. 152 FRACTURES OF THE VERTEBRA. § 4. Fractures of the Bodies of the Vertehrje. The same causes which produce fractures of the arches produce also fractures of the bodies of the vertebras, 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 vertebras are broken by falls upon the top of the head, by which the vertebras are not only driven forci- bly together, but often doubled forwards upon each other; or the patient may have alighted upon his feet or upon his sacrum. Reveillon has reported a case of fracture of the fifth cervical verte- bra 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 ease of fracture of the fourth and fifth cervical vertebras occasioned by diving, in which it was supposed that the fracture was caused by the concussion of the head upon the water.2 Malgaigne says the spine bends at three principal points; comprised, the first between the third and seventh cervical vertebras, 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 vertebras occur at these points of flexion. He makes an argument from this also that these fractures " are generally the result of counter- strokes 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 comminuted. In some cases a narrow piece is chipped from the mar- gin, 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 displace- ment ; 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. 1 Reveillon, Chelius's Surg., note by South, vol. i. p. 584. * South, ibid., p. 583. FRACTURES OF THE BODIES OF THE VERTEBRA. 153 Fig. 34. Oblique fracture of the body of a vertebra. In the first and last of these examples the spine becomes bent for- wards at the point of fracture, producing an angle of which the most salient point posteriorly is represented by the extremity of the spinous process be- longing 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. Symptoms.—Severe pain at the seat of frac- ture, felt especially when the part is touched or the body is moved, tenderness, swelling, ecchy- mosis, occasionally crepitus, a slight angular distortion of the spine, or simply a trifling irre- gularity 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 displace- ment 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 vomit- ing. A few become comatose before death. 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 accidents 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 Vertebrse. The spinal cord terminates, in the adult, at the lower border of the first lumbar vertebra, but in the child at birth it extends as low as the third lumbar vertebra. The remainder of the vertebral canal is occupied by the leash of terminal nerves, called collectively the cauda equina. 11 lo-A FRACTURES OF THE VERTEBR.E. The nerves which emerge from the intervertebral foramina below the fourth and fifth lumbar vertebras, unite with the sacral nerves to form a plexus which supplies the sphincter and levator ani, the peri- neal muscles, the detrusor and accelerator urinas, the urethra, the glans penis, and a great proportion of the lower extremities; It will be apparent, therefore, that a fracture, with displacement, of even the last vertebra of the column, involves the possibility of more or less paralysis of all those parts supplied by this plexus, and that in pro- portion as the fracture is higher in the vertebral column will the pro- bability of additional complications be increased. In other words, in addition to the more or less complete loss of function in the organs, supplied by the ilio-sacral plexus, there will probably be associated loss of function in other organs, supplied from sources above this point of the vertebral canal. A fracture, however, of the bodies of the fourth or fifth lumbar vertebra, produced by a direct blow, is exceedingly rare, owing to the protection which it receives from the alas of the pelvis. Dr. Alexander Shaw has reported four cases of fracture below the second lumbar vertebra, which were unaccompanied with any degree of paralysis, and which were followed by speedy recovery,' a circum- stance which he ascribes to the fact that the cauda equina is composed of nerves possessing considerable firmness, and suspended loosely together; for this reason they escape pressure by slipping among themselves, and suffer less injury from the same amount of compression than the medulla spinalis. In the two following cases the results were less fortunate, yet reco- veries seem to have taken place. A boy was admitted into St. George's Hospital, in Sept. 1827, with a fracture and considerable displacement of the third and fourth lum- bar vertebras, 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 vertebras, 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.2 Dr. Thompson, of Goshen, N. Y., reports, also, a fracture of either the third or fourth lumbar vertebra, followed by recovery. The patient fell from the roof of a house, striking first upon his feet and then upon his buttocks. This occurred in October, 1853. The usual signs of a fracture 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 con- fined to his bed seven months. After eighteen months he began to use crutches. At the end of about three years all improvement ceased; at which time he could not quite stand alone, yet with the aid 1 Shaw, London Med. Gaz., vol. xvii. 2 Brodie. Sir Ast. Cooper on Disloc, op. cit., p. 471. FRACTURES OF THE BODIES OF THE VERTEBRAE. 155 Fig. 35. of apparatus he was able to get about the coun- try and vend books, prints, &c. This was also his condition one year later.1 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.2 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 ascer- tained that the fracture had united by bone, and that the spinal marrow was almost com- pletely cut in two, the divided extremities being enlarged and sepa- rated nearly" an inch from each other.3 Key's case of fracture of the first lumbar vertebra. § 2. Fractures of the 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 dis- turbance 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 vertebras, 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 com- pletely separated, yet the patient survived the accident two months.4 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.5 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 1 Thompson. Amer. Journ. Med. Sci., Oct. 1857. Lente's paper. 2 Key, A. Cooper on Disloc, &c, op. cit., p. 4(i7. 3 Harrold, A. Cooper, op. cit., p. 4(34. 4 Parkman, New York Journ. Med., March, 1853, p. 23J. 5 Dupuytren, op. cit., pp. 35ti-7. 156 FRACTURES OF THE VERTEBR-E. found with nearly complete paralysis of his lower extremites, and of his bladder. Swelling existed over the lower dorsal vertebras, and this point was very tender. Subsequently, when the swelling subsided, the prominence of the spinous processes of the tenth and eleventh dorsal vertebras put the question of a fracture beyond doubt. Gradu- ally 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 fif- teen 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.1 § 3. Fractures of the Bodies of the five lower Cervical Yertebrse. We shall now have added to the symptoms already enumerated, paralysis of the upper extremities, greater embarrassment of the res- piration, 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 ten recorded examples of fractures of the five lower cervical vertebras which I have been able to collect, 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, one fifteen months, and one, reported by Hilton, survived fourteen years.2 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, set. 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 dia- phragm 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 appe- tite, had frequent attacks of purging, and thus she gradually wore out.3 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 extremi- ties. 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 1 Lente, Amer. Journ. Med. Sci., Oct. 1857, p. 361. 2 Hilton, Lond. Lancet, Oct. 27, lMJO. 3 Greenwood, Sir A. Cooper on Disloc, p. 472. \ \ \ FRACTURES OF THE BODIES OF THE VERTEBRAE. 157 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.1 The following example furnishes a fair illustration of the usual phenomena which accompany fractures of the third or fourth cervical vertebra. 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 phy- sical 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 vertebras were broken, and the spinous processes slightly depressed upon the cord. The bodies of the corresponding vertebras were comminuted, and the vertebras 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. 1 Dupuytren, op. cit., p. 358. 158 FRACTURES OF THE VERTEBRAE. 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 vertebras, 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, set. 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 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 for- wards 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 vertebras, 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 men- tioned 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 recover- ing 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 involun- tary discharge of the feces, and some disorder in the function of respira- tion. 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 § -4. Treatment of Fracture of the Bodies of the Vertelrse, when the frac- ture occurs in any portion of the column lelow the Second Cervical. In a few instances, I have noticed among the recorded examples of fractures of the bodies of the vertebras, 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 1 A. Cooper, op. cit.. p. 454. 1 Hover, Lecture on Diseases of the Boiies, Amer. ed., 1805, p. 55. FRACTURES OF THE BODIES OF THE VERTEBRAE. 159 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 suf- fered 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 seldom 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 esti- mate 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 usually inflicts upon the unfortunate sufferer great pain, and for these reasons, it ought generally to be discouraged. I have recently seen one case of fracture of one of the lumbar vertebras, in which relief was afforded by extension. When the fracture is below the middle of the vertebral column extension, if employed, should be made by adhesive straps, weights and a pulley, as will hereafter be directed in fractures of the femur; the counter-extension being made by the weight of the body. It will be understood, however, that when paralysis exists the ligation of a limb with bandages will expose the patient to great danger of ulceration and sloughing at and below the points of pressure, and the amount of extension must be very moderate. When treating of fractures of the arches of the vertebras, I took occasion to call attention to Mr. Cline's operation, occasionally recom- mended 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 vertebras 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 pro- priety 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 vertebras. 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 com- fortable, 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 ouo-ht 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 160 FRACTURES OF THE VERTEBRAE. six hours. It is especially necessary to attend to those 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 irri- tated and inflamed by the excessively alkaline urine, suffers additional injury from any degree of painful distension of its walls. It is unneces- sary 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 conse- quent motion, will probably do much more harm than the evacuation can do 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 enter- tained 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 para- lyzed, nothing could be more rational than the employment of strych- nia 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 fric- tions, good fresh air, and nourishing diet, become at last essential to recovery. From an early period, and 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. FRACTURES OF THE AXIS. 161 § 5. Fractures of the Axis. The phrenic nerve is derived chiefly from the third and fourth cer- vical 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 compres- sion have been inconsiderable, or there has been no displacement at all. Mr. Else, of St. Thomas's Hospital, says that a woman in the vene- real 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 examina- tion 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 both the "lamina and the transverse process" of the axis. He died on the fourth day.2 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 Eichet, 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. Eokitansky says that there is a specimen contained in the Vienna Museum taken from a patient who survived the accident some time, although the fragments never united. 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 tempera- ment, 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 mer- curials 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 Riving- ton Street in this city, a distance of more than two miles. There was 1 Else, A. Cooper on Disloc, &c, op. cit., p. 462. 1 A. Cooper on Disloc, etc, op. cit., p. 476. 162 FRACTURES OF THE VERTEBRAE. 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 incapaci- tated to rotate the head, which led to the suspicion of some injury to the articulations of the upper cervical vertebras; but so great a degree of swelling existed about the neck as to prevent efficient examina- tion. 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 adminis- tered. 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 vertebras. "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 with one hand applied to the occiput. He often remarked, if he could 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 indendation. 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 occu- pation 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 vertebras. "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 8 o'clock A. M., on the 12th of January, precisely five months from the receipt of the injury. FRACTURES OF THE ATLAS. 163 " The autopsy was made thirty hours after death by Dr. C. E. Isaacs, in presence of several medical gentlemen. Muscular develop- ment 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 vertebras, the parts were found to be very vascular. These vertebras were removed en masse, and a care- ful 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 oc- curred at the time of the accident, and after- Fig- 36- wards to have prevented the union of the bones. The spinal cord exhibited no appearances of any lesion. The odontoid process 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 fa- 1 , . U "1 Fracture of the odontoid pro- VOreCl ttllS result. _ cess of the axis. Parker's case. Dr. Philip Bevan presented to the Surgical A. Broken surface, b. odon- Society of Ireland, in 1862, a specimen obtain- toid process. ed from the dead room, and which was sup- posed to be an epiphyseal separation of the odontoid process, occur- ring in early life. The history of the case is not known, although the woman was forty years old when she died. It does not appear very clear to us whether this was really an epiphyseal separation, or the result of some morbid process.2 § 6. Fractures of 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 1 Biselow, New York Journ. Med., March, 1853, p. U>4. 2 Bevan, Am. Journ. Med. Sci., April, 18ti4. From Dublin Med. Press, Feb. lb, ISM. 164 FRACTURES OF THE VERTEBRAE. 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.1 § 1. Fractures op the First two Cervical Vertebra (Atlas and Axis) at the same time. A woman, ast. 68, fell down a flight of steps, striking upon her fore- head, and died immediately. Upon making a dissection, it was found that the atlas was broken upon both sides near the transverse pro- cesses, and the odontoid process of the axis was broken at its base. These fractures were accompanied with a rupture of the atloido-odon- toid ligaments, and a dislocation of the atlas backwards.2 South says there is a specimen in the museum of St. Thomas's Hos- pital, 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 ver- tebra 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.3 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 cervi- cal vertebra, pressure upon which caused a slight pain. He com- plained 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 dis- covered. 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 walk 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 vertebras were united to each other firmly by complete bony callus.'1 1 Cline, Sir Astley Cooper, op. cit., p. 459. * Malgaigne, op. cit., torn. ii. p. 333. 3 Chelius' Surgery, note by South, vol. i. p. 588. 1 Phillips, Med.-Chir. Trans., vol. xx. 1837, p. 384. FRACTURES OF THE STERNUM. 165 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 cross- bar which intercepted his fall, in consequence of which the abdominal and sterno-cleido-mastoidean muscles were so stretched that the ster- num broke asunder between its upper and middle portions.1 Sabatier reports another case of fracture at the same point, produced in a simi- lar manner ;2 and Eoland has described a third example in a woman sixty-three years old, who, falling from a height backwards and strik- ing upon her back, broke the sternum near its centre.3 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.4 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.5 Maunoury and Thore have reported an analogous case, where a man fell from a height of twelve or fifteen metres, first striking upon his feet and then falling over upon his back and head.6 Mr. Johnson, late editor of the London Med.-Chir. Eev., 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 ' Boyer on Bones, p. 57. 2 Malgaigne, from Sabatier, Mem. sur la Fract. du Sternum. 3 Ibid., from Bull, de Therap., torn. vi. p. 288. * Ibid., from Bull de la Soc. Anat., Juin, 1826. 5 Ibid., from Archiv. de Med., Janv. 1827. 5 Ibid., from Gaz. Med., 1842, p. 361. 166 FRACTURES OF THE STERNUM ^ rcvrcly unite, | except Dioi-daqt 35-1,0. third rib, the lower fragment projecting in front of the upper. The fragments were easily replaced by simply throwing the head back, and fell into place with an audible snap, but immediately resumed their unnatural position when the head was flexed. They finally united, but with a slight projection and overlapping.1 Gross has reported one more example.2 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 remain- ing explanation is that in such cases the sternum has been broken by the violent shock, or contrecovp. Seat and Direction of Fracture.—The sternum is separated most fre- quently either in the long cen- Fig- 3". tral 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 fre- quently as a diastasis or dislo- cation 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 cen- tral piece, also, will explain the infrequency of its fracture. Boyer believed that the xi- phoid cartilage was not suscepti- ble of being permanently dis- placed 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 elas- ticity."3 The following case, however, which has come under my own ob- servation, 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 eve^ five or six days. Both Dr. Green, of Albany, and Dr. White, of Cherry Valley, 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 20-2S!!> year soon afterpu.he-rtij rlly cartflagirtous in advanced life Sternum, showing the periods at which its several parts unite by bone. (From Gray ) 1 London Med.-Chir. Rev., vol. xvii., new series, p. "36, 1S32. 2 fiross. System of Surg., vol. ii. p. 167. 3 Boyer on I'iseases of Bones, p. 59. FRACTURES OF THE STERXUM. 167 year 1818, while he was an inmate of the Buffalo Hospital of the Sisters of Charity, I examined his chest and found the xiphoid carti- lage 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 find 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 car- ried upwards under the upper fragment to the extent of twenty-eight millimetres. I have recently seen a remarkable case of separation of the manu- brium from the gladiolus, accompanied with a true fracture and other complications. Louis Wilson, ast. 60, was admitted into the Long Island College Hospital, April 1, 1866, having just fallen through the hatchway of a vessel. He had a compound, comminuted fracture of the right leg ; a fracture of the four first ribs on each side at their necks; a dislo- cation of the sternum from the cartilages of both second ribs; a dislocation of the left third cartilage from its rib; a dislocation of the first from the second bone of the sternum; and a transverse fracture of the sternum three-quarters of an inch below the top of the gladiolus. The dislocation of the manubrium was complete, and it was thrust behind the upper end of the gladiolus, underlapping it half an inch. The transverse fracture three-quarters of an inch lower down was also complete, and the fragment thus separated was divided into two, namely, an anterior and a posterior fragment, by a transverse splitting; the anterior moiety retaining its attachment to the periosteum below, and not being displaced, while the posterior moiety retained its attachment to the periosteum both above and below, and was pushed downwards by the descent of the manubrium. His mind was clear, but he had paralysis of the bladder, and was breathing with some embarrassment. I had no difficulty in diagnosticating the dislocation of the third cartilage, and of the manubrium. There was no swelling or discoloration on the front of the chest, but it was quite tender. His head was not thrown forward. He complained of some soreness on the back of his head. His general condition was such that I did not attempt reduction. The following day he expectorated blood, and on 1 Buffalo Med. Journ., vol. xii. p. 2S2, Cases of Fractures of the Sternum. 168 FRACTURES OF THE STERNUM. the third day he died. The autopsy revealed some effusions of blood underneath the pleura, but no lesions of the heart or lungs. The evidence is in this case conclusive that he struck upon his back and head, in fact that it was a fracture from counter stroke by which the head, neck, and three or four upper vertebras were bent forward with great force, thus doubling forward the top of the sternum. Dr. Eobert Watts, Jr., of this city, has reported a very similar case, in which death occurred on the same day. The fragments of the sternum were not displaced, but the ribs had suffered similar lesions.1 Diagnosis.—In a few cases the patients have felt the bone break at the moment of the accident. When displacement exists it may gene- rally 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 exist- ence 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 car- tilage which he at first suspected to be a fracture. It was so much curved backwards that, as Mr. Cooper thinks, its pressure upon the stomach produced a constant disposition to vomit whenever he had taken a full meal, or had taken a draught of water.2 Prognosis.—In simple fracture of this bone, uncomplicated with lesions of the subjacent viscera, and especially when the fracture is the result of muscular action or of a counter stroke, no serious con- sequences are to be apprehended. The bone unites promptly even where it is found impossible to bring its broken edges into ap- position. Indeed, generally, where the fragments have been once completely displaced, although it is not difficult to replace them mo- mentarily, 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 persist- ence 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 incon- veniences 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. 1 Watts, Am. Med. Times, vol. iii. p. 55. 2 B. Cooper, Princ. and Pract. of Surg., p. 359. FRACTURES OF THE STERNUM. 169 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. A remarkable case of recovery after gunshot injury of the sternum is reported by the IT. S. Medical Bureau:— Private C. Betts, 26th N. J. Vols., set. 22, was struck by a three- ounce grape-shot, May 3, 1863, in the charge upon the heights at Fredericksburg, Va. The ball comminuted the sternum, opposite the third rib on the left side, penetrating the costal pleura. The patient removed the ball from the wound himself. On the following day he was admitted to the hospital of the second division of the sixth corps. Through the wound the arch of the aorta was distinctly visible, and its pulsations could be counted. The left lung was collapsed; when sitting up there was but slight dyspnoea. Several fragments of the sternum were removed. The wound soon began to heal, and he made a complete recovery.1 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 lace- ration 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.2 Treatment.—When the fragments are not displaced, the only indi- cations of treatment are to immobilize the chest, and to allay the in- flammation, 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 dis- arranged. It should be pinned while the patient is making a full 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 1 Circular No. 6, Washington, D. C, Nov. 1, 18G5, p. 23. 2 New York Journ. Med., vol. iii. p. 351. 12 170 FRACTURES OF THE .STERNUM. 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 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 ten- dency 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 symp- toms 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 remov- ing a portion of the bone."2 Ashhurst, referring to the same point, 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."3 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 dis- location even. Maisonneuve, Vidal (de Casis), Malgaigne, and other French surgeons speak of it as a dislocation, and Vidal has collected 1 Gibson, Institutes and Practice of Surgery, vol. i. p. 269. 2 Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242. 3 Ashhurst, Am. Journ. Med. Sci., Jan. and Oct. 18(J2. FRACTURES OF THE RIBS. 171 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. CHAPTEE XVII. FRACTURES OF THE RIBS AND THEIR CARTILAGES. § 1. Fractures of 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, not including fractures from gunshot injuries, only twenty-three 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 fifty-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 res- piration, 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 have not met with so often. Malgaigne has collected eight examples of fractures of the ribs pro- duced 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, 172 FRACTURES of the ribs and their cartilages. 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 four times; the fourth, six times; the fifth, eleven times; the sixth, twelve times; the seventh, eight 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 ; nine through their middle thirds; and nineteen through their posterior thirds. Mal- gaigne 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 tranverse or slightly ob- lique ; 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 hav- ing penetrated the lungs, and not by a tegumentary wound. In only eleven of the twenty-three 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 propor- tion 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 re- ceived 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 suc- cumbed at a later period to acute pneumonitis. Lonsdale saw a case in which the body of a man having been tra- versed 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- ture, two of which are particularly described in his Clinical Lecture.3 Amesbury has seen a case of death from rupture of the intercostal artery, where there was no injury of the lungs.4 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 thiug for these injuries i Lonsdale on Fractures, p. 258. 2 Chelius's Surgery, by South, vol. i. p. 599. 8 Dupuytren, op. cit., p. 79. * Amesbury ou Fractures, vol. ii. 612. FRACTURES OF THE RIBS. 173 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 ;* 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 dis- charge of matter, and in which a removal of the ends of the fragments resulted promptly in a cure of the sinus ;2 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.3 The union generally occurs with only a slight degree of displace- ment. 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 there is no ensheathing callus; and the remain- F'g- 38- ing four, all occurring in the same person, are united with displace- ment, but without a pro- per ensheathing callus. In some specimens I have observed sharp spi- culae, in others broader sheets, of bone extend- ing 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, 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 mam- mas in the female. In three instances, where the presence of emphy- Fractured ribs joined to each other by osseous matter. Dr. Gross's cabinet.) (From i Malgaigne, op. cit., p. 435. S. Cooper's Surg., vol. ii. p. 321. 2 Eve, N. Y. Journ. Med., vol. xv. p. 136. 171 FRACTURES OF THE RIBS AND THEIR CARTILAGES. sema 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 preter- natural 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-three 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 ex- pectorate 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 frac- ture 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 great relief from the distressing pain, and they will not consent to have it removed even for a moment. In nearly all cases of commi- nuted fracture, it is inadmissible, on account of its tendency to force the pieces inwards. Hannay, of England, has suggested the use of adhesive strips 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. 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 1 American Journ. Med. Sci., vol. xxxix. p. 19S. From Lond. Med. Gaz., Nov. 1S4.J. FRACTURES OF THE RIBS. 175 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 pro- duced 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 re- sumed 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 Eossi alone claims to have actu- ally put the suggestion into practice. No doubt, if the necessity was urgent, this method might be suc- cessfully 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 gunshot fractures, which are nearly all compound and comminuted, the loosened or detached fragments should be at once removed. 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 exten- sive 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. 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 1 Ranking's Abstract, vol. ii. p. 204, from Gaz. des Hopitaux, July 8, 1845. 176 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 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 or 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 The reader is referred also to my own and Dr. Watts' cases reported in the chapter on Frac- tures of the Sternum. 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 car- tilages 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. AYarren, 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. Pathology.—The fracture is clean and vertical, or transverse; never irregular or oblique. The direction of the displacement varies as in 1 Boston Med. and Surg. Journ., vol. Iii. p. 316. 2 Rauking's Abstract, vol. i. p. 147, from the Lancet, Oct. 1844. FRACTURES OF THE CLAVICLE. 177 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 ensheating callus appears to be supplied by the peri- chondrium, while the experiments of Dr. Eedfern render it probable that the intermediate callus may result from a conversation or trans- formation 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, set. 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 recom- mended for fractured ribs. CHAPTEE 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.—If we except gunshot fractures, 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 the recoil of an overloaded gun, especially when the person lies upon the ground with the butt of the gun resting against the clavicle. Gibson has seen a case in which it was broken in a child at birth, 178 FRACTURES OF THE CLAVICLE. by an ignorant midwife pulling at the arm,1 and Dr. Atkinson has re- ported an example of intra-uterine fracture of the clavicle.8 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 en- sheathing 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 Revista 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 some- thing had broken, followed by acute pain in his left shoulder, and, on examination, it was found that the clavicle was fractured in the mid- dle. 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 pro- duced 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 accom- panied 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 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 1 Gibson, Principles of Snr., sixth el., vol. i. p. 272. 2 Atkinson. Bost. Med. and Sur^. Journ., July 23, 1860. » Parker, N. Y. Journ. Med., July, Ib52. FRACTURES OF THE CLAVICLE. 179 Fig. 39. from this point downwards and inwards, toward the sternum, em- bracing one inch or less of its entire length. In some cases the obli- quity is greater, and the amount of bone involved is much more considerable. Why the bone should break more frequently at this point, espe- cially 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 one hundred and five fractures, including partial and comminuted, and not including gunshot fractures, eighty-eight have oc- curred 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. Four have occurred through the inner third, three of which were within one inch of the sternum; and thirteen 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, but once, seen a complete fracture of this bone pro- duced 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 mid- dle third, the direction of the dis- placement is almost uniformly the same. The sternal fragment is slightly lifted by the action of the clavicular portion of the sterno- cleido mastoid muscle, notwith- standing the resistance of the rhom- boid 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 mus- cles 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 Complete oblique fracture of clavicle, near its middle. (From Gray.) 180 FRACTURES OF THE CLAVICLE. acromial end of the fragment, with the 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 the acromial end. Desault has recorded one example of an overlapping by the eleva- tion of the acromial fragment over the sternal j1 and Bicbat 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 Gudretin, Malgaigne,3 and Stephen Smith, have each re- ported 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 Hos- pital, 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, break- ing 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 dis- placement. 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, break- ing the collar bone near the middle. The fragments were movable, but not displaced. He was treated successfully and without any re- sulting 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 dis- placement at first, but the fragments being reduced, were found to sup- port themselves. A. cross, secured with straps, was applied to the back, and on the twenty-eighth day the union was complete, and with- out 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 Amer. Journ. Med. Sci., vol. xvii. p. 251. * Malgaigne, p. 461. * N. Y. Journ. of Med., May, 1857. FRACTURES OF THE CLAVICLE. 181 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 trans- verse 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, how:ever, 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. March 22, 1865,1 presented to the New York Pathological Society a similar case, obtained from a patient in Bellevue Hospital. The man from whom this specimen was taken, was forty-five years old, and the fracture, occasioned by a fall upon the shoulder, extended from the sterno-clavicular articulation upwards and outwards one inch and a half. The fragments were overlapped three-quarters of an inch, and were firmly united. The character of the accident was not recognized until after death. The specimen is now in the museum of the Bellevue Hospital. With regard to the amount of displacement usually attendant upon fractures near the outer end of the bone, surgical writers have gene- rally united in declaring that it was in a majority of cases very incon- siderable, while some have even affirmed that there would be found no displacement whatever; neither of which opinions, according to the observations of Kobert 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 pre- sent 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 1 Pesault on Fractures, op. cit., p. 15. 2 Lonsdale on Fractures, p. 206. 3 Malgaigne, op. cit., p. 491. 182 FRACTURES OF THE CLAVICLE. coracoclavicular ligament, there is seldom any displacement of either fragment, and always much less than in fracture of any other portion of the bone. AVhen 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 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 Fig- 40. 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 iuwards, so as to bring sometimes its broken sur- face into contact with the anterior surface of the Fracture outside of trapezoid . - .. . . ligament. United. inner fragment, and placing it nearly at right angles with this fragment, in which position it is generally 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 occur- ring 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 dissec- tions 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, except in cases of gunshot injuries, 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. FRACTURES OF THE CLAVICLE. 183 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.' Two similar cases are reported from the New York Hospital, as having been observed during the last ten years. The whole number of ex- amples of fracture of the clavicle during this period was 191.2 Lente also mentions a case, seen by himself, occasioned by the fall 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 dis- charged from the wound.3 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.4 Malgaigne says it has only happened to him to see it once in 2,353 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, doubt- less, 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 explain their infrequency in hos- pital, and their relative frequency FiS- 41. 1 London Med. Gaz., vol. ii. p. 382. 2 New York Med Times, March 16, 1861. ' Lente, N. Y. Journ. of Med., July, 1F50. » Rep. on Def. after Frac, Cases 5, 6, 10. 181 FRACTURES OF THE CLAVICLE. 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 dis- placement, occurring in the middle third of the bone, I have particu- 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 accorn panied 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 seventy-two complete fractures only sixteen united without shortening; and of twenty-seven 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 Keckerley, had anything to do with the result. Six 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 frac- ture 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: some- times, 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 frac- tures 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 FRACTURES OF THE CLAVICLE. 185 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, and occasionally 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 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 situa- tion 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 of transverse fracture already men- tioned as having been seen by me, the union seemed to be tolerably firm in seven days. Wallace re- ports one case from the Pennsyl- vania Hospital, which was cured in eight days, and another in nine days.2 Velpeau says the clavicle will unite in from fifteen to twenty- five days; Benjamin Bell, in four- teen; Stephen Smith has seen it firm in fifteen days. Whatever may be the degree of displacement, or the condition of the system, unless in a case of gun- shot fracture, 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 will illustrate:— Edmund Nugent, a stout Irish laborer, now twenty-five years old,. Fig. 42. Comminuted Fracture.—United. tare.) (From na.' 1 Trans, of Amer. Med. Assoc, for 1855, Case 13 of Frac. of Clavicle. 2 Am. Journ. Med. Sci., vol. xvi. p. 115. 13 186 FRACTURES OF THE CLAVICLE. 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- 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 r seemed as well developed as those of the right. u-/ Chelius also refers to two cases mentioned by Gwrdy and Velpeau, '/ in which, although an artificial joint remained, the use of the limb was but little impaired.1 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, accom- panied, 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. Earle 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.2 Desault saw a case at Hotel Dieu, in which, although 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 1 Chelius, Amer. ed., vol. i. p. 603. z S. Cooper's First Lines, fourth Amer. ed., vol. ii. p. 323. FRACTURES OF THE CLAVICLE. 187 external part of the left clavicle. A considerable wound, followed by swelling, pointed out the place on which the blow had been received. No apparatus was applied, and on the third day a numbness and par- tial 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.1 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 con- tinued 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, ex- isted, 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 in- flammation to blend them inseparably together. Complete paralysis and atrophy of the whole arm ensued, and the patient's object in visit- ing 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 in- flicted 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 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. 1 Desault on Frac. and Disloc, Amer. ed., p. 14, 1805. 2 Gibson, op. cit., 6th ed. vol. i. p. 271. 188 FRACTURES OF THE CLAVICLE. Parker, of New York, in a note to the edition of S. Cooper's Sur- 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 wedge- shaped pad, over which the limb was confined, in order to pry the shoulder outwards. Stephen Smith mentions a case of partial para- lysis 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, ap- plied 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, pro- duced 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 frac- tures 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 Chelius remarks : " Setting of this fracture is easy, yet only in very rare cases is the cure possible without any deformity." * * * * " 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 direction of the fracture; (therefore, in spite of the most careful application of 1 New York Journ. of Medicine, May, 1857. 2 Erichsen, Surgery, Amer. ed., p. 205. 3 tfew York Journ. Med., May, 1857, p. 382. FRACTURES OF THE CLAVICLE. 189 this apparatus, some deformity often re- Fig- 43. mains.")1 Velpeau, in a lecture given in 1846, and published in the Gazette des Hdpi- taux, declares that with all the bandages imaginable in the case of an oblique fracture at the junction of the outer third with the inner two thirds we can- not prevent deformity. Vidal observes: "Fracture of the clavicle is almost always followed by deformity, whatever may be the perfec- tion of the apparatus and the care of the surgeon."2 " Hippocrates has observed that some degree of deformity almost always ac- companies the reunion of a fractured clavicle; all writers since his time have made the same remark; experience has confirmed the truth of it."3 Turner remarks as follows: "As to the reduction of this fracture, it must be owned the same is often easier re- placed 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 costae 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 "extra- ordinary, 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 pro- tuberance 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."4 Says Johannis de Gorter: "Restituiter facile tractis humeris a ministro posterius, dum simul suo genu locato ad spinam dorsi, dor- sum sustentet minister, nam tunc chirurgus fobs digitis claviculam Velpeau's dextrine bandage; no axil- lary pad. 1 System of Surgery. By J. M. Chelius, of Heidelberg, with notes by South. First Amer. ed., vol. i. pp. 603, 605. 1 Vidal (de Cassis), Paris ed., vol. ii. p. 105. ' Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav. Bichat, and translated by Charles Caldwell, M. D. Philadelphia, 1805, p. 9. ♦ The Art of Surgery, by Daniel Turner, vol. ii. p. 256. London ed., 1742. 190 FRACTURES OF THE CLAVICLE. fractam reponere potest. Dijficilius autem in reposita sede relinetur, sed loca cava supra et infra claviculam spleniis implenda."1 Says Heister, writing only a little later: " 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; lut the difficulty is much greater to keep the lone in its place when the fracture is once reduced, especially if the lone was Iroken olliquely."2 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, how- ever, not much unlike a multitude of others, and is liable 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- 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.4 Says M. Malgaigne: "The prognosis, considering the trivial cha- racter 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 extrava- gant 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 re- marks :— " This apparel is very simple; but neither will it remedy the over- lapping." * * * * "Of all the apparels which we have passed in review, there is, then, not one which fills completely the three indi- cations 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 1 Johannis de Gorter ; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742. 2 Heister's Surgery, vol. i. p. 134. London ed., 1768. J Treatment of Fractures, by Joseph Amesbury, vol. ii. p. 527. London ed., 1831. * Nouveau Systeme de Deligation Chirurgicale, par Mathias Mayor, de Lausanne p. 384. etc.: (also Atlas, plate 3, fig. 23.) Paris edit., 183H. 5 Traite des Fractures et des Luxations, par J. F. Malgaigue, tome premier, p. 473, Paris ed., 1847. FRACTURES OF THE CLAVICLE. 191 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."1 "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, with- out obvious deformity."2 I need not say that the " venerable gentleman" to whom Dr. Coates refers in this passage, was the late Dr. Physick, of Philadelphia. Dr. Gross says that according to his experience "fractures of the clavicle are seldom cured without more or less deformity, whatever pains may be taken to accomplish the object."3 Treatment.—If evidence were needed beyond that which has been furnished, of the difficulty of bringing to a successful issue the treat- ment 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, ac- complished, 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 1 Elemens de Pathologie Chirurgicale, par A. Nelaton, tome premier, p. 720, Paris ed., 1844. 2 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. 3 Gross, System of Surgery, vol. ii. p. 155, 1859. 192 FRACTURES OF THE CLAVICLE. patients should be confined in this position during most of the treat- ment ; and from the account given by Dr. Lente, it will be understood that a similar plan is generally adopted in the New York City Hos- pital. "But this result (deformity) rarely happens when the patient has strictly followed the directions of the surgeon, as to position espe- cially, 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 uni- formly 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 termi- nated with very little deformity ;J and I have myself treated many cases by this plan with more than average success. Jan. 2, 1856.—Mary Ann S., set. 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 over- lapping of the fragments of less than half an inch, and with scarcely any perceptible deformity. Alexander Mooney, aet. 33, was admitted to the Buffalo Hospital, December 3, 1856, with an oblique fracture of the left clavicle, at the outer end of the middle third. On measurement we found the frag- ments overlapped nearly half an inch. In presence of a class of medical students I applied Bartlett's appa- ratus, a very convenient form of the sling dressing, and the same which has been much employed at the Mass. General Hospital, in Bos- ton. On the following day the apparatus was found to be loose, and it was carefully retightened. On the third and fourth days, 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 over- lapping 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, N. Y., have also employed this method successfully;'2 while Malgaigne declares it to be the most reliable means of obtaining an exact union. .» N. Y. Journ. of Med., vol. ii. p. 226. 8 Bost. Med. and Surg. Journ., vol. lvi. p. 468. FRACTURES OF THE CLAVICLE. 193 Albucasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, Brun- ninghausen, Parker, and very many others, especially among the English, Fig- 44. 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, Breffield, Keckerly,1 Coleman,2 Hunton,3 prefer, for this purpose, some form of back- splint, 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 Figure-of-8. 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." Fox,4 Brown,5 Desault, and others bring the elbow a little forwards, and then lift the shoulder upwards and backwards. Wattman and Lonsdale carry the elbow still further forwards, so as to lay the hand across the opposite shoulder, while Guillou carries the hand and fore- arm 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 lehind 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. Hollings worth, of Philadelphia, has also treated one case successfully by Guillou's method, and adds his testi- mony 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 1 Keckerly, Amer. Journ. Med. Sci., vol. xv. p. 115 ; also, my Report on Deformi- ties after Fractures, in Trans, of Amer. Med. Assoc, vol. viii. p. 440. 2 Coleman, New York Journ. Med., second series, vol. iii. p. 274, from New Jersey Med. Rep. 8 Hunton, ibid. ; also, New Jersey Med. Rep., vol. v. p. 146. 4 Fox, Liston's Practical Surgery, Amer. ed., p. 47. 6 Brown, Sargent's Minor Surgery, p. 132. 194 FRACTURES OF THE CLAVICLE. Fox sought to accomplish by pressing the elbow upwards and back- wards, as easily attained by pressing the elbow upwards and forwards ? Fig. 45. n U2 u a d U E. C Keckerlt'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,bb. 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 uninjured side is to be pressed close to the back of the shoulder, and retained so by drawing the bandage tight, and retaining it by means of the buckle. Previous to fixing 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 the 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 arm of the injured side close to the body, give it support, and prevent its falling down " Or are we not compelled to infer that there has been some mistake as 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 ^Egineta, Boyer, Desault, Pecceti, Liston, Fergusson, Samuel Cooper, Erichsen, Miller, Skey, Levis, Dorsey,2 Gibson,3 Fox, H. H. Smith,4 Norris,5 Sargent, Eastman," recommend an axillary pad, while Eicherand, 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 1 Coates, Amer. Journ. Med. Sci., vol. xviii. p. 62. 2 Dorsey, Elements of Surgery, vol. i. p. 133. 5 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, Aurora, 111. ; Bos- ton Med. and Surg. Journ., vol. xxiii. p. 179. 7 Cabot, Bost. Med. and Surg. Journ., vol. Iii. p. 232. FRACTURES OF THE CLAVICLE. 195 Fig. 46. 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 Vel- peau, 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, Velpeau, and others, constitute only another form of the bandage dressing of Desault. In this connection it ought to be noticed that Velpeau does not regard the employment of this apparatus, or of any other demanding great restraint, as imperative. In his great work on anatomy, re- ferring 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 re- marks: "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 over- lapping,"1 etc. The sling, in some of its forms, is employed by Eicherand, Huberthal, Colles, Miller, Fox, Stephen Smith,2 II. H. Smith, Bartlett,3 Levis,4 Dugas,5 Ben- jamin Bell, Bransby Cooper, Earle, Chapman, Keal, and by a large majority of the English surgeons; while Dr. Gibson declares the sling bandage, em- ployed so much by the English, "the most inefficient, contemptible, and inju- rious of all contrivances for such pur- poses." No apparatus, perhaps, has been so generally employed, among American surgeons, as that form of the sling in- troduced 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 -r-r J . n t ■■ • , E. Bartlett's Apparatus.—" For an Hospital, and by surgeons in private axillary pad> roll a strip of woolleu practice, Cured without perceptible de- flannel, four or five inches wide, around fbrmitV " *^e axiUar7 strap, to the size required. ■kt • • r • j ) T> ~ 4'~~ 7 The apparatus may be used for either Norris, in a note to Liston s Jrractical vv . f ^.iwiJi^>, i»x i* ^.wv u^ i • r> • j • 81"e fcy changing the attachment of the Surgery, affirms that " the chief mdica- snng." (Bartieu.) 1 Velpeau, Anatomy, Amer. ed., vol. i. p. 242. 2 Stephen Smith, New York Journ. Med., vol. ii. 3d series, p. 384 (May, 1857). 5 Bartlett, My "Report on Defor.," etc., Appendix ; also Bost. Med. and Surg. Journ., vol. Ii. p. 404. 4 Levis, H. H. Smith's Practice of Surg., p. 363. Am. Journ. Med. Sci., April, 1860, p. 428. 5 Dugas, Report on Surgery. 196 FRACTURES OF THE CLAVICLE. Fig. 47. tions in the treatment of fracture of the clavicle are perfectly fulfilled by the use of this apparatus." H. H. 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 (Pennsyl- vania Hospital) with any other deformity save that which time cures, viz., the deposition 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 atten- tion ; 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 gene- ral 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 gentle- men. I have seen others employ it, also, and with pretty much the same re- sult. Nor ought it to 'be forgotten that, in Great Britain, by far the greater ma- jority of surgeons employ an apparatus essentially the same. I have seen it in many of the hospitals, and Mr. Bicker- steth, one of the surgeons of the Liver- pool Infirmary, informed me, in 1844, that it had been in use with them as long as thirty years. All that has j ustly been said against the English mode of dress- ing by 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 Penn- sylvania Hospital, the axillary pad em- ployed 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 George Fox's Apparatus "consists of a firmly stuffed pad of wedge shape, and about half as long as the humerus, hav- ing a band 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 muslin stuffed with cotton to encircle the sound shoulder, and serve as means of acting upon and receiving the sling." (Sargent.) FRACTURES OF THE CLAVICLE. 197 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 Hos- pital, and in the hands of private practitioners, so far as they have seen, deformities have become the " exception. It is affirmed to an- swer "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 accom- plished, 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 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 round- ness 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 non- muscular. 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 disposi- tion 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 198 FRACTURES OF THE CLAVICLE. (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 un- natural 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 alterna- tive but to trust to that action of the muscles attached to the scapula, by which, as Desault first explained, when the shoulder is lifted per- pendicularly, 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 unaccom- plished ; 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 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 sough, 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 for- wards 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, only in a greater degree, to M. Guillou's method of carrying the fore- arm 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 1 Amer. Journ. Med. Sci., vol. xviii. p. 62. FRACTURES OF THE CLAVICLE. 199 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 Fig. 48. 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 be- hind the body—toward the stuffed collar; and each set of front and back tapes, at- tached 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 fracture1 aCCOmpa- The Author's Apparatus. nied 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 any- thing in this way. Nor is it a matter of much consequence, I 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. 1 See Chapter on Incomplete Fractures. 200 FRACTURES OF THE BODY OF THE SCAPULA. 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 .of the Body op 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, and Dr. March has a specimen of fracture of the body. I believe also that in the collection of the late Dr. Charles Gibson, of Kichmond, there are one or two specimens of this fracture. I know of no other museum specimens in 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 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 is 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. FRACTURES OF THE BODY OF THE SCAPULA. 201 Symptoms.—Since this bone is seldom broken except by great force directly applied, the usual signs of fracture are likely to be con- cealed by the speedy occur- rence of swelling. It is for Fig. 49. 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 be- lieved 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 e by merely carrying the finger along the crest. In the example to which Dr. Neill called my attention in the Pennsylva- nia Hospital, although there was scarcely any displace- ment, 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 margins and render them more prominent. In examining the poste- rior angle, the hand of the injured limb may be placed upon the oppo- site 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 sepa- rated 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 11 Fracture of the posterior angle of scapula, with fissure. Mutter's collection, specimen C. No. 187. 202 FRACTURES OF THE SCAPULA. Fig. 50. 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 embarrass- ment 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 frac- ture 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 sur- geons 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 trans- verse, and especially if its direction is ob- lique from before backwards and down- wards, 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- 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- 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 Fractures of the body, and acromion process of the scapula. FRACTURES OF THE BODY OF THE SCAPULA. 203 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, Ne'laton, Gibson, Malgaigne, and others have spoken of the difficulty or impossibility generally of keeping these fragments in place. Ne'laton 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 injur}*- 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 commi- nuted, and the soft parts adjacent so much injured that suppuration and necrosis have ensued. And in a recent case of gunshot fracture of the scapula, attended with much comminution, and resulting in necrosis, I have had occasion to remove the entire scapula. 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 en- deavored 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 down- wards 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 Ne'laton 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 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 in- closes not only the body, but also the arm; neither of these last-men- tioned 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 204 FRACTURES OF THE SCAPULA. 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 for- wards. 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 band- ages 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 com- pletely 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 with which it is secured to the body, and with which we seek to im- mobilize the scapula and chest, is turned from before backwards, or in a direction of antagonism to the action of the muscles which pro- duce 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 FRACTURES OF THE NECK OF THE SCAPULA. 205 irksome, and sometimes insupportable, and which does not offer in any case sufficient advantages to render it worthy of a trial. § 2. Fractures of the Neck of the Scapula. If by the "neck" of the scapula, surgeons mean that slightly con- stricted 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 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 cora- coid process, then its existence is certain; yet the fracture is not com- mon. 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 Fig. 51. Fig. 52. Comminuted fracture of the glenoid Fracture of the neck of the scapula; according to cavity. Sir Astley Cooper. 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 206 FRACTURES OF THE SCAPULA. 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 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 cora- coid process moves with the humerus instead of the scapula. Occa- sionally, 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 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, Ne'laton, Malgaigne, West,2 Brainard,3 Stephen Smith4 and others. I have myself seen three examples.5 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 epiphysis," 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 acro- mio-clavicular articulation, and was accompanied with an upward dislocation of the outer end of the clavicle. 1 Remarks on Frao. of Scapula, by L. A. Dugas, Georgia. Am. Journ. Med. Sci., Jan. 1858. 2 West, Penin. Journ. of Med., vol. v. p. 254. & Brainard, Bost. Med. and Surg. Journ., vol. xxxi. p.' 501. * 5 S. Smith. Hamilton, Report on Deform., op. cit. FRACTURES OF THE ACROMION PROCESS. 207 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 sepa- ration 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 frac- tures, 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." Dr. Jackson says there are four specimens in the museum of the Massachusetts Medical College, and in the museum of the Boston Society for Medi- cal 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." 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 Jef- ferson 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. The mode of development of the scapula will explain these cases. The scapula is formed from seven centres; namely, one for the body, one for its posterior border, one for its inferior border, two for the acromion process, and two for the coracoid. Ossification of the body exists to a certain extent at or near the period of birth. It commences in one of the centres of the coracoid process, about one year after birth, and unites to the body at about the fifteenth year. All the other centres remain cartilaginous until from the fifteenth to the seventeenth years, when ossification commences, and is completed by 203 FRACTURES OF THE SCAPULA. a common union among all parts, usually between the twenty-second and twenty-fifth years. Fig. 53. Scapula, with epiphyses. (From Gray.) 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 frac- tures, and that there generally results a false joint, the fragments uniting by a fibrous tissue; but sometimes the surfaces, instead of uniting either by bone or ligament, become polished, and even ebur- nated. FRACTURES OF THE CORACOID PROCESS. 209 Malgaigne has noticed, also, in a specimen contained in the Dupuy- tren 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 symp- toms, they must depend very much upon the point at which the fracture has taken place. If in front of the acromio-clavicular articu- lation, 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 dis- location 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 acromio- clavicular 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, there- fore, 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 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 separa- tion 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 con- 210 FRACTURES OF THE SCAPULA. tinuous 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, Va,, informs me also that he has in his cabinet a dried specimen, from an adult, which has been broken ob- liquely 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 dis- placed a little forwards, as well as downwards. Eeuben D. Mussey, of Cincinnati, is in possession of a very remarkable and conclusive ex- ample 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 frac- ture 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 humerus was partially dislocated forwards, the clavicle, acromion pro- cess, 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.4 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.5 Duverney, Boyer, and Malgaigne have also reported four additional examples confirmed by dissections.6 The existence of this form of fracture, established by at least nine or ten dissections, can no longer be denied; yet it is usually accom- panied 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 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. * South, Lond. Med.-Chir. Rev., 1840, vol. xxxii., new series, p. 41. 6 Erichsen, Surgery, p. 207. 6 Malgaigne, op. cit., p. 512. FRACTURES OF THE CORACOID PROCESS. 211 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 ap- plied 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 be- fore, 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 coraco- clavicular ligaments are_ ruptured Fracture of the coracoid process. 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 accom- panied 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; 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 continu- ance 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 gene- rally have little or no regard to this particular injury. Fig. 54. 212 FRACTURES OF THE HUMERUS. CHAPTEK XX. FRAOTUEES 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; non- impacted 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 separation 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 113 fractures of the humerus examined by me, 25 occurred through the upper third, 17 through the middle third, and 71 through the lower third. An observation which is in contrast with the state- ment made 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 16 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, 16 were at the base of the condyles, 6 through the condyles and across the base at the same time. The remainder, 16, 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 " sur- FRACTURES OF HEAD AND ANATOMICAL NECK. 213 gical 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 epi- physis 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. § 1. Fractures of 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 com- pound fracture, but the head of the bone is almost necessarily broken into fragments. If the patients recover, sooner or later the frag- ments 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 always according to Eobert Smith, within the inferior or outer mar- gin of this insertion. He calls them, therefore, intra-capsular. It is probable, however—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. Gibson, however, thinks that the fragment occasionally remains, being gradually absorbed and changed in figure. He says that his ' Boston Med. and Surg. Journ., June 24, 1858, p. 410. 211 FRACTURES OF THE HUMERUS. Fig. 55. Fracture of the anato mical neck. 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. Eobert 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, aet. 47, was admitted into the Eich- mond Hospital under the care of the late Dr. Mc- Dowell, 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-capsular 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 promi- nent 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."2 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. Boardman, soon after the accident, and found him com- plaining 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 re- ceived. All motions of the shoulder-joint were painful; and there Gibson, Elements of Surgery, vol. i. p. 279. South, Fractures in Vicinity of Joints, pp. 191-3. FRACTURES OF HEAD AND ANATOMICAL NECK. 215 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 and the greater tu- bercle 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 mea- surement 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- 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. 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. Eobert Smith has described a specimen of this kind which he re- moved from the body of a woman, aged forty, who many years pre- vious 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 216 FRACTURES OF THE HUMERUS. 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 pro- cess. 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 ana- tomical 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 por- tion 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 Fig- 56. Fig. 57. scapula in the direction of the cora- I£33k\ iui^ co^ process.1 Ne'laton saw a similar specimen in M . *%llk the possession of M. Dub led, the re- volution of the upper fragment being complete; but there was no later dis- placement, and the union had been 'Ijyp v^; °g^ accomplished in a manner similar to that which is seen after intra-capsu- f 1% lar, impacted fractures, without re- version.2 I have also been permitted to ex- amine 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 frag- ment 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 \ti S* Dr. Pope's Specimen. Front view. Side view. ' R. Smith, op. cit., pp. 193-6. 2 Nelaton, Elements de Pathol. Chirur., torn. prem. p. 307. FRACTURES OF HEAD AND ANATOMICAL NECK. 217 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 unne- cessary. It is, that these are all of them examples of 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 com- paring it with a specimen of dislocation and partial absorption of the head of the humerus, contained in Dr. Neill's Museum, the points of resemblance were so numerous and striking that we felt compelled to doubt whether Dr. Pope's specimen, together with those seen by Smith and Ne'laton, did not belong to the same class with this of Neill's. In a case of fracture of the "cervix humeri within the capsular liga- ment," 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 princi- pal 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, 1 A. Cooper on Dislocations, &c, p. 372. 15 218 FRACTURES OF THE HUMERUS. 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- 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 Eobert 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 press- ing beneath the acromion, an osseous tumor could be distinctly felt, occupying the greater part of the glenoid cavity; it formed a promi- nence 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 1 Robert Smith, p. 181, from Lond. Med. aud Phys. Journal. LONGITUDINAL fractures of head and neck. 219 head of the humerus, lay beneath the base of, and internal to, the cora- coid 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 appre- ciable 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, how- ever, 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 pro- cess, and the inner edge of the glenoid cavity corresponded to the pos- terior 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 en- larged, and bone had been deposited in its tissue. The injury had 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 Eichmond 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.1 The following I believe also to have been an example of this rare accident:— John Hill, aet. 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 antero- posterior diameter of the upper end of the bone was greatly increased; there was occasional distinct crepitus, but the limb was not shortened. 1 Robert Smith, op. cit., p. 178. 2 A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. Cooper. American edition, p. 384. 220 FRACTURES OF THE HUMERUS. Subsequently, the examinations were repeated many times, and the depression between the fragments becoming more palpable, the diag- nosis was at length confirmed. No treatment was adopted, except confinement in bed, and stimulat- ing embrocations. Two months after the accident he still remained an inmate of the hospital, his shoulder being quite stiff) and the pro- jection continuing in front. Mr. Eobert 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 upper 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 dis- placements 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 Fig. 58. separation occurs at the epiphysis, than when a separation occurs at any other point of the surgical neck. A brief description of the plan of development of the humerus will enable the reader better to under- stand the occasional separation of the epiphysis, both at the upper and lower ends of the bone. The humerus is originally formed from seven car- tilaginous centres, namely, one for the shaft, one for the head, one for the greater tuberosity, one for each epicondyle, and two for the lower, articulating end of the bone. At birth the shaft is ossified in nearly its whole length. Between the first and fourth years ossification commences in the several centres com- posing the upper end of the bone, and they coalesce by the end of the fifth year, so as to form a single epiphysis, which finally unites with the shaft at about the twentieth year. At the lower end of the bone ossification commences in the radial portion of the articular surface at the end of two -years, in the trochlear portion at twelve years, in the internal epi- condyle at the fifth year, and in the external epicon- dyle at the thirteenth or fourteenth. At the sixteenth or seventeenth year all the centres are joined to each other, and to the shaft, except the inner epicondyle, Humerus, with which does not unite by bone until about the eighteenth Trw™* year. It will be observed, therefore, that although FRACTURES THROUGH THE SURGICAL NECK. 221 ossification commences in the upper epiphysis first, it is the last to form bony union with the shaft. The following is an account of the only case of separation at the upper epiphysis which I have ever recognized:— MikeBovin, set. 13 months, fell sideways from his cradle in Novem- ber, 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 less rough. There was no short- ening of the limb. When the elbow was carried a little forwards upon the chest the fragments seemed to be restored to complete coap- tation ; 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 disappear- ance 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 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. Eobert 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 Eichmond Hospital, under the care of Dr. McDowell. About a week previous to his admission he had fallen upon the shoul- der, 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 lit- tle separation of the elbow from the side, but it was directed slightly backwards. " 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 222 FRACTURES OF THE HUMERUS. 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 differ- ence 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 posi- tion."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 frac- tured 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.—Alex. Balentine, aet. 62 ; admitted to the Buffalo Hospital of the Sisters of Charity, December 19, 1851. He had fallen upon the side-walk, 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 fore- arm, that the crepitus became distinct, and gave unequivocal evidence of the existence of a fracture, and of its situation. Fracture of the surgical neck of the humerus. (From Gray.) 1 Robert Smith, op. cit., p. 201. 2 A Cooper, op. cit., 382. FRACTURES THROUGH THE SURGICAL NECK. 223 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. 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 third 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 reduc- tion 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 re- peated the effort, with precisely the same result. I now applied an arm sling, and directed leeches and cold evapo- rating 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 pro- ceeded 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 Sur- geon 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 shoul- der-joint being unimpaired. CASE 3. Simple fracture, with displacement; resulting in deformity and non-union.—L. B., of Lockport, set. 43, was thrown from his horse in February, 1854, striking upon his right elbow. Dr. Maxwell, an experienced surgeon of Lockport, examined and 224 FRACTURES OF THE HUMERUS. dressed the fracture. Dr. Fassett was present and assisted at a subse- quent 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 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." 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, aet. 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 frag- ment 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 child- ren, 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-eight cases in which I find the ages recorded, the average age is about 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 fifty-three years. Both epiphyseal separations and fractures at this point are oc- casioned, in most cases, by direct blows or falls upon the shoulder. Of twenty-seven examples in which I find the cause recorded, eighteen were from direct blows, eight from indirect blows, and one from muscu- lar action, as in throwing a ball. Of the eight resulting from indirect FRACTURES THROUGH THE SURGICAL NECK. 225 blows, one was from a fall upon the hand, seen by Desault, and seven were from falls upon the elbow, of which two were seen by Desault, and five by myself. Pathology.—I have found the fragments sensibly displaced in ten cases out of fifteen; a proportion much greater than has been observed by Malgaigne, who has only seen a displacement twice in more than twenty cases. It is certain, however, that complete or sensible dis- placement 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 cora- coid process four 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 specimens 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 spe- cimen 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 men- tioned four times, and the displacement toward the axilla but once. I am compelled, therefore, to doubt the accuracy of Malgaigne's obser- vations, who thinks be 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 ontwards; and I have in my cabinet the copy of a speci- men in which both fragments are drawn outwards, but the lower frag- ment 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. Eobert Smith has given, in his treatise, an engraving intended to illustrate the relative position of the fragments in extra-capsular impacted frac- tures, 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 ter- 226 FRACTURES OF THE HUMERUS. minates 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." Results.—Eight of the examples of fracture of the surgical neck seen by me are known to have resulted in perfect limbs, and three are more or less deformed. 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 the patients have recovered the free and complete use of their arms. Symptoms, or Differential Diagnosis of Accidents about the Shoulder- joint.—No place could be more appropriate than this to call attention to the difficulty of diagnosis in the case of accidents about the shoul- der-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 shoulder- joint, 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 under- neath the outer extremity, but more or less in front or behind, accord- ing as the dislocation may be into the axilla, forwards or backwards. 6. Eound, smooth head of the bone felt in its new situation, and very plainly removed from its socket; moving with the shaft. Ab- sence of the head of the bone from the socket. 7. Elbow carried outwards, and in certain cases forwards or back- wards, and not easily pressed to the side of the body. 8. Arm shortened in the dislocation forwards, and slightly length- ened when in the axilla. 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. DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 227 b. Signs of a Fracture of the Neck of the Scapula. (Cause, generally a direct blow.) 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, with the elbow resting upon the front of the chest. 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 acro- mion 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. Intra- capsular. (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, with the elbow against the front of the chest. 5. Very 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. Extra- capsular. (Cause, direct blows.) 1. Generally, there is neither marked mobility nor immobility, ex- cept what immobility may be due to a contusion of the muscles. 2. Crepitus, discovered, but not so easily as in intra-capsular frac- tures, 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. 228 FRACTURES OF THE HUMERUS. 4. The hand can be placed upon the opposite shoulder, with the elbow against the front of the chest. 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. 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 rotat- ing 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, while the elbow rests against the front of the chest. 5. Some depression under the acromion process. 6. A smooth bony projection directly underneath the coracoid pro- cess, 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, generally, 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. The hand can be easily placed upon the opposite shoulder, while the elbow rests against the front of the chest. 5. A slight depression below the acromion, not immediately under- neath 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. DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 229 7. Elbow hanging against the side when the fragments are not dis- placed, 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 frag- ments are completely displaced, the arm is shortened. g. Signs of a Separation at the Epiphysis. (Cause, direct blows.) 1. Preternatural immobility. 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 one 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 can seldom occur after the twentieth year. There are other accidents about the shoulder-joint such as a patho- logical partial luxation of the humerus, dislocation of the tendon of the biceps, &c, which might possibly be confoundt,d 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 resection or 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. 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 pur- pose 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 230 FRACTURES OF THE HUMERUS. is gently supported against the side, merely to insure quietude. No splints are necessary or useful. Treatment of Fractures through the Tubercles (Extra-capsular); Non- impacted 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- placement of the fragment, 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 appli- cable 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 short- ening 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 Tulercle.—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 of 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, how- ever, 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 treat- ment can essentially vary in separations at the epiphysis, from those in true fractures through any part of the surgical neck, since the rela- tive 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 epiphy- sary separations. In a considerable proportion of these cases not much displacement 1 B. Cooper's edition of Sir A. Cooper on Dislocations, &c, American edition, p. 835. FRACTURES THROUGH THE SURGICAL NECK. 231 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 treat- ment 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 summit of which was lodged in the axilla, while the elbow was se- cured 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 towards 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 sus- pend 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 re- commend :— 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 1 Dupuytren on Bones, Sydenham edition, p. 99. 232 FRACTURES OF THE HUMERUS. i i i avie. more examples ot fracture ot 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 exclu- sively 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 con- cussion 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 direc- tion 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 down- wards toward the hand, but this accident was originally complicated with a dislocation of the radius backwards. The dislocation was im- mediately 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 ex- tended it became strikingly deflected to the radial side. FRACTURES OF THE INTERNAL CONDYLE. 259 The symptoms which characterize this fracture are crepitus, almost always easily detected; mobility of the fragment, discovered espe- cially by seizing upon the epicondyle, or by flexing and extending the 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, though 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 dis- location; 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 expresses 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 disloca- tions 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, or felt, 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, be- lieving 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 ad- justed or supported. Upon this point, however, surgeons are not very 1 Markoe, New York Journal of Medicine, May, 1855, p. 382, second series, vol. xiv. 260 FRACTURES OF THE HUMERUS. 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- 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 accom- plished ; 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 pre- vention 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 re- duce, 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 displace- ments are usually not considerable, and in a few cases there is none at all. AYhatever 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. FRACTURES OF THE EXTERNAL CONDYLE. 261 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 Fi&- 74- was much swollen, and the external condyle could not be distinctly felt, but when pressure was made directly upon it, crepitus and motion became mani- fest. 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 influ- ence of ether, I have no doubt of the fact. Several other surgeons who were present concurred with Fracture of the external • ■ n 11 x condyle. 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 con- tinued afterward to move with the radius. As a consequence, probably, of the displacement of the lesser frag- ment 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 occa- sioned 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:— 262 FRACTURES OF THE HUMERUS. A girl, set. 3, 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 dis- missed 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 brought her to me for examination. There was no anchylosis, but the lesser fragment had never united, unless by ligament, moving freely with 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. Two other examples are reported at length in the second part of my Report on Deformities after Fractures as Cases 57 and 59 of frac- tures 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 appa- rently 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. Dorsey1 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 frac- tures of the internal, but does not mention it in connection, with frac- tures 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, com- pletely disappears after a few years. Treatment.—I do not know that I need add much to what hag 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 one of two which 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 1 Elements of Surgery, by Philip Syng Dorsey, Phila. ed.,. 1813, vol. i. p. 140. FRACTURES OF THE EXTERNAL CONDYLE. 263 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 posi- tion, 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 derived from the use of Physick's splint, intended to obviate the out- ward or inward inclination of the forearm. It is especially deserving of notice that, in the four 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, inas- much 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 resist- ance 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 firm- ness to prosecute it. The consequence has been that in a great num- ber 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 opinon 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 measures to other joints, particularly to the shoulder and knee. This has now become his settled practice, with the results of which he is 204 FRACTURES OF THE RADIUS. 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. FRACTURES OF THE RADIUS. Of eighty-six fractures of the radius which have come under my observation, not including gunshot fractures, or fractures demanding immediate amputation, three belonged to the upper third, three to the middle third, and eighty to the lower third. Three were compound, and eighty-three simple. Forty-eight are recorded as occurring in males, and thirty-five in females; thirty-nine as having occurred in the left arm, and twenty-four in the right. Fracture of the neck of the radius, as a simple accident, uncompli- cated 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, pro- ceeds, 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 Bobert Smith have alluded to this difficulty, and the case reported by Dr. Markoe to the New York Pathological Society, and published in the American Medical Monthly, will serve to illus- trate 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 exist- ence as a form of fracture was doubted by Sir Astley Cooper, and by others has been actually denied. I have seen no specimen obtained from the cadaver, except the doubtful one contained in Dr. Watts' 1 Transactions of the American Medical Association, vol. i. p. 174. FRACTURES OF THE NECK OF THE RADIUS. 265 Fig. 75. 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. 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 inser- tion of the biceps, that muscle appears to have drawn forward and upward the lower end of the short upper fragment. In conse- quence of this movement, the articulating facet of the head of the radius is tilted back- wards, 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 exist- ence of this fracture in a dissection, but the fracture was accompanied with a fracture also of the coronoid process; and BeVard 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 sub- luxation 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 uncompli- cated 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 dis- location of the ulna, 1 am prepared to admit that some doubt remains in my own mind as to whether in either case the fact was clearly ascer- tained; nor do I think, speaking only of the simple fracture, that it will Fracture of neck of radias (Mat- ter's cabinet.) a. Original articu- lating facet. 6,6. New articulating facets, c. Projecting fragments. 18 1 Transactions, vol. ix. pp. 157 and 229. 266 FRACTURES OF THE RADIUS. 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 diag- nosis 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. Town- send, 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 for- wards. The same anterior displacement I have noticed in all of the sup- posed 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 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, 1 Amer. Med. Gazette, vol. vii. p. 299. FRACTURES OF THE HEAD OF THE RADIUS. 267 Fig. 76. at a right angle with the arm. On the twenty-eighth day, all dress- ings 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. 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 at- tempts 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 com- pletely lost. I have seen, in Dr. Mutter's cabinet, two spe- cimens 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 position was adopted. A single dorsal splint, properly padded, should support the forearm, while the surgeon, having placed a compress tu^' Fracture of head of radius. (MQtter's collection. Speci- men A., No. 105.) 268 FRACTURES OF THE RADIUS. 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 Relieve, 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 frag- ment 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 supi- nation must be forever lost; since the union has been effected while the head and upper fragment are already in a state of complete supi- nation, and if such is the fact it is evident that the whole bone, to- gether 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 render- ing 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 frag- ment 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 duriug treat- ment 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 when- ever 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 forearm, whether fractures, or only severe contusions of the muscles, &c, namely, the constant and almost uncontrollable tendency FRACTURES OF THE HEAD OF THE RADIUS. 269 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 our- selves 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 eighty-six, only three be- longed to the middle third. An observation which is in striking con- trast with the remark of Chelius, that it is broken most frequently in its middle. If the fragments are com- FiS- 77- pletely separated at this point, the lower end of the upper half is drawn forward by the action of the biceps aided by the pronator radii teres, in case the fracture is below its insertion; while the lower fragment is tilted toward the Ulna by the COn- Fracture of the shaft of the radius. (From Gray.) joined action of the supi- nator radii longus, and pronator quadratus. But as to the direction of the displacement much will depend upon the direction of the force by which the fracture has been occasioned. 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 cause 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 railroad 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 re- placed, 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 270 FRACTURES OF TnE RADIUS. 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 a perfect limb, even when but 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 recorded five; one of which it will be proper to relate as a representative example. Geo. Vogel, set. 30, was admitted to the Buffalo Hospital of the Sis- ters 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 displace- ment 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, espe- cially where the fracture has been produced by a fall upon the hand, and the radio-ulnar 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 eighty fractures belonging to the lower third of the radius, seventy-five 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 colles' fracture. 271 true fractures, and probably a small proportion separations of the epiphysis. In every instance, except one, which has come under my notice, where the cause of a Colles' fracture has been ascertained, it has been occasioned by a fall upon the palm of the hand. The exceptional case was in the person of Mrs. D. B., who fell in getting out of a street car in the city of New York, May 20th, 1865, striking upon the back of her hand while the hand was shut. The displacement was in the same direction as in cases caused by a fall upon the palm. Robert Smith has seen a similar accident cause a displacement of the frag- ment forwards. Colles described this fracture as occurring always about one inch and a half above the carpal end of the bone; but Robert Smith, who has carefully examined all of the cabinet specimens he could 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. Fracture of the radius near its lower end. Case. A woman, aet. 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 twenty- sixth 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. 11, was brought to me having just fallen from a pair of stilts. His right radius was broken transversely, three-quarters 272 FRACTURES OF THE RADIUS. 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 ex- isted when the dressings were removed. Case. George Lofinch, set. 42, fell upon an icy side-walk, striking 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-quar- ters 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 de- formity or anchylosis. Case. Margaret Reed, aet. 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 hos- pital. The arm had been previously dressed carefully by one of my colleagues, with curved dorsal, and palmar splints; but, on examina- tion, we found the fragments a good deal displaced. It was found necessary now to use both extension, and pressure from behind to re- store 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 colles' fracture. 273 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 com- pletely; but on this last day an erysipelatous inflammation had com- menced 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 irritations were directed. The inflammation soon subsided, but the splint was never resumed, as the fragments were found to stay in place perfectly with- out its aid. At the end of five weeks, union seemed to be consum- mated ; 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 mu- seum 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 suffi- cient to enable it to escape completely from the upper; and that where, in extremely rare instances, and in consequence of extraordinary vio- lence, such complete separation does occur, a disruption of those liga- ments 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, up- wards, and outwards. Surgeons have spoken of a falling in of the upper end of the lower fragment toward the ulna, 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 274 FRACTURES OF THE RADIUS. 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 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 ourselves that the action of the pronator quadratus upon the upper fragment, whose broken extremity was not completely, or at all dis- engaged 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 any of the museum speci- mens of this fracture thus united. But they may be found constantly tilted back in the manner I have described, occasionally tilted for- wards, and, still more rarely, slightly displaced upon their broken surfaces antero-posteriorly. The general absence of this internal displacement may find its ex- planation 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 circum- stance which its secure ligamentous attachment to the ulna at its op- posite extremities, and its complete apposition to the wrist and elbow- joint, do not allow. The mistake of those surgeons who have attempted to describe this fracture has originated in the appearance presented in nearly all re- cent 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 in- stances, to the relaxation, stretching, or more or less disruption of the radio-ulnar ligaments, which permits the hand to fall to the radial side by a simple rotatory movement over its articular surface. For COLLES' FRACTURE. 275 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 frag- ment 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 con- siderable, downwards, backwards, and outwards. Diday maintained that there existed usually in this fracture an over- lapping or shortening of the bone in its entire diameter, and Yollemier thought that the specimens which he had examined proved that an impaction was almost universal. Both of these opinions have been 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, according to R. Smith, the result of the motion of the lower fragment already described ; and the appearance of impaction being due 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 observa- tions may be necessary. Indeed, some recent observations made by Mr. Callender, of Saint Bartholomew's Hospital, London, go far to sustain the opinion of Diday, that some impaction generally exists, but rather upon the posterior margin than upon either the radial or ulnar side.1 Meanwhile there is no doubt that occasional ex- amples may be found illustrating one or more of all these varieties of displacement, and that to the im- paction is sometimes added a comminution of the lower fragment, the lines of the fracture extending freely into the joint. One of the most curious exam- ples of which has been reported by Dr. Bigelow, of Boston. The patient had fallen, and being other- wise seriously injured, ultimately died in the Massa- chusetts 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 met with a similar case two years before, when a patient with the same symp- toms 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 fis- Bigelow's case of com- minuted fracture of the lower end of the radius. 1 Callender, St. Barth. Hosp. Rep., p. 231, 18G5. 276 FRA.CTURES OF THE RADIUS. sures penetrated the'shaft for an inch or more. Dr. Bigelow thought that the bones of the wrist acted as a wedge to spread the correspond- ing 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 patho- logical 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 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. Ne'laton 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 Ne'laton 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 apophy- sis 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.3 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. 1 Boston Med. and Surg. Journ., vol. lviii. p. 99. 2 Trans. Am. Med. Assoc, vol. ix. p. 145. 8 New York Journ. of Med., 1857. colles' fracture. 277 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 symp- toms were the same as in the first case, and we adopted the same treat- 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, up- wards 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 frac- ture 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. Eighty examples of fracture of the lower third of the radius have 1 Malgaigne, Traite des Frac, etc., torn. ii. p. 700. 278 FRACTURES OF TnE RADIUS. furnished no cases of non-union, nor indeed do I remember ever to have seen the union delayed; yet only eighteen 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 some- what extended. 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 into 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, 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. Robert Smith found this displacement almost constant in the cabinet specimens examined by him; and it is verv 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 cover this part of the arm, and perhaps by some per- manent 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 passH, with these condi- tions. 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 pro- duced in a few instances by extension of the inflammation to these joints, but much more often by the inflammatory effusion and conse- colles' fracture. 279 quent 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 dis- use, or, as it is usually termed, by passive contraction of these liga- ments. The fingers are quite as often thus anchylosed after this frac- ture as the wrist-joint itself, a circumstance which is wholly inexpli- cable 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 frequently 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 malposi- tion of the lower fragment after a fracture of the radius, is not sufficient 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 dis- placement; in examples of displacement without anchylosis, but in which the anchylosis has yielded gradually to the lapse of time, while the displacement has continued. The following case is in point: James Ryan, a private in the 15th N. Y. volunteers, fell from a height into a ditch during the battle of Fair Oaks, Ya., May 31,1862, striking upon the palm of his left hand, and causing a simple fracture near the lower end of the radius, accompanied probably with impaction. I do not know what treatment was adopted, but when he came under my observation in March, 1863, at the Central Park General Hospital, New York, I found the most extraordinary deflection of the hand to the radial side which I have ever seen after this fracture. The hand could be turned laterally, to a right angle with the arm; yet the motions of flexion and extension at the wrist-joint were nearly as per- fect as in the opposite arm, and the hand was in all respects as useful as before the accident. To what I have said as to the prognosis in these acccidents, 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 manage- ment 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 280 FRACTURES of the RADIUS. 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 asper- sions 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 pistol- shaped splint, instead of a straight splint, by means of which the hand may be thrown more or less strongly to the ulnar side. Heister2 speaks of inclining the hand toward the ulna, while re- ducing 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 in this position, were Mr. Cline, of London,3 and M. Dupuytren, of Paris.4 Mr. Cline, and after him Bransby Cooper,5 and Mr. South,6 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,7 Ne'laton,8 and Goyraud,9 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 pistol- shaped, and they thus avoid the necessity of the ulnar splint. Thus, Ne'laton,l0 Robert Smith,11 and Erichsen,1'' recommend this peculiar form 1 Boston Med. and Surg. Journal, vol. xxv. p. 289. 2 De Lavrentii Heisteri, Institutiones Chirurgicae, pars prima, p. 203, Amsterdam el., 1739. 3 Malgaigne, Traite de Frac. etc., torn. i. p. 614, Paris ed. 1 Dupuytren, on Bones, London ed., p. 140. B. Cooper, Lectures on Surg., p. 232, Amer. ed. 5 Chelius's Surg., vol. i. p. 613. 7 Malgaigne, op. cit . torn. i. p. 014. " Nelaton, Elem. de Path. Chir., torn. i. p. 747. 9 Ibid., p. 741 IJ Nelaton, op. cit., p. 747. » R. Smith, op. cit., p. 168. 12 Erichsen, Surgery, p. 215. COLLES' FRACTURE. 281 only in the dorsal splint; while Bond,1 Hays,2 E. P. Smith,3 G. F. Shrady,4 and others, especially among the Americans, place the pistol- shaped splint against the palmar surface of the forearm and hand. Fig. 80. N61aton's splint for fracture of the radius. Fig. 81. Bond's splint. Fig. 82. Hay's splint. A few modern surgeons have not seen fit to adopt this peculiar principle of treatment, or this form of dressing under any of its modi- fications. Colles5 recommends a straight palmar and dorsal splint, and does not incline the hand. Barton6 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 1 Bond, Amer. Journ. Med. Sci., April, 1852. 2 Ibid., Jan. 1853. 8 E. P. Smith, Buffalo Med. Journ., vol. ix. p. 225. 4 Shrady, Am. Med. Times, 2 cases, Dec. 22, 1860. s Colles, Lectures on Surgery,p. 325. 6 Barton, Phil. Med. Exam., 1838. 19 282 FRACTURES OF THE RADIUS. object will be attained by inclosing the entire forearm and hand in a well-applied sling."1 Professor Fauger, of Copenhagen, has undertaken to treat this frac- ture in some sense without any splint, the forearm and hand being Fig. 83. E. P. Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with incurvated margins. Fig. 84. C.......-... E. P. Smith's splint. B. Opposite surface. X>, the hand-block, 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 nui seen on the brass plate. The letters C C indicate the extent of motion allowed to the hand-block. Fig. 85. Geo. F. Shrady's splint. To be applied to the palmar surface of forearm and hand ; the hand being dedected 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. 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 posi- tion 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."2 M. Velpeau, in a report 1 Skey, Operative Surgery, p. 161. 2 Fauger, London Lancet, May 8, 1847. colles' fracture. 283 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."1 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 frag- ment in place. We come now to consider how far this peculiar treatment is capa- ble 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 condi- tions coexist; 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 con- sidered 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. 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. I do not here speak of impaction, which is usually upon the posterior margin, if it exists at all. In regard to the second supposition, namely, that where such dis- placements 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 authorita- tive 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, 1 Velpeau, Boston Med. Journ., vol. xxxv. p. 213. 284 FRACTURES OF THE RADIUS. 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, then, 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 injured 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 liga- ments 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 adduc- tion 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 inclina- tion has no power to do good so far as extension is concerned, any more than it has power 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, Ne'laton, and others, sufficiently indicate that their distinguished inventors in- tended to accomplish by these means a forced and violent adduction. Malgaigne, speaking of other means of extension applied to the 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 observa- tions 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 re- tention in any case, yet I am not prepared to deny it to 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 re- commend its continuance, a reason which I cannot so well explain, or colles' fracture. 285 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 con- sidered 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 indica- tion, the existence of which is at least rendered doubtful, and by means which appear to me totally inadequate, if it did exist, they have proba- bly too often overlooked or regarded indifferently an indication which is almost uniformly present, namely, to press forwards the tilted frag- ment 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. Some of the cases which I have reported in the early part of this chapter, are intended to illustrate the value of this principle. 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 oppo- site 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, 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 con- tinued 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 ter- minating also at the metacarpo-phalangeal articulations, instead of at the wrist, as the short straight splint must do when the hand is ad- ducted, enables the hand to be flexed upon its extremity over a hand- block, or pad of proper size. Such are the not insignificant advantages 286 FRACTURES OF THE RADIUS. 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 Fig. 86. 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 The author's splint. 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 stuf- fing 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. 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 perma- nency of that which I have now described. In all cases it is better to employ, also, at least during the first fort- night, 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 carpus. 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, FRACTURES OF THE RADIUS. 287 Fig. 87. 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-pro- nation ; 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 re- duction 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 circum- stances 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 lig- aments connected with the joint. I am persuaded that to this violence, 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- 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 accom- plished, 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 The author's dressing complete. The curved palmar splint is not in view, only the dorsal. The faint white lines represent the roller. The sling is omitted for the purpose of bringing the other dress- ings into view. 288 FRACTURES OF THE RADIUS. 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, inflamma- tions, 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 in- tent 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 swell- ing 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 pre- caution : 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 Eilard, 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 hand was cold and oedematous, 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 pre- sented 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. "K., 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 ap- FRACTURES OF THE RADIUS. 289 plied 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; cam- phorated 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 immedi- ate 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 likely to result from the employment of an immovable apparatus, of which an example occurred in the practice of M. Thierry, 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 am- putation was the only resource; on examining the limb no trace of fracture could be discovered. Had a simple apparatus been here em- ployed, 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 1 Dupuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7. 290 FRACTURES OF THE RADIUS. tightly around the wrist. On the following day the limb was in- tensely 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."1 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, pro- ducing 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 sur- geon being summoned, found him suffering more pain and quite rest- less; 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 shoul- der, 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 investiga- tion, 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. On the other hand, Drs. Hayward, Bigelow, Townsend, and Ains- worth, 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.2 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 1 R. Smith. Treatise on Fractures, &c, Dublin, 1854, p. 170. 2 Bost. Med. and Surg. Journ., vol. xlviii. p. 281. FRACTURES OF THE RADIUS. 291 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 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 condyle. Severe constitutional symptoms arose, making amputation of the arm necessary."1 A lady, set. 50, was also seen by ThieVry, who, having broken the radius near its lower end, lost her ringers by the sloughing consequent upon a tight bandage.2 A woman was admitted into one of Dr. Wood's wards in the Belle- vue Hospital about the first of Feb'y, 1863, who had fallen upon her hand a few days before and broken the radius just above the wrist. Her arm was dressed with splints and bandages at one of the dis- pensaries in this city. Gangrene ensued, and when I saw her on the 8th of Feb'y the death had extended to the middle of the forearm; the dead tissues being dry and black. Dr. Wood amputated the arm, but she died. 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 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 1 Norris, note to Liston's Surgery, p. 54. 2 Amer. Journ. Med. Sci., vol. xxv. p. 461, from L'Experience for 1838. '■>!»'} FRACTURES OF THE RADIUS. Fig. 88. of the lower end of the ulna, and allowed the muscles to become com- pletely 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. -. i r ■. 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 fingers 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 grati- fying to the humane surgeon, he does not fail to appre- ciate 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. Epiphyseal Separations.—This bone is formed from three centres, namely, one for the shaft and one for either extremity. The shaft is ossified at birth. About the end of the second year ossification commences in the lower epiphysis, and it becomes united to the shaft at about the twentieth year. The same process commences in the upper epiphysis at about the fifth year, and is completed by consolidation with the shaft at the age of puberty. I have met with no recorded examples of separation of the upper epiphysis, and the examples of separation of the lower epiphysis have seldom been clearly made out. I have already mentioned one as having been reported by Robert Smith. He speaks also of other cases occurring in conjunction with a separation of the lower end of the ulua, and which is very liable to be mistaken for a dis- location.1 The treatment of this accident will not require any special consideration, since it will not differ essentially from the treat- ment required in a fracture occurring at the same point. Radius, with epiphyses. (From Gray.) 1 Robert Smith, op. cit., p. 161. SHAFT OF THE ULNA. 293 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 Voisin has related in the Gazette Medicale 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 thirty-three cases, I find the shaft has been broken eleven times in its upper third, twelve times in its middle third, and ten 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; eleven complicated with a forward, or for- ward and outward dislocation of the head of the radius; one with a partial dislocation of the lower end of the 8hann>f7hViiiiia! radius backwards, and one with a dislocation of both radius and ulna backwards at the elbow-joint. It will be seen, there- fore, that sixteen, or nearly one-half of the whole number, have been seriously complicated. Symptoms.—Occasionally this fracture is found to exist without sensible displacement. In such cases the diagnosis is sometimes diffi- 204 FRACTURES OF THE ULNA. cult, 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 devia- tions 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 con- sequent 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, oc- casioned by the backward projection of the broken ulna, and with a complete loss of the power of supination. It will not surprise us that 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; }^et 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 sty- loid 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 seven times after a fracture of the ulna, and in each example the forearm was shortened. A boy, a3t. 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 coun- try practitioners, a few hours after the accident. The whole left arm was then greatly swollen. Crepitus was distinct, and we easily recog- nized the fracture of the ulna about three inches below its upper end, with which an open wound was in direct communication. We sus- pected, 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 SHAFT OF THE ULNA. 295 to a right angle and a little beyond; and he could straighten it per- fectly. 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 aet. 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 dislocationof 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 head of the radius displaced forwards, and the forearm shortened one inch. Three times I have noticed after the 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 dislo- cated, 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 ac- complish this. A gentleman fell and broke the right ulna near its middle. He came immediately to me, and t found the fragments dis- placed 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 fore- arm, 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 back- wards, in the direction in which they were at first. If the displacement is in the direction of the radius, it is more diffi- cult 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 well supinated, the fingers of the surgeon should be pressed firmly, and in 296 FRACTURES OF THE ULNA. 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 thrust- ing 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 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 reduc- tion 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 press- ing upon and rendering tense the tendon of the biceps. July 29, 1845, a lad, set. 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 pbliquely near its mid- dle, 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 Eose's angular splint, constructed with a joint opposite the elbow. This was laid upon the palmar sur- face, and the whole was nicely padded, especially in front of the head of the radius. In two weeks pasteboard was substituted for the angu- lar 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 motions of the arm were fully restored. CORONOID PROCESS OF THE ULNA. 297 June 2, 1845. C. C, set. 9, fell upon his arm, breaking the ulna obliquely near its middle, and dislocating the head of the radius for- wards. 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. AVith 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 com- pletely 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 conserva- tive 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 ; 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 arte- ries 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. Gay and Flint. The skin sub- sequently 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 use- ful; 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 20 298 FRACTURES OF THE ULNA. 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 ex- tension, 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 dis- location was immediately reproduced. These attempts to reduce and retain in place the dislocated bones were repeated several times during Fig. 90. 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 of an occasional crepitus during the manipulation, inclined me to be- lieve 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 re- sumed their position, however, I made certain by a very careful exami- nation 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 how again in its natural position, and with every structure about it in a condition as complete as it was before the accident. For myself, CORONOID PROCESS OF THE ULNA. 299 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 dis- locations 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 these gentlemen need to have furnished some more conclusive evi- dence 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 pub- lished by Combes Brassard, an Italian surgeon, in 1811, which Bras- sard 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 for- 1 Dorsey. Elements of Surgery, vol. i. p. 152. Philadelphia, 1813. 300 FRACTURES OF THE ULNA. wards. 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."' Dr. Couper, of the Glasgow Infirm- ary, also has reported a dislocation of the forearm backwards and out- wards, occurring in a young man aged seventeen, and which he tliinks was accompanied with this fracture. The dislocation wras easily re- duced, 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. "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, cseteris paribus, the symptoms should rather be referred to the common than the extraordinary injury. The contrary practice introduces a dangerous laxity in diagnosis."* Dr. Duer, of Philadelphia, has reported a case which occurred in a boy six years old, and in which he felt and moved the fragment with his fingers. It was complicated with a dislocation, which remains un- reduced. This case was last seen about seven weeks after the accident.3 If at a later period we could be permitted to examine the patient, it is probable that the diagnosis might be rendered certain. 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 nonsuit 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." 1 Fahnestock, Amer. Journ. Med. Sci., vol. vi. p. 2(17. 2 Couper, Lond. Med.-Chir. Rev., new ser., vol. xi. p. 509. 3 Duer, Aiuer. Jouru. Med. Sci., Oct. lbb'3, p. 390. CORONOID PROCESS OF THE ULNA. 301 Fig. 91. 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.1 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 ;"2 after whom, Miller, Erichsen, Skey, Lonsdale, and most of the Scotch and English sur- geons 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 bra- chialis anticus is inserted upon its summit. The coronoid process is never an epiphysis, but is formed from a com- mon point of ossification with the shaft; the olecranon process and the lower extremity of the ulna having also separate points of ossification: the olecranon becoming united to the shaft at the sixteenth year, and the lower epiphysis at the twentieth. Moreover, the brachialis an- ticus has its insertion at the base of the process and partly upon the body of the ulna, but in no part upon its sum- mit ; indeed, the process seems rather to be intended as a pulley over which the brachialis anticus may play; re- sembling also somewhat, in its function, the patella; serv- ing to protect the joint and perhaps the muscle itself from becoming compressed in the motions of the joint. Cer- tainly 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 pos- sibly 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 possi- ble, 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 ; nine 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 r Ulna, ■with epiphyses. (From Gray ) 1 Op. cit., vol. iv. p. 339. Liston, Practical Surgery, p. 55. 302 FRACTURES OF THE ULNA. 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. Duer's case could have been better verified at a later period. 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 dislo- cations 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 dis- sections, 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. 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 com- plicated 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 Eichmond, 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 1 A. Cooper, Dislocations and Fractures, p. 411. CORONOID PROCESS OF THE ULNA. 303 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 circum- stantial 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 can- not 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 dislo- cation, 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 conse- quence 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: per- haps 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 numerous muscles and ligamentous attachments, being indirectly con- veyed 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 fore- arm 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. Pen- neck'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 back- wards 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 304 FRACTURES OF THE ULNA. 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 diag- nostic, 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 suppo- sition of a fracture of this apophysis, than without such a supposition. If the reduction of both bones is once effected, even though the sup- port 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 com- pletely lost; and at the same moment the resistance, and consequent power of the triceps to produce the luxation, are greatly increased. 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 exten- sion the ulna slipped back behind the inner condyle of the humerus. Brassard's patient, seen after three months, retained the power of pro- nation 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 CORONOID PROCESS OF THE ULNA. 305 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 com- pletely," 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 case of the University College specimen the radius is dislocated forwards and upwards, and the ole- cranon 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 ex- press 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, how- ever, 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 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 acci- dent, 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 Vel- 306 FRACTURES OF THE ULNA. peau preferred four; but I cannot agree with them, believing that the question of the future mobility of the elbow-joint is vastly more im- portant 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 Fahnes- tock placed the arm at right angles, and Sir Astley Cooper has re- commended 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.—My records furnish me with accounts of only seven of these fractures, and so far as I have been able to ascertain, all were occa- sioned 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 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. Mal- gaigne, who has been able to find upon record only two cases of a frac- ture 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. We think, also, we have reasons for believing that these only occur as a consequence of a fall upon the elbow, or of a FRACTURES OF THE OLECRANON PROCESS. 307 blow upon the extreme point of the elbow, when the forearm is con- siderably flexed upon the arm; the direction of the obliquity, when any is found to exist, being gene- rally from above downwards and Fig. 92. 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 ac- Fracture at the bas™ cident can scarcely happen, except 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 dis- placement 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, aat. 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 sub- sided, a distinct 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 alwajrs prudent to leave this fracture thus unsupported, since it has occasionally happened 308 FRACTURES OF THE ULNA. 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 neckcloth. Symptoms.—The usual signs of a fracture of the olecranon process, are, when the fragments are not separated, crepitus discovered espe- cially by seizing the process, and moving it laterally; or, when dis- placement 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 posi- tion, as if a fracture was known to exist. Prognosis.—In a large majority of cases, this process becomes re- united 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 be- tween the fragments. This was an ancient fracture at the base of the olecranon; the superior fragment remained immovable during the 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 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 distant 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 FRACTURES OF THE OLECRANON PROCESS. 309 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 Fig. 93. far as could be discovered in a very careful exami- nation. 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, uniontyligament. 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 excel- lent 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 treat- ment of a fracture of the olecranon process, a wide difference of opinion 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 essen- tial 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 fore- arm is very slightly bent upon the arm ; while Sir Astley Cooper, and a large majority of the English and American surgeons, employ com- plete or extreme extension. The arguments presented by the advocates and antagonists of these various plans deserve a moment's consideration. 310 FRACTURES OF THE ULNA. 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 more- over, if anchylosis should unfortunately occur, the limb is in a much better position for the proper performance of its most ordinary func- tions than if it were extended. Some have also added to this argu- ment 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 suc- cessfully met by a statement of the infrequency of permanent anchy- losis 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 liga- ment, is almost inevitable. 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 FRACTURES OF THE OLECRANON PROCESS. 311 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 extension—that is, in a condition of extension approaching dorsal flexion, which is certainly beyond what is natural. Indeed, perhaps we may admit that, in order to perfect apposition, the extension ought to be less by one or two degress 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 them- selves as being more comfortable in this position than in the flexed. Finally, the advocates of complete, natural extension claim that in this position alone, is the triceps most perfectly relaxed, and conse- quently the most important indication, namely, the descent of the ole- cranon, 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," as opposed to flexion, demi-flexion, or extreme 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. 94. 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 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 firm- ness 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 312 FRACTURES OF THE ULNA. against which the compress or the roller can make advantageous pressure? If, then, these accidents, swelling, ulceration, and gan- grene, 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 re- laxing 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. 95. y Fig. 96. J The author's method. thickly padded with hair or cotton-batting, so as to fit all of the in- equalities 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 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 back- wards 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 elbow- joint is covered. This completes the adjustment of the fragments, FRACTURES OF THE OLECRANON PROCESS. 313 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 advantageof 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 around the joint are about to follow rapidly; and on each suc- cessive 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 com- pletely ; and while the fingers of the surgeon, resting upon the 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 substi- tuting a very thick sheet of gutta percha for the board. Dieffenbach 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, 21 314 FRACTURES OF THE RADIUS AND ULNA. in which he divided the tendon of the triceps, secured the upper frag- ment 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. Eecently a gentleman called upon me with his son, aged seven years, who had an unreduced dislocation of the radius and ulna backwards of nine weeks' standing. While reducing this dislocation, it being necessary to flex the arm forcibly, the epiphysis constituting the olecranon process gave way, and became separated from one-half to three-quarters of an inch. This is the only example of separation of this epiphysis which has come to my knowledge. CHAPTEE XXIII. FRACTUEES 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 frac- tures 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 sixty fractures of both bones, not including gunshot frac- tures, or those demanding immediate amputation, I have found six broken in the upper third; twenty-fonr in the middle third, and thirty in the lower third. Fig. 97. 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 Dieffenbach, American Journal.of Medical Science, vol. xxix. p. 47S ; from Cas- per's Wochensclirift, Oct. 2d, 1&41. FRACTURES OF THE RADIUS AND ULNA. 115 Four of the fractures belonging to the lower third were probably epiphyseal separations. Forty-six were simple, eight 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 accidents fully in the general chapter on Incomplete Fractures, 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 six- teenth week. Once 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. F'g- 99. On the other hand I have once seen the union de- layed four months in the case of the ulna, when the radius had united in the usual time; and in one ex- ample of compound fracture both bones refused to unite until after the fifth month. Thirty-three of the whole number have united with- out any appreciable deformity, and fifteen are known to have left some marked defect, while two have re- sulted finally in the loss of the arm. Of the remainder I cannot speak positively. 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 com- pound 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 frac- ture 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. / Union with slight lateral displacement. 316 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 re- sults so disastrously. A boy, aged about ten years, fell from a tree, April 22, 1856, frac- turing 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 treat- ment since the patient was seen by Dr. Wilcox, except that the band- ages 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 dili- gently applied and chloroform administered by inhalation; but the fatal event was delayed only a few hours. I shall not stop to inquire the cause 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; JSTorris, in a note to the American edition of Liston's Surgery, mentions a case which came under his observation in the Pennsylvania Hospital, the fracture hav- ing taken place just above the condyles, and still another has been related to me lately. I have brought together also no less than six FRACTURES OF THE RADIUS AND ULNA. 317 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. Eobert Smith says, that similar cases have been recorded in the Gazette Medicale. To these I shall now add two examples of sloughing after fracture of both radius and ulna; making a total of twelve cases in the upper extremities, in addition to those reported in the Gazette Medicale, 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. 318 FRACTURES OF THE RADIUS AND ULNA. 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 fore- arm, 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 im- mediately 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 off, 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 mortifica- tion produced by splints applied too tightly, and previous to the acces- sion 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, re- marks 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 appa- ratus."2 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 Koux 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 apparel, which must almost infallibly compress the arteries to a great extent."3 ' South, note to Chelius's Snrg., vol. i. p. 69. * Malgaigne, Frac. et Disloc, torn. i. p. 580. 3 JN'elatou, Pathologie Chirurgicale, p. 735. FRACTURES OF THE RADIUS AND ULNA. 319 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 shoulder- joint. 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 ill- ness, 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 skin, and securing them in place by a roller. Boyer adopts the same method without any modifications, and Mr. Hind, in his illustrations of frac- tures 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 com- presses, 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 today 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, 320 FRACTURES OF THE RADIUS AND ULNA. use only pasteboard splints above the compresses, over which is im- mediately 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 accom- plished countryman, Dr. Reynell Coates, if in the following para- graph 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 possi- ble 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 ra- tional explanation of this practice, without effect. It is directly at war with the acknowledged indications in the coaptation of the frag- ments, 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. 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 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 super- ficial 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, are situated upon a broad and flat surface of bone, along which this FRACTURES OF THE RADIUS AND ULNA. 321 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 chieflv 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 su- pination and pronation, so that the radius should be uppermost; it being assumed that in this position the two bones are most nearly par- alleCand least inclined to displacement. Such, indeed, was the prac- tice 'of Hippocrates, Paulus ^Egineta, Celsus, Albucasis, and of most surgeons down to this day; but Lonsdale, Robert 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. I have before mentioned, when treating of fractures of the ulna, i Bandages et Appareils a. Pansements, on Nouveau System* de Deligation Chirur- gicale, par M. Mathiaa Mayor, Chirurg. eu Chef de l'Hopital de Lausanne, Switzer- land. Paris ed. 1838, p. 345. 322 FRACTURES OF THE RADIUS AND ULNA. that M. Fleury had, in one instance, been unable to bring the frag- ments 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 Ne'laton declares that in frac- tures 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 in- genious, 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 coapta- tion of the broken ends, less liability of the fragments to encroach upon the interosseous space, and consequently less danger of anchy- losis 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 owti cases, treated by the usual method, have shown that while supination is frequently impaired, and sometimes entirely lost, prona- tion is rarely affected; and that lateral displacements are much more common than displacements forwards or backwards. How this posi- tion, semi-pronation, may tend to the production of a permanent pro- nation, 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. 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 FRACTURES OF THE CARPAL BONES. 323 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 in- evitably 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 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 XXIY. 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 com- plicated, 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 inter- ference, 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 even in the normal condition they enjoy so little motion as to render it doubtful whether its complete loss would be very sensibly felt. In cases of comminuted, compound, and otherwise complicated frac- tures 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 324 FRACTURES OF THE METACARPAL BONES. character of which it would be difficult to anticipate, and for the treat- ment of which it would be unsafe to attempt in a written treatise to provide. CHAPTER XXV. FRACTURES OF THE METACARPAL BONES. Development of Metacarpal Bones.—These bones are each formed from two centres of ossification. In the case of the metacarpal bones of the four fingers there is one centre for each shaft, and one for each distal extremity; but in the case of the metacarpal bone of the thumb there is one centre for the shaft and one for the proximal extremity. All these epiphyses unite with the shafts at about the twentieth year. 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 incon- siderable number, however, are the results of indirect blows, and es- pecially 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 metacar- pal 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 meta- carpal 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, ast. 8, fell down a flight of steps, Sept. 11, 1855, FRACTURES OF THE METACARPAL BONES. 325 breaking the metacarpal bone of the index finger of the right hand near its lower extremity, and apparently at the junction of the epi- physis with the diaphysis. 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 con- tinuing. A partial explanation of the fact that the joint end of the lower frag- ment 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 neces- sarily 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 displace- ment 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 with- out 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 re- ceived, he consulted me. There existed at this time a complete anchy- losis 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. 326 FRACTURES OF THE METACARPAL BONES. Miss E., of Erie Co., N. Y., set. IS, fell, Aug. 7, lb53, 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 found the metacarpal bone of the ring finger broken about three- quarters 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 dis- posed 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 frag- ment 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 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 fore- arm. I therefore secured the hand in this position with appropriate splints, and it was maintained in this posture during most of the sub- sequent treatment. Union finally took place, but not without some backward displacement. Four months alter 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 pro- jection 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.—AYith moderate extension made upon the finger cor- responding 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 paste- board 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 pad- FRACTURES OF THE FINGERS. 327 ded, 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- 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 precau- tions must be adopted to prevent anchylosis as in the case of similar fractures in other bones. CHAPTER XXYI. FRACTURES OF THE FINGERS. Development of the Phalanges of the Hand.—The phalanges of the hand are formed from two centres of ossification, namely, one for each shaft and one for each proximal end. Ossification commences in the shafts at about the sixth week ; in the epiphyses of the first phalanges between the third and fourth years, and in the epiphyses of the two last phalanges somewhat later. Complete bony union takes place between the epiphyses and the shafts at from the eighteenth to the twentieth year. 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 frac- tures without complications. Point of Fracture and Direction of Displacement.—In the following case there was probably an epiphyseal disjunction. A lad four years old 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. OOQ FRACTURES OF THE FINGERS. 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. I have never seen the fragments much overlapping, 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 Ave 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 satis- factorily explained. Results.—At least ten have left no appreciable lameness or deform- ity, 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 ex- tremity 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 FRACTURES OF THE FINGERS. 329 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 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. Ex- amples 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 re- ported to me a case exactly in point. " A man in the employ of the Toronto Rolling 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 per- mitted. 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 de- formity, 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 22 330 FRACTURES OF THE PELVIS. 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. 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 with a single piece of 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. Development of the Os Innominatum.—This bone is formed from eight centres, three of which are called primary, and five secondary. The three primary centres belong respectively to the ilium, ischium, and pubes, and by their extension form eventually the greater portion of the innominatum. They have a common point of union in the acetabulum; and the ischium unites with the pubes, also, by the junc- PUBES. 331 tion of their rami. These conjunctions occur usually between the fifteenth and twentieth years of life. The secondary centres do not begin to ossify until the age of puberty, and may therefore properly be considered as epiphyses. One forms the crest of the ilium; one Fig. 100. Development of the os innominattfm. (From Gray.) its anterior inferior spinous process; one forms the symphysis pubis; one the tuberosity of the ischium; while the fifth constitutes the centre of the bottom of the acetabulum. The epiphyses become joined to the primary bones, or the bodies of the innominata, at about the twenty-fifth year. § 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 admit the thumb.1 Similar accidents have been several times met with 1 Lente, New York Journ. Med., 2d ser., vol. iv. p. 286. 332 FRACTURES OF TnE PELVIS. by surgeons. Hall reports a case in the Provincial Medical and Surgi- cal Journal, May 1, 1814, 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;1 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, sst. 22, was admitted into Guy's Hospital on the 30th of July, 1832, having sustained a severe injury in conse- quence 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 pro- duced 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, pro- ducing 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."2 Malgaigne has collected four cases of simple separations at the sym- physis 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 sym- physis 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 pubes and ischium in three places. The man, set. 29, had been caught 1 Hall, Amer. Journ. Med. Sci., vol. xxxiv. p. 248. 2 Sir Astley Cooper, Frac. and Disloc, Amer. ed., p. 144. PUBES. 333 Fig. 101. 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 sur- vived 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 tube- rosity.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 re- sulted 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 fracture of the ilium, accompanied with great displacement. Marat 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.2 Cappelletti relates that a man, aet. 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 that this fragment of bone consisted of a part of the ramus of the Clark's case of fracture of the pelvis. e 1 Clark, Boston Med. and Surg. Journ., vol. liii. p. 185. 2 Marit, from Malgaigue, op. cit. p. 64(i. 334 FRACTURES OF THE PELVIS. 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 Lewistown. 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 dis- placement, 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 inevi- table, 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 re- cumbent 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 separa- tion 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 innominatum 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 tubero- sities ; but, perhaps, the most remarkable instance is that mentioned £, by Mar^lt as having occurred in a female during labor. 1 Cappelletti, Ranking's Abstract, No. viii. p. 83 ; from Giornale per servire al Pro- gressi della Patologie della Terapeutica, 1S47. a Whitaker, Amer. Journ. Med. Sci., July, 1857, p. 283. ISCHIUM. 335 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 afracture 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 crepi- tus. If the patient is a female, this exploration can be best made through the vagina. By flexing and extending the thigh, also, crepi- tus 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. 336 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 complication. In the two following examples the anterior superior spinous process alone was broken off:— John Kelly, aet. 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 con- tusion 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 frag- ment, 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 por- tion 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 pros- trated; the fragment of the pelvis broken off was quite movable, and ILIUM. 337 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 fomenta- tions 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 displace- ment. 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 mova- ble, 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 with- out 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 pro- cess, and I do not know of any other example. Miss B., ast. 19, was thrown from her horse backwards, striking with her back upon the ground. She was 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 suf- fered 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 accom- panied 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 irregu- larly. 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 338 FRACTURES OF THE PELVIS. large and irregular mass of ossific matter or callus around the frag- ments. 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 Dr. Cheever, of the same hos- pital, reports a case of fracture of the ilium, with fracture of the as- cending ramus of the pubes, resulting in complete recovery; but the leg became shortened and the toes inverted. Dr. Cheever believes that the lines of fracture met in the acetabulum.2 The following case illustrates the more fatal injuries of this cha- racter :— John O'Keaf was crushed under a heavy stone, Oct. 23,1851, break- ing and comminuting the alae of the pelvis on both sides, and wound- ing 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 sys- tem 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 commi- nution 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.3 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 off with only a small portion of the crest, the fragment may be seized with the fingers and carried outwards 1 Sargent, Boston Med. and Surg. Journ., vol. liii. p. 121. 2 Cheever, Bost. Med. and Surg. Journ., May 3, 1866. 3 Lente, New York Journ. of Med., Jan. 1851, p. 29. ACETABULUM. 339 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- 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 displace- ment. Second, Fractures of the rim, with or without displacement. In fractures of the base of the cavity, not accompanied with displace- ment, 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 sur- gical appliances could be of service. An injury so severe as to frac- ture 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. 340 FRACTURES OF THE PELVIS. M. Bouvier related to the Academy the case of a man, ret. 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 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 accom- panied 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. Mr. Travers has reported two similar cases, and in the paper accom- panying the report he maintains, that very acute pain caused by press- ing upon the projecting spine of the os pubis, and the inability of the patient to maintain the erect posture, may be regarded as signs diagnostic of the accident.2 It is doubtful, however, whether these phenomena, so common to many other accidents, could be relied upon as evidence of this peculiar lesion. 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 pro- 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 acci- 1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486; from Bullet, de l'Acad. Roy. de Med., August 15, 1838. 2 Travers, Holmes' System of Surgery, vol. ii. p. 478. BASE OF THE ACETABULUM. 341 dent 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 disloca- tion. 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 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 com- menced 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 coxae 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 ante- rior 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-Lavallee, 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.2 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. Bar- 1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv. p. 481; August, 1839 ; from London Med. Gazette, March, 1839. 2 Morel-Lavallee, from Malgaigne, op. cit., vol. ii. p. 881. 342 FRACTURES OF THE PELVIS. tholomew's Hospital, the toes were everted; the two persons seen by Lendrick and Morel-Lavallee 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 innomina- tum was divided into three portions, corresponding to the three bones of which it was composed in infancy; the head of the femur had com- pletely penetrated the basin—the limb was shortened two inches, and in a position of slight flexion and adduction, but neither rotated out- wards nor inwards.1 There seems, therefore, to be no certain rule in relation to the posi- tion of the limb; but it is found to take the one position or the other, 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 im- mediately 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-La valine, 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 counter- extension ; 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 peri- neum 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 con- verted into a double-inclined plane; allowing the knees to be sus- pended 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. Or we may adopt Buck's method, as will be described hereafter when treating of fractures of the femur. Fractures of the rim of the acetabulum have frequently been dis- ' Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851. RIM OF THE ACETABULUM. 343 covered 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 suffi- cient reason perhaps, to this fracture. Dr. M'Tyer, of the Glasgow Royal Infirmary, published in the Glas- gow 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 the supposition that this was actually the nature of the accident. Subsequently, the toes became slightly turned in, but this circum- stance was not regarded as sufficiently distinctive to warrant a change in the diagnosis. Having succumbed to the injuries after a few days, the autopsv revealed a fracture extending through the bottom of the right aceta- bulum, 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 frag- ment 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 towards 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 his- tory of the case is not known. A fragment of the superior and pos- terior 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 1 M'Tyer, Amer. Jouru. Med. Sci., vol. viii. p. 517, Aug. 1831. 344 FRACTURES OF THE PELVIS. 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 disloca'tion, to which must be added crepitus and a difficulty, if not impossibility, of retain- ing 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 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 Buffalo, 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 measure- ment 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 SACRUM. 345 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 dislo- cated downwards, and could be felt lying against the tuber ischii, and 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 re- duction 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 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 displace- ment; 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 extend- ing apparatus, secured moderately tight, simply as a measure of pre- caution. § 5. Sacrum. Simple fractures of the sacrum, known to be exceedingly rare,2 are occasioned either by such injuries as break at the same time the other bones of the pelvis, 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 fall upon the sacrum, it will generally be transverse, and below the sacro-iliac symphysis. The displacement in this latter class of cases is almost invariably the same, the coccygeal extremity being simply carried forwards, yet 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. Some- times, 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 angu- lar projection at the point of fracture, with a corresponding retiring angle upon the opposite side; mobility. Experience has shown that where the fracture of the sacrum is 1 KeaSe, Amer. Journ. of Med. Sci., vol. xvi. p. 225. 2 Maijaigne has referred to eight cases ; and I have not been able to find a record of any others. 23 346 FRACTURES OF THE PELVIS. 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 falls upon the sacrum, occurring below the sacro-iliac symphysis, are generally followed by speedy recoveries, although the inward displace- ment 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 cylinder, which he compelled the patient to wear forty-five days; removing it, however, every third day, in order to cleanse the rectum with an enema. Ber- mond introduced first a linen bag, which he immediately proceeded to fill with lint, but during the night it became necessary to remove it in order to relieve 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 com- fort. To the same end, also, the diet ought to be light and dry; nothing should be allowed which might prove laxative. By consti- pating 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 faeces, 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, but which was accompanied also with a fracture of the ilium and a dislocation of the hip. Seve- ral 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. Dr. J. T. Banks, of Griffin, Ga., has reported one example of com- plete recovery in an adult male, in which the right sacro-iliac sym- physis was separated "by a blow received upon the tuberosity of the ischium, driving the ilium up an inch or more, causing complete paralysis and anaesthesia of the right leg for two or three weeks;" motion of the hip caused also severe pain. No attempt was made to FRACTURES OF THE FEMUR. 347 reduce the bones, but union occurred, and he gradually regained the use of his limb.1 In a few instances 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. In nearly all the traumatic examples reported, the diastasis has been accompanied with a fracture extending parallel with the margins of the synchondrosis; and it is for this reason that I have preferred to consider these accidents as fractures, rather than as dislocations. § 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.2 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. Due to the same causes which produce fractures of the coccyx itself, its symptoms differ only in the increased length of the movable frag- ment, 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. CHAPTEE XXYIII. FRACTURES OF THE FEMUR. Development of Femur.—The femur is formed from five centres of ossification; namely, one for the shaft, commencing at about the fifth week of foetal life; one for the lower end, including the condyles, com- mencing at the ninth month of foetal life; one for the head, com- mencing at the end of the first year after birth; one for the great tro- ' Banks, Atlanta Med. and Surg. Journ., May, 1866. 8 Cloquet, art. Bassin, of Diet. 3d vol. 348 FRACTURES OF THE FEMUR. Fig. 102. chanter, commencing during the fourth year; and one for the lesser trochanter, commencing between the thirteenth and fourteenth years. None of these epiphyses are joined to the shaft until after puberty, but consolidation is generally com- pleted at the twentieth year. The order in which union occurs is exactly the reverse of the order in which ossification commences, the lower epiphysis being the first to exhibit traces of ossification, and the last to unite. Division of Fractures.—Of 156 fractures of thefemur not including gunshot, which have come under my observation, 63 belong to the upper third, 67 to the middle third, and 26 to the lower third; or, if we confine our analysis to the shaft alone, 23 belong to the upper third, 67 to the middle, and 26 to the lower. The femur constitutes, therefore, a striking excep- tion to the rule which my observations have estab- lished, 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 gene- rally near the upper end of this third; that is to say, above its middle. § 1. Neck of the Femur. Development of Femur. (From Gray.) Forty of the whole number were fractures of the neck, either intra or extra-capsular. The youngest of these patients, excepting one case of supposed epi- physeal separation, was thirty-nine years, the oldest eighty-four, and the average age was about sixty. Seventeen were males and twenty-three females. All were simple. Thirteen were believed to be without the capsule, and sixteen 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 exa- mination of cabinet specimens, finds in four large collections sixty- one 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, Ne'laton 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 case he found the fracture extra-capsular. This testimony, so far as it goes, is positive, but the number is not sufficient to establish any- NECK, WITHIN THE CAPSULE. 349 thing 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 pend- ing between Dupuytren and Sir Astley Cooper as to the probability of bony union in intra-capsular fractures, to accumulate cabinet speci- mens 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. Fig. 103. Causes.—In no other fractures do the predisposing causes play so important a part as in fracture of the neck of the femur, and this whether within or without the capsule; indeed, experience has shown that with- out the concurrence of those pathologi- cal 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-capsu- lar; but Robert Smith has given us the ages of sixty persons having fractures of the neck of the femur, and the aver- age 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 testi- mony in proof of the inaccuracy of the opinion held by Sir Astley Cooper; but I trust it will not be regarded imperti- nent or hypercritical for us to inquire how Mr. Smith became possessed of the ao-es of all these persons from whom these specimens were obtained; for more than half of the whole number, that is, just thirty-two, have Fracture within the capsule. 350 FRACTURES OF THE FEMUR. 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 pre- tend 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 rela- tion to this point; and until better evidence is furnished I shall con- tinue to think, with Sir Astley Cooper, that fractures within the cap- sule belong generally to an older class of subjects than fractures with- out 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 the 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 frac- ture ; 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 proposi- tions so ingeniously maintained by Rodet, I am nevertheless 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. I have seen also the intra-capsular fracture produced by so slight a 1 L'Experience, March 14, 1844. NECK, WITHIN THE CAPSULE. 351 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 re- ported 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 frac- ture 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 com- plained of pain in the hip, but there was neither shortening nor ever- sion 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 lacera- tion of the soft parts.2 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 intra-capsular 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 trans- verse. In one example of an old fracture I have seen the ends dove-tailed upon each other, the fracture having a double obli- quity, and not admitting of displacement. There may occur also a species of impac- tion, 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 illus- trated by the annexed woodcut (Fig. 104), copied by Mr. Smith from a specimen in the Dupuytren Museum at Paris; or the impacted fracture within the capsule. ' Colles, Dublin Hosp. Reports, vol. ii. p. 339. 2 Stanley, Med.-Chir. Trans., vol. xiii. 352 FRACTURES OF THE FEMUR. 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 ;'u by which we understand him to mean that a separation of the epi- physis 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 he felt so little inconvenience from it that he several times left his bed and walked about. We have no informa- tion as to the result; or as to the further progress of the case.2 A girl, aet. 18, was brought before Dr. Parker, of New York, at his surgical clinic, Nov. 1850, who had been injured by a fall upon a curbstone, 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 incon- venience." Dr. Parker thought this circumstance alone sufficient to distinguish it from hip disease in which anchylosis is the termination.3 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 remains from a quarter to half an inch shorter than its fellow." Aug. 14, 1865, Andrew Leroy, set. 15, in attempting to escape from the House of Refuge, fell from the fourth story. On the following morning he was admitted into my wards, at Bellevue Hospital. I found his right thigh shortened three-quarters of an inch, and slightly abducted; toes everted. Placing him under the influence of chloro- form, we detected a dull crepitus in the vicinity of the joint. It was unlike the crepitus of broken bone. With fifteen pounds of extension we were able to overcome the shortening entirely, and to put the limb 1 Liston, Elements of Surgery, Phila. ed., 1837, p. 480. 2 South, Note to Chelius's Surgery, vol. i. p. 619. 3 Parker. Amer. Med. Uazette, vol. i. p. 342, Nov. 30, lS.'O. 4 Post, New York Journ. Med., vol. iii. p. 190, July, 1840. NECK, WITHIN THE CAPSULE. 353 in position. This was maintained with Buck's apparatus. At the end of two weeks, however, it was ascertained to be shortened half an inch. Four more pounds were then added. At the close of my term of service, I lost sight of the boy, and have not been able therefore to verify my diagnosis; but I believe it to have been a separation of the upper epiphysis. These four constitute the only examples of this accident which I find reported or of which I have any knowledge, 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. Symptoms.—Whether the limb will be shortened or not must de- pend upon whether the fragments have become displaced in the direc- tion 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 short- ening 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 displace- ment of the fragments is complete; but under no circumstances is it easily developed. AVhen 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 354 FRACTURES OF THE FEMUR. 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, con- sequently, 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 un- like crepitus, but less harsh, produced by the friction of the trochan- 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. Eversion 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 Langstaff, Guthrie, Stanley, and Cruveilhier have each seen one example, and Robert Smith has seen two.1 I have myself seen one. 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, 1 Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. cit., p. 151, note. NECK, WITHIN THE CAPSULE. 355 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 indis- tinctly upwards and backwards from its usual position. The patient having been placed under the influence of an anaesthetic, we may prosecute the investigation still farther, and by rotating the limb in- wards 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 conse- quently 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 pos- sibility of this union, and to maintain that no exception to the general rule can take place, would be presumptuous, especially when we con- sider the varieties of direction in which a fracture may occur, and the degree of violence by which it may have been produced. For example, 356 FRACTURES OF THE FEMUR. 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 fracture of the neck of the thigh-bone, and therefore I beg at once to be under- stood 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 liga- mentous sheath and periosteum of the neck of the bone are torn through, that the bones are consequently drawn asunder by the mus- 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 mili- tate 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 attri- butes 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 im- possible 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. 1 Sir Astley Cooper, on Dislocations and Fractures of the Joints, edited by Bransby Cooper, Amer. ed., p. 156. NECK, WITHIN THE CAPSULE. 357 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."1 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 doc- trine that fractures of the neck of the thigh-bone were incapable of 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 Frac- tures 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."2 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 hear- ino- 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 ex- amples 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 absorp- tion. Some were partial rather than complete fractures; others were partly within and partly without the capsule; and for this he was ac- cused of wilful blindness or stupidity, chiefly by those who themselves beino- 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 1 See also Sir Astley's letter to Prof. Cos, written in 1835, and published in the Prov. Med. and Surg. Journ. for July 12, 1848, New York Journ. Med. for Sept. 1848, and appendix to Cooper on Dis. and Frac, Amer. ed., 1851, p. 482. 2 Lettsomian Lectures on the Physical Constitution, Diseases, and Fractures of Bones, by John Bishop, F. R. S. London, 1S55, p. 55. 358 FRACTURES OF THE FEMUR. 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 con- tinue to be mentioned by any surgical writer as probable examples.1 Robert Smith reduces the number to seven, but Malgaigne recog- nizes only three, namely: Swan's case, admitted by Sir Astley him- self; 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. AVhen 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."2 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:— 1 The following European surgeons have claimed to have in their possession, each, oneexample: Langstaff (Med.-Chir. Trans., vol. xiii. 1827); Brulatour (Ibid., vol. xiii. 1^27) ; 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. (j21) ; 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. 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. 2 Malgaigne, Traite des Fractures et des Luxations, torn. i. p. 678. NECK, WITHIN THE CAPSULE. 359 " 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, p. 59.) In this case the patient was an old lady, above eighty years of age, with the fracture not certainly made out; 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 Since writing the above, my friend, Dr. Voss, of this city, has placed in my hands an elaborate paper on this subject, from the pen of Dr. Edward Zeis, of Dresden, and which has been translated by Dr. R. Newman, Prosector to Chair of Surgery, Long Island College Hos- pital. Dr. Zeis, after rejecting all other European specimens, claims that bony union has occurred within the capsule in a specimen now in his possession, and also in a specimen which may be found in the pathological cabinet of the medico-chirurgical academy of Dresden.2 I regret that I am not able to publish these cases at length, as well, also, as the able review of their claims sent to me by Dr. Newman, in which Dr. Newman clearly shows that Dr. Zeis has completely failed to establish the correctness of his opinions. There is no con- clusive evidence that the bones were ever broken, nor, if they were broken, that the fractures were entirely within the capsule. On this side of the Atlantic, the number of specimens for which 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 sen, vol. ii. p. 295. 1 Description of two specimens of intra-capsular fracture of the neck of the femur, and union by callus; by Dr. Edward Zeis, Dresden, 1864. 360 FRACTURES OF THE FEMUR. 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 sur- geon, Reuben D. Mussey, late Professor of Surgery in the Miami Medi- cal College, at Cincinnati, Ohio, and whose many valuable contribu- tions 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 appa- ratus. 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 bedclothes Dr. Mussey noticed that the foot and knee were turned considerably outwards. He immediately took off the Fig. 105. Fig. 106. Left, or injured femur of Mr. S. Vertical section of the same. splint, and moved the hip-joint; finding that it gave him no pain, he flexed the thigh to a right angle with the body, and kept it a minute NECK, WITHIN THE CAPSULE. 361 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 de- cided uneasiness. No shortening could be detected. 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 cre- pitus. 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 thigh-bones were obtained. The right femur was sound (Fig. 107), 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-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. 105, 106), 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 cap- sular 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 24 Right, or sound femur of Mr. S. 362 FRACTURES OF THE FEMUR. that bony union does not take place in intra-capsular fracture. His views, among the surgeons of Great Britain, were extensively admit- ted 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 com pletely 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 jour- ney 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 wdien 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 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 be- fore 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 iii his convictions, and each one of whom was equally competent to decide the point at issue. NECK, WITHIN THE CAPSULE. 363 Fig. 108. 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 ro- tated 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 caue, the shortening, which was about half an inch, being concealed by a high- heeled shoe. This man survived the injury twelve years, and eight years after his death Dr. Mussey obtained the specimen of injured bone (Fig. 108), together with its fellow (Fig. 110). 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 speci- men. A section (Fig. 109) shows a white, condensed tissue travers- ing the neck, near its junction with the head. The left, or injured femur of Mr. X. Fig. 109. Fig. 110. Vertical section of the injured femur of Mr. N. ELJH The right, or sound femur of Mr. N. 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 364 FRACTURES OF THE FEMUR. knee and foot were a little everted, with slight shortening and tender- ness on pressure in the groin and behind the trochanter major. She 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. 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. The neck of the bone (Fig. Ill) is shortened to seven-eighths of an inch anteriorly, and to half an inch posteriorly. A considerable ridge Fig. 111. Fig. 112. Vertical section of the injured femur of Mrs M. runs across the anterior part of the neck, between which and the head is an irregular superficial groove. A section of the bone (Fig. 112) 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 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 in- formation 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 The right, or injured femur of Mrs. M. NECK, WITHIN THE CAPSULE. 365 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 direc- tion 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 coapta- tion, the rough points become absorbed. If we allow for this absorp- tion, 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 Twenty- third Street 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 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 Bar- nard, Vt. 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 speci- men 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 366 FRACTURES OF THE FEMUR. it was inserted; a line is pointed out about three lines below the so- called 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 can- cellated structure being more compact than in other points. On com- paring this specimen with the femur of the well limb, a very marked difference is observable; this line or buttress is stronger, better deve- loped, 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 cap- sule. 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 corre- sponding 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, Vt., 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 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 in- serted, and it is probable, if there was a fracture, it was partly extra- capsular. "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 im- pression 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 NECK, WITHIN THE CAPSULE. 367 bone is in some degree preserved. This state of things may be fre- quently seen in very old persons.' ' When the absorption of the neck proceeds faster thaa 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 addi- tional 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 con- sequence 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 ex- panded, 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 inter- stitial absorption, and has adduced cases which we would copy if our limits would allow. He shows by his specimens that the head is en- larged 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 anchy- losis ; 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 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 pro- bably partly extra-capsular; if not, it was a case of interstitial ab- sorption."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 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. 368 FRACTURES OF THE FEMUR. 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, w7as submitted to the ex- amination 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 com- pletely 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 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 im- possible, in my opinion, to determine whether the fracture was not in part without the capsule. This remark will apply to all similar ex- amples, 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. NECK, WITHIN THE CAPSULE. 369 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, accord- ing to the testimony of respectable citizens, was attended by a surgeon, and treated, as they think, for a fractured thigh; but it does not ap- pear 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 appear- ing 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 attri- tion, and as having occurred at an advanced period of life. On the anterior superior part of the neck is a ridge of bone, to which a portion of the capsular ligament remains attached. Most of the cartilaginous covering of the head has been either entirely re- moved, 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 im- bedded in the fibres of the psoas magnus and iliacus internus, 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. 370 FRACTURES OF THE FEMUR. 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 un- healthy 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. Dr. Mutter thought also that specimen B, 71, in his collection of bones, now lying in the Jefferson Medical College at Philadelphia, was 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 ques- tion 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 Univer- sity, 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 fit- ting 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 Dupuytren on Dis. and Injuries of Bones, p. 187. NECK, WITHIN THE CAPSULE. 371 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 dis- tinguished 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 re- covery 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 recived; that she could draw up her legs; that she rode sitting upon the seat of a wagon; that the extending splint 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 Rogerses 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. Warren2 and Hay ward 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 ' Boston Med. and Surg. Journ., Jan. 26,1842; Amer. Journ. Med. Sci., April, 1857, p. 310. 2 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. 372 FRACTURES OF THE FEMUR. 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 be- lieved 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. I have also in my own cabinet a femur of no inconsiderable preten- sions, 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, aet. 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 intelli- gent 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 exami- nation 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 NECK, WITHIN THE CAPSULE. 373 Fig. 113. that after two or three years she could walk on crutches, her toes turn- ing 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 testi- mony upon this interesting but difficult subject. In it all we think we see enough to warrant a belief that under certain favorable circumstances bony union may occur, but not enough to establish it be- yond 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 care- ful examination, proved satisfactory; but unless our want of conviction can be shown to be the result of a wilful blind- ness, we shall demand protection against the assaults and insinuations which have so frequently fallen upon those who ventured to doubt the authenticity of every specimen which was laid before them. Within the last few years, Dr. Geo. K. Smith, of the Long Island College Hospital, has made a most valuable contribution to our know- ledge 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, Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule. 374 FRACTURES OF THE FEMUR. 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 wall 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, 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 impu- dence 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 cylin- drical 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 repa- ration 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 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"(RobertSmith); "chronic rheumatic arthritis"(Adams); "inter- stitial absorption of the neck of the thigh-bone" (B. Bell); and by others " interstitial and progressive absorption;" but the exact nature 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, lb62. NECK, WITHIN THE CAPSULE, 6tD Fie. 114. 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 flatten- ing and eburnation of the articular sur- faces, and Gulliver has shown that similar changes of form in the neck of the bone may occur in tolerably young persons. I suspect also that it will be found to occur under a greater variety of circum- stances, and to present a greater variety of forms than have yet been described; and we shall perhaps find a partial ex- planation of this diversity and fre- quency in one single circumstance, namely, the peculiar anatomical struc- ture 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 gradu- ally 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 Section of a sound adult femur. Fig. 115. Chronic rheumatic arthritis. (Miller.) cause whatever, such as a blow upon the trochanter or upon the foot, the neck or head is made to suffer, and inflammation, or perhaps 376 FRACTURES OF THE FEMUR. only a slight degree of increased action in the absorbents, ensues, resulting in an equally slight softening of the bony tissue, these patho- logical 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- 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 occurr 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 per- forms 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; sinous 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 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 conden- sation 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 1 Gulliver, Lond. Med.-Chir. Rev., vol. xxxix. p. 544. NECK, WITHIN THE CAPSULE. 377 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 ma- lady of which he finally died, he received a blow upon his right tro- chanter, 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 per- cussed. 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 short-' ening or deformity of any kind. 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 hip- joint 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 25 378 FRACTURES OF THE FEMUR. 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. 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 flattened out by pressure and friction, it having gained as much gene- rally in thickness as it has lost in length. To this observation, how- ever, 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 ace- tabular fragment. (Fig. 116.) 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. 117), 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 spicula 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 NECK, WITHIN THE CAPSULE. 379 the invariable consequences of this accident. Indeed, not a few succumb rapidly to the injury, perishing from a low, irritative limb, are Fie. 116. Fig. 117. Fracture of cervix femoris within capsule. Mayo's specimen. United by ligament. Patient Ununited. Opposite surfaces irregularly con- lived nine months after the accident. The tro- vex and concave, and polished ; moving slightly chanter minor arrested the descent of the head. upon each other. (From a specimen in the pos- (From Sir A. Cooper.) session of Dr. Crosby.) fever, or from gradual exhaustion, within a month or two from the 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 thefracture 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 indica- tion 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, 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 380 FRACTURES OF THE FEMUR. at the neck, the hip of the broken limb being prevented from descend- ing by the lateral pressure of the two long splints. This apparatus Fig. 118. Gibson's modification of Hagedorn's splint. possesses also this advantage, namely, that it presses the broken frag- ments more firmly against each other, and thus operates to prevent their displacement in the direction of the axis of the shaft. Fig. 119. 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 be proper, inasmuch as the fragments are not overlapped; and they need only a moderate assistance to enable them to maintain their posi- tion 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 pa- tients 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 ques- tion must rest with the individual cases and the good sense of the surgeon. Not very many old and feeble people will bear such con- finement 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 768694�90136166471 NECK, WITHIN THE CAPSULE. 381 months; In Mussey's second case Hartshorne's straight splint for ex- tension 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 a 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: Harris1 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. Mus- sey himself removed all dressings from Dr. Dalton's patient on the eighteenth day, and placed him upon his feet, and Dr. Wakelee re- moved the apparatus from his mother on the fifth day. Nor are we without evidence that the careful and judicious applica- tion of splints, long continued, and employed under the most favor- able 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 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 compli- cation 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 dis- turbed 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 382 FRACTURES OF THE FEMUR. 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 Rodgers. A frac- ture 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. Shortly after his admission, an immense abscess formed over the joint, which discharged profusely. The man died shortly after from exhaus- tion, and the specimen came into Dr. Yan Buren's hands, the patient having been in his service. Dr. Yan 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. Yan Buren, of the University Medical College, New York. Such equal results from opposite plans, and unequal results from 1 Johnson, op. cit., pp. 13-15. NECK, WITHOUT THE CAPSULE. 383 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 can- not 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 con- sequences. (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 pre- ceding section that fractures without the capsule seem to be the result generally of falls or of blows received directly upon 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- able uniformity; the trochanter major being usually divided from near the centre of its summit, obliquely downwards and forwards towards its base, and the line of fracture terminating a little short of the tro- chanter 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 accompa- nied 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 with- out union of any kind, in which no traces remain of a fracture of the 384 FRACTURES OF THE FEMUR. 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. Fig. 120. Fig. 121. Fig. 122. Impacted extra-capsular fractures. (R. Smith, and Erichsen.) 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 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 NECK, WITHOUT THE CAPSULE. 385 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 cailus 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 impac- tion 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, accord- ing to the degree of impaction; rotated outwards or inwards, or in netther direction, perhaps, according to the direction of the force and of the fracture. In other cases, owing to the extreme comminu- tion, 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 injudicions hand- ling 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- ening and eversion of the limb. The trochanter major is not as pro- minent as upon the opposite side, and it rotates upon a shorter axis. There are also several other signs to which I shall refer when consi- dering 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 direc- tion bv 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 com- plete 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 impac- tion 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-quarters of an inch, but 386 FRACTURES OF THE FEMUR. Robert Smith has established the following distinction. When the fracture is extra-capsular and impacted, that is, when it remains im- 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 aver- age 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. During the winters of 1864 and '65 I found a case of this kind in my wards at Bellevue Hospital. 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 signs 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 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. Fracture of the neck of the Femur. (Fergusson.) Signs of a fracture within the capsule. I Signs of a fracture without 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 lower extremity of the malleolus externus or internus.) Shortening at first less than in extra- capsular fractures, often not any. 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 pain- ful to press upon and around the trochan- ter. Shortening at first greater, almost always some. NECK, WITHOUT THE CAPSULE. 387 Signs of a fracture within the capsule. 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 of a fracture without the capsule. 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. Fig. 124. 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 frac- ture 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. This deposit is no less remarkable for its abund- ance than for its 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 direc- tion, 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 vascu- larity would naturally lead to such results. The same, but in a less Extra-capsular fracture. (Erichsen.) 388 FRACTURES OF THE FEMUR. degree, has already been noticed as occurring in impacted fractures at the anatomical neck of the humerus, Avhere certainly such bony abut- ments could not serve any useful purpose. Fig. 125. Fig. 126. Extra-capsular fractures. (E. 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, Fig. 127. namely, where the fragments are not dis- placed or are impacted, the straight splint, with only moderate extension, constitutes the most rational mode of treatment; so also in this fracture, whenever the frag- ments are impacted and remain impacted, a straight splint, employed only as a re- tentive apparatus, is the most suitable. It is only by employing this plan of treat- ment, which no one has yet shown to be inapplicable to either of these two varie- ties 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 Extra-capsular fracture. NECK, WITHOUT THE CAPSULE. 389 retentive apparatus is generally 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 urg- ing 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 mode- rate extension, such as may be obtained from the use of Hagedorn's splint modified by Gibson, or by the use of Miller's splint, or Buck's apparatus with only six or eight pounds of extension. That it is not impacted we may know often, or generally, by the amount of displace- ment, 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 per- mit, 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. If any surgeon, acting upon the suggestions here made, shall con- fine a feeble or an aged person in the horizontal posture, and in a Fig. 12?. Miller's splint for extra-capsular fractures. (From Miller.) straight splint until the powers of nature have become exhausted, and death ensues, as our readers have already been admonished may 390 FRACTURES OF THE FEMUR. happen, we are not to be held responsible for his want of judgment or 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 ex- amples 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 diffi- cult to diagnosticate than either of those forms of which we have just spoken. The symptoms will be mainly, however, those which cha- racterize 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. § 2. Fracture through the Trochanter Major and Base of the Neck of 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 con- firmed 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 Hos- pital, 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 1 Sir Astley Cooper, op. cit., p. 183. BASE OF THE TROCHANTER MAJOR. 391 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."1 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 confine- ment of several months to her bed, the woman was sufficiently re- covered 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 pro- gress 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."2 Sir Astley relates three other examples in which he believes the fractures to have been of the character above described; and he details the peculiar plans of treatment which, in each case, he saw fit to recom- mend. I can see no reason, however, why the treatment need differ from that which has already been reeommended 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 acci- dent is the one reported by Mr. Key to Sir Astley Cooper.3 The sub- ject 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 1 Op. cit., p. 184. 2 Stanley, Med.-Chir. Trans., vol. xiii. 3 Sir Astley Cooper on Dislocations and Fractures, etc., Amer. ed., 1851, p. 192. °>09 FRACTURES OF THE FEMUR. 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 (1.^35), J. Clarke, Esq., reports a case of comminuted fracture of the trochanter major, which has been mentioned by Mal- gaigi^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 trochan- ter was found crushed and shattered, several pieces entirely detached, and fissures extending deeply into the shaft of the bone."1 I shall venture to express the same opinion in relation to the case reported by Bransby Cooper.2 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 the narrative to render it improbable that there existed also an im- pacted extra-capsular fracture of the neck. I have also myself reported one example of this fracture as having come under my own observation,3 but of which I wish now to speak somewhat less confidently. The patient, James Redwick, a travelling showman, set. 23, fell, in August, 1848, from a high wagon, striking upon his left hip. When he got upon his feet, he found himself un- able to walk, and was carried to his room. Dr. Wilcox, of Buffalo, 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 inver- sion ; 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 five 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. 1 Clarke, Amer. Journ. Med Sci., Nov. 1836, vol. ix. p. 181. 2 B. Cooper, A. Cooper on Dislocations, &c, op. cit., p. 19!iJ. 3 Hamilton, Trans. Amer. Med. Assoc, op. cit., vol. x. p. 254. FRACTURES OF THE SHAFT OF THE FEMUR. 393 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. 129. 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. Fractures of the Shaft of the Femur. Etiology.—Unless the fracture has taken place just above the con- dyles, 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 con- dyles, and these were all produced by falls upon the feet; but of the remaining eighteen, all of which occurred higher in the limb, only 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 some- what above the middle of the shaft. I have made the same observa- tion 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 ex- ception, oblique; and the obliquity is generally greater than in the case of other bones. This fact, which it is very difficult to deter- mine, 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. Mut- ter's collection, specimen B 71 is an adult femur, broken nearly trans- versely through its middle third; and it is united with a shortening of about one inch. Indeed, it is more common to find a transverse 26 1�21111163�6 394 FRACTURES OF THE FEMUR. 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 addi- tional 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 FiS-13°- third its direction is, with only rare excep- tions, downwards and forwards, and the su- perior 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 downwards and for wards, just above the condyles. Very little inflammation ensued, and although it was found impossible to employ extension, union occurred readily, and with only a mode- rate overlapping. In the left limb, however, Fracture at base of condyles. the upper fragment pressed down sufficiently to interfere somewhat with the patella, and the patient was unable, after several months, to straighten the knee completely. The motions of the right knee were 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 some- what at length. FRACTURES OF THE SHAFT OF THE FEMUR. 395 George Taylor Aiken, of Lockport, N. Y., ast. 7. May 18, 1854, in jumping down a bank of about three feet in height, he broke the right thigh obliquely, just above the knee-joint. 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. On the second or third day, Dr. G. noticed that the toes looked un- naturally white, and were cold. Counsel was now called at the request of Dr. G., when it was de- termined 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 ex- amining the fracture I noticed that the anterior line of the femur seemed nearly straight, and this appearance was owing in some de- gree 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 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 ex- tremely 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 medi- cal gentlemen examined as witnesses declared that this circumstance 396 FRACTURES OF THE FEMUR. 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 unfor- tunate 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 artifi- cial leg and foot could be. The Hon. Judge, in a speech remarkable for its clearness and libe- rality, sought to impress upon the jury the value of the medical testi- mony. 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 ob- servation 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 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 disjunc- tion, occurring in a child twelve years old, was attended with a dis- placement of the upper fragment backwards, and amputation became necessary.8 I shall refer to this case again. I know of no other cases of this rare accident which have been re- ported. 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 popli- teal 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. ' Remarks on Fractures, &c, by Joseph Amesbury, vol. i. p. 293. London, 1831. 2 Archiv. Gen. de Med., torn. ix. p. 267. FRACTURES OF THE SHAFT OF THE FEMUR. 397 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 direc- tion of the line of fracture, the lower end of the upper fragment inclines forwards and outwards, and the upper end of the lower frag- ment 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 some- times to the swelling which immediately follows the injury, it is often very difficult to determine at what precise point the fracture has oc- curred, and still more difficult to say whether the fracture is oblique or transverse; indeed, this latter question is sometimes decided ap- proximately 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 ex- perienced surgeons as to the question of shortening in other fractures, 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 seem, 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 is 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 frac- 398 FRACTURES OF THE FEMUR. ture, 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 disgrace."1 Says Chelius: " Fracture of the thigh-bone is always a severe acci- dent, 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 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, evi- dently shows that we are still deficient in this branch of practice."3 Velpeau says that " after fractures of the femur there is no limp- ing 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 ob- viate 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."4 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 1 The Chirurgeon's Store-house, by Johannes Scultetus, a Famous Physician, and Chirurgeon of Ulme in Suevia. London, 1674. 2 System of Surgery, hy J. M. Chelius, translated, &c, by South. First Amer. ed., vol. i. p. 627, 1847. See also p. 625, paragraph 679. 3 System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. » Peninsular Journ. of Med., vol. iii. p. 384; also Memphis Med. Journ., vol. iv. p. 254, 1856. 5 Elemeus de Pathologie Chirurgicale, par A. Nelaton, torn, prem., p. 752. Paris, FRACTURES OF THE SHAFT OF THE FEMUR. 39.9 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 ap- paratus 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- 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 per- sons; and they have believed that they have cured with their appara- tus a shortening which had never existed. In short, when the frag- ments 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 exten- sion. They allege, moreover, that an overriding of even three centi- metres 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 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. 400 FRACTURES OF THE FEMUR. denticulated (engren^es): when they ride, on the contrary, we must look for a shortening as almost inevitable."1 Air. Holthouse says2 that in 1857 he examined all the fractured thighs then under treatment in the different hospitals in London, and in the case of adults all were shortened except three, and he thinks it doubtful whether in these three cases his examinations were of any value. In thirty-five examples the average shortening exceeded one inch. In the case of children 40 per cent, were shortened. In our own country several of the most distinguished surgeons have testified to the constant difficulty, if not impossibility, of curing frac- tures 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 Jona- than 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 the most simple kind, in which there was not some remaining de- formity; 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." 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."4 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 seven- teen 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 accom- plished." 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 Hospi- tal 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:— 1 Op. cit., p. 718. 2 Holthouse, Holmes' System of Surgery. London, 1861, vol. ii. p. 613. 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. * New York Journ. of Med., second series, vol. xvi. p. 261. FRACTURES OF THE SHAFT OF THE FEMUR. 401 " After carefully scrutinizing over one hundred cases of fracture of the femur, taken from the register of the N. Y. Hospital, and elimi- nating such as involved the cervix, or condyles, or belonged to the class of compound fractures, there remained an aggregate of seventy- four 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 differ- ence 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 re- maining 55 cases was a fraction less than f of an inch. " Seventeen cases in the above aggregate were under 12 years of age, 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 short- ening in the remaining 44 cases was a fraction over § 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 prac- tice, 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 par- ticular notice."2 Mr. South, in a note, commenting upon an opposite sentiment ex- pressed 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 state- ments, Mr. Gamgee exclaims: " This is conservative surgery. What 1 Buffalo Med. Journ., vol. xv. p. 22, June, 1859. 2 Practical Remarks on Fractures, by Joseph Amesbury, vol. i. p. 384. London ed., 1831. » Op. cit., vol. i. p. 627. * Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson Gamgee. London ed., pp. 159, 160. 402 FRACTURES OF THE FEMUR. 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, Burggraeve, Crocq, Velpeau, and Salvagnoli Marchetti record numerous cases no less remarkable and demonstratively con- clusive."1 Desault, also, according to the passage from Malgaigne which I have already quoted, " pretended to cure all fractures without short- ening." I do not find, however, any other authority for this state- ment, as here made; neither in his Treatise on Fractures and Luxa- tions, edited by Bichat, nor elsewhere. Bichat even says positively that " Desault himself did not always prevent the shortening of the limb."2 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."3 Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault, as modified by Physick and Hutchinson (Fig. 131), was equally suc- cessful.4 Fig. 131. >= -----------fr-n Phtskk's Splint.—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 6plint. 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.5 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 expe- rienced. 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 1 Op. cit., p. 167. 2 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. Bichat. Amer. ed., p. 251. 1805. » Op. cit., p. 223. * Elements of Surgery, by John Syng Dorsey, vol. i. p. 163. Philadelphia, 1813. 5 " Medical Chronicle" of Montreal, vol. i. No. 7, 1853. FRACTURES OF THE SHAFT OF THE FEMUR. 403 lack of faith in their testimony is only a necessary result of our expe- rience, 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 argu- ment than may be found in the overwhelming testimony of practical surgeons, that broken femurs do in their experience rarely unite with- out 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 dress- ing, which, in itself peculiar, and more perfect than all others, has fur- 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 of Dorsey, adopts also the straight position; but he makes no perma- nent 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'1 he uses the following emphatic language: " The contrivances which are com- monly 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 inju- riously, 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 thus broadly contradicts the statements of ' Works of Desault. Op. cit., p. 225. * Amesbury on Fractures, &c, vol. i. p. 310. s Op. cit., vol. i. p. 384. 404 FRACTURES OF THE FEMUR. Desault, South, Dorsey, and Amesbury, he administers a severe rebuke even upon the illustrious Liston: " Pott's plan, the long splint, Mclntyre, 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 long splint (Fig. 132), and of the leg by the modified Mclntyre, which are admitted equal, if not superior, to other splints, was rigidly followed in that in- stitution, the patients admitted with broken thighs or legs were fre- quently discharged with manifest deformity."1 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 Velpeau, already quoted, who claims no result better than an average shortening of half an inch. It is true, however, that M. Velpeau 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. 132. Liston's method, recommended by Samuel Cooper, Fergusson, 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 1 Advantages of the Starched Apparatus, by Joseph Sampson Gamgee. London, 1853, pp. 54, 55. FRACTURES OF THE SHAFT OF THE FEMUR. 405 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 short- ened less than one inch. Specimen B 63, 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 mid- dle 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 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 occuring in children or in per- sons 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 short- ening, 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 three- quarters 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 occa- sionally in the production of shortening, but only that muscular con- traction 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 406 FRACTURES OF THE FEMUR. the straight position in the treatment of fractures of this bone; either with simple lateral splints, or with long splints, with or without exten- sion, 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 origi- nality 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- come by posture, without the aid of extension; and that for this pur- pose, 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 ad- hesion 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. To the support of this system of Pott's, thus Fig. 133. Double inclined plane employed in Middlesex Hospital, London. modified, Sir Astley Cooper, C. Bell, John Bell, Earle, White, Sharp, and Amesbury, lent the influence of their great names, and its triumphs, so far as the judgment of British surgeons was concerned, soon became complete. Fig. 134. Amesbury's splint. In France, and upon the continent generally, the reception of this system was more slow and reluctant; but Dupuytren now for once FRACTURES OF THE SHAFT OF THE FEMUR. 407 taking ground with his great rival, Sir Astley, adopted almost without qualification these novel views. The decision of Dupuytren deter- Fig. 135. Amesbury's splint applied. mined 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, the great surgeon of St. Bartholomew might have con- tinued 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. 136. 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 sur- geons who adopt universally the flexed position m 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 hos- pitals of Great Britain and upon the continent of Europe, I do not remember to have seen the flexed position once employed in the treat- ment 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 ot the treatment of fractures of the thigh. 408 FRACTURES OF THE FEMUR. First. That in which the straight position was universally adopted, and which reaches from the earliest periods to the period of the writ- ings 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 splint of Desault, and the more complicated apparatus of Boyer (Fig. 136), 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 sur- geons may fairly be regarded as original inventions. Nathan Smith, of New Haven ;T Nathan E. Smith, of Baltimore ;2 Nott, of Mobile ;3 McNaughton, of Albany ;4 and Valentine Mott, of Fig. 137. Nathan R. Smith's suspending apparatus, or double inclined plane. New York, are the only American surgeons of distinguished reputa- tion, and with whose practice I am familiar, who recommend exclu- sively 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 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. FRACTURES OF THE StfAFT OF THE FEMUR. 409 construction of straight splints, and in the means of extension and counter-extension. Fig. 138. Josiah C Nott's Double Inclined Plane. In this apparatus the limb is secured to the splint by vertical pins and leather straps ; the upper sur- face 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. "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 in- clined plane. "The Drs. Burges, brothers, Court St., Brooklyn, Long Island, have made an improvement upon the extended principle (Figs. 141, 142). Their apparatus is now complete, and is in use at the Bellevue Hos- pital, where I advised, some time since, that it should be tried. It has succeeded admirably in two cases." Dr. Nathan E. 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. It is my opinion, however, that it is more applicable to gunshot fractures of the leg than to those of the thigh. The splint, if splint it can be properly called, is simply a frame composed of stout wire and covered with cloth, which being 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 27 410 FRACTURES OF THE FEMUR. toes, the lateral bars being separated about three inches at the top and one-quarter of an inch less at the lower extremity. Fig. 139. N. E. Smith's anterior splint 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 fracture, and the lower hook should be placed a little above the middle of the leg. Fig. 140. Dr. J. T. Hodgen, of St. Louis, Mo., has invented a similar wire suspension splint, which I much prefer. The bars of wire are traversed with a cotton sacking, upon which the limb is laid. He does not, however, advocate its general use, but he has designed it especially for gunshot fractures.1 On the other hand, among the advocates of the straight position are found the names of Physick, Dorsey, Gibson, Horner, J. Harts- horne, H. H. Smith, Neill, E. Coates, H. Hartshorne, Norris, Gross. 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 ' Hodgen, Treatise on Mil. Surg., by F. H. Hamilton, 1865, p. 411. FRACTURES OF THE SHAFT OF THE FEMUR. 411 Fig. 141. Burge's Apparatus. Fig. 142. 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 trans- portation, 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 he 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 the long splint J, and the other for the attachment of a short splint /, 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 briDg them to the level of the limbs, and fixed at the proper altitude by the screws already mentioned. They are also mutually transferable, thus adapting the apparatus to fractures of either thigh. '■ SjS Counter-extending pads. These are attached by leather straps to the upper surface of the plat- form D, about twelve inches apart. Passing under the cushion G, and becoming well-rounded pads, they traverse the tuberosities of the ischia, pass between the thighs and thence perpendicularly to the hori- zontal iron rod or crossbar L. The crossbar L is supported at each end by a perpendicular bar extend- ing upwards from the platform D. 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 6trips 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 one extremity a swivel and hook tied to a strip of wood in the loop of adhesive plaster below the foot." 412 FRACTURES OF THE FEMUR. 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 foot- piece, and two crutches, one for the axilla and the other for the peri- neum, 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. In children, I have effected some excellent cures simply by means of a sole-leather trough, well padded and provided with a foot-piece. John Neill's Straight Thigh-Splint.—Extension and counter-extension made at the same moment. " The great objection to the flexed position is the difficulty of keep- ing the ends of the broken bones in apposition; the upper one having Fig. 144. Fig. 145. Pelvic belt, and perineal strap. (From draw ings fur- Foot-piece and screw nished by Dr. L. M. Sargent, Boston, Mass.) 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 1 Trans. Am. Med. Assoc., vol. x.; also System of Surg., by S. D. Gross, 1859, p. 221. FRACTURES OF THE SHAFT OF THE FEMUR. 413 Dr. Neill, of Philadelphia, has contrived a very ingenious mode of making both extension and counter-extension at the same moment by Fig. 146. Lateral view of the apparatus, without the belt. Fig. 147. Front view, with folded sheet laid across. Fig. 148. Fig. 151. Figs. 150, 151. Mode of making extension with adhesive plaster. means of a twisted rope which is fastened by its two ends respectively to the perineal band above and the extending bands below. 414 FRACTURES OF THE FEMUR. J. F. Flagg's thigh apparatus, as used in the Massachusetts General Hospital, by Warren, Bigelow, and others (Figs. 148 to 156 inclusive). Fig. 152. Fig. 153. 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. 152), 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. The splints being ap- plied with also short side splints, junks, contain- ing 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 Louis- ville, Ky., Armsby, of Albany,1 also recommend some form of the straight splint. Says Dr. Mus- sey :— " 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 at- Sanborn's Splint, a. The movable crutch, b. The screw which fixes the crutch, c. The cross-bar to which the ends of the strap are fastened, d. The moving screw. 1 Trans. Am. Med. Assoc, vol. x. Report on Deformities after Fractures. FRACTURES OF THE SHAFT OF THE FEMUR. 415 tempted, I have found the straight position of the limb to be the most reliable." And Dr. Kimball, who employs generally Sanborn's splint, 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 unhesi- tatingly answer, never! I have long since abjured the double in- clined 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 straight position, the limb being laid in a kind of long box, and the extension being made with a weight and pulley.1 Dugas, of Augusta, Georgia, employs the pulley and weight also, but uses the long side splint instead of the box.3 Howe, of Boston, recommended a similar method in 1824.3 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 lamp wick, 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 Fig. 154. Gurdon Buck's apparatus. an elastic rubber cord. The weight necessary to make suitable ex- tension will vary from five to twenty pounds. 1 Amer. Journ. Med. Sciences, vol. iv. p. 330, 1829. 2 Southern Med. and Surg. Journ., Feb. 1854. 3 Howe, New Eng. Med. Journ., July, 1824. 416 FRACTURES OF THE FEMUR. At Bellevue, where we use the pulley and weight a good deal, I seldom employ the perineal band as a means of counter-extension, ex- cept in the case of children, relying altogether upon the weight of the body for this purpose; the foot of the bedstead being elevated always about four inches. With children, and especially with very young children, this method is insecure; and the long double splint, inclosing both thighs (Fig. 170), is the only apparatus which I have found reliable. It is not necessary to use the complicated screw described in connection with that apparatus, as the weight and pulley are equally applicable in this form of splint. The perineal band is also, in the case of children, regarded by me as indispensable. Wm. E. Horner, of Philadelphia, employed a long outside splint (Fig. 155, a), extending into the axilla, and padded, so as to avoid the necessity of junks; with fenestras, for extending and counter-extending bands; and also a foot-piece; and a short inside splint (I), made to extend from the perineum to the bottom of the foot. Across the ex- Fig. 155. W. B. 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. The head of the outside splint may also be cushioned, but Fig. 156. Joseph Hartshorne's thigh splint. 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 re- moved in case of a compound fracture, without disturbing either the extension or counter-extension.2 George F. Shrady, of New York, Act. Asst. Surgeon U. S. Army, 1 Treatise on the Practice of Surgery, by Henry H. Smith. * Ibid. FRACTURES OF THE SHAFT OF THE FEMUR. 417 has lately devised a very simple and ingenious mode of suspending the thigh and leg. The apparatus is composed of strong iron bars George F. Shrady's suspending apparatus. bent as in the above drawing (Fig. 157, 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 sur- geon 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. 158, 1, 2, 3, 4) represent a very simple and easily-constructed apparatus devised by Dr. Alonzo Chapin, Fig. 158. o o o o "rJaol arJnl Alonzo Chapin's thigh apparatus. of Massachusetts, which has many points of real excellence.1 It will serve at least to instruct the reader how he may furnish himself ex- temporaneously with a complete apparatus when he is not otherwise prepared. The iron screw and swivel for making extension can be made by any blacksmith in a few minutes. Dr. Chapin uses two of 1 Amer. Journ. Med. Sci., April, 1859, p. 355. 418 FRACTURES OF THE FEMUR. 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 vthe 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, never- theless, 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,1 De Lamater, of Cleveland, Ohio,1 Pope, of St. Louis, Mo.,1 Knight, of New Haven,1 and Eve, of Nashville, Tenn.1 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 con- dyles) 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 tro- chanter 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 frac- tures of the thigh. " My cabinet presents several specimens of broken femurs which illustrate the soundness of these views: in which the abnormal direc- tion of the fragments alluded to as occurring in fractures of the upper and lower thirds, is very marked; the deformities having resulted 1 Trans. Amer. Med. Assoc, vol. x. ; Rep. on Def., etc. FRACTURES OF THE SHAFT OF THE FEMUR. 419 from treatment in the straight position. So far as function and sym- metry 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 in- clined 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 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 ten- dency 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 up- wards 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 1 Trans. Amer. Med. Assoc, vol. x. Rep. on Def., etc. 2 Amer. Journ. of the Med. Sci., vol. xix. p. 270; Transylvania Journal, April, 1836; Boston Med. and Surg. Journ., vol. xxxiv. p. 35. 420 FRACTURES OF THE FEMUR. 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- 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 pene- trate 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, Velpeau, Gamgee, and others, cannot be regarded as a safe or effectual appara- tus; 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 ta- lented countryman, Dr. Swinburne, of Albany, N. Y., and by which he also proposes to dispense with lateral splints altogether.2 My re- marks 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. 165): 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, suffi- cient 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 a 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. 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. FRACTURES OF THE SHAFT OF THE FEMUR. 421 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 be 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. 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 counter- extension. 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 ex- tending bands about the ankle. This, together with the injuries oc- casionally 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 while the bands can generally be made to retain their places against an extension of twenty pounds or more, it is very seldom, indeed, that they occasion any inconvenience. I re- gard 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 sug- gestion. By Dr. Brinton it has been claimed for Dr. Ellerslie Wal- lace, of Philadelphia;* by Dr. Sargent for Dr. Gross, of the same city;2 1 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. 422 FRACTURES OF THE FEMUR. and by others for Dr. Swift, of Easton, Pa.;1 but, however this may be, to Dr. Josiah Crosby, of New Hampshire, is certainly due the credit of having brought it into notice.2 The mode of using adhesive plaster for extension is briefly as fol- lows :— 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. Each band should now be brought down below the bottom of the foot, and folded over a piece of board, the purpose of which board is to keep the bands asunder, so that they shall not press upon the malleoli. For an adult, the board may be three inches long by two and a quarter or two and a half inches wide, and three-eighths of an inch in thickness, perfo- rated in the centre for the passage of a stout cord. The cord being finally made fast to the foot-piece, the movable block, or to the weight, in case the latter is employed. 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, notwith- standing 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.3 In the fracture appa- ratus lately invented by the Burgeses, 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. 1 North Amer. Med.-Chir. Rev., vol. iv. p. 584. 2 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. 3 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. FRACTURES OF THE SHAFT OF THE FEMUR. 423 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.1 Dr. Gilbert, as I have already stated, believes also that the adhesive plaster may be employed as successfully in making counter-extension as in extension. He published his first case of treatment by this method in the American Journal of the 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. 159) nothing is intended to Fig. 159. D. Gilbert's mode of making Counter-extension, and Extension. 1. Anterior and posterior counter-extending adhesive hands, two and a half inches wide, crossing each other hefore 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. 160. Gilbert's Apparatus applied in a Case op Fracture op 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. 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, ' Packard, Amer. Journ. Med. Sci., July, 1862. 424 FRACTURES OF THE FEMUR. 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.1 H. L. Hodge, of Philadelphia, adopting the same measures of counter- extension, namely, the adhesive straps, has modified the idea of Gil- bert 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 Fig. 161. H. L. Hodge's method of counter-extension in fracture of the femur. 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 apparatus described by him possesses also many other peculiarities, and such as demand for it especial attention. I shall, therefore, per- 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 d'appui, but failed, as we have seen, in his attempt to do so; and various sur- geons have since contrived as many different plans for effectually carrying out his idea, but without complete success. No one, how- ever, has approached this nearer than the Burgeses. 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. 162), extending, in a curved form, from the upper 1 Gilbert, Amer. Journ. Med. Sci., April, 1859, pp. 410-424. 2 Hodge, Amer. Journ. Med. Sci., April, 1860. FRACTURES OF THE SHAFT OF THE FEMUR. 425 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 counter- extending force of this portion of the band correspond to the axis of the limb, instead of oblique; and, furthermore, it allows me to dis- pense 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 De- sault, 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 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 men- tioned 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 in- tended, 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 Fig. 162. 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. 162), secured by a thumb-screw, and several holes at different contiguous points in the splint, to which it may be shifted with facility. The posterior end of the perineal band is either passed under the outer splint and buttoned, as shown at B, Fig. 162, or carried between the 28 426 FRACTURES OF THE FEMUR. cushion and splint, over the top of the latter to the button, as indi- cated at E, Fig. 163. The latter arrangement is applicable especially to fat and muscular subjects,.particularly females, who have an abun- dance 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 sug- gesting 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 will give too much to the extending force, and had better be dispensed Fig. 163. 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 trac- tionon the muscles of the thigh, thus tending still further to diminish the shortening, and to counteract the effect of any stretching or yield- ing in any part of the apparatus. In order to render the pressure ot the perineal band still less unpleasant, and less likely to cause excori- ation 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 FRACTURES OF THE SHAFT OF THE FEMUR. 427 found 1;o 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. 162), attached by a slide and thumb-screw to the mortise in the external splint, and capable of removal at pleasure. * * * In Fig. 163 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 as the foot-piece (D, Fig. 162). (F) is a wedge-shaped cushion, very useful 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 gut- tered 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. Neil,1 who uses for this pur- pose a Spanish windlass, I have had the foot-block of my own splint (Fig. 164) 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 counter- extension, 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 direc- tion, and the rollers which secure the limb to the splint do not be- come 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 occasionally employ the simple splint shown in Fig. 1 Philadelphia Med. Exam., vol. xi. p. 579. 428 FRACTURES OF THE FEMUR. 165; yet if the little patient is restless and disposed to throw himself about the bed, I prefer, as I have before stated, the double splint shown in Fig. 166, to which is attached a screw of peculiar construction, called the "endless screw" (Figs. 167, 168, 169, 170), the pattern for which Fig. 164. The Author's Single Straight Thigh-Splint, for 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 foot-block. The perineal 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. Cross- piece, to steady the long splint. Fig. 165. The Author's Single Straight Thigh-Splint, for Children: or the straight splint in its simplest and elementary form. Fig. 166. The Author's Double Straight Thigh-Splint, for Children or Adults.—Both of the long splints are laid outside of the two thighs. Fig. 167. Fig. 168. Fig. 169. Fig. 170. SCALE ONE-FOURTH OF FULL SIZE. Endless Screw, used by the Author ior making Extension in the Double Straight Splint.—Fig. 167. Front view. Fig. 163. Side view. Fi?. 169. End view ; a is a screw working in a toothed wheel, b. Fig. 170. Front removed, showing the plane part of toothed wheel for extension strap, c, c. Two small screws to fasten extension strap. was sent to me by some gentleman in Boston, whose name, I regret to say, I cannot now recall; or, employing the same double splint, I FRACTURES OF THE SHAFT OF THE FEMUR. 429 make extension with the weight and pulley, and counter-extension with a perineal band. Indeed this has been my practice altogether of late. 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, upon each limb. In addition to this, a broad band should be passed around the body and splints, over the pelvis. In this way alone can children be prevented from constantly disturbing the dressings. AVhen 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 upon every part of the leg and thigh as many as may be necessary to prevent unequal pressure. 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 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 frac- Fig. 171. tures 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 ex- planation. It is not directly upwards, but rather outwards and upwards, that the lower end of the proximal fragment is thrown bv 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 430 FRACTURES OF THE FEMUR. outwards also, a position which would certainly be found very incon- venient, 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. 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, the upper fragment will rise spasmodically, yet, 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 prac- tical surgeons, I am compelled to regard the question of posture in this particular fracture as still open. I will take the liberty to sug- gest, 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 ques- tion 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- stead, 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. 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 Burgeses, Addinell Hewson, of Philadelphia,1 J. Rhea Barton, B. H. Coates, of the same city,2 and J. Crosby, of Manchester, N. H.3 Of these several contrivances, Jenks' bed (Fig. 172) has been for the 1 Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101. 2 Eclectic Repertory, 5th and 9th vols. 3 Crosby, Treatise on Milit. Surg., by Frank H. Hamilton, 1865, p. 413. FRACTURES OF THE SHAFT OF THE FEMUR. 431 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 Fig. 172. Jenks' fracture-bed. From Gibson. 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 hol- lowed 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 fasces and urine evacu- ated 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 uni- versally applicable as the fracture-bed invented more recently by Daniels- and which may be used either as a double inclined plane or i Gibson's Surgery, vol. i. p. 320. 432 FRACTURES OF THE FEMUR. 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- 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 ar- ranging 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. The "invalid bed," to which I have already alluded as a "fracture" bed, invented by Dr. Josiah Crosby, of Manchester, N. H., and which was introduced into many of the U. S. general hospitals by order of the Surgeon-General, has been found to be of great service, not only in the management of invalids, in the general sense of that term, but also in the treatment of gunshot fractures of the thigh. Indeed, I have had occasion to use this bedstead in Bellevue Hospital, and I can say that its value in many cases can scarcely be over-estimated. 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 FRACTURES OF THE SHAFT OF THE FEMUR. 433 Fig. 174. Fig. 175. |j|pf^v E. Daniels' Fractdre-Bed. "A (Pig 173) represents a platform of suitable length and width, supported by four legs, a. To the upper I^face of the platform is attached a cross-piece, b, at a short distance from the centre and Zcly through the centre of the platform is made a circular hole, c (in dotted ines), said hole hav g"a . mTcircular cut or recess in the cross-piece b. To the straight edge •' "j «^^ there Is attached, by hinges, d, a board, B, termed the body plane the wid;h owhi h »TJJ» ^ -tv. tw nf the nlatform A and when depressed its outer edge may be even with the edge f, in which pawls, ,", catch, said pawls being attached to the sides of the^ pUtes,C £ depressions to correspond to the shape oi tne legs. ,,♦,,„ „„vR hive bars ra projecting attached ametal guide, l,ln which arack, «, works ; the outer end.,of ^^ pTIf« p. aiS »tel«t! from them at right angles. To each leg plane » at ached a shaf ^J^T "outer sides of 434 FRACTURES OF THE FEMUR. are covered by a suitable mattress, E, with a hole made through it to correspond with the hole 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 is attached by hinges a flap, F, having a stuffed pad or cushion, t, upon it, which, when the flap is secured upwards against the platform, fits iu the hole in the platform and mattress. The flap is secured against the platform by a button, w." 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 sack- ing 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 hori- zontally to support and steady the apparatus as it extends beyond the oot. 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 ob- served 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 trans- versely where the broken thigh is to repose ; over the four transverse bands lay a firm splint, long enough to reach from the tuberosity of the ischium to the lower margin of the popliteal space, 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 pre- vent the fragments from penetrating the flesh; while the surgeon lays his long strips of adhesive plaster upon each side of the leg in the FRACTURES OF THE SHAFT OF THE FEMUR. 435 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. Every- thing 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 imme- diately 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 pro- ceed 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 be- tween 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 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 experi- ence as to what method is generally the most convenient and useful; but circumstances must occasionally require that they should be some- what varied or modified; and when other forms of apparatus are em- ployed than those for which I have already indicated my preference, the rules of procedure must be determined by the peculiarities of the 436 FRACTURES OF THE FEMUR. 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 ap- parel 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 aud readjusted. Gene- rally they can be tightened by over-stitching or by additional band- ages. 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 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 become 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. FRACTURES OF THE CONDYLES. 437 Fig. 176. § 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, par- tially 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 ex- ample 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 Hospital, Dec. 1834, the knee was much swollen, and crepitus was plainly felt, but the frag- ment 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 of the joint did not give severe pain; but when in any degree flexed, all motion was very painful. The limb was placed in a long straight frac- ture box, and cold applications were made; great swelling followed. It was kept extended in this manner, or in the long splint of De- sault, 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.2 Sir Astley has related a case of compound fracture of the same Dr. Crosby's specimen of fracture of the external con- dyle. Fig. 177. Sir Astley Cooper's case of fracture of the external con. dyle. 1 Crosby, New Hampshire Journ. of Med., 1857. 2 Kirkbride, Amer. Journ. Med. Sci., May, lb35, vol. xvi. p. 32. 438 FRACTURES OF THE FEMUR. condyle, produced by falling from a curbstone upon the knees. The man died on the twenty-fourth 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.1 (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 walk- ing 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 dis- closed, 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.* A case reported to me by Dr. Lewis Riggs, a very intelligent sur- geon, 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 acci- dent, 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 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 appear- ance, 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 pre- sent. 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 per- fect 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 1 Sir Astley Cooper, On Disloc, &c, op. cit., p. 239. 2 Wells, Amer. Journ. Med. Sci., May, 1832, vol. x. p. 25. FRACTURES OF THE CONDYLES. 439 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 dress- ings. Very little inflammation followed. A portion of the integu- ment 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 acci- dents 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 arti- cular 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 posi- tion 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 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. 440 FRACTURES OF THE FEMUR. (c.) Fractures between the Condyles and across the Hose. 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. Each 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 im- minent, and anchylosis of the knee is to be anticipated as the most favorable result, since the joint surfaces are likely to be rendered im- movable 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 imme- diately 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 Gruerbois 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 all responsible for the results, the error consisted in too long and un- necessary 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, 1 Lancet, Aug. 28, 1858. Trans. London Path. Soc, 1860. FRACTURES OF THE CONDYLES. 441 and that replacement of the fragments is easily accomplished, is evi- dence 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 appa- ratus 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 being caught 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 semi- flexion. .On the 18th of November, 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 December 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.—A gentleman living about eighty miles from town was thrown from his carriage, breaking the left femur just above the con- dyles 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 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. Separation of the Lower Epiphysis.—M. Coural relates the case of a boy 11 years old, who, while his leg was buried in a hole up to his knee, fell forwards, separating the lower epiphysis from the shaft, and at the same time driving the shaft behind the condyles into the popli- teal space. The epiphysis also became tilted in such a manner that its lower extremity was directed forwards. The limb was amputated. Madame Lachapelle mentions a case in which traction at the foot of a child in the act of birth caused at the same time a separation of the lower epiphysis of the femur and the upper epiphysis of the tibia. The child was born dead.2 Dr. Little presented to the New York Pathological Society, May 24, 1 A. Cooper on Disloc, &c, op. cit., p. 239. 2 Malgaigne, op. cit., t. i. p. 69. 29 442 FRACTURES OF THE PATELLA. 1865, a specimen obtained from his own practice. A boy, a^t. 11, while hanging on tothe back of a wagon, had his right leg caught between the spokes of the wheel while it was in rapid motion. A few hours after the accident, Dr. Little found the upper fragment of the femur projecting through an opening in the upper and outer part of the popliteal space. On examination, the wound did not appear to communicate with the knee-joint. Under the influence of an anass- thetic the fragments were reduced; the reduction occasioning a dull cartilaginous crepitus. There was at the time no pulsation in the posterior tibial artery, and the limb was cold. The limb was laid over a double inclined plane. The following day the upper fragment was again displaced, and it was found that it could only be kept in place by extreme flexion of the leg. This position was therefore adopted and maintained; considerable traumatic fever followed, with swelling, and on the thirteenth day a secondary hemorrhage occurred from the anterior tibial artery near its origin, and it became necessary to amputate. The boy made a good recovery. The specimen showed that the line of separation had not followed the cartilage throughout, but had at one point traversed the bony structure. Dr. Voss at the same meeting remarked that he had met with the same accident. There was no protrusion of bone, but an abscess formed, and it became necessary to amputate. Dr. Buck saw a case which occurred in the practice of Dr. Hugh Walsh, of Fordham. The subject was a boy 14 years old, and it hap- pened in the same manner as with Dr. Little's patient.1 I know of no other cases of this accident. CHAPTER XXIX. FRACTURES OF THE PATELLA. Causes.— Of twenty-one fractures of the patella which have come under my observation, twenty 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 Hos- pital, 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 2d of December, and on the 20th of April following she was readmitted, with a fracture of the left patella, produced in the 1 Little, Voss, Buck, N. Y. Journ. Med., Nov. 1865. FRACTURES OF THE PATELLA. 443 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 ;J and Dr. Hayward, of Boston, saw a case in the Massachusetts General Hospital, in a man set. 67, which occurred in consequence of a false step in descending a flight of stairs.2 Pathology.—All the fractures produced by muscular action have been found to be transverse, and the same is true generally of fractures Fig. 179. produced by direct blows; occasionally, however, we meet with lon- gitudinal fractures, or with fractures more or less oblique and com- minuted. Seventeen 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 Fig. 180. after, I could not discover any traces of the accident. _ There is a specimen, illustrating a similar fracture, but not united, in the collec- 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. 444 FRACTURES OF THE PATELLA. tion 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 patellas, 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. 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 Fig. 181. knee 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 de- gree 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 cora- thIkTeentS separated by flexioa °f pletely lost. Usually a good deal of swell- 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 frac- ture. 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 sus- pended 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 frag- ment was drawn up toward the body. Eighteen months elapsed be- fore he could walk, even with the aid of a cane. March 27,1855, twenty-nine years after the injury was received, he 1 A. Cooper, On Disloc, &c, op. cit., p. 232. FRACTURES OF THE PATELLA. 445 was an inmate of the Buffalo Hospital, and I was permitted to ex- amine 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, Fig-1§2- and when it is flexed upon the thigh the upper fragment is removed five inches from the lower. 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. Fifteen 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 the case of a man set. 40, 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 appeared to be united by a short liga- ment, except on the inner side, where there was a separation oc rupture of the ligament to the-extent of one-quarter of an inch. The 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. During the autumn of 1865 I examined the leg of Dr. B., a graduate of Bellevue Medical College, and found a transverse fracture of the right patella, with great displacement of the upper fragment. He in- formed me that he had fallen six years before, when nineteen years old, upon a stone, striking upon the patella. The fracture was recog- nized, and the limb was laid upon a straight splint. At the end of three months the limb was removed from the splint, and the union was found to be complete, with a separation of the fragments to the extent of half or three-quarters of an inch. The knee was much anchylosed. Soon after this the upper fragment began to draw up, and at the end of a year was as much displaced as it is now. At this moment it is dis- placed three inches, and seems to be held to the lower fragment only by a narrow ligament attached to their inner margins. He extends and flexes the leg perfectly, and walks without the least halt, but this limb wearies sooner than the other. February 16, 1866, John Donahue, set. 50, was admitted into my wards at Bellevue, with a refracture of the right patella. He stated that it was first broken eight weeks before, and that it had united, but 446 FRACTURES OF THE PATELLA. that the day before his admission, while seated on the ground, he attempted to rise, and that the ligament suddenly gave. I found the fragments separated one inch, and by pressing the upper fragment against the lower a slight crepitus was occasioned. His limb was placed upon a single inclined plane, and union soon occurred. 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. Dr. 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 dis- covered, 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 pre- vented 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 fifty- eighth 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 frag- ments 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 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. 3 Coale, Boston Med. and Surg. Journal, vol. liv. p. 4U2. FRACTURES OF THE PATELLA. 447 want of apposition in the fragments. It might seem that it would be easy to accomplish apposition in all longitudinal fractures, but expe- 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 re- sulted 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 Pennsylvania, 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 knee- joint." Treatment.—The dressing which I have usually employed in the treatment of this fracture consists of a single inclined plane, of suffi- cient 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 hori- zontal 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 care- fully adapted to all the irregularities of the thigh and leg, especial care being taken to fill completely the space under the knee, the 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. 1 Levergood, Amer. Journ. Med. Sci., Jan. 1860. 448 FRACTURES OF THE PATELLA. 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. 183. 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 he passed to secure the foot, and with pins on each margin, d. Single inclined plane fastened to the foot- piece at any height, hy means of a hook dropped over the pins, e, e. Cushion ; thicker under the knee than at either end. /. Roller 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 one- quarter 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. 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 FRACTURES OF THE PATELLA. 449 straps and bandages touch the limb, there is a space, more or less con- siderable, 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 efficiency, 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, set. 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 im- mediately proceeded to inclose each leg, from the toes upwards as far as the knee, with a paste bandage, and then having properly cush- ioned 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 occasion- ally renewed. November 28, 1852, thirty-seven days after the fractures had oc- curred, the splints and bandages were finally removed. Both patellae had united by ligamentous tissue, the length of which was about one- quarter 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 Yal de Grace,1 is similar to that 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 attain- ment 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.8 Such, also, I understand to be Mr. Alcock's method of using the adhesive plaster.3 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 accom- panying drawing, the splint is only five or six inches wide. Dr. Wood has substituted hooks for the notches.4 Dr. Dorsey, of Philadelphia, employed a very simple apparatus, which will serve to illustrate the general plan adopted by many sur- geons, both at home and abroad. It is liable, however, to the objec- tion already stated, namely, that it interrupts too much the circula- 1 Malgaigne, Traite des Fractures, etc. op. cit., p. 764. 2 Philada. Med. Examiner, vol. x. p. 1. 3 Practical Observations on Fractures of the Patella and of the Olecranon, by Thomas Alcock, p. 296. * Fergusson's Surgery, p. 307. 450 FRACTURES OF THE PATELLA. tion 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 Fig. 1S4. Wood's apparatus. 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 laid upon it, a Fig. 185. John Syng Dorsey's patella splint. roller being first applied from the ankle to the groin, encompassing the knee 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, aet. 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 99999999999999999 FRACTURES OF THE PATELLA. 451 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 gan- grene was perceived to extend within seven inches of the knee, and was arrested in its progress. The foot was cold, and was totally in- sensible ; the epidermis was raised up, and was beginning to be sepa- rated 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. Amputa- tion was performed, and the patient recovered.'" Yery 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. 186, 187. Fig. 186. Sir A. Cooper's method hy circular tapes. Fig. 187. Sir A. Cooper's method by a leather counter-strap. Mr. Lonsdale's instrument, Fig. 188, is ingenious, but complicated. It is also liable to the serious objection that it forbids almost entirely the use of bandages, which, while they are capable of doing great mis- chief 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. Malo-aigne'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. In case the fracture is oblique or longitudinal, it will only be neces- sary to lay the limb in a straight position, so as to prevent that lateral i Amer. Journ. Med. Sci., vol. xxiv. p. 462, from Gazette Medicale, No. 2S. 452 FRACTURES OF THE PATELLA. 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 Fig. 188. 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-joint, 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 lengths. 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. From the beginning, cloths moistened in cool water should be con- stantly 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-con- tinued 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 encumbrance. The patient was a laboring man of about forty years of age. This opera- tion was made in preference to amputation, at the request of the man himself.1 1 Post, New York Med. Gazette, vol. i. p. 309, Nov. 1850. FRACTURES OF THE TIBIA. 453 CHAPTER XXX. FRACTURES OF THE TIBIA. Development of the Tibia.—The tibia is formed, usually, from three centres of ossification ; one for the shaft and one for either extremity. Ossification commences in the shaft at about the fifth week of foetal life. In the upper epiphysis it appears FiS-189, at birth, and unites with the shaft at about the twenty- fifth year. Generally it forms the tubercle, but occa- sionally the tubercle has a distinct point of ossification. The lower epiphysis commences to ossify during the second year, and unites with the shaft at about the twentieth year.. The malleolus internus is occasionally formed from an independent centre. Etiology of Fractures of the Tibia.—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 occa- sionally 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 exam- ple of fracture of the tibia in utero, produced in the sixth month of pregnancy, by violent pressure upon the abdomen.1 Pathology, Division, &c.—In an analysis of twenty- seven fractures of the tibia, not including fractures of the malleoli, six were found to have occurred in the upper third, eleven in the middle third, and eight in the lower third. Six of the twenty-seven 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. Many examples of fractures of the tibia extending into the knee- joint are recorded by surgeons, most of which were compound, or otherwise seriously complicated, so as to render amputation necessary, Development of the tibia. (From Gray.) 1 Proudfoot, Cost. Med. and Surg. Journ., vol. xxxv. p. 268, 1S-16; from New York Jouru. Med. 454 FRACTURES OF THE TIBIA. and the consideration of which scarcely belongs properly to a treatise upon fractures. The malleolus internus is broken frequently at the same time that the ankle-joint is dislocated, and this accident will be considered in that connection. Separation of Epiphyses.—"We have already mentioned (p. 441), that Madame Lachapelle has reported a case of separation of the upper epiphysis of the tibia, and of the lower epiphysis of the femur, occa- sioned by pulling at the foot during birth. Dr. Voss, of New York, has seen a separation of the lower epiphy- sis in a boy 14 years old, who in falling had caught his foot between two blocks of wood. The upper fragment protruded through the skin. Eeduction was effected, but subsequently a portion of the epiphysis became necrosed and was removed. He finally recovered with a useful joint.1 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; unless, indeed, the fracture occurs -above the fibula, or the fibula bends and remains bent, or the comminution and direction of the fracture is such at either end as to allow the femur or the astragalus to become impacted. I have never recognized either of these conditions. Occasionally the upper fragment has been slightly displaced for- wards. 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 in- temperate. Ten weeks after the accident no union had occurred, and Dr. Donne introduced a seton, and in about six weeks the fragments were firm.2 If the fracture extends into either the knee or ankle-joint, the danger of anchylosis is imminent, yet experience has shown that it may some- times be avoided. When the malleolus is broken off, it generally becomes slightly displaced downwards, and in this position a complete bony or liga- mentous union takes place. Treatment.— The tendency to displacement, in a fracture of the tibia, is usually 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 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. 1 Voss, N. Y. Journ. Med., Nov. 1865, p. 133. 1 Donne, Amer. Journ. Med. Sci., vol. xxviii. p. 524 ; from Western Journ. Med. and Surg., Aug. ls>41. FRACTURES OF THE TIBIA. 455 The fall was the result of a misstep on level ground, and was at- tended with only slight bruising of the soft parts. She says that on attempting to rise she discovered what had happened, the bone pro- jecting 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 frag- ments were found to have united firmly, and so perfectly as that the point of fracture could not be traced. Peter Hamil, of Buffalo, ast. 29, was admitted into the hospital Aug. 31, 1849, with an injury to his left leg, which had occurred two days 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 November, 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, how- ever, occasionally render the treatment more difficult and the results less satisfactory. John Mahan, set. 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 back- wards, 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 frag- ments 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, 456 FRACTURES OF THE TIBIA. 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 should 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 defend this as a universal practice in fractures of the leg, 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, aet. 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 exces- sive bandaging and splinting in this kind of fracture, as well as in all other fractures of the lower extremities.2 Fractures of the malleolus, unaccompanied with any other accident, 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. 1 Boston Med. Journ., vol. liv. p. 1, March, 1856. 2 Norris, Amer. Journ. of Med. Sci., vol. xxiii. p. 291. FRACTURES OF THE FIBULA. 457 CHAPTEE XXXI. FRACTURES OF THE FIBULA. Development of the Fibula.—The fibula is formed from three centres of ossification—one for the shaft, and one for each extremity. Bone begins to be deposited in the shaft at about the sixth week of foetal life, in the lower extremity during the Fig. 190. second year, and in the upper extremity during the fourth year. The lower epiphysis unites with the shaft about the twentieth year, and the upper about the twenty-fifth year. I have not found any recorded examples of separation of these epiphyses. Causes of Fracture.—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, but which were probably accompanied with a twist 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. Both Malgaigne and Dupuytren have noticed a dis- location in the opposite direction, or a turning of the c . • j n ,i • ,i T Development of foot inwards, more often than a turning outwards. I Fibllla ,From cannot think their observations were carefully made. Gray.) Moreover, in at least seven of the twelve fractures pro- duced hy 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. 30 458 FRACTURES OF THE FIBULA. Fracture of fibula near lower end. 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 ankle remained stiff.1 Other surgeons have met with simi- lar 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 re- mained almost immovable after twenty years; and in a still more remarkable instance, I examined the limb thirty years after the acci- dent, when the man was sixty-three years old, and although there existed no swelling or deformity, yet this leg was not as muscular 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 dis- placements 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 ' Boston Med. and Surg. Journ., vol. xxxiv. p. 336, from Southern Journ. of Med. FRACTURES OF THE FIBULA. 459 relative position of the ankle-joint surfaces, are, I am satified, 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 wholly prevented, usually, by any mechanical contrivance. Indeed, it would be easy to demonstrate, as I have often done to my pupils, that even Dupuytren'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 displace- ment 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 ankle- joint 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 " Dupuytren's splint." I believe, indeed, that this splint ought gene- rally 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 all that its illustrious inventor proposed. Treatment.—I have already expressed my preference for Dupuy- tren's mode of dressing as a general practice, and especially would I give the preference whenever the accident has been accompanied with Fig. 192. ^— =»■ Dupuytren's splint modified. an outward luxation of the foot, and a consequent rupture of the in- ternal 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 460 FRACTURES OF THE FIBULA. Fig. 193. 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 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; aud in others it is repre- sented as encircling the limb two or three inches above the malleolus (Fig. 193); 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. 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. 194). Modified Dupuy- ren's splint, incor- rectly applied. Fig. 194. Dupuytren's splint as originally applied by himself. 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 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 anchy- losis 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, im- FRACTURES OF THE TIBIA AND FIBULA. 461 portance, 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 pro- perly 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 of 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 one hundred and eleven 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 forty have been referred to a direct cause, and two to an indirect; and in the lower third thirty-nine to a direct cause, and eighteen to an indirect. An observation which does not sustain the remark of Malgaigne, based upon his analysis of sixty- seven cases, that fractures of the upper third are produced by direct causes alone, those of the middle third much more frequently by indi- rect causes, and that those of the lower third are especially due to indirect causes. Direct causes produce a large majority of the frac- tures 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 muscu- lar 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 462 FRACTURES OF THE TIBIA AND FIBULA. 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, &c.—We have seen that fractures of both bones through some part of the lower third are most frequent. Thus, of one hundred and fifty-five fractures, eleven belonged to the upper third, forty-five to the middle, and ninety-three 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 seventeen 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 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, with- out 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 down- wards, forwards, and inwards; but I have found almost every con- ceivable 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 conse- quence, 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 just idea of their proportion FRACTURES OF THE TIBIA AND FIBULA. 463 to simple fractures; yet even in these tables, of one hundred and seventy-two fractures, sixty-two were compound, and also, generally, more or less comminuted. Of eighty cases reported by W. W. Mor- land, of Boston, from the Massachusetts General Hospital, and in which the character of the accident is recorded, thirty-nine were com- pound.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. 195. Compound and comminuted 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 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 seven cases, five of which were simple fractures, and two were compound. The longest period was seventeen weeks. F. 0. 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. ' Transac. of Mass. Med. Soc. for 1840; Fractures, by A. L. Pierson. 464 FRACTURES OF THE TIBIA AND FIBULA. 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. Con- siderable 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 oedematous, 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 trans- versely, 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 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 inter- posed, in which the union has been sq 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 cases has 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 :— FRACTURES OF THE TIBIA AND FIBULA. 465 John Granger, of Hungerford, England, aet. 43, was tripped by a stone while walking, breaking his right leg through its lower third. Fracture simple and oblique. It was treated by Kichard 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 seven times, as a result of undue pressure upon this part, have, however, been presented but three times in a case of simple fracture. It is not very unusual to find, also, over the exact point of frac- ture, 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 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. A gentleman residing in Quincy, Chautauque Co., N. Y., had his tibia and fibula broken near the ankle-joint in the year 1844, by the passage of a carriage-wheel across his limb. The skin was a good deal 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 1 Trans. Amer. Med. Assoc. Report on Deformities after Fractures. 466 FRACTURES OF TnE TIBIA AND FIBULA. 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 contain- ing 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, how- ever, it disappears in a few weeks, and seldom remains to any con- siderable 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 knee- joint 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 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 applica- tion, 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 prefer- ence 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 nine- tenths of all the simple fractures of the leg, and to some of the com- pound fractures. The apparatus will consist of two splints with pads and bandages. First we are to construct a splint, 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 FRACTURES OF THE TIBIA AND FIBULA. 467 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. 196. 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 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 frac- tures 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 pull- in »• aside the skin with the fingers, or with a blunt hook. This simple 468 FRACTURES OF THE TIBIA AND FIBULA. 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. Kesecting 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 pro- vided 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 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-adj ustment 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 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. Dr. Krackowitzer presented to the New York Pathological Society, June 10,1863, a leg which he had amputated for gangrene occasioned by tight bandages. A boy, five years old, sustained an injury of the FRACTURES OF THE TIBIA AND FIBULA. 469 ankle-joint, which his medical attendant pronounced a fracture of the fibula, and for which he applied only a tight bandage. The child suffered a good deal after the bandage was applied, and the following morning the toes were blue, but the doctor paid no attention to this circumstance. The pain subsided on the third day, and on the fourth the bandages were removed, and the limb found to be gangrenous. The specimen showed that the fibula was not broken, but that there was a fissure or crack in the lower part of the shaft of the tibia.1 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, set. 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 oedematous, and on the twenty-seventh of October the leg was amputated by Dr. Barrett, of Le Eoy; 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 gene- rally 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 examples of ulcers upon the heel which I have seen have been 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. 1 Krackowitzer, Amer. Med. Times, Nov. 7, 1863. 470 FRACTURES OF THE TIBIA AND FIBULA. 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 manage- ment, 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 rela- tion to the action of the muscles, the indications are as easily and naturally fulfilled with the limb upon its side as upon its back. Gene- rally 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 recom- mend 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 conve- nient 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, experience will prove true. If the fracture is near the middle of the leg, quite remote from the points upon which the appliances for ex- tension, &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 firm- ness 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 FRACTURES OF THE TIBIA AND FIBULA. 471 what is known among American surgeons as "Hutchinson's splint"1 (Fig. 197), 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. 197. 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 pro- ductive 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 diffi- Fig. 198. John Neill's apparatus for fractures of the leg requiring extension and counter-extension. culties in the way of making extension in fractures of the legs, by substituting adhesive plaster for the usual extending or counter- extending bands. Says Dr. Neill: "For simple fractures of both bones of the leg, at- i Elements of Surgery, by John Syng Dorsey, vol. i. p. 181. Philadelphia, 1813. 472 FRACTURES OF THE TIBIA AND FIBULA. tended with shortening and deformity not easily overcome, the limb should be placed in a long fracture-box with sides extending as high as the middle of the thigh, and a pillow should be used for compresses. "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."1 Dr. Neill further remarks : "In compound fractures of the leg, short- ening and deformity are often difficult to overcome, as is well known Fig. 199. John Neill's apparatus for compound fractures of the leg. 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 frac- ture-box sawed in two parts at the knee, so that the sides of the box above the knee, from the upper ends of which the counter-extension is made, need not be disturbed during the dressing, while that portion of the side of the box, corresponding to the leg, may be opened at Fig. 200. Gilbert's Box for Cojipocnd Fractures of the Licu. 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. :i. Tourniquet. pleasure, without diminishing the tension of the extending or counter- extending bands." 1 Philadelphia Med. Exam., vol. xi. p. ."SO. 1855. FRACTURES OF THE TIBIA AND FIBULA. 473 In compound fractures of the leg, Dr. Gilbert recommends a modifi- cation of the common fracture-box. 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 seg- ments. 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 counter-exten- sion, maintained by the permanently attached upper and lower seg- ments. The following wood-cuts (Figs. 201, 202, 203) are intended to illus- trate the apparatus invented by R. 0. Crandall, for the purpose of Fig. 201. Section of Crandall's apparatus, applied to the limb; showing adhesive plaster counter-extending bands and gaiter for extension, &c. Fig. 202. Posterior view of the lower portion of Crandall's apparatus. Fig. 203. Crandall's apparatus complete. The counter-extending straps are passed over a block of wood sup- ported 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 sur- geon whether he shall employ the gaiter or adhesive straps.1 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. 31 474 FRACTURES OF THE TIBIA AND FIBULA. 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 mus- cles 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 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 accomplish all that we 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 counter-extension from the thigh and perineum. The paste, starch, or dextrine bandage I have used in a few cases of simple fracture of the leg within a day or two after 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 recom- mend its employment at a period so early. But as soon as the fragments have united in almost any form of frac- ture of the leg, it will not be improper to put on the paste bandage and FRACTURES OF THE TIBIA AND FIBULA. 475 Fig. 204. allow the patient to go about carefully upon crutches; or if, indeed, the fragments have not united, but the swelling has completely sub- sided, and the wounds have healed, it cannot be regarded as unsafe to adopt this practice. The young sur- geon cannot, however, be too much impressed with the danger of this mode of treatment, as a universal or general plan, employed without dis- crimination. Its most devoted ad- vocates, Seutin, Velpeau, Gamgee, and others, will not deny the neces- sity of caution in its use; and the nu- merous 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, 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. 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 cases 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- " Immovable" apparatus applied to the leg. (From Fergusson.) 1 Accidents resulting from the use of the immovable apparatus. Sci., vol. xxv. p. 460, Feb. 1840 ; from Gazette des Hopitaux. Amer. Journ. Med. 476 FRACTURES OF THE TIBIA AND FIBULA. joint, have the line of fracture directed obliquely downwards and for- wards. But there are many compound fractures which demand the Fig. 205. Liston's double inclined plane ; applied to the leg in a case of compound fracture. (From Miller.) 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, when they are formed to fit the limb accurately, possess some advantages which must recom- mend them to the attention of surgeons; but neither these splints nor Fig. 206. Louis Bauer's wire splints for the leg.1 any others, however accurately fitted, ought to be applied directly to the naked skin. They require always the interposition of a well- padded lining. 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 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 or made to move on a suspended railway. But, however they are ar- 1 Bauer, Buffalo Medical Journal, April, 1857, vol. xii. FRACTURES OF THE TIBIA AND FIBULA. 477 ranged, 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 Fig. 207. Swing box or "cradle." (From Skey.) deviations in the line of the bone, as he would probably have other- wise employed. The swing invented by James Salter, of London, 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 push- Fig. 208. Salter's cradle. (From Fergusson.) ino- the fragments upon each other is obviated. This is accomplished bv 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. Dr Hodgen, of St. Louis, suspends the box over a pulley placed transversely, so that by drawing the rope to the right or to the left, the box may be turned upon either side. 478 FRACTURES OF THE TIBIA AND FIBULA. 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 Phi la- Fig. 209. delphia,1 and has been much used in the Pennsylvania Hospital. It pos- sesses 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 Fracture-box, with movable sides. fresh bran. The Support which it gives to the limb is also uniform 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 Fig- 21°- be found necessary to protect the limb from the weight of the bedclothes by some contri- vance similar to that figured in the accom- panying drawing. Malgaigne, who declares that the whole world knows how impossible it is, in an im- wire rack for fracture of leg. mense majority of cases, to overcome the pro- jection of the superior fragment when the limb 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 Fig. 211. Malgaigne's apparatus for oblique fractures of the leg. (From Malgaigne.) value of which, also, he claims to have already fully demonstrated. His apparatus consists simply of a steel band of sufficient size to en- 1 Barton, Amer. Journ. of Med. Sci., vol. xvi. p. 31, and vol. xix. p. 515. FRACTURES OF THE TIBIA AND FIBULA. 479 circle 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 thumb-piece. 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, the steel arch effectually prevents any ligation of the limb. Fig. 212. Malgaigue'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. The first case of which I have seen any mention made, where the bones were actually resected, is reported by Charles Parry, of Indian- apolis, Ind. A young man, set. 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 gentle- man 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 1 Parry, Amer. Journ. Med. Sci., Aug. 1839, p. 334. 480 FRACTURES OF THE TIBIA AND FIBULA. the case was made five months subsequently, the patient was doing well.1 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.2 Cases may occur which will justify a resort to these extreme mea- sures, or in which they may be preferred to amputation ; but an exa- mination of the several examples reported will show that these ope- rations 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 much, 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, in the end, make it any longer 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 de- ference 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 over- come ; 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.3 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 ■ Key, Amer. Journ. Med. Sci., Aug. 1839, p. 339, from Guy's Hospital Reports. April, 1839. 2 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. 3 Horner, New York Journ. Med., May, 1851, p. 432. FRACTURES OF THE TARSAL BONES. 481 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 pres- sure, 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 pos- terior 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 pro- duced by violent efforts on the part of the patients to sustain them- selves when falling. In one of these the fragment was immediately drawn up three inchs.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, &e. 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 dislo- cation 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 com- pound. The direction of the fracture is found to vary greatly; thus, it has been found broken in its length antero-posteriorly, in its breadth or transversely, and in one instance it has been divided nearly hori- zontally, so as to separate the upper face completely from the lower. Sometimes it suffers a species of impaction, the fragments being ac- tually 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 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, bv Bernard Monahan, M. D. " * South, Notes to Chelius's Surgery, vol. i. p. 639, Amer. ed. 3 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 482 FRACTURES OF THE TARSAL BONES. 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. Con- stance 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 exter- nal 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 sepa- rated by the action of the muscles, and the fragment is drawn up- wards, it may be discovered in its new position, and the heel will be 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 them- selves 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 cold water lotions assidu- ously 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. 1 Constance, Amer. Journ. Med. Sci., vol. v. p. 222, Nov. 1829, from the Midland Med. and Surg. Reporter. FRACTURES OF THE TARSAL BONES. 483 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 re- move 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 set. 30, who was admitted into the Pennsylvania Hospital on the 26th of Sept. 1831. " An hour previous to admission, while decending 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 exami- nation, 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 admis- sion 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 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 inteo-uments, parallel with the course of the tendons, commencing a short distance above the projection on the foot, and extending down far enouo-h to expose fairly the astragalus and its torn ligaments. The bone was then seized with forceps, and easily removed after the ' Ashhurst, Amer. Journ. Med. Sci., April, 1862. 484 FRACTURES OF THE TARSAL BONES. 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 cari- ous ; 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 anything in reference to the value of the procedure which I have recommended. For reasons which seemed satisfactory to the sur- geons 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, constitutes 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 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 indi- cations. A bandage, padded strap, or a stuffed collar may be fastened about the thigh just above the knee, and made fast to the heel of a slipper by a tape (Fig. 213). 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 Norris, Amer. Journ. Med. Sci., vol. xx. p. 379. FRACTURES OF THE METATARSAL BONES. 485 Fig. 213. suitable compresses, the object of the roller being to diminish mus- cular 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 them- selves 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 fibula. As soon as the inflammation has suffi- ciently subsided, passive motion must be given to the ankle, in order to pre- vent, 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 re- sult 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 acci- dents, accompanied with comminution and extensive laceration, which forbid the hope of saving the foot, and for which immediate amputa- tion is the only proper resource, but which constitute, in fact, the great majority of all the fractures of the tarsal bones. Apparatus for fracture of the tube- rosity of the calcaneum. CHAPTEE XXXIY. 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 486 FRACTURES OF THE METATARSAL BONES. 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. Mal- gaigne relates an example of this latter accident in which, the three middle bones being broken by the wheel of a carriage, and the integu- ments 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 sub- jects 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 the cast of a bone which has united with an enormous backward projection. In one instance I have seen the metatarsal 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. 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 frac- ture, 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. GUNSHOT FRACTURES 487 CHAPTER XXXY. 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, set. 18, was admitted Dec. 23, 1853, having several days before received an injury upon the great toe which contused the flesh severely arid 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 sub- sided, but not until a portion of the toe had sloughed away. Even- tually 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 dis- placement, and a well-moulded gutta-percha splint will generally secure a perfect and rapid union. CHAPTER XXXY I. CUNSHOT 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 further allusion to this class of accidents must be found in the special interest which they possess at this moment in my own country. 488 GUNSHOT FRACTURES. 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 re'sum^ of what I have myself observed, and of the well-attested obser- vations of others. To which will be added a few general statistical statements, drawn chiefly from the published records of the late war. 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 gun- powder, 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 caus- ing a fracture, for the reason that they are easily deflected; and this happens especially when they are not moving with great velocity. Conical 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. 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, ex- cessive. 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 arti- culation, the comminution, or a single longitudinal fissure, may some- times 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. GUNSHOT FRACTURES. 489 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 perfora- tion 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 under- stood to say that fissures occur less often at the points last mentioned, simply because perforations are there less common. It must be known that if perforations do occur at these points, a splitting or fissure communicating with the joints is almost inevitable. A mis- understanding here would lead to a very fatal error 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 hu- merus, of the shafts of the radius and ulna, and of the carpal, meta- carpal, 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 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 dimi- nishes 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, pro- ducing 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 prac- tised with a reasonable chance of success when the arteries and nerves are untouched. Resection is also made successfully at the shoulder- joint 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 am- putation 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 32 490 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 extremi- ties; 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 circum- stances, 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. I have seen no resections of the knee-joint, and but few 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 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 rela- tively 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 articu- lations. Resections at the ankle-joint are much more hazardous than ampu- tations, 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 GUNSHOT FRACTURES. 491 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 em- ployed 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 com- prises 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 insure 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 means, and especially by the use of water lotions whenever its em- ployment 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 em- barrass 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 position. _ In general I have preferred Buck's apparatus, with moderate extension ; and by moderate extension is to be understood such as may be effected with from five to ten pounds. Hodgen's straight splint, or " cradle," has been found exceedingly useful, and much preferable to any form of double-inclined plane, whether suspended or not. The cradle is simply a skeleton box, of the length of the thigh and leg, made of light strips of wood. Across the two upper bars are laid, transversely, cloth bands, upon which the limb is laid at full length.2 As supplementary to this chapter, it seems proper to add a brief resume of the statistics of the war of the rebellion just closed, drawn from the report of the Surgeon-General, made in November, 1865.J Of 4,167 gunshot wounds of the face, 1,579 were accompanied with fractures of the facial bones. Of these latter 107 died, and 891 re- ' Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol. 8vo. Punished by Bailli^re Brothers. New York, 1861; also enlarged ed. of same work in 18b5. 2 Hodgen, Treatise on Military Surg., by the author, p. 408. 3 Circular No. 6, Surgeon-General's Office. 492 GUNSHOT FRACTURES. covered. The remainder are undetermined. Secondary hemorrhage is said to have been the most frequent cause of death. Of 187 examples of gunshot injuries of the spine (not including those in which the chest or abdomen was penetrated), 180 died. Six of those reported as having recovered were examples of fracture of the transverse or spinous processes. The seventh is that of a soldier wounded at Chicamauga, September 20th, 1863, by a musket-ball, which fractured the spinous process of the fourth lumbar vertebra, and penetrated the vertebral canal. The ball and fragments of bone were extracted, and one year after he was reported as " likely to recover." Of 359 gunshot wounds of the pelvis (not including those in which the abdominal cavity was penetrated), 77 died and 97 recovered. In the remainder the result is not ascertained. In 256 cases the ilium alone was injured; in 19, the ischium alone; in 12, the pubes; in 32, the sacrum; and in 40 cases the lesions extended to two or more por- tions of the innominata. Pyaemia was a frequent cause of death. Of 1,689 gunshot fractures of the humerus, 436 died, and 1,253 re- covered. Nine hundred and ninety-six of these 1,689 cases were treated by amputation or resection, with a mortality of 21 per cent. In 693 cases the conservative treatment was adopted, with a mortality of 30 per cent. Of 68 cases in which attempts were made to save the limb after gunshot injury of the hip-joint, without resection, all died. (I have seen two cases of successful treatment of these accidents by the con- servative plan, and others have been reported.) Twenty amputations at the hip-joint gave two successful results. (The Surgeon-General's report includes a third—Dr. Fenner's case— but this is now known to be an error.) Thirty resections furnished three successful results. (The report includes two more resections—Cases 19 and 30—which must be rejected as not belonging to this class.) Three hundred and thirty cases of gunshot fracture of the upper third of the shaft of the femur, in which neither amputation nor resec- tion was practised, gave a mortality of 71.81. Thirty-two cases in which amputation was made gave a mortality of 75 per cent. Twenty- two in which resection was made, gave a mortality of 81.18. ('We have rejected three cases given in the report as cured. Two of these were resections of the head, and one was merely a " rounding off of sharp edges.") Two hundred and thirty-two cases of gunshot fractures of the mid- dle third, treated without amputation or resection, gave a mortality of 55.46. Ninety-three treated by amputation gave a mortality of 54.83. Fifteen treated by resection gave a mortality of 86.66. One hundred and seventy-three gunshot fractures of the lower third, treated without amputation or resection, gave a mortality of 57.79. Two hundred and forty-three amputated—mortality 46.09. Two resected—both died. Of 308 gunshot wounds of the knee-joint, with or without fracture, treated without amputation or resection, 258 died—mortality 83.76. Of the 50 which recovered there were, however, only six or eight in GUNSHOT FRACTURES. 493 which the testimony is unequivocal that the joint was opened. Of 452 amputated, 331 died—mortality 73.23. Of 10 resected, 9 died—mor- tality 90 per cent. Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal. No analyses have been made of fractures of the smaller bones. It is much to be regretted that in these comparative analyses of the treatment of gunshot fractures by the three methods it is not stated whether the amputations or resections were primary or secondary. In all secondary amputations and resections, which, for aught that appears, may have constituted a majority of the whole number, the conservative treatment had been tried and had failed, and the deaths which followed ought in justice to be charged to conservatism and not to the operation. As the reports now stand, they are of little or of no value in determining the relative value of conservative and operative treatment. From the reports of the Confederate army, as published in the Con- federate States Medical Journal, we learn that of 221 cases of gunshot fractures of the thigh treated without amputation or resection, 105 died, and 116 recovered. The shortest period of recovery was 41 days; the longest, 255 days; the average, 104 days. The shortest period of fatal termination was one day; the longest, 185 days; average, 52 days. Greatest shortening, five inches; least, half an inch; average, one inch and nine-tenths.1 Of 507 amputations for gunshot fractures of the thigh, 250 recov- ered.2 1 Richmond Med. Journ., Feb. 1866, from Confederate States Med. Journal. 2 Ibid., January, 1866, p. 52. PART II. DISLOCATIONS. 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, sponta- neous or pathologic, and congenital. Our remarks upon the etiology, pathology, symptomatology, prog- nosis, 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 desio-nate 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 complicated in the same way, and with the addition, perhaps, of exten- sive laceration and destruction of integument, muscles, nerves, &c. A recent luxation has taken place within a period of a few days, or, 498 GENERAL CONSIDERATIONS. 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 is not fully determined by surgeons, and the application of these terms is therefore always somewhat arbitrary. A primitive luxation is a luxation in which the bone remains nearly or precisely in the position into which it was at first thrown; while a secondary or consecutive luxation is one in which the bone has sub- sequently, in consequence of the action of the muscles, or from un- successful efforts at reduction, or from some other cause, changed its position sufficiently to entitle the accident to a new designation. Thus a primitive dislocation upon the ischiatic notch may become a second- ary 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 ad- vanced 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 abso- lutely 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, respon- sible 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 sur- round 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 effu- sions, 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. 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, GENERAL SYMPTOMS. 499 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 crepi- tus, 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 pre- ternatural 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, sio-ns 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 suffering under the shock, or in any other circumstances where the 500 GENERAL CONSIDERATIONS. 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 in- flammation and more or less covered with lymph, and, when the rigidity is great, may sometimes deceive the most experienced sur- geon, 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 dis- coloration. 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 super- ficial. PATHOLOGY. 501 § 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 func- tions. 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 deposi- tions, 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 502 GENERAL CONSIDERATIONS. trunks, by which their functions become partially or completely anni- hilated, and their structure even may be wholly obliterated. In conse- quence 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 specifi- cation. 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 func- tions, 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. § 7. General Treatment. The first indication of treatment is to reduce the bone. 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 GENERAL TREATMENT. 503 the least apt to inflict additional injury upon the muscles and liga- ments. A person wholly unacquainted with anatomy or surgery may occa- sionally 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 whom- soever 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 char- latan bone-setter does not often allow himself to fail, unless the cou- rage 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 resist- ance, 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 antag- onize 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 phy- siognomy 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 under- take to treat dislocations, since he is constantly liable to mistake frac- tures 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 practise 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 un- certainty 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 off their ffuard we often practise successfully the diversion of the mind of the natient At the very moment that the limb is moved or extension » made, a question is addressed to him, or he may be suddenly surprised bv some unexpected intelligence. Extension and counter-extension, made with our own hands or with 504 GENERAL CONSIDERATIONS. Fig. 214. the hands of assistants, constitute the second resort where manipula- tion alone has failed. The surgeon, seizing upon the limb firmly with his hands, makes the extension, while the assistants make the counter- extension ; or, instead of grasping the limb directly, the operator may use for this purpose circular and longitudinal bandages, or the bandage or handkerchief tied in the form of the clove hitch. Extension is thus applied in connection with manipula- tion, 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 over- come. For this purpose surgeons employ generally in the case of the large limbs the compound pulleys or the simple rope windlass, which is thus described by Dr. Gilbert, of Philadel- phia: "Place the patient, and adjust the ex- tending 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 ex- tending 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 Clove hitch. (From Erichsen.) Fig. 215. Compound pulleys and ring to which one end of the pulley rope is fastened. stick 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 DOUBLE OR BILATERAL DISLOCATION. 505 over the pulleys, which may, perhaps, entitle it to the preference in a few cases. 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 overestimated. Only when some unusual circumstance or condition of the patient forbade the use of an anaes- thetic, 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. CHAPTEE II. DISLOCATIONS OF THE LOWER JAW. There are two principal forms of this dislocation, namely, the double or bilateral dislocation, and the single or 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 Dislocations. 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 twen- tieth 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 Ne'laton 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. Ne'laton attributes its more frequent occurrence in middle life to the great length and strong anterior inclination of the coronoid process. 3 In a majority of cases the direct or immediate cause has seemed to be muscular action alone. Malgaigne found this cause to prevail in twentv-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 ra°-e Dr. Physick, of Philadelphia, found both condyles dis- located in°a woman in consequence of the violent gesticulation of her iaw while scolding her husband. But in a more remarkable case still, this surgeon found the jaw dislocated after recovery from a profuse ' Robert, Journal de Chir., 1844. 33 506 DISLOCATIONS OF THE LOWER JAW. 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 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 appren- ticeship 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 Rochester, 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 cartilage of incrustation, is placed an interarticular car- tilage, 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 fora- men, 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"; i Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. * Andrews, Peninsular Jour. Med., vol. iii. p. 101. 1855. 3 Gilbert, Thesis ou Dislocation of the Inf. Max. University of Buffalo, 1858. DOUBLE OR BILATERAL DISLOCATION. 507 it is drawn downwards by the action of the digastricus, mylo-hyoideus, and genio-hyoglossus muscles; forwards by a few fibres of the masseter 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 dis- located it only needs that the capsule shall be somewhat relaxed, or that it shall actually give way in front, when the condyles slide for- wards and occupy a position directly in front instead of behind this eminence. It is easy to comprehend how the combined action of the two ex- ternal 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 an- terior portion of the capsule becomes lacerated; for it must be noticed that the ascending ramus, with its prolonged condyloid process, con- FlS- 216- stitutes a lever of the first kind, in which the temporal muscle, attached to the coronoid process, the masseter, and even the mas- toid process, constitute the ful- crum, 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 de- scends toward the neck, and the 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 immov- able It has been noticed generally that, by pressure, the chm may be slightly depressed, but that, owing probably to the pressure of the coro- noid 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 iaw is also slightly advanced; a depression, covering a con- siderable 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 m Ordinarily the patient suffers considerable pain, but not always, from the pressure of the condyles upon the branches of the temporal nerves. Double dislocation of the inferior maxilla. 508 DISLOCATIONS OF THE LOWER JAW. There is a constant flowing of the saliva from the mouth ; the patient 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 diminishes, the saliva ceases to drib- ble 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 incon- venience from the displacement. Robert Smith relates the case of a woman whose lower jaw was dislo- cated during an epileptic convulsion. She was at the time in one of the metropolitan hospitals, but the acci- dent was not noticed by the surgeons, and it remained ever afterwards un- reduced. 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 involun- tary flow of saliva had ceased, and the faculty of speech had been re- gained.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 ate, 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 ninety- eight 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 Double dislocation of the inferior maxilla 1 Robert Smith, on Fractures and Dislocations. 2 Sir Astley Cooper, on Disloc. and Frac, Amer. 8 Donovan, Amer. Journ. Med. Sci., Oct. L--42 May 25,1842. I Dublin, 1854, p. 288. ed., p. 316. p. 470, from Dublin Med. Press, SINGLE OR UNILATERAL DISLOCATIONS. 509 zygomatic fossae. Many surgeons prefer to sit or stand in front of 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 gradu- ally 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 sur- geons. 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 pre- caution 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. 510 DISLOCATIONS OF THE LOWER JAW. Tartra has seen one exceptional example in a child only fifteen 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 dis- location ; the jaw is nearly immovable; the teeth are advanced; the condyloid process can be felt in front of the articular eminence, leav- ing 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 import- ant diagnostic mark between a fracture of the neck of the condyloid process and a dislocation of one condyle. In the latter the chin in- clines 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 dislo- cations, 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 op 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 interarticular cartilages, and thus for the time render the jaw immovable. No posi- tive evidence, however, has ever been presented, either by Sir Astley or others, that any such derangement of the joint apparatus does actu- ally 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 ques- tion is the true one, yet it is not impossible that it has no relation whatever to the interarticular 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 scro- fulous diathesis. Relaxation of the capsule, ligaments, and muscles 1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 388, from London Lancet. CONDITIONS OF THE JAW SIMULATING LUXATIONS. 511 about the joint may, therefore, be regarded as the principal predispos- 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 articula- tions. 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," con- cluded 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. Maltraio-ne, 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 youno-' man who was suffering from paralysis and spasmodic contrac- tions °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 con- tracted 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 imme- diately to press upwards against the under surface of the chin in order to oppose their action. This condition would last from one to three 512 DISLOCATIONS OF THE SPINE. minutes, and was relieved, generally, by frictions made with the hand 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, with- out 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 vertebrae, their articular processes being placed 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 cir- cumstance may have been overlooked in some cases; but a consider- able 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 frac- tures 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 being attended with pain, especially when an attempt is made to move the body. In very many cases the symptoms are so nearly like those presented DISLOCATIONS OF THE LOWER VERTEBRA. 513 in a case of fracture, that the diagnosis is rendered exceedingly difficult. 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 frac- tures, 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- 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 disloca- tions of the spine in the same order in which I have treated of fractures of the spine. § 1. Dislocations of the Lumbar Vertebrae. Sir Astley Cooper plainly intimates that he does not believe a dis- location 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, unac- companied 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 bv a movement of rotation about the left articular process, the two oblique processes of the left side preserving their connection, while those of the ri^ht were separated quite half an inch. The right verte- bral plate was°broken, and the canal of the vertebra was thus thrown 0PDupuytren says that a man was crushed by the falling of a bank of i Cloquet, Malgaigne, from Journ. des Difformites de Maisonabe, torn. i. p. 453. 514 DISLOCATIONS OF THE SPINE. 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 his lower extremities were completely paralyzed; and that there existed in the upper part of the lumbar region a hard tumor, by pres- sure 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 vertebrae had been pushed for- wards more than one inch, lacerating the spinal marrow, breaking the transverse and oblique processes of the last dorsal and first two lum- bar vertebrae, and tearing off a small fragment of the body of one of the vertebrae where the intervertebral substance adhered to it.1 These are all the cases of dislocation of the lumbar vertebrae of which I am able to find any record. Both were accompanied with fractures. In neither case was any attempt made to reduce the dis- locations. 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 rota- tion in a direction opposite to that in which the displacement had taken place, it is possible that a reduction might have been accom- plished. 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 Yertebr^e. Malgaigne enumerates twelve examples of dislocations of the dorsal vertebrae. 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 fre- quency of their occurrence in the different vertebrae 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. 1 Dupuytren, Injuries and Dis. of Bones, Syd. ed., p. 340. DISLOCATIONS OF THE DORSAL VERTEBRAE. 515 Two of those which were unaccompanied with fracture, occurring respectively in the tenth and sixth dorsal vertebrae, were examples of a dislocation forwards, and the third, belonging to the ninth vertebra, was a dislocation backwards. A lateral luxation without fracture has 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 frac- ture of the oblique apophyses is impossible, and that in the direction backwards the luxation can only occur to the extent of about one- quarter of an inch, constituting only a species of articular diastasis, without breaking off the articulating apophyses of the lower corre- sponding vertebra. The first two examples, therefore, notwithstanding they have been received without question by Malgaigne, I shall un- hesitatingly reject. The third, which alone carries evidence of its having been correctly reported, and which was only a partial disloca- tion, 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 vertebrae 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 un- dergone 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 accom- plished 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, aet. 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 re- duction, and for this purpose he placed the patient upon his face, and secured a folded sheet under his armpits and another around his hips, directino- 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 1 Melcbiori, Gaz. Medica, stati sardi, 1850. 2 Melcbiori, loc. cit. 516 DISLOCATIONS OF THE SPINE. 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, and at the end of six or eight weeks he was able to control the evac- uations 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 dis- placement 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 pres- sure was replaced by a board underlaid with compresses and sustain- ing 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 re- ceived 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, aet. 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 extremi- ties 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 con- stantly upon his side. The upper portion of his body was well de- veloped, 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 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. DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAE. 517 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. 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 com- pletely 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 dis- location 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 ver- tebras 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 lux- ation 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 (" uni- lateral" of Malgaigne). Schranth2 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. Three 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 gene- rally 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 proba- ble 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. 1 Charles Bell, on Injuries of the Spine. 1824. * Schranth, Amer. Journ. Med. Sci., May, 1848, from Archiv fur Phys. Heilkunde 518 DISLOCATIONS OF THE SPINE. 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 one of the shoulders. Neither of these malpositions of the head is uniformly present in these several dislocations, and indeed not un- frequently, 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 consider- able 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 trans- verse 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 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 Roux'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 exe- cuted 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 » Lente, New York Journ. Med., May, 1850, p. 2^4. * Lente, ibid. p. 397. » Horner, Amer. Journ. Med. Sci., April, 1843, from Med. Exaui. DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA 519 Dr. Purple, of New York, has reported a case of what was called a dislocation of the fifth and sixth cervical vertebrae, producing complete paralysis of the lower part of the body, in which the patient survived 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 occupa- tions, suffering no further inconvenience than what was occasioned by the unnatural position of his head.2 Notwithstanding the authori- tative testimony of Sanson that this was a dislocation backwards, one cannot avoid the conclusion that it was either a unilateral subluxa- tion, 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, aet. 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 trans- verse processes had become so interlocked that every effort proved abortive," and he died forty-eight hours after the injury was received3 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 m 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 dislo- i Pnmle New York Journ. Med., May 1853, p. 319. * g"JJon Amer. Journ. Med. Sci., Feb. 1836, p. 514 ; from Gaz. des Hopitaux. » Spencer, Boston Med. and Surg. Journ., vol. x. No. 11. « Gaitskill London Repository, vol. xv. p. 282. s Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. 118. 520 DISLOCATIONS OF THE SPINE. cations 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." Dr. Shuck, of Vienna, relates that a man, set 24, while engaged at his work on the 5th 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 ex- tension 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 vertebrae, the original account of which I have not seen, but only an abridged state- ment 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 per- ceptible. 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 es- tablished. 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 1 Shuck, Amer. Journ. Med. Sci., July, 1841, p. 207. 8 Hickerman, But. Med. Journ., vol. x. p. 702, April, 1855. DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRA. 521 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 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 ad- vised 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 faint- ness 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."2 Rust,3 Wood, of this city," and others, have seen and reported simi- lar 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 prac- tice. We have now to relate a case in itself unique, namely, a suc- cessful 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 1 Schranth, Amer. Journ. Med. Sci., May, 1848. 2 Maxson, Buffalo Med. Journ., Jan. 1857, p. 479. 3 Rust, Chelius, note by Smith. * Wood, New York Journ. Med., Jan. 1857, p. 13. 34 522 DISLOCATIONS OF THE SPINE. did not recover from the combined effects of the shock and his liba- tions until the following morning, when he was supposed by his wife to be laboring under cold and a stiff neck. She made some domestic applications 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 cautiousl}7. 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 vertebrae, 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 Avas 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 dislo- cated. The marked rigidity of the head seemed to preclude the pro- bability 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 invi- tation, all of whom confirmed the diagnosis, and rendered efficient services. " The patient was placed upon a strong table in a recumbent posi- tion, with a pillow resting under the shoulders, the head being sup- DISLOCATIONS OF SIX LOWER CERVICAL VERTEBRAE. 523 Fig. 218. ported 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 and properly held, the head was grasped by one hand placed under the chin, the other over the occiput, and by steadily and firmly draw- ing the head directly backwards, and then upwards, an attempt was made at reduction, but failed for want of sufficient power. Dr. Ingra- ham 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 di- rected 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 re- stored, 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 fol- lowing, 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. Beyond 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 Ayres' case of bilateral dislocation of the fifth cervical vertebra. 1 Ayres, New York Journ. Med., Jan. 1857, p. 9. 524 DISLOCATIONS OF THE SPINE. § 4. Dislocations of 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 ver- tical ligament which binds the transverse ligament to the axis, nor without a separation of the atlas from the axis posteriorly and a rup- ture of the posterior atlo-axoidean ligament. Second, a similar incli- nation 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 displace- ment 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 unre- duced 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 Mal- gaigne, 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. Accord- ingly 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-exten- sion, 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 pain- ful, but at last, while the head was lifted as far as possible, it was sud- denly drawn backwards, and immediately it resumed its natural DISLOCATIONS OF THE HEAD UPON THE ATLAS. 525 direction. 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 dislo- cation 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 posi- tion 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 of the Head upon the Atlas, or Occipito-Atloidean Dislocations. Lassus, Palletta, and Bouisson2 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 luxa- tion 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 • Malgaigne, Ehrlich, Malgaigne, op. cit., torn. ii. p. 334. 2 Lassus, Palletta, Bouisson, Malgaigne, op. cit., p. 320. » Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Geu., May, 1838. 526 DISLOCATIONS OF THE RIBS. CHAPTER IY. DISLOCATIONS OF THE RIBS. The ribs may be separated from the bodies of the vertebrae, from the cartilages of the ribs, and from each other. The cartilages of the ribs may also be separated from the sternum. § 1. Dislocations of the Ribs from the Vertebrae. The heads of the ribs are joined to the bodies of the vertebrae by strong ligaments. The articulations are ginglymoid, admitting of motion chiefly in the direction of the axis of the spine. The mobility gradually increases as we proceed from the first rib downward to the last. Each joint is furnished with a capsule. The necks and tubercles are also united to the transverse processes bv ligaments, and the articulations are furnished with synovial cap- sules. I am not aware that any examples have ever been reported of dis- locations of the ribs from the transverse processes. Examples of dislocation of the heads of the ribs 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 gentle- man, 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 1 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. DISLOCATIONS OF THE RIBS FROM THEIR CARTILAGES. 527 rib has always been found to be displaced inwards. The lower ribs, including the false and floating, are those which have been most fre- quently 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 ex- tremity. 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. 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. Eeplacement 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 their Cartilages, and of the Car- tilages from the Sternum. The cartilage of the first rib has no proper articulation at either extremity, but the remaining six upper ribs, where they join the sternum, are furnished with synovial capsules. In old age these articulations generally disappear, yet not always. 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 stands 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 Mal- gaigne, reported one example of traumatic dislocation ; in all of which the cartilages were thrown forwards in advance of the sternum. When treating of fracture of the sternum I have related one case which has come under my own observation of dislocation of three or four cartilages at the same time. 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 528 DISLOCATIONS OF THE RIBS. 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 inflam- mation 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, pro- duced 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 § 3. Dislocation of one Cartilage upon Another. The cartilages of the sixth, seventh, and eighth ribs are furnished at their lower borders with a true arthrodial joint, by which they articulate with the corresponding cartilages. This arrangement some- times extends to the fifth and sixth ribs. A displacement of these articulations 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 be- hind the lower margin of the upper. The inferior cartilage is, there- fore, 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. Boyer, Martin, and Malgaigne have each reported one example. 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 full in- spiration. 1 B. Cooper's ed. of Sir Astley Cooper, &c, op. cit., p. 447. DISLOCATION FORWARDS AT THE STERNAL END. 529 CHAPTEK Y. DISLOCATIONS OF THE CLAVICLE. Of 30 dislocations of the clavicle observed by me, 6 belonged to the sternal end and 24 to the acromial. Of those belonging to the sternal end, 4 were dislocations forwards, 1 was a dislocation upwards, and 1 a dislocation forwards and upwards. I have never met with a dislo- cation 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 cla- vicle 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 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 acci- dents, 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 Fero-usson has once seen this displacement in a newly-born in- fant, 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 sterno- cleido-mastoid muscle presents an unusually sharp and projecting out- line, and a careful measurement indicates, if the dislocation is com- plete, a sensible approach to the acromion process toward the centre 1 Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 530 DISLOCATIONS OF THE CLAVICLE. Fig. 219. Dislocation of the sternal end forwards. 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 charac- terize this accident will generally pre- vent the possibility of a mistake; but Pinel mentions the case of a man who having presented himself at one of the 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 pre- sented himself to Velpeau, who had been treated for a dislocation, when the bone was only expanded by dis- ease. 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 cap- sular ligament suffers a complete disruption, and also the anterior with the posterior sterno-clavicular ligaments. The rhomboid and interarticular ligaments suffer more or less according to the extent of the displacement. The interarticular cartilage may retain its attach- ment 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. Richerand 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 six 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, al- though faithfully attempted, was never accomplished. Mr. H., of Buffalo, aet. 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 bv 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 V e also endeavored to reduce it by pressing directly upon the pro- jecting 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 manipu- lating he was very much enfeebled by the shock of the accident DISLOCATION FORWARDS AT THE STERNAL END. 531 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. 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 men- tioned 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. Pro- bably 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 remark- able, however, that of the three examples furnished by Bichat to con- firm'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 com- plete than in either of the other cases.1 Richerand and Guersant suc- ceeded no better with Desault's dressings.3 i Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 53. * Malgaigne, op. cit., torn. ii. p. 417. 532 DISLOCATIONS OF THE CLAVICLE. Other surgeons have made similar claims for their own forms of apparatus, but experience still continues to show that a complete re- tention of the dislocated bone is FiS- 220' seldom to be expected. Sir Astley Cooper recom- mends an apparatus, the con- struction and application of which are illustrated by the ac- companying sketch, 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 dress- ing is then completed by placing the arm in a sling. He advises, however, that in some way direct pressure should be made upon the projecting point of bone. Velpeau objects to any plan which will draw the shoulders back; but, on the contrary, he thinks that the shoulders should Sir Astley Cooper's apparatus for dislocated clavicle. 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 further 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 1 Folts, Boston Med. and Surg. Journ., vol. liii. p. 260. OF THE STERNAL END OF CLAVICLE UPWARDS. 533 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.1 Jerry McAuliffe, aet. 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 respira- tion, and loss of speech. Reduction was easily effected, and a retentive apparatus was immediately applied, consisting of a gutta-percha splint, moulded to the clavicle and ribs, and retained in place with adhesive plaster. Suitable bandages, a sling, &c, were also employed to main- tain complete rest. Notwithstanding all the care employed, the bone again became displaced, and when, near 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 correspond- ing shoulder was slightly depressed. McAuliffe 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 1 Rochester, Buffalo Med. Journ., vol. xiv. p. 262. 534 DISLOCATIONS OF THE CLAVICLE. direction completely the intra-clavicular space, aud 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 dimi- nution 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-cleido- mastoid 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 accom- plished 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. § 3. Dislocations of the Sternal End of 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 Medicale; 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 crush- ing 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 THE STERNAL END OF CLAVICLE BACKWARDS. 535 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 backward, 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 wind- pipe, 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 fol- lowed, 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 back- wards, and rather more movable than natural.1 The following example, related by Morel-Lavalle'e, 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 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 gradu- ally 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. De- sault'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.2 Symptoms.—The most constant symptoms are, the absence of the head of the bone from its socket, and its complete or partial disap- pearance behind the sternum, an approach of the corresponding shoul- der to the median line, an inclination of the head to the opposite side, elevation of the shoulder, pain at the 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-Lavalle'e. 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 1 South, note to Chelius's Surgery, Amer. ed., vol. ii. p. 218. 2 Morel-Lavallee, Amer. Journ. Med. Sci., vol. xxix. p. 229, 1S42; from Gaz. Med. 536 DISLOCATIONS OF THE CLAVICLE. 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 main- tained 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 em- ployed 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 twenty-four 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, and once by a bolt thrust directly up from under 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 acro- mion 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 in- jury, 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 bodv 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 after- eport on Dislocations, by the author. Transac. of New York State Med. Soc, OF THE ACROMIAL END OF CLAVICLE UPWARDS. 537 Fig. 221. Dislocation of the acromial end of the clavicle, upwards and outwards. wards 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 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 grat- ing 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 shoul- der, the clavicle is seen to move more freely than natural immediately under the skin, and these motions are usually at- tended with some pain at the point of dis- location. This accident has been sometimes mis- taken 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 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 liga- ments immediately investing the joint, so that the clavicle rises from its socket only about half an inch, more or less, according to its dia- meter, and is carried outwards just sufficiently far to allow it to rest upon the upper margin of the acromial articulation. In at least nine- teen of the cases seen by me this has been the position of the acro- mial 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 m 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 dis- ruption ; indeed, without a rupture of its external fasciculus, which 35 538 DISLOCATIONS OF THE CLAVICLE. anatomists have called the trapezoid ligament, such a dislocation can- not take place. Prognosis.—It is impossible for me to say what has been the pre- cise 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 undimin- ished 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 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. The case to which I have already referred as having been caused by a bolt thrust upwards under the clavicle, will furnish the best illustra- tion of this general principle. James O'Brien, 1st U. S. Artillery, was injured in September, 1862, by being run over by a horse-car. A bolt, three-quarters of an inch in diameter, was driven through the skin on the anterior margin of the left axilla, breaking the first rib, severing the coraco-clavicular ligaments, and forcing the clavicle upwards from its socket. No attempt at reduction was ever made. When seen by me one year after the accident, the outer end of the clavicle was lifted directly up two inches from the acromion process, to which it was united only by a long and slender ligament. He was not conscious of any loss of power or limitation of motion in the injured arm. At my request, my son, then in the U. S. service, insti- tuted a series of experiments to test the relative strength of the two arms, and with the following result: First with the right arm, and then with the left, he lifted from the ground fifty-six pounds and three ounces, and sustained this weight above his head 30 seconds, with his arms fully extended. With his right arm extended at full length, at OF THE ACROMIAL END OF CLAVICLE UPWARDS. 539 right angles with his body, he sustained twenty-five pounds for fifteen seconds. With the left arm he sustained the same weight, in the same position, seventeen seconds.1 Treatment.—When the bone simply rises upon its socket, the re- duction is always easily accomplished by pressing firmly upon its extremity with the fingers; but if, at the same time, it has been car- ried outwards, 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 pro- cedures 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, abso- lutely 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 exer- cise 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.2 Dr. Folts is no doubt correct in regarding this strap as an import- ant if not the essential part of the apparatus; and it is surprising that by Sir Astley Cooper, as well as by many other experienced sur- geons, its value should have been overlooked. The chief obstacle to the retention of the bone in place is the powerful action of the tra- pezius, 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. Bradsor's tourniquet, or Petit's, secured by a strap brought under the point of the elbow, Boyer's double shoulder- ' Am. Med. Times, Oct. 24, 1863. 2 Folts, Bost. Med. and Surg. Journ., vo'. liii. p. 259. 540 DISLOCATIONS OF THE CLAVICLE. straps and Default's third bandage, all aimed at the accomplishment of the same purpose; yet Boyer and Desault found all these con- trivances fail in a majority of cases. Mayor employed a dressing constructed with a strap to buckle over the dislocated clavicle, but Ne'laton has seen this apparatus Fig. 222. 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 com- pletely 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 per- fectly by this mode, but in seve- ral others which seemed equally favorable we have met with par- tial or complete failures. The practical difficulties are, the sensibility and consequent Mayor's apparatus for dislocated clavicle. ("Tri- inability SOmetimeS of the point angle cubito-bis-scapuiaire.") of the elbow to bear the requisite pressure, and the even greater 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 suffi- cient 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 exco- riations 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 OF THE ACROMIAL END OF CLAVICLE DOWNWARDS. 541 the shoulder-strap or the axillary pad in certain cases, but also, it seems to me, of the mischief which may result from their too diligent appli- cation ; 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 ex- cept 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 communi- cation 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 espe- cially 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 mus- cles 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 keep- ing 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 well-authen- ticated cases having been placed upon record, one of which was seen and dissected by Melle, 1765, the second was met with by Fleury, 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. 542 DISLOCATIONS OF THE CLAVICLE. 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 process, 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 coraco-acromial and coraco-clavi5ular 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 out- wards and backwards; nor has it been found any more difficult to maintain it in position when once replaced. When the scapula is re- stored 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 of 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 Cassis). * Godemer, Recueil des travaux de la Soc. Med. d'Indre et Loire, 1843, from Vidal. DISLOCATIONS OF THE SHOULDER. 543 with a corresponding projection of the acromion and coracoid pro- cesses ; 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 fin- gers, 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 out- wards, 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 subcora- coidean space by the tendons and muscles which pass from its extre- mity 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. 544 DISLOCATIONS OF THE SHOULDER. Writers have not been agreed as to the precise anatomical relations of these dislocations, nor as to the nomenclature. Velpeau, Malgaigne, Vidal (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 rela- tions 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 cause of this accident is a blow received directly upon the upper end and outer surface of the humerus. I have found the arm dislocated into the axilla by this cause eleven times; four 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 car- riage; in two cases the patients have fallen through a hatchway and been caught and suspended by 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, that she was returning from the Jura Mountains, near Neufchatel, 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 DISLOCATION OF THE SHOULDER DOWNWARDS. 545 she threw down the load at her door, the right shoulder was dislocated. The arm soon became 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 displace- ment.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 of the triceps, until the capsule gives way, and continuing to FiS- 223- descend in the same direction it is finally arrested by the triangular surface of the in- ferior edge of the scapula im- mediately 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 mus- cle. The capsule is generally torn quite extensively, especially be- low and in front; and, the ten- don of the long head of the biceps may be broken asunder, or detached completely from its insertion; 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 Dislocation of the shoulder downwards into the ax- illa. (Subglenoid.) i Lehman, Amer. Journ. Med. Sci., vol. i. p. 242, 1828. 546 DISLOCATIONS OF THE SHOULDER. 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 condi- tion of extreme tension; while the teres major and minor in this respect are subjected to but little change. In some cases a portion or the whole of the greater tuberosity is completely detached, and the fragment displaced by the action of the muscles inserted into it. Symptoms.—A palpable depression immediately under the extrem- ity 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; allowing, Fig. 224. Dislocation of the shoulder downwards into the axilla. (Subglenoid.) 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 DISLOCATION OF THE SHOULDER DOWNWARDS. 547 while at the same moment the elbow touches the thorax; the head of the patient, and sometimes the whole body, inclined toward the in- jured arm; the arm lengthened from half an inch to an inch ; a chaf- ing 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 car- tilaginous covering. (For a more complete differential diagnosis, see chapter on fracture of the humerus.) 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 consid- erable effusions of blood and of lymph may have taken place; while at a still later period, when the swelling has 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 can- dor to state to the patient that the difficulty of detecting the nature of the accident is exceedingly diminished by the cessation of inflamma- tion, 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 dis- location. 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 ' Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv. p. 236, May, 1839. 548 DISLOCATIONS OF THE SHOULDER. freely in all directions: very little swelling follows, and in a short time a perfect restoration of all the functions of the limb is accom- plished. 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 re- sume its perfect form and symmetry until a much later period; occa- sional 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 termina- tions 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 the axilla. 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 Eogers, 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. East- man 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 DISLOCATION OF THE SHOULDER DOWNWARDS. 549 after this the patient consulted me on account of the immobility of the shoulder-joint, and because several surgeons had expressed a doubt 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 dis- appearing. 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 an- chylosis in question seems to be a result simply of laceration or more generally of a severe strain of the muscular fibres, resulting in in- flammation 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 cer- tain number of cases. Especially has it been noticed that the deltoid muscle is liable to atrophy; and in their attempts to explain the fre- quency 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 supra-spinatus, 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 re- markable fulness just in front of the head of the bone, which has continued sometimes for many months and even years after the re- duction 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 stiff- 550 DISLOCATIONS OF THE SHOULDER. ness 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 surgeon, 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 Burwell, 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. Carry- ing 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 disloca- tion, 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 gentlemen came to me accom- panied 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 DISLOCATION OF THE SHOULDER DOWNWARDS. 551 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- 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 in- stances, 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 subluxa- tion, 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. I have myself met with these cases quite often. During the present year I have seen two dislocations of the humerus into the axilla, both of which had been seen and examined by New York hospital surgeons within a few hours after the receipt of the injury, but the nature of the accident had not been recognized. One of these I reduced at Bellevue Hospital on the seventh day and one on the tenth. There was also presented to me, at the Charity Hospital (Blackwell's Island), in my service, an axillary dislocation of twenty years' standing, which a sur- geon saw immediately after the receipt of the injury and failed to recognize. In other cases the dislocation has been clearly made out, but the surgeon has been unable to reduce the bone. It has been my OO'J DISLOCATIONS OF THE SHOULDER. 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, ast, 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 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 influ- ence 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 Fls- 225- the appearances presented on dissection of a dislocation which had been long un- reduced : " The head of the bone altered in its form; the surface towards 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 in- ferior costa of the scapula; but this was shallow, like that from which the New socket, in an ancient luxation of bone had escaped." the shoulder downwards. (From sir a. When the dislocation into the axilla Cooper) remains unreduced, the consequences DISLOCATION OF THE SHOULDER DOWNWARDS. 553 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 intoxi- cated, producing a dislocation of the left arm into the axilla. Eleven hours after the accident, he was received into the 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 humerus 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., aet. 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 ex- tension 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 occasion- ally 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, aet. 47, was admitted to the hospital, with a dis- location 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 dis- located. 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 chloro- form, 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 36 554 DISLOCATIONS OF THE SHOULDER. 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. 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 men- tion 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 uncom- plicated 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, i Scott. Amer Journ of Med. Sci., vol. xx. p. 515, Aug. 1837, from the London Lancet for March 4, 183^. DISLOCATION OF THE SHOULDER DOWNWARDS. 555 most of which were originally only in a condition of moderate exten- sion, and some of which were rather relaxed than extended, sym- pathize with those which are suffering the most, and a general con- traction and rigidity ensue, increased also at the last by the superven- tion 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 over- strained 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. 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 indica- tions 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 main- tains 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 suffi- cient 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 neces- sary, there must be afforded some point of resistance beyond the bone; and this it is really which has constituted one of the greatest impedi- ments to reduction. It is not that the muscles are in such an extra- ordinary 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 ex- planation 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 55<3 DISLOCATIONS OF THE SHOULDER. angle, or to a right angle with the body, when, the resistance of the deltoid and supra-spinatus being overcome, the bone will at once re- sume 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 recom- mend. 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 manipula- tion 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 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 prac- tice, 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 be- tween 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 ex- tension. 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 DISLOCATION OF THE HUMERUS DOWNWARDS. 557 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 ap- prove of the same method,1 and perhaps a majority of American sur- geons regard it favorably. If we pull directly outwards, at a right angle with the body, we 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 en- countered 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 Fig. 226. N. R. Smith's method. finders of an assistant or the split band, and concludes by stating what seems to him the most effectual mode of rendering the scapula • Physick, Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorsey's Elements of Surgery, vol. i. p. 214. Philadelphia, 1813. 558 DISLOCATIONS OF THE SHOULDER. immovable, 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 reduc- tion had already been made by a respectable surgeon. Dr. Smith being called, proceeded as follows: Two gentlemen made counter- extension from the 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 con- tinued for two or three 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 E. 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 Fig. 227. La Mothe's method, modified. dislocated arm, he drew the patient up until the whole body was sus- pended. No pressure, however, was made upon the scapula from 1 Nathan Smith, Med. and Surg. Memoirs, 1831, p. 337. « Nathan R. Smith, Amer. Journ. Med. Sci., July, 1861. s La Mothe, Amer. Journ. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges de Med. et Chir., Paris, 1812. DISLOCATION OF THE HUMERUS DOWNWARDS. 559 above, which is no doubt the most essential part of the process.1 By La Mothe's plan, Jobert succeeded after twenty-three days when all the usual methods had failed.2 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. 227). 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. 228):— Fig. 228. Sir Astley Cooper's method of applying extension with the heel in the axilla. " The patient should be placed in the recumbent posture upon a table or sofa, near to the edge of which he is to be brought; the sur- geon then binds a wetted roller around the arm immediately above the elbow upon which he ties a handkerchief; then he separates the 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 pos- ture 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. Placing the patient upon a low chair, the axilla is laid over the knee of the operator, and while one . C. White, Amer. Journ. Med. Sci., Nov. 1836, from Med. Obs. and Inquiries, vol. ii. p. 273, London, 1764. 2 Ibid., vol. xxiii. p. 237, Nov. 1838. f»(»0 DISLOCATIONS OF THE SHOULDER. hand steadies the acromion process and scapula, the other presses downwards upon the lower end of the humerus (Fig. 229). If some hours or days have elapsed since the occurrence of the dislocation, it will be necessary to re- sort to chloroform or ether for the purpose of paralyzing the muscles, as well as with the view of prevent- ing pain, and it may be necessary, in addition, to resort to pulleys, or to some similar permanent mode of ex- tension. The same measures also sometimes become necessary in very recent cases, especially in muscular subjects. In employing the pulleys we gener- ally operate not exactly in a line with the axis of the body, nor at more than 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 pul- leys, but which plan would, in my judgment, be very much improved by a counter-extending 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 pul- leys, 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 Fig. 230. Sir Astley Cooper's method of operating with the knee in the axilla. Iron knob employed by Skey, instead of the heel. 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 DISLOCATION OF THE HUMERUS DOWNWARDS. 561 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 by 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 the plan especially applicable to cases which require long and per- sistent extension. Fig. 231. 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 (Fig. 232). The instrument invented by Dr. Jarvis, of Portland, Conn., called the adiuster, useless and even mischievous as we have found it in its appli- cation to the treatment of fractures, possesses considerable merit as an apparatus for reducing old dislocations, especially of the shoulder The 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 direc- tions • 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 suro-eons it has occasionally been successful when other means have failed Dr Jarvis has related a case presented at the Marine Hos- pital at Mobile, Tenn., of forty-two days' standing, which he reduced 1 Skey, Operative Surgery, Amer. ed., p. 93. 562 DISLOCATIONS OF THE SHOULDER. on W the second attempt, after other means had failed j1 and Dr. May, of ashino-ton, reduced a similar dislocation at the end of six weeks, Fig. 232. Sir Astley Cooper's mode of making extension with pulleys. by the same apparatus, without, however, having previously resorted to any other means.1 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 fore- arm 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 further 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 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. DISLOCATION OF THE HUMERUS DOWNWARDS. 563 the reduction of old dislocations, or of dislocations requiring the inter- position 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 with- out 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 pos- sible 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. 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 fore- arm 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 564 DISLOCATIONS OF TnE SHOULDER. 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 inconsider- able. 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, 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 every- thing 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; occasion- ally rotating the humerus, and occasionally lifting its head toward the socket. Meanwhile, it is understood that the principal counter-ex- tension 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 counter-extension 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 ex- hausted, it very often happens that the reduction is easily accom- plished. 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 dislo- cation 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., aet. 52, a laborer, and a DISLOCATION OF THE HUMERUS DOWNWARDS. 565 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 appa- ratus, and found the bone in its place. John Harrington, aet. 50, a very large and powerful man, fell while intoxicated, and dislocated his left humerus into the axilla. No sur- geon was called until the tenth day, when he first consulted Dr. Dud- ley, 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 acro- mion 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 accom- plished. John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably muscular, but spare. Bowles fell down a flight of stairs, and dislo- cated 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 adminis- tered 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 566 DISLOCATIONS OF THE SHOULDER. 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! 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 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 com- pletely 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. Dieffenbach 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 atten- tion 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 distin- guished 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 1 Dieffenbach, Bost. Med. and Surg. Journ., vol. xxii. p. 382, from Medicin. Zeitung. DISLOCATION OF THE HUMERUS DOWNWARDS. 567 man, and about fifty years of age, decided to submit to the same mani- pulation, 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 com- menced my manipulations, adducting, rotating, abducting, and elevat- ing 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 of a sponge and broad roller. On removing this the next morning, the tumefaction had nearly disappeared. The patient con- tinued 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." The following is a resume of similar accidents which have from time to time occurred in the practice of other surgeons. Desault twice observed, after attempts to reduce old luxations of the shoulder, " tumeurs aeriennes." It is quite probable, however, that in each case the tumor was caused by the rupture of a bloodvessel.1 Pelletan, also, attempting to reduce a luxation of four months' stand- ing, thought he produced a tumeur aerienne, but it being opened the patient bled to death.2 Malgaigne, attempting to reduce a dislocation of sixty-eight days' standing, was surprised by a sudden tumefaction in the axilla, and on the shoulder, which caused so much alarm as to induce him to discon- tinue his efforts. Ice was applied, and the hemorrhage, which he thought came from muscular branches, was arrested.3 Verduc saw the axillary artery ruptured in the same manner, in consequence of which the patient died.4 J. L. Petit met with a similar case. Platner mentions a case of rupture of both axillary artery and vein. C. Bell reports an example of rupture of the artery with extensive laceration of the muscles, and which demanded immediate amputation. Delpech ruptured the artery, and his patient died immediately.5 Flaubert was more fortunate, the effused blood being absorbed after a few days. Froriep saw his patient die within one hour and a half after a rupture of the axillary vein. John C. AVarren, of Boston, tied the subclavian artery to arrest the progress of an enormous aneurismal tumor in the 1 Desault, Journ. de Chir., t. iv. p. 301. 2 Pelletan, Chir. Clin., t. ii. p. 951. 3 Malgaigne, op. cit., p. 150. « Verduc, Operat. de la Chir., 1693, t. i. p. 559. 5 Malgaigne, op. cit., p. 152. 568 DISLOCATIONS OF THE SHOULDER. axilla, caused by the reduction of a recent dislocation.1 Gibson, of Philadelphia, lost two patients in attempting to reduce old luxations of the humerus,' and he relates another fatal case occurring in the practice of David, of Rouen. Leudet, of Rouen, lost a patient in this way in 1^2-i. In this latter case, and in both the cases occurring in the practice of Gibson, there was a fracture, also, of the lower margin of the glenoid cavity. In addition to these lesions of arteries and veins caused by attempts at reduction of dislocated shoulders, in both recent and ancient cases, there are several examples recorded of sudden death when no such lesions were disclosed in the autopsy. In the case reported by Lis- franc death was ascribed to cerebral congestion. MM. Lenoir and Larrey refer to cases, also, of lesions of the brachial plexus, causing paralysis, yet these were recent cases, and the reduction was easily accomplished.3 In the following case an attempt to reduce an ancient dislocation of the humerus occasioned a fracture of the surgical neck. Martha Hogan, get. 70, of Brooklyn, N. Y., was admitted into the Long Island College Hospital during the spring of 1860. The dislo- cation had existed six weeks, and was subcoracoid. On the day of admission an attempt was made to reduce it, both by Dr. Johnson and myself, without an anaesthetic, in which we both failed. I then gave her ether, and now discovered that she had a fracture of the second and third ribs on the same side. The fractures were ununited. While manipulating, pulling the arm gently and rotating, the surgical neck of the humerus gave way. She did not survive the injury many days, and the autopsy confirmed this diagnosis. 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 unreduced 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.4 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, agree in declaring the re- duction 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. Dr. Warren, of Boston, 1 Warren, Amer. Journ. Med. Sci., vol. xi. N. S. 1846. 2 Gibson, Elements of Surg., vol. i. p. 824, 4th ed. 3 Lisfranc, Lenoir, Larrey, Bui. de la Soc. Chir., t. i. 4 Norris, Amer. Journ. Med. Sci., xxxi. p. 24. DISLOCATION OF HUMERUS NEAR ITS UPPER END. 569 himself reduced the dislocation at the end of four weeks, when the fracture was found to have united.1 But since the introduction of anaesthetics immediate attempts at reduction have more often proved successful; and in no case can the surgeon excuse himself for having omitted to make the effort. 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 com- plete use of his arm.2 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 pros- trated at the time of being admitted into the hospital, and the exami- nation 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 sweep- ing 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.3 In the Transactions of the American Medical Association, I have re- ported a case of supposed dislocation accompanied with a fracture, which I succeeded in reducing on the eighth day." During the last two years, however, I have twice failed in attempts to reduce similar dislocations. The first patient, John Riley, aet. 49, was admitted to Bellevue Hospital, March 29th, 1864, having received the injury two days before. The dislocation was subcoracoid, and the humerus was broken at its surgical neck. Having placed him under the influence of ether, assisted by Dr. Stephen Smith and several other surgeons of the hospital, I attempted to reduce the dislocated bone, but after a trial prolonged through one hour or more, the effort was abandoned. The second case was in a man aged about 40 years, who was ad- mitted to Bellevue Hospital in July, 1864, with a dislocation of the head of the humerus forwards, and a fracture of the surgical neck, of four weeks' standing. A surgeon had attempted reduction immedi- ately after the receipt of the injury, but had failed. We found the fracture still ununited, and placing him under the influence of ether, we tried faithfully, by pushing and pulling and by various other ma- noeuvres, to reduce the dislocation, but without success. 1 Boston Med. and Surg. Journ., No. i., 1828; also, Amer. Journ. Med. Sci., vol. ii. p. 233. 2 Richet, Amer. Journ. Med. Sci., vol. xii., new ser., p. 293, from Bulletin de Therap. 8 Watson, Amer. Journ. Med. Sci., vol. xvi., new ser., p. 383. 4 Op. cit., vol. ix. p. 93. 37 570 DISLOCATIONS OF THE SHOULDER. The fractures united in both cases promptly, and attempts were subsequently made to reduce the dislocation, but to no purpose. Other examples have been recorded by surgeons in which the re- duction has been accomplished immediately, and without much diffi- cultv, by simple pressure upon the head of the bone, while the patient was under the influence of an anaesthetic, and without the aid of ex- tension ; 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;1 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 dis- cussed in a separate chapter devoted to the general consideration of compound dislocations of all the joints connected with the long bones. § 2. Dislocation of the Humerus Forwards. (Subcoracoid and Sub- clavicular.) 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 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 originally thrown directly downwards upon the inferior edge of the scapula, may have been made to assume the position forwards, be- neath 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 consecu- tive only upon a dislocation downwards. In several instances which have come under my notice the disloca- tion has been due to muscular action alone. In one example the dislocation occurred frequently in consequence of epileptic convul- sions. 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 fre- quently 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 at reduction, adopting all the usual modes of manipulation, but 1 Hartshorne, Case reduced by Manipulation, Amer. Journ. Med. Sci., Jan. 1855, pp. 273—1, from Med. Examiner. DISLOCATION OF THE HUMERUS FORWARDS. 571 without resorting to mechanical appliances. The father now refused to allow me to proceed, and he was taken home with the bone unre- duced. 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- pared to question, we shall proceed at once to describe the anatomical relations and the various lesions which generally accompany a com- plete 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, having the conjoined tendon of the short head of the biceps and of the coraco-brachialis 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 subscapular muscle. 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. AYood, 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." suhcoracoid dislocation. The drawing which accompanied the report, made from the autopsy, sufficiently shows that it was a dislocation of the same character as that which we are now describ- ing.1 Dr. Parker has called attention to a similar case, an account of which was first given in Reese's edition of Cooper's Surgical Dic- tionary. The head of the humerus reposed in the "subscapular fossa."2 By Malgaigne, Vidal (de Cassis), and others, this is called a subcora- coid dislocation, a term which, as being more distinctive and appro- priate than either of the others, I shall choose to adopt. In the second variety, 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 the pectoralis minor, and also behind the short head of the biceps and coraco-bra- i Wood, New York Journ. of Med., May, 1850, p. 282. 2 Parker, New York Journ. of Med., March, 1S52, p. 187. 572 DISLOCATIONS OF THE SHOULDER. chialis; or between these several muscles on the one hand, and the serratus magnus, covering the second and third ribs, on the other hand. Upon the appearances which accompany this more advanced form of dislocation writers have generally Fig. 234. based their descriptions, diagnosis, treatment, &c, of forward luxations. In either form of the accident, the deltoid, with the supra, and infraspina- tus, is greatly stretched, and the two latter sometimes torn; the subscapu- laris is displaced upwards and back- wards, while its tendon is in some in- stances completely wrenched from the head of the humerus. Mr. Erichsen has seen the lesser tubercle itself com- pletely broken off in two examples of this accident which he has been per- mitted to examine after death.1 Occa- sionally the axillary nerves are carried forwards with the head of the bone; subclavicular dislocation. 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. 234), a depression exists under the outer end of the acromion process, extending also un- derneath 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 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, the head of the bone will be found below this process and deep in the anterior 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 one 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 1 Erichsen, Science and Art of Surgery, 2d Amer. ed., p. 250. DISLOCATION OF THE HUMERUS FORWARDS. 573 laceration, on the other hand, the difficulty of reduction has been often increased, and consequently a large number of examples, in propor- tion to the actual number which occur, have been left unreduced. Fig. 235. Subcoracoid luxation. 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- 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, generallv 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 es- caped 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. ' Norris, Amer. Journ. Med. Sci., vol. xxv. p. 279. 574 DISLOCATIONS OF THE SHOULDER. 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 dis- tinctly 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 hu- merus 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, aet. 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 depres- sion 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. AVhile Dr. Boardman supported the acromion process I lifted the elbow from the side, carrying it first upwards and backwards, and then for- wards, making thus a short detour with the arm, and when the ma- noeuvre was nearly completed the bone slid into its socket with a slight snap. No extension was used, and no more force was employed than 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 Octo- ber, 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 DISLOCATION OF THE HUMERUS BACKWARDS. 575 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 cf 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. AVhite nor myself had much expectation of accomplishing a re- duction 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 cha- racter. 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 into requisition all the expedients which the experience of other surgeons has shown to be worthy of a trial. Within the last year I have seen two ancient subcoracoid disloca- tions at Bellevue Hospital. One of these cases, in the person of James Thompson, aet. 49, has existed two years or more. He is employed about the hospital as a carpenter, and has a tolerably useful arm. The second, in the person of Rosanna Casey, aet. 32, had existed six weeks when she was admitted. Various attempts had been made to reduce the dislocation before admission. During the week following her admission an attempt was made at reduction by Dr. Verona, an in- telligent house surgeon, subsequently by Dr. James R. AVood, and at the end of three months the attempt was made by myself, before the class of medical students, the patient being each time under the influ- ence of an anaesthetic. She was finally discharged with the bone still unreduced. Mary Coffee, aet. 46, was admitted also to the Charity Hospital, in Feb. 1864, with the same dislocation, which had existed six months, having been mistaken at first for a fracture. I found her arm free from swelling or paralysis, and moving quite freely in its new socket, and declined to make any attempt at reduction. § 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 576 DISLOCATIONS OF THE SHOULDER. cases are mentioned.1 Sedillot,2 Malgaigne, Desclaux,3 Van Buren,J AV. Parker/ Lepelletier,6 Towbridge,7 Physick, Snyder,8 and myself, have each seen one example.9 Causis.—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 push- ing a person violently with the arm elevated; and a fourth, seen by Coley, was " pulled down by a calf which he was driving, a cord hav- ing 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 dis- covered when I was preparing to amputate the arm soon after the accident occurred. Of the manner in which the othercases were pro- duced 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, aet. 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 dis- section 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 five 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 de- pression, 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 re- mained, 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 1 A. Cooper, op. cit., p. 352. 2 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. » Van Buren, ibid., Nov. 1851, p. 110. * Parker, ibid., March, 1852, p. 186. 6 Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1834. ? 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, Fi- zeau, Velpeau, Fergusson and Kirkbride. New York Journ. Med., March, 1852 p. 193. DISLOCATION OF THE HUMERUS BACKWARDS. 577 ruptured. The glenoid fossa was rough and irregular upon its sur- face, the cartilage being absorbed. The fact that the bone would not remain in place when reduced, was explained by the rupture of the subscapularis, 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 Cassis), Malgaigne, and others, as only subacromial, and as a variety of the dis- Fis- 236- location 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 subspinous dislocation. 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 front or side 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 dis- location backwards. In this instance the limb could not be rotated outwards, as the subscapularis was not torn, and continued to offer » Sir Astley Cooper, op. cit., p. 354. 573 DISLOCATIONS OF THE SHOULDER. resistance when the arm was moved in this direction; he was also suffering much more pain than did the other patients, owing, as Sir 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 disloca- tion several weeks before the nature of the accident was fully determined. Prognosis.—The reduction has always been sooner or later accom- plished, 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 hume- rus 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 car- rying the arm upwards and backwards, but when the patient had be- come 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 successfully, the ex- tension being made downwards and forwards; while Dr. Parker suc- ceeded 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 ac- cident. " I readily reduced the bone," he remarks, " by raising the hand and arm, and by turning the hand backwards behind the head." In one other instance, having failed to reduce it by slight extension PARTIAL DISLOCATIONS OF THE HUMERUS. 579 outwards, he raised the arm perpendicularly, at the same time forced it backwards behind the patient's head, and the reduction was promptly effected. In the case of Kretner, I first attempted reduction by pres- sure directly upon the head of the humerus, but failing, I proceeded to pull the arm with moderate force outwards and downwards, which procedure 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 or 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 con- firmation 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 dislo- cation, 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. AVithout intending to discuss very much at length the value of these opinions, I shall content myself with declaring that the exist- ence of this, or of any other form of partial luxation of the shoulder- joint, 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, subcoracoid 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 relatio to this tendon in the case seen by him, but it is distinctly stated thac 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; 580 DISLOCATIONS OF THE SHOULDER. 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 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 cap- sule. 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, accord- ing 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. Fig- 237. John G. Smith1 and Mr. Soden2 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 co- raco-acromial ligament. Says Mr. Soden: " To enable the bone to main- tain 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 Displacement of the long head of the biceps, downwards), "it is suggested that this office is performed by the sin- 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. 237) 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 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. PARTIAL DISLOCATIONS OF THE HUMERUS. 581 to lead to a suspicion that it is not properly reduced. Quite recently I have been consulted in the case of a lad about fourteen years of age, who 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 perhaps the same, the long head of the biceps has been broken or displaced; or, when it follows a dislocation, some of the muscles inserted into the greater tuberosity have been torn from their attach- ments. I mean to say that in these circumstances 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 of the biceps 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 exami- nation, 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 i Mercer, Buffalo Med. Journ., vol. xiv. p. 641, April, 1859. 582 DISLOCATIONS OF THE nEAD OF THE RADIUS. 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 displace- ment of the long head of the biceps.1 CHAPTER VII. DISLOCATIONS OF THE HEAD OF THE RADIUS. I have met with twenty-one examples of traumatic dislocation of the head of the radius; of which seventeen were dislocated forwards, or forwards and outwards, 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. I have seen one congenital dislocation of the head of the radius outward and forward, which I will describe more particularly in the chapter on congenital dislocations. § 1. Dislocations 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 Denuc6, 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 luxa- tion, 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 acci- dent produced in this way. Batchelder,2 Sylvester,3 Goyrand,4 and many other surgeons, have mentioned similar cases. Dr. Krackowizer related to the New York Academy, in 1856, a 1 Broomfield's Chirurg. Observ., vol. ii. p. 76. 2 New York Journ. Med., May, 1856, p. 333. 3 Amer. Journ. Med. Sci., vol. xxxi. p. 2o6, Jan. 1843. * Ibid., vol. xxxii. p. 228, July, 1&43. DISLOCATION OF HEAD OF RADIUS FORWARDS. 583 Fig. 238. 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.1 Pathological Anatomy.—The head of the radius is carried forwards upon the humerus, and generally a little outwards; the anterior and external lateral ligaments, with the annular, are in most cases more or less broken. Sometimes the ante- rior 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 re- main 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 depres- sion 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 in- clines 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 luxa- tion related by Robert, it was found impossible to maintain a reduc- tion which he thought he had several times accomplished, and he believed that the difficulty consisted in a portion of the torn annular lio-ament having become entangled between the head of the radius and the condyle of the humerus.2 1 Krackowizer, New York Journ. Med., March, 1857, p. 262. « Memoire sur les Luxations du Coude, par Paul Denuce. Paris, 1354. Head of radius forwards. Anatomical relations. 584 DISLOCATIONS OF THE HEAD OF THE RADIUS. Fig. 239. Sir Astley Cooper was nnable to accomplish the reduction in two recent cases; and of the six cases which came under his immediate observation, only two were ever re- duced . In B ransby Cooper's edition of Sir Astley's work, other similar examples of non-reduction are re- lated. Malgaigne says that in a collec- tion of twenty-five cases which he has made, the accident was unrecog- nized or neglected in six, and in- effectual 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-set- ter," 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, aet. 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 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. H. H. B., aet. 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. Head of radius forwards. External appear ance of limb. DISLOCATION OF HEAD OF RADIUS 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 thrown from a carriage, producing 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 re- quested 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 ascer- tained, 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. , . ., „ ri, , , 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 dis- located 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, exceot 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 ot the same age as the other, was treated by Dr. Austin Flint and my- ' Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 21. 38 58G DISLOCATIONS OF THE HEAD OF THE RADIUS. self. 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 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 frac- ture was certainly incomplete :— Elizabeth Carmody, aet. 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 surg*eon 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 ' This case was erroneously reported to the N. Y. State Medical Society as an example of fracture of the radius, with dislocation. DISLOCATION OF HEAD OF RADIUS BACKWARDS. 587 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 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 sud- denly 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 Mal- gaigne, 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,2 one by Bransby Cooper,3 one hy Lawrence,4 one by Liston,5 two by Case,6 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 sup- posed 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 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. 6 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. s Parker, New York Journ. of Med., March, 1852, p. 188. 9 Markoe, ibid., May, 1855, p. 382. 533 DISLOCATIONS OF THE HEAD OF THE RADIUS. 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- firms his conclusion. 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, aet. 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 dis- tinctly 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 gradu- ally 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 liga- ment 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 chil- dren, 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 DISLOCATION OF HEAD OF RADIUS OUTWARDS. 589 Fig. 240. The forearm is slightly flexed and prone; and the whole arm is de- flected outwards from the elbow downwards; flexion and extension are difficult, while supination is impossible. Treatment.—Most surgeons have agreed that while extension and counter-extension are being made, the forearm should be forcibly 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 supina- tion seemed to throw it again out of place. According to Markoe, where the accident is com- plicated 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 band- ages, &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 He ad of the Radius Out wards. Dislocation of the head of the radius Denucd has collected four examples of this accident, backwards. 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 luxa- tion, 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 consecu- tive 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. 590 DISLOCATIONS OF UPPER END OF ULNA BACKWARDS. CHAPTEE VIII. DISLOCATIONS OF THE UPPER END OF THE ULNA BACKWARDS. This accident, the existence of which, as a simple luxation, is ren- dered 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 accu- racy. 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 back- wards, 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 re- porters 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 subluxa- tion of the ulna backwards may occur without either of the above Fig. 241. 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 olecranon process, while the head of the radius might be felt DISLOCATIONS OF THE. RADIUS AND ULNA. 591 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. Grosset, 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, "re- duction 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 CHAPTEE IX. DISLOCATIONS OF THE RADIUS AND ULNA (FORE- ARM AT THE ELBOW-JOINT). The radius and ulna may be dislocated at the elbow-joint back- wards ; laterally, that is, either inwards or outwards; and forwards. § 1. Dislocations of the Radius and Ulna Backwards. Causes.—In forty-four cases observed by me, the average age is about eighteen years; the youngest being four years old, and the oldest fifty-three. Twenty 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, 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 1 Gosset, Pirrie's Surg., Amer. ed., p. 259. 592 DISLOCATIONS OF THE RADIUS AND ULNA. Dislocation of the radius and ulna backwards. Fig- 242. still retaining its relative position to the ulna, lies upon the back of the humerus, or rather upon the posterior margin of its ar- ticulating 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 ten- sion, while the brachialis anticus is forcibly stretched or even torn. The median nerve is also pressed upon in front by the humerus, and the ulnar is occa- sionally painfully stretched over the project- ing 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 any- thing 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 accu- rate. 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-three 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; and in the case of a patient admitted to Bellevue Hospital, on the 14th of December, 1864, the dislocation having existed thirty- one days, but unaccompanied with a fracture, I found the arm straight, and there existed also a preternatural lateral mobility of the elbow- joint ; but never, in any instance, have I found it flexed to a right angle; yetl 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 diag- nostic of this accident. Sir Astley Cooper and Miller declare that in this dislocation the forearm is usually supinated; Pirrie says: "The hand is between prona- tion and supination, but more inclined to the latter;" Desault thinks it is sometimes in supination and sometimes in pronation; Denuce' con- cludes that it will occupy that position, whatever it may be, in which DISLOCATION OF RADIUS AND ULNA BACKWARDS. 593 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 pro- nation 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 projec- tion, 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 in- creased ; 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 forearm is shortened; the same result will be obtained also by measuring from the acromion process to either of the styloid pro- cesses ; 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 diag- nosis may be rendered exceedingly difficult, if not impossible; and in such cases we should confine the patient at once to his bed, and pro- ceed to reduce the tumefaction by cold 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 impos- sible, but by the aid of a perfect intimacy with the anatomical struc- ture of the joint, to detect the relations of one part with another; but 591 DISLOCATIONS OF THE RADIUS AND ULNA. even under this difficulty, the two points in question are readily dis- tinguishable. 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 circumfer- ence of oue-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 acci- dent and supposed that they had accomplished reduction, while in others the dislocation was mistaken for a fracture. A lad, AV. F., twelve years old, residing in Erie County, K 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 band, and producing a dislocation backwards of both bones at the elbow-joint. A Canadian surgeon, who saw the patient within three hours, recognized the dislo- cation, 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 imme- diately 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 com- plete 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. DISLOCATION OF RADIUS AND ULNA BACKWARDS. 595 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 fall- ing from a horse. The surgeon who was called regarded it as a frac- ture 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 hume- rus 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 Bochester, I renewed the attempt at re- duction. 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 pro- cedures. 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, set. 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 ao-ain; 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 supi- nation I did not think it prudent to make any attempt to reduce it, 596 DISLOCATIONS OF THE RADIUS AND ULNA. 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. The four last cases which have come under my notice, three of which were presented in my service at Bellevue Hospital, were all examined previously by reputable surgeons and declared to be frac- tures. 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 dis- located six months before, and the reduction of which had been ac- complished 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 improve- ment. Treatment—Sir Astley Cooper thus describes his own method of reducing this dislocation: "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 recom- mended by Erichsen, Gibson, Samuel Cooper, and others. The plan recom- mended by Dorsey is nearly identical with that just described, only that, in- stead of the knee, he advises that the surgeon " interlock his fingers in front of the arm, just above the elbow, and draw it backwards." On the other hand, Liston and Miller recommend, as a better mode of procedure, 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. Reduction with the knee in the bend of the elbow. DISLOCATION OF RADIUS AND ULNA BACKWARDS. 597 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 mid- dle, 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 pre- dilections 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 reduc- tion, 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, set. 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 re- duce 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 ansesthetic, and, if neces- sary, 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, set. 10, fell from a tree upon her hand. I was in attendance within half an hour, and found the usual signs charac- terizing this accident. Keduction 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 598 DISLOCATIONS OF THE RADIUS AND ULNA. 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 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 mani- fest. 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. Belinquishing my o-rasp, 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 placed 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, how- ever, 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 four- teen 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 ;x 1 Capelletti, Am. Journ. Med., vol. xix., from Annal. Univ. de Med. for Oct. 1835. DISLOCATION OF RADIUS AND ULNA BACKWARDS. 599 Sir Astley Cooper at three months;1 Malgaigne after three months and twenty-one days.2 Roux succeeded in a case of a young man twenty-two years of age, whose elbow had been dislocated five months.3 Blackman, of Cincinnati, informs me that he has reduced a lateral luxa- tion 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.4 Gorre, Gerdy, and Drake succeeded in four cases after six months ;5 and finally, Starch claims to have been successful after two years and one month.6 To which enumera- tion Denuce' has added seventeen other examples, said to have been reduced at various periods, ranging from one month to one hundred and fourteen days.7 I have reduced quite a number of these old luxations, the four last of which will be briefly recorded. Mrs. E. Broadway, set. 53, was admitted to Bellevue Hospital in Oct. 1865. When she came under my notice the dislocation had ex- isted ten days. The internal condyle was broken also, and the surgeon had supposed this to be the only accident. I reduced it easily, after giving her chloroform, by the method recommended by Dorsey. A woman, set. 30, was admitted to the same ward in Jan. 1866, with a supposed fracture at the base of the condyles. On the eleventh day she was brought to my notice. The reduction was effected in the same manner, before the class, but not until ether had been employed, and much greater force had been applied than was required in the 'previous case. Thomas Robertson, set. 35, was admitted Dec. 14th, 1864, with a simple dislocation of the radius and ulna backwards, which had existed thirty-one days, but which had not been up to this moment recognized by his surgeon. I reduced it before the class, by Sir Astley's method, the patient being under the influence of ether. Con- siderable force was required. Each of these patients recovered without any accidents. The next case possesses unusual interest. J. G., set. 7, was brought to me in Nov. 1865, with a backward dis- location of the right radius and ulna which had existed nine weeks. The arm was nearly straight and fixed. Having placed him under the influence of ether, assisted by Dr. Gurdon Buck, of this city, I proceeded to flex the arm slowly, and after a few seconds, and when the elbow was bent about ten or fifteen degrees, the olecranon process separated at the line of epiphyseal union. In a few moments the reduction was completed, and the arm brought to an acute angle, but the olecranon had separated full half an inch. We were quite certain that the ulna was perfectly reduced, but the head of the radius did not 1 Sir Astley Cooper, On Dislocations and Fractures, Amer. ed., p. 388. 2 Malgaigne, Amer. Journ. Med. Sci., vol. xxiii. p. 238, from Revue Med., Dec. 1837. 3 Roux, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Archives Gen., Dec. 1834. 4 Brainard, Illinois and Indiana Med. Journ., 1847. 5 M^moire sur les luxations du coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 6 Denuce, op. cit., p. S7. r °P- cit- 600 DISLOCATIONS OF THE RADIUS AND ULNA. seem to occupy its original position fully. Only moderate inflam- mation ensued. Passive motion was soon commenced, and I have since been informed that the motion of the joint is steadily increasing. Dr. W. F. Westmoreland, of Atlanta, Ga., has recently reported a case in which he succeeded readily in reducing a dislocation of the elbow backwards of five months' standing, in a woman aged 22 years. The reduction was followed by great pain, a good deal of swelling, temporary improvement of circulation in the radial artery, complete paralysis of the little finger and partial paralysis of the middle and ring fingers. On the fourteenth day, at which period the history of the case closes, all these symptoms were rapidly disappearing.1 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 late period, they are not probably in the proportion of one to five as com- pared 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 ex- amples 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.2 The dislocation being reduced, it may be a matter of prudence, some- times, 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 liga- ment, 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. ' Westmoreland, Atlanta Med. and Surg. Journ., May, 1866. 2 Crosby, Mussey, Trans. Amer. Med. Assoc, vol. iii. p. 357. DISLOCATION OF RADIUS AND ULNA OUTWARDS. 601 Fig. 244. § 2. Dislocation of the Radius and Ulna Outwards (to tee Radial Side.) The large majority of outward dislocations of the forearm are in- complete; 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 ex- amples, 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 direction. Of course those forces must act upon the bones somewhere in the neighborhood of the elbow-joint. 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 re- duction 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. If the annular ligament remains unbroken, the radius is displaced in the same di- rection 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 dislo- cation approaches more nearly to the character of a complete luxation. At the same time, owing perhaps to the resist- ance 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 rup- ture of the annular ligament. We have now only to suppose the action of a more considerable force in the same direction to render the dislocation complete; in 39 Most frequent form of incomplete outward dislo- cation of the forearm. 602 DISLOCATIONS OF THE RADIUS AND ULNA. which case the upper end of the radius is sometimes thrown com- pletely 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. Denuc£, 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 ex- tensively 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; once I have found it nearly or quite straight; occasionally it is flexed to a right angle. In all the cases seen by me the forearm has been pronated, and the elbow-joint has been very 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 dis- tinctly 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 de- grees, and immovably fixed. The head of the radius could be dis- tinctly 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 oppo- site arm. The inner condyle projected sharply to the inside, and the DISLOCATION OF RADIUS AND ULNA .OUTWARDS. 603 olecranon fossa was plainly felt with the fingers. The child was suf- fering very little pain. Seizing the wrist with my right hand and the lower end of the humerus with the left, and making moderate extension in these oppo- site directions, the bones easily, and after only a moment's effort, re- sumed their places. Her recovery was rapid and complete. James O'Neil, set. 16, was admitted to Bellevue Hospital in Dec. 1865, with a dislocation caused by the kick of a horse, the blow having been received on the ulnar side of the forearm, near the elbow- joint. When he came under my notice the dislocation had existed three weeks. I found the head of the radius reposing upon the radial and posterior side of the humerus. The ulna was displaced one inch to the radial side. The forearm was not at all, or but very slightly flexed upon the arm. The natural deflection of the forearm to the radial side was a little exaggerated: forearm pronated: elbow-joint admitting of a little motion; but motion caused great pain. This patient was not in my service, and I have not learned the result of the attempt at reduction. 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 an- other 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 haying been thrown into this position during the violent twistings to which the arm had been subjected.' 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, Wm. Kinkaid, fourteen years old, who had fallen from a wagon and struck upon the palm of his left hand. The sur- geon 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 1 Denuc6, op. cit., p. 103. 004 DISLOCATIONS OF THE RADIUS AND ULNA. prone nor supine. There existed only a slight motion at the elbow- joint. I did not think it worth while to make any attempt at reduc- tion. 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 elbow- joint, 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, N. Y., on the 31st of September, 1857, fell from the sweep of a 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 straight- ened 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 ex- tension was made at times with the arm flexed, and at others extended. At 9 P. M. another physician was called, who made efforts at reduc- tion until 3 A. M., upwards of six hours, at which time he also aban- doned 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 prona- tion 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 DISLOCATION OF RADIUS AND ULNA INWARDS. 605 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- 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 dislo- cation 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 1 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. 245), but it may suffer a luxation and be found a little in advance of the ulna, or possibly a i 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 acci- dent the coronoid process of the ulna is thrust upwards above the 606 DISLOCATIONS OF THE RADIUS AND ULNA. 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 dislo- cation is peculiarly liable to contusion, in conse- quence 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 concealing the epi- condyle ; while the head of the radius, having aban- doned its socket, may be felt indistinctly in the bend of the arm. The external condyle (epicon- dyle) is remarkably prominent. The forearm is generally more or less flexed, and the hand forci- bly 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 in- wards, 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 con- sidered 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 boards, and, in falling, he turned a summersault. The mother, to whom the child immediately ran, grasped his 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 con- dyle 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 Most frequent form of incomplete inward dislo- cation of the foreaTm. DISLOCATION OF RADIUS AND ULNA INWARDS. 607 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 epicon- dyle, 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. Dubruyn 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- maining example which has been put upon record, the precise cha- racter 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 than 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 per- fect as in the normal condition. . Treatment.—The indications of treatment are the same as m dislo- cations 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 ot the forearm which had just occurred. The hand and forearm were ma 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-exten- sion upon the arm, while a second made direct extension upon the forearm At first the tractions were made in the direction of the fore- arm (flexed and prone), but gradually the arm was straightened and ♦ supinated. Then the surgeon, seizing with one hand the superior ex- tremity 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. i Denuce, op. cit., pp. 154-156. 2 Ibid., p. 608 DISLOCATIONS OF THE RADIUS AND ULNA. § 4. Dislocation of 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 pro- cess ; but Monin, Prior, Velpeau, Canton,1 and Denuce" have each re- ported 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. Alex- andrine 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 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. 246. E. Canton's case of dislocation of the radius and ulna 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.2 1 Dub. Quart. Journ. of Med. Sci., Aug. 1860. * Denuce, op. cit., p. 110. DISLOCATIONS OF THE WRIST. 609 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 swft-luxation forwards, in which the extremity of the olecranon process has been found rest- ing upon the extremity of the humeral trochlea.1 Treatment.—If the dislocation is complete, and the forearm is short- ened 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. CHAPTEE 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 of the older writers, its frequency began to be questioned by Pouteau, and finally its ex- istence 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 de- clared that he would not positively deny the possibility of the acci- dent, 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 per- ceive 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 compose them. These tendons are bound together beneath the ante- rior annular ligament of the wrist; and thus offer so efficient a resist- ance 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-jomt 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 i Denuce, p. 120. 610 DISLOCATIONS OF THE WRIST. would be inadequate to overcome it; and the known power of the tendo Achillis is sufficient to prove that this computation is not ex- aggerated. " The risk of dislocation backwards by a fall on the dorsal surface of the hand is equally precluded by the tendons of the extensor mus- cles. Their arrangement and relations at the back of the joint tire 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 backwards is owing to the obstacles opposed by the flexor or extensor tendons.1' The opinion of such a writer as Dupuytren, whose experience was very great, and who described only what he had seen, is always en- titled 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 not- withstanding 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 re- markable 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 acci- dent 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 natu- ral 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, set. 18, by a fall upon his hand, broke the left DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 611 forearm below the middle, and at the same time, as he affirms, par- tially dislocated the carpal bones backwards. Dr. Spaulding, of Williamsville, N. Y., 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 horizon- tally, 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 push- ing 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 one-third of an inch, which shortening was due, no doubt, to the overlapping of the broken bones. § 1. Dislocations of 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 frac- ture 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 dislo- cation 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 pre- sented 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 projec- tions 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, 612 DISLOCATIONS OF THE WRIST. 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 was no grating, or chafing, or crushing, nor was the reduction accom- plished 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 fol- lowing 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, 1S58, 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 compli- cated 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 Fig. 247. lower part of the forearm and displaced; the first row of the carpal bones lying underneath the tendons, and upon the bones of the fore- DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 613 arm, sometimes having been carried directly upwards, sometimes up- wards 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, also, in a lesser or greater degree, in nearly all cases of simple dislocations. In compound dislocations, however, the muscles, or rather the ten- dons, 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 arm caught between the bumpers of two cars, bruising the hand and dis- locating the carpal bones backwards, the radius and ulna being thrown forwards and pushed completely through the skin into the palm of the 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 dili- gently 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 four- teenth 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 pro- jecting bones; the relation of these prominences to the styloid apophy- ses ; 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 ra- dius was broken higher up, and that it was not a dislocation at all. Prognosis.---In Compound dislo- Dislocation of the carpal bones backwards cations the prognosis is exceedingly (From skey.) grave, unless the surgeon determines to resort to amputation, or, what is generally much preferable, to re- section. In dislocations complicated with fracture of the posterior 014 DISLOCATIONS OF THE WRIST. 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, consti- tutes 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. 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 accident resemble in so many ■El; 0,4.0 ** g" points those of the preceding dislocation, with only the differ- ences 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 Disloca- tions. The case did not come under the observation of Mr. Cooper himself, but was related to him by Mr. Hay don, a sur- geon residing in London. It is especially interesting as furnish- ing an example of a dislocation of both wrists at the same moment, 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 formino- an " irregular knotty tumor, terminating abruptly" anteriorly. A very careful examination was made to determine what parts Dislocation of the carpal bones forwards Fergusson.) (From 1 Philadelphia Medical Examiner, lSli-S. DISLOCATIONS OF LOWER END OF ULNA BACKWARDS. 615 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- panied with a fracture. "More- over," says Mr. Haydon, " we were Fi§- 25°- strengthened in our opinion that this was a case of dislocation, un- attended with any fracture, because the dislocations appeared so per- fect ; the two tumors in each mem- ber so distinct; the reduction so , u 1V , . ' i p i Dislocation of the carpal bones forwards. (From complete; the strength ot the parts Skey.) 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 frac- ture." CHAPTEE 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 of 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 acci- dent 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 prona- tion 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 (sacci- form ligament), and also of the ligament which binds the ulna to the 616 DISLOCATIONS OF THE LOWER END OF ULNA. cuneiform bone: the little head or lower extremity of the ulna aban- doning 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 accom- plished 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 pro- jected 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 wrist-joint were now completely restored, and both pronation and supination were perfect. Symptoms.—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 con- stant tendency to displacement when the pressure was removed has rendered it necessary to employ splints and compresses. § 2. Dislocations 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, I think, to warrant any posi- tive conclusions as to the relative frequency of the two accidents. While the dislocation backwards is usually caused by violent pro- nation 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 re- duction was effected only while the hand was pronated. DISLOCATIONS OF THE CARPAL BONES. 617 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 ex- ists, 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 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 redislocation, 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 amor><* themselves, the carpal bones seldom become displaced except in gunshot wounds, or in con- nection with extensive lacerations and fractures of the neighboring parts. Simple dislocations, or rather subluxations 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 suf- fered simple backward subluxation, are the semilunar, cuneiform and pisiform of the first row, and the magnum of the second row. Richerand, the editor of Boyer's Lectures, says that he once met 1 Parker, Amer. Journ. Med. Sci., April, 1843, p. 470; from Lond. and Edin. Month. Journ. Med. Sci., Dec. 1842. 40 618 DISLOCATIONS OF THE CARPAL BONES. with a subluxation of the os magnum backwards, of which he has given us the following account: "Mrs. B., in a labor pain, seized vio- lently 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 Pro- fessor Baudelocque, she showed her left hand to this celebrated ac- coucheur, 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 extend- ing the hand, and as it would have been but little apparent in any state 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 pro- jection 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 repro- duced ; 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 some- times thrown a little backwards, from simple relaxation of the liga- ments, 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.2 Gras has described a dislocation of the pisiform bone,3 and Fergus- son says he has known an example in which this bone was detached 1 Richerand, Boyer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 2G1. 2 Sir A. Cooper, op. cit., p. 435. J Note to Chelius, by South, op. cit., p 234. DISLOCATION OF THE METACARPAL BONES. 619 from its lower connections by the action of the flexor carpi-ulnaris.1 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 con- sequence. Erichsen thinks he has seen a dislocation of the os lunare produced by a fall upon the hand when forcibly flexed. By exten- sion and pressure it was easily replaced, but when the hand was flexed the dislocation was immediately reproduced.2 Notwithstanding that Sir Astley, Miller, and others have taught that the cuneiform bone is liable to displacement, and that South has affirmed the same of the unciform, I have found no account of an ex- ample 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, with- out wound of the integuments, at the middle carpal articulation. A man had fallen forty feet, and was carried dying to the Hotel Dieu. The symptoms were almost precisely those of a dislocation of both rows of the carpal bones backwards. The reduction was not accom- plished 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 frag- ment of both the scaphoides and cuneiform remained attached to the second row, but with this exception, the separation was complete.3 CHAPTER XIII. DISLOCATION OF THE METACARPAL BONES (AT THE CARPO-METACARPAL ARTICULATIONS). The metacarpal bone of the thumb may be dislocated either back- wards or forwards. The former is the most frequent; and it is pro- duced 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 flask of rJbwder is exploded in the palm of the hand, or a blow is received upon the extremity and palmar 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 1 Fergusson, op. cit., p. 190. - 2 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 259. 3 Maisonneuve, Malgaigne, op. cit., from Mem. de la Soc. de Chirurg., t. n. 620 DISLOCATION OF THE METACARPAL BONES. 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 meta- carpal 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 Bour- guet, the head of the metacarpal bone almost reached the styloid pro- cess of the radius. 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 accom- plished 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 accom- plished, although the attempt was made on the second day by a sur- geon, 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 dis- location, 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 (de Cassis), Traite de Pathologie Externe, etc., 3d Paris ed., t. ii. p. 564. FIRST PHALANX OF THE THUMB BACKWARDS. 621 aid of splints it was retained in position, and the cure was perfect. The second, seen by Roux, was a backward luxation at the carpo- metacarpal 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 exten- sion 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), men- tioned by Malgaigne, occasioned by a fall upon the clenched band 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 he called upon a surgeon immediately, but he was unable to keep the bones in place. The projection was very manifest at the time ot my examination, and the hand had never recovered the power of grasp- ing: bodies firmly. . , . ■. ., During the same year I found in the hospital a precisely similar case in the person of Francis M'Coit, aet. 32, a sailor, which had occurred four years before, in consequence of a blow given with his fist, lhe same bones were partially displaced backwards, and remained unre- duced. This man had also consulted a surgeon soon after the injury rrrnn T6C61VGQ - • 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 1 have obtained casts of both in order to illustrate partial dislocations of the metacarpal bones. CHAPTER XIY. mmOCATIONS OF THE FIRST PHALANGES OF THE DITHU^B In% FINGBBS (AT THE METACARPO-PHA- LANGEAL ARTICULATIONS). § 1. Dislocations of the First Phalanx of the Thumb Backwards. This bone may be dislocated backwards or forwards, but most fre- nuln% the dSoLtion is backwards. I have met with the backward dislocation seven times, and the forward twice. Dislocation of the first phalanx of the thumb back- wards. 622 OF FIRST PHALANGES OF THUMB AXD FINGERS. 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 pha- lanx sliding back upon the distal extremity of the metacarpal bone, and standing off from it at an angle, the last being again flexed upon the first phalanx; meanwhile the distal end of the metacarpal bone is seen projecting strongly in the palm of the hand. (Fig. 251.) These are the usual signs which characterize this accident, and they are always sufficiently diagnostic. In a few cases, however, the pha- langes have been found extended upon the meta- carpal bone in almost a straight line. I have twice found them in this position. The reduction is sometimes, in recent cases, accomplished with great ease, as the following examples will illustrate. A servant girl, ast. 25, fell down a flight of steps Nov. 15, 1850, striking upon 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. Yery little swelling followed, and in three weeks she was able to use her needle without incon- venience. Michael Wolfe, 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 Wolfe 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 ioint was soon completely restored. Examples, however, are constantly occurring, which are only re- duced after long-continued and painful efforts, or which, indeed com- pletely exhaust the patience and baffle the skill of the most experienced surgeons. r Mary J. S, at. 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 success- fully m the case of the servant girl; only that he made extension upon the last phalanx at the same moment. The surgeon believes that the FIRST PHALANX OF THE THUMB BACKWARDS. 623 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 Gr. 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 conse- quence 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. In Sept. 1864,1 found in my service at the Charity Hospital (Black- well's Island), New York, an unreduced dislocation of this kind in a girl. The surgeons had tried to reduce it, but had failed. On the 25th of July, 1857, Catharine 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 un- successful attempts at reduction had been made. The dislocation was backwards, but the phalanges, instead of standing at an acute or 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 deter- mine, but the'same thing has been noticed occasionally by other sur- geons. 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 liga- ments or flexor tendons, so the bone remains unreduced. In the following case the relative position of the bones was the same as in the preceding case, but the reduction was not difficult. Bernard Lawler, a3t. 10, was admitted to Bellevue Hospital in Jan. 1864, with a fracture of the femur and other severe injuries. The dislocation of the thumb was not noticed until the ninth day. The 624 OF FIRST PHALANGES OF THUMB AND FINGERS. reduction was then easily accomplished, in presence of the class of medical students, by forced backward flexion. Surgical writers have recorded, from time to time, a great many cases in which it has been found difficult or impossible to effect re- duction; 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, Erich- sen, 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 Koser 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 mem- ber, 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 luxation the tendon of the long flexor so displaced inwards and en- tangled behind the extremity of the bone as to prevent reduction. Deville discovered in an autopsy a similar displacement of this tendon outwards. Wadsworth has made the same observation.2 The modes of reduction practised and recommended by these different surgeons are as diversified and Fi8- 252- irreconcilable as their views of the me- chanism 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 muscles as much as possi- ble ; and then by fastening a clove hitch 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 ' 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 2 Wadsworth, Amer. Med. Times, Feb. 13, 1864, p. 77. FIRST PHALANX OF THE THUMB BACKWARDS. 625 having been continued a considerable length of time, he advises that a weight shall be suspended to the thumb, passing over a pulley. 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. 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, Beinhardt, Gibson, of Philadel- phia, 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. Boser, 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. Vidal (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 Beuben 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 articu- lating 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 re- duction of the first phalanx from backward displacement is the short 026 OF FIRST PHALANGES OF THUMB AND FINGERS. 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 bv 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 collo- dion, and the thumb supported by a splint. As the patient was in- temperate, 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 dis- location."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 displaced extremity of the dislocated phalanx for the pur- pose of forcing it downwards, and at the same time grasp the displaced thumb with his other hand, and move it forcibly backwards and for- wards, 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."2 Six successive cases of treatment by this method are mentioned in the American Journal of Medical Sciences for April, 1858 ; one by Bickard, one by Morgan, two by Cutter, and two by Crosby. 1 Mussey, Trans. Amer. Med. Assoc, vol. iii. 1850, p. 357. 2 Batchelder, New York Journ. Med., May, 1856, p. 340. FIRST PHALANX OF THE THUMB BACKWARDS. 627 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;1 Lawrie advises that the thumb shall be thrust into the open handle of a large door key ;2 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. Bichard 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. 254. 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 oppo- site end is partly cut away, forming a projecting pin, and leaving a shoulder on each side of it. Towards this end of the strip, a sort of handle shape is given to it, so as to insure a secure grasp to the ope- rator. 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 encTof 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, 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. The loop nearest the first joint is then tightened by drawing on the Fig. 255. Levis's instrument applied to the first finger. 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, cross- i Op. cit., p. 561; also Bost. Med. and Surg. Journ., Oct. 1, 1857. 2 Lawrie,'Am. Journ. Med. Sci., vol. xxii. p. 229. 628 OF FIRST PHALANGES OF THUMB AND FINGERS. ing 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 pha- lanx 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," and know no other use for it than to Fig. 256. Indian "puzzle," employed for the reduction of dislocations in small joints. 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 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 pam and injury upon the limb. When we wish to remove it, we have only to cease pulling, and it drops off spontane- 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. "«»o Finally, in some compound dislocations it would be better not to ' Levis, Amer. Journ. Med. Sci., Jan. 1*57 p 62. Irans. Am. Med. Assoc, vol. i. p. 267. ' FIRST PHALANX OF THE THUMB FORWARDS. 629 attempt the reduction of the dislocation until resection has been prac- tised. Samuel Cooper relates a case in which the reduction was fol- lowed 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.1 Boux, Evans, Wardrop, Gooch, 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 Fiest Phalanx op the Thumb forwards. Up to the present moment, I have met with but two examples of this dislocation, while, as has been already stated, the backward dis- location has been seen by me seven times. Horace Kneeland, of Bochester, 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- ration under the palmar fascia; and in the end the thumb was almost completely anchylosed.2 On the 24th of April, 1855, J. M. Booth, of Buffalo, set. 19, called at my office, having a dislocation forwards of the first phalanx, occa- sioned, 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. ' Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 16. 8 Trans. N. Y. State Med. Soc, 1855, p. 73. 630 OF FIRST PHALANGES OF THUMB AND FINGERS. 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 re- duced ; Lenoir was able to effect the reduction by moderate measures, after the bone had been dislocated thirty-eight days. Ward succeeded by simple extension.1 Lombard, after the trial of other plans, finally succeeded by revers- ing 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 disloca- tions backwards. My own experience also authorizes me to recom- mend this plan. § 3. Dislocations of the First Phalanx of 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, set 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 as to render an error in the diagnosis impossible. Beduction 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 Fig. 257. Backward dislocation of first phalanx. Reduction by extension. bone. In short, the process was the same as that which we have recommended m dislocations of the thumb backwards. In the example of dislocation forwards, occasioned by a blow from 1 Ward, New York Med. Times, Sept. 8, 1860. PHALANGES OF THE THUMB AND FINGERS. 631 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. Beduction 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 OP THE SECOND AND THIRD PHA- LANGES 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 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 dislo- cation. In most cases 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 632 PHALANGES OF THE THUMB AND FINGERS. 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 °he 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 reduc- tion was accomplished. Fig. 258. Dislocation of the second phalanx backwards. James Cooper, aet. 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, com- pletely, 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. 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 sur- geon, 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 Fig. 259. Dislocation of the second phalanx forwards. 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 PHALANGES OF THE THUMB AND FINGERS. 633 occurred, but had failed. The joint was nearly anchylosed, yet the finger was quite as useful for all ordinary purposes as before. 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 gutta- percha 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, fre- quently 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. In one case of simple dislocation of the last phalanx of the thumb backwards I have been obliged to resort to section of the lateral liga- ments before accomplishing the reduction. This was in the person of a woman admitted to Bellevue Hospital in February, 1864. The acci- dent had happened seven days before, by falling and striking upon the end of the thumb. The position of the last phalanx was extended,' that is, in a line with the axis of the first phalanx. She said, how- ever, that it was at first " bent straight back," but that a man took hold of it and pulled it out. Having placed her under the influence of ether I attempted reduction by forced backward flexion, but failed. I then cut the lateral ligaments by subcutaneous incision and the reduc- tion was accomplished with great ease. 41 634 DISLOCATIONS OF THE THIGH. CHAPTER XVI. DISLOCATIONS OF THE THIGH (COXO-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 neces- sary 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 here- after 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 pro- cess 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 back- wards 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 anoma- lous 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, re- versed the order of the last two varieties, arranging dislocations upon the pubes, in the order of frequency, before dislocations into the fora- men thyroideum. DISLOCATIONS OF THE THIGH. 635 Coxo-femoral dislocations may occur at any period of life; one example is mentioned, in the Gazette Medicale, 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,2 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 Frovincial Medical and Surgical Associa- tion 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 ad- mitted 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 manipu- lation.5 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 years 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 " 2!) " 45 to 60 "... 7 " 60 to 85 1 case ' New York Journ. Med., Nov. 1850, p. 416. 2 Amer. Journ. Med. Sci., vol. xxxi. p. 207, Jan. 1843. 8 London Med.-Chir. Rev., Dec. 1828, p. 251. 1 New York Journ. Med., Sept. 1848, p. 281. 5 Ibid., March, 1852, p. 259. 6 Boston Med. and Surg. Journ., vol. xxiv. p. 220. i A. Cooper, on Disloc, Amer. ed., p. 83, Case 27. 8 Buf. Med. Journ., vol. viii. p. 6. Trans. New York State Med. Soc, 18.'5. My Report on Disloc. 9 Amer. Journ. Med. Sci., Feb. 1839, p. 296. 10 Gibson's Surg., vol. i. p. 389. u Gauthier, Malgaigne, op. cit., p. 805. 086 DISLOCATIONS OF THE THIGH. 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 m women; owing, pro- bably 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 bv me one hundred and four were in males and eleven in females Dr J K Dodgers, of New York, mentioned, however, at a meeting ot the New York Kappa Lambda Society, that he had seen and reduced four dislocations of the femur upon the dorsum ilii m 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. Sun__" Upwards on the dorsum ilii;" Sir A. Cooper, Miller, Pirrie. " Upwards and outward ;" 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 mo- ment 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. B., of Bochester, N. Y., set. 10, fell, in Feb. 1841, from the top of the high bank just below the Genesee Falls, at Bochester, a distance of about one hundred feet. Before he reached the bottom of the preci- pice, he struck upon an oblique plane of ice, from which he slid gradu- ally 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 as- sistance. He remembers very well that when he struck the glacier, the concussion was received upon the right side of the right knee, and a 1 J. K. Rodgers, New York Journ. Med., July, 1839, vol. i. First ser. p. 220. '■ Gibson's Surg., vol. i. p. 385. Sixth ed. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 637 Fig. 260. mark of contusion at this point confirmed his statement. Dr. Ellwood, of Bochester, 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 appli- cation 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 ex- tensively, but especially in its posterior half; the round ligament is ruptured; some of the small external rotator muscles are generally stretched or torn completely asunder, the glutaeus 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 tri- ceps 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 re- duction 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 con- fidence ascribed the opposition to an en- tanglement 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. Beid 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 condi- tion 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- Dislocation upon the dorsum ilii. 1 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 63S DISLOCATIONS OF THE THIGH. 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 mus- cles 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 re- sistance 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."2 Dr. Moore, of Rochester, who has often repeated the same experiments upon the cadaver, de- clares, 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 accom- plished until this was more completely broken up;3 while Markoe, of New York, attributes the resistance to both the muscles and the cap- sule, 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 par- tially 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 some- times 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 ' New York Journ. Med., Sept. 184S, p. 268; from New Orleans Med. and Sur*. Journ., July, 1848. a \ \Y-^' *?0V' I???' P* 423' et Se<1' 3 Ibid-> July, 1855, p. 69. 1 Ibid., Jan. 1855. "" ' r UPWARDS AND BACKWARDS ON THE DORSUM ILII. 639 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 the average'shortening is about one inch or one inch and a half, it does occasionally reach three inches. The thigh is rotated inwards, ad- ducted and slightly flexed upon the pelvis. The great toe of the dis- located 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 pa- tella. 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, flex- ion, &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 asun- der, or only put upon the stretch, and perhaps also according to the amount of injury and conse- quent relaxation which they may have sustained from the shock. The thigh can be easily flexed; adduction is more difficult, but ab- duction is almost impossible,except to a very limited extent: the body of the patient is a little bent for- wards- he roundness of the hip is lost in consequence of the relaxa- tion of the gluteii muscles; the trochanter major is depressed, and approaches the anterior superior spinous process of the ilmm, 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 mav 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 it possible, in the erect posture; after which, it will be well to place the Dislocation upon the dorsum ilii. 640 DISLOCATIONS OF THE THIGH. 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 mode- rately or not at all; the patient is sometimes able to walk for a short distance; fractures of the neck of the femur generally occur in ad- vanced life. In dislocation, crepitus is not often present, and only when a frac- ture 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-quar- ter 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 Bhiladelphia, 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 neighbor- ing 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 re- placing 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 men- tioned 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 inflam- mation 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. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 641 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, set. 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 livino- 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 arrrange the various methods of reduction which have been employed by surgeons under two principal heads, namely, mam- pulationPand extension8 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 ex- tension has usually been employed alone, but almost always some He^of extension has been recommended in connection with he manipulation; if not in the first instance at least in the event ot the Silure of manipulation alone; while on the other hand, extension is eklorif™verPpractised without manipulation. We intend then to mply by these designations respectively that either manipulation or extension has constituted the prevailing feature in the treatment Beduction by manipulation dates from the earliest records of our scienceSays Hippocrates: "In some the thigh as reduced with no Preparation with slight extension directed by the hands and with sliXt movement; and in some the reduction is effected by bending ^^^^^^^^^^ - follows: "If the thigh-bone be luxated inwards, and the patient young and of a tender i Works of Hippocrates, Syd. ed., vol. ii. p. 643. 642 DISLOCATIONS OF THE THIGH. 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 consider- able muscles being upon the stretch, the bowing of the knee as afore- said reduceth it; yet in rough bodies it may require stronger exten- sion."1 Bichard Boulton repeated, in 1713, almost the same instructions, affirming that this plan was applicable especially to dislocations in- wards, in the case of " young and tender children."2 In 1742 Daniel Turner declared that he had reduced three disloca- tions 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 counter-extension 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 pre- ence 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 ap- ply. 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 exten- sion. " 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 ' Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King Charles II. London, 1676. Book vii. chap. viii. 8 ^A System of Rational and Practical Surgery. By Richard Bovlton. London, 1713, » The Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 339. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 643 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 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 dislo- cation 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 coun- ter-extension ; 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 re- turn to the cotyloid cavity during extension; fifth, that feeble exten- sion 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 cor- rect 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 dislo- cated hip, or any other dislocation." He further adds that he once reduced a dislocation upon the dorsum ilii after he had pulled in every direc- tion but the right, " by carrying the knee towards the patient s face. Subsequently the son of Dr. Smith, Nathan B. Smith, the present dis- tinguished 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 prac- ' Anderson. Medical Commentaries, Edinburgh, 1776, vol. ii. pp.1261-4. 2 Vidal (de Cassis) ; from ffiuvres posthumes de Pouteau Paris, 1783. 3 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. s 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. 644 DISLOCATIONS OF THE TniGII. tice, 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 given as follows: " The patient being prepared for the operation by whatever means may be deemed necessary, may be placed in an atti- tude 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 band- age. 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 versd, 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 Avhich, therefore, the abductor muscles would drag it with less diffi- culty 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 Boston, who was a pupil of Nathan Smith's, gives the following account of the method practised by him success- fully, about the year 1820, and which method, he says, was recom- mended 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 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. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 645 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, 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 in- wards. It then readily returned to its socket, with an audible snap. Fig. 262. 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 re- quired 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 ligament, become the natural fulcrum, over which the thigh as a lever, acts to bring the head down and inwards into the socket Kluo-e 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.* Wathman, m 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 i Howe. Boston Med. and Surg. Journ., vol. xxii. p. 249, May, 1840. * Chelius's Surg., by South, Amer. ed., vol. n. p. 241. 646 DISLOCATIONS OF THE THIGH. angle with the long axis of the body; when, if the outward "self- twisting of the thigh" occurs, "which cannot be prevented by fast 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 Bust recommended also, in 1826, a similar plan, combining mode- rate extension by the hands, with flexion and abduction of the thigh.' Colombat, whose opinions date from 1830, suggested that the pa- tient should lay himself forwards upon a bed or 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 cir- cular rotation, either from within outwards, or from without inwards, as the surgeon may choose.3 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 dislo- cation 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 car- ried 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 ace- tabulum. At this moment he directed the limb to be forced toward its fellow, by which the reduction was effected with the greatest pos- sible ease and elegance."5 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 ;6 Desprez, in 1835 ;7 Yial in 1841 ;8 Fischer, Mahr, and Clarke, in 1849.9 In 1851, Dr. W. W. Beid, of Bochester, N. Y., published an account of the method practised by himself successfully in three cases of dis- location 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 m " flexing the leg upon the thigh, carrying the thigh over • Chelius's Surg., by South, Amer. ed., vol. ii. p. 240. » Ibid., p. 241, note by South. 3 Malgaigne, op. cit., vol. ii. p. 825 4 Malgaigne, op. cit., p. 823. ' " P 1852IngallS' BraDSby C°°Per'S ed* °f SiF Astle7'S En§lish e 1842> and Amer- ed., I 5b1;Jius's SurS-> note *>y S°uth. ' Malgaigne. B Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1652. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 647 the sound one, upwards over the pelvis as high as the umbilicus, and then abducting and rotating it."1 Dr. Markoe, of New York, adopts the same procedure, except that 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 re- sume its place in the socket.2 Beduction by extension dates from a period equally early with re- duction 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-ex- tending bands being secured around the chest under the armpits, and also, if thought necessary, in the perineum of the sound side. Fig. 263. 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 in- sisting that a flexion should be increased.to a right angle with the V. A * The French surgeons, including Boyer and Yidal (de Cassis), prefer ' Reid, Buf. Med. Journ., vol. vii., Aug. 1851, pp. 129-143. « Markoe, New York Jouru. Med., Jan. 1855. 3 Works of Hippocrates, Syd. ed., London, vol. ii. p. 641. 648 DISLOCATIONS OF THE THIGH. 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 pres- sure of the bandages. Mr. Skey adopts the same method. Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 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 Boux, follow- ing 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 beattempted by simply placing the heel in the perineum and making the exten- sion 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 Fig. 264. Reduction of a dislocation on the dorsum ilii, by pulleys. relaxed by nauseating doses of antimony and by the hot bath, he is to be placed on his back upon a table of convenient height between two 1 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 649 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 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 oppo- site ends of this bundle of ropes being made fast to the limb and the Fig. 265. 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 speak- ino- 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 1 Gilbert, of Philadelphia. Note to Pirrie's Surg.; also Amer. Journ. Med. Sci., vol. xxxv., April, 1845. , , . 2 Crandall, Bost. Med. and Surg. Journ., vol. xxxix. p. 11 ; Atlee, Trans. Amer. Med. Assoc, vol. iii. 1850, p. 357. 42 6.">0 DISLOCATIONS OF THE THIGH. 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. Fig. 266. Jarvis's adjuster, applied for reduction of a dislocation of the hip. Mr. Fergusson says that the Lancet for July 26, 1845, contains a description of a similar apparatus constructed by Coxeter at the suggestion of G. N. Epps;1 and L'Estrange, of Dublin, has invented Bloxham's "dislocation tourniquet," applied for reduction of a dislocation on the pubes. a "windlass" for making extension, with a "forceps" by which the extending power can be instantly disengaged.2 Mr. Bloxham's "dis- location tourniquet" is also very simple, and Mr. Erichsen affirms that 1 Fergusson, 4th Amer. ed., p. 200. 2 Ibid., p. 198. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 651 by it " any amount of extending force that may be required can be readily set up and maintained."1 Sedillot, a French surgeon, has suggested that when pulleys are used, we should measure the exact power employed in the reduction, by an ingeniously contrived appa- ratus called the dynamometer.2 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 impossi- ble 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 ques- tion. 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 reduc- tion 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. Beid, of Bochester, again called the attention of the profession to this subject, illustrating his views by the results of several successful experiments and by in- genious 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 manipula- tion having been reported since the year 1851, the period of Dr. Beid'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.3 " 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, travel- lino- from the dorsum of the ilium to the ischiatic notch, and from thence to the foramen ovale; or directly from the dorsum to the fora- men, and back again; or in other directions, according to the character i Erichsen, Amer. ed., 1858, p. 242. 2 Amer. Journ. Med. Sci., vol. xv. p. 530. 3 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 Damainville. 652 DISLOCATIONS OF THE THIGH. 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. One of my own cases will especially serve to show with what impunity sometimes these changes may be made. " John Caswell, set. 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 be- fore. 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 my- self 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 revers- ing the movements, it was easily replaced upon the dorsum ilii. The seventh trial was made in the same manner, except that when I sup- posed 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 Since this paper was written the following cases have come to my knowledge. December 9th, 1865, Dr. James B. Wood attempted, at the Bellevue Hospital, the reduction of a dislocation of the femur upon the dorsum ilii of five months' standing, in a man sixty years of age, in the presence of Dr. Sayre, myself, and the class of medical students. The patient was under the influence of ether. Manipula- tion alone was employed. Probably half an hour had been consumed in the various efforts, when, at a moment when the thigh was being forcibly abducted, the neck was broken within the capsule, and very close to the head. I was able to feel the head of the bone distinctly, after the fracture, and to move it freely separated from the neck. Dr. Daniel Prince, of Illinois, who was present at the time, informed me that he had himself fractured the neck of the femur in attempting the reduction of an ancient dislocation of the hip by manipulation. " 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, aet. 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 1 Buffalo Medical Journal, vol. xiii. p. 682. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 653 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 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 manipula- tion. "Assisted by my pupil, Mr. Hodge, I have also succeeded in collect- ing sixty-two cases of attempts at reduction by extension; a great majority of which, we find, were reduced in the first trials; but five cases 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 pro- fesses 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.2 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 Bandolph 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. "The fifth case is related by Sir Astley Cooper, as having occurred at the Brighton Hospital, under the care of Mr. Gwynne; the dislo- cation was upon the dorsum ilii, and was supposed to have existed about one month. The neck of the femur was broken in the first at- i London Med.-Chir. Rev., Nov. 1828, p. 239. 2 Malgaigne, op. cit., vol. ii. pp. 146 and 830. » Gibson's Surgery, sixth ed., vol. i. p. 389. 654 DISLOCATIONS OF TnE TniGH. tempt at reduction, and while the surgeon was making extension, with gentle rotation.1 "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 Lancet2 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.3 "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.* " As to the relative chances of failure by the two methods, the testi- mony 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 Hos- pital ; 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.5 " 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 o-eneral rule unsuccessful cases are not published by private practitioners, but suc- cessful cases are pretty certain to be made known; while, on the other 1 Sir Astley Cooper on Disloc, &c, Amer. ed., p. 88 J Op cit., vol. i. p. 767, 1840-41. Cooper on Disloc*., p. 69. Malgaigne, op. cit., vol. ii. p. 164 et seq. * S,r Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96. 1 Van Buren, New York Med. Times, Jan. 1856, p. 126. UPWARDS AND BACKWARDS ON THE DORSUM ILII. 655 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 succes- sive 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 cir- cumstance 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 convic- tions upon this subject, reserving to ourselves the right of a change of opinion whenever the proofs shall warrant it. "Manipulation, owing to the greater power which may be brought to bear upon the neck and head of the bone through the action of the 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, suppura- tion, 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 under- stood, these evils may be lessened; yet we can scarcely persuade our- selves that by any future observations, the state of the question will ever be greatly changed. We cannot but think, also, that some con- clusions 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 conse- quence 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 ot 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; 656 DISLOCATIONS OF THE THIGH. 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 direc- tion 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 inclina- tion. 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 out- wards, 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 in- terpreted by some writers to mean that he would carry up the limb 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 modifica- tions, 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 prac- tised in successful manipulation. . We repeat, however, that as a general rule, the knee must be car- ried 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 opera- tion, if successful, is not usually painful, and we need that the patient UPWARDS AND BACKWARDS ON THE DORSUM ILII. 657 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 pre- liminary 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 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 Fig. 268. Reduction of dislocation upwards and backwards upon the dorsum ilii, by the pulleys and thigh belt. choose, a leathern thigh belt. For the purpose of counter-extension a sheet is folded diagonally, and its centre being applied to the peri- 658 DISLOCATIONS OF THE THIGH. neum 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 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. Under- neath the upper part of the dislocated limb a strong and broad band- age 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 de- scent. The length of time which will be required to bring down the limb must differ greatly in different persons, according to the peculiar cir- cumstances 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 j the flexion, or suddenly release the tension, or, in fine, again resort to I. manipulation alone. f When the reduction is accomplished, the patient should be laid j upon his back, with the knees resting over a pillow, and tied together i lightly with a towel or a strip of cotton cloth. In order also the more i * certainly to prevent a reluxation, the thigh of the dislocated limb ! should be gently rotated outwards, by which the head will be pressed i * forwards against the anterior portion of the capsule. ! I 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 UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 659 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 un- timely 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 off, and the head of the femur has consequently lost its natural support in this direction. The possibility of this accident is also confirmed by the examples of "voluntary" dislocations which I shall relate in the last section of this chapter. § 2. Dslocations Upwards and Backwards into the Great Ischiatic Notch. Syn.—"Upwards and backwards into the ischiatic notch;" Sir A. Cooper. "Up- wards 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 upon a disloca- tion upon the dorsum ilii; but it is very certain that it often occurs as a primary accident. Not unfre- quently, 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 re- cently dead, whose thigh had been dislocated into the ischiatic notch, found the glutaeus maximus nearly torn asunder, the head of the femur Fig. 269. Dislocation upwards and backwards into the great ischiatic notch. (From A. Cooper.) i Malgaigne, op. cit., torn. ii. p. 630. 2 Ibid., p. S40. 660 DISLOCATIONS OF THE THIGH. 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 com- pletely 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 269 is a representation of this specimen. Dr. Joseph C. Hutchinson, of Brooklyn, N. Y., has reported an ex- ample of this dislocation in which death having occurred four days after reduction, he was able to ascertain the character of the lesions. By the courtesy of Dr. Fig. 270. Dislocation upwards and backwards, into the great ischiatic notch. H., I was permitted to be present at this autopsy, and the lesions were found to be much the same as in the case related by Syme; but the glutaeus minimus was not torn, and there was added a laceration of the obturator externus. Dr. Lente has reported one other dissec- tion made after reduction.2 Symptoms.—The posi- tion of the limb is in some cases nearly the same as in certain dislocations upon the dorsum. It is shortened usually about. half an inch, the thigh being flexed upon the body, adducted and ro- tated inwards; but the flexion is usually less than in dislocations upon the dorsum, while on the other hand, it is some- times much greater. Generally it is such that when the patient is stand- ing 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 1 Amer. Journ. Med. Sci., vol. xxxii. p. 460. 2 Lente, New York Journ. Med., Jan. lsul. UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 661 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 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 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 projec- tion of the head of the femur may be felt by passing the finger into the rectum or vagina. In this way Dr. Sayre and myself determined a dislocation into the ischiatic notch which had existed six months in a boy twelve years old; and Dr. Wood with myself diagnosticated the same dislocation in a woman at Bellevue Hospital, which had existed four weeks, in the same manner. Prognosis.—I have seen two dislocations of this character which were not recognized by the surgeons at the time of the receipt of the injury, nor for some weeks afterwards. One 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 short- ened one inch; it was also forcibly adducted and rotated inwards. Dr Colegrove a very excellent surgeon, 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 I he second was in the case of the boy seen by Dr. Sayre and myself to which 1 have just referred. , Treatment—In employing manipulation, we may follow, with onfy 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 i Am"! J°oZ: ^tt^^lU^l, from Lond. and Edinb. Month. Journ., July, 1^43. 662 DISLOCATIONS OF THE THIGH. 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. Dost 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 coxa- rius. Barker 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. In Dr. Hutchinson's case, to which I have already referred, the first attempt at reduction was made without an anaesthetic, and by manipu- lation after the method described by Beid. The first two attempts failed, and in the third, the limb being more abducted than before, the head of the bone was thrown into the foramen ovale. By reversing the movements it was replaced in the ischiatic notch: and this change of position was made seven or eight times. The patient was now etherized and the bone was lifted into its socket in the same manner which I have described in the case of Caswell. 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 McCormick, aet. 21, a laborer on the "State Line Bailroad," 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 im- mediately 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 arrano-e- ments 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 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 direction, 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 accom- plished; 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 slip ping was felt, and on dropping the limb it was found to be in place and in form, with all its mobility completely restored. 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. 663 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 pro- cedure was only a few seconds. Fig. 271. 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 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 so 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, 664 DISLOCATIONS OF THE THIGH. therefore, to be made at an angle of 45°; and if this is not alone suffi- cient, 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 con- stantly disposed to do, when the limb is so much flexed. This dis- position 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 fol- lowing 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, 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 re- laxed by cutting the cord, and the thigh, at the same instant, was abducted and rotated outwards, the head of the femur left the ischiatic 1 Annan, Amer. Journ. Med. Sci., vol. xix. p. 382, Feb. 1837. INTO THE FORAMEN THYROIDEUM. 665 notch, and rose upon the dorsum ilii, assuming a position directly above the acetabulum, and below the anterior superior spinous pro- cess ; and from which position it was subsequently, with great diffi- culty, returned to the socket.1 § 3. Dislocations Downwards and Forwards intp the Foramen Thyroideum. Syn.—"Downwards into the foramen ovale;" Sir A. Cooper. "Downwards into the obturator foramen;" Lizars. "Downwards and forwards into the foramen obtu- ratorium ;" B. Cooper. "Inwards and downwards into the oval hole;" Chelius. " Downwards and forwards into the foramen ovale;" Pirrie. "Downwards and in- wards;" Boyer. "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. Ferhaps 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 lodge- ment upon the obturator externus muscle, over the foramen thyroi- deum. 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. _ Ferhaps it was only an example of a partial luxation; of which species of for- ward luxation I shall hereafter relate another case as having come under my own notice. Jacob Lower, aet. 10, fell from a tree, a height of about twelve feet, to the o-round. It is not known how he struck. He became imme- 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 lus- tily 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 le°- carried away from the other, and turned outwards. He lifted him up to place him in a small hand wagon, which was long enouo-h for his body, but only one foot and a half in width. Finding that his right leg was so much abducted as to prevent his being laid ' Lente, New York Journ. Med., Nov. 1850, p. 314. 43 666 DISLOCATIONS OF THE THIGH, 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 Fig. 272. Fig. 273. Dislocation downwards and forwards into the fora- men thyroideum. 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 he- morrhage from the bladder contin- ued 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. If we attempt to reduce by manipulation, it will be necessarv to follow the same rule which we have stated as applicable to disloca- tions 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 abdo- men, 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 Dislocation downwards and forwards into the foramen thyroideum. INTO THE FORAMEN THYROIDEUM. 667 should be gently rotated inwards for the purpose of directing the head toward the acetabulum. The reduction may also be sometimes facili- tated 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 direc- tion 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 E. L. Brodie, of the U. S. Arm}7, were successful ;* 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, prac- tised 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, aet. 33, fell from the second story window of the city post office, upon a stone pave- ment, 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- bly abducted; slightly rotated outwards, and lengthened, by measure- ment 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 in- ' W. H. Van Buren, New York Med Times, Jan. 1856, p. 127. 2 11. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 90; from Charleston Med. Rev. 668 DISLOCATIONS OF THE THIGn. wards. 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. Sir Astley Cooper's mode of reducing a recent luxation 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, 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 UPWARDS AND FORWARDS UPON THE PUBES. 669 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.2 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. Syn,—" Upwards and forwards on the horizontal branch of the share-bone ;" Che- lius. " Forwards upon the pubes ;" Pirrie. "On the body of the pubes, below the spine and transverse part of the bone ;" Skey. " Sur-pubic ;" Gerdy. "Ilio-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. Ure, into St. Mary's Hospital, London, with a dislocation upon the pubes, occa- sioned by swimming. His account of it was, that, when in the act of "strikino- 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 good deal of difficulty. The examination proved that he had a dis- location upon the pubes, which Dr. Ure easily reduced3 Pathological Anatomy.—-Sir Astley Cooper dissected the hip ot 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 i Practical Surg., Amer. ed., p. 93. 2 Brainard, North Western Med and Surg. Journ 1852 » Medical News and Library, vol. xvi. p. 1; from Lond. Lancet, Nov. 7, 1857. 670 DISLOCATIONS OF THE THIGH. 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. 275.) Fig. 275. Specimen of dislocation upon the puhes, in 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. 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. Larreysaw 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- bulum," in which the limb was not at all shortened, but, on the con- trary, a very little lengthened.' 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 1 Dorsey's Surgery, vol. i. p. 238, 1813. UPWARDS AND FORWARDS UPON THE PUBES. 671 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 Fis- 276, unnatural position. Prognosis.—Sir Astley Cooper remarks that although this acci- dent 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 oc- casionally recovered with very useful limbs. Treatment.—From the several reported examples of dislocation upon the pubes reduced by mani- pulation, 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., and the two remaining examples were both reported by E. J. Foun- tain, of Davenport, Iowa. Dr. In- galls succeeded by carrying the limb 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 dislo- cating 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 Dislocation upwards and forwards upon the pubes. 672 DISLOCATIONS OF THE THIGH. 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 oppo- site 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 subse- quently 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. Baron Larrey has reported a case of dislocation " before the hori- zontal 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."2 This is the same of which we have already spoken as being attended with the unusual pheno- menon 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 1 Fountain, New York Journ. Med., Jan. 1856, p. 69 et seq. 2 Larrey, Lond. Med.-Chir. Rev., Dec. 1820, p. 500 ; vol. i. first ser., from Bullet. de la Fac. de. Mea\, No. 1. ANOMALOUS DISLOCATIONS. 673 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. 277. 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 of the Four Principal Divisions before described.1 1. Dislocations directly Upwards. Syn.—" Sus-Cotylo'idiennes ;" 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 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 ot the limb, slight abduction and extension, with extreme eversion or rotation outwards. The eversion of the -toes together with the slight • Malgaigne, Traite des Frac. et des Lux., torn. ii. p. 869 et seq Samuel Cooper, FirsiLines8, 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 a HrDital Reports ;01. i. 1836, pp. 79 and 97 ; vol. iii. 1838, p. 163. London Lancet, £nd ed voL i 1848, p. 184; vol. ii., 1840, p. 281; vol. i., 1846 p. 412 ; vol. ii. p. 159 London Med. Gaz., vol. xix. pp. 657 and 659; vol. x. p. 19 ; vol xxxui. p. lad !£5 fh Trans vol. xx. p. 112. Lente's paper on "Anomalous Dislocations Sth, H?tf Joint » in New Yok Journ. Med. for Nov. 1850, p. 314 et. seq. Philadelphia Id F^aminer 'No 51 Amer. Journ. Med. Sci., vol. xvi. p. 14. New York Med. and Phyrjoum., 1826 vol. v. p. 597. New York Journ. Med., Jan., 1860, Dr. Shrady's case. 674 DISLOCATIONS OF THE THIGH. 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 diffi- cult, 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 bpne 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 conse- quent 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 chlo- roform, and by rotation of the limb in various direction.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, car- ried up toward the face, abducted, then rotated inwards, gently ad- 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 exten- sion 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 1 Cummins, Guy's Hospital Reports, vol. iii. p. 163, 1838. * Lente, New York Journ. of Med., Nov. 1850, p. 314. » Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper. anomalous dislocations. 675 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 in- wards, 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 suffi- ciently 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 Ischi- atic 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 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 re- peated the attempt at reduction, but without success, as the result 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 i Kirkbride, Amer. Journ. of Med. Sci., vol. xvi. p. 13. 1176 DISLOCATIONS OF THE THIGH. bone, but with no better success than had attended the efforts pre- viously 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, con- sidering 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 short- ened 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.3 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 glutaeus 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. Syv.—" Sous-cotylo'idiennes ;" Malgaigne. The following is one of several similar examples now upon record:— A man aet. 50, was admitted into the London Hospital under the care of Mr. Luke. A dislocation of the left femur was easily diagnos- ticated, but the symptoms were peculiar, inasmuch as the limb was lengthened one inch, without either inversion or eversion; yet the 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 house- surgeon, before dissecting the parts, again dislocated the bone. This was done with ease, and it was clear that the original form of disloca- tion 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 be- tween the two, immediately beneath the lower border of the acetabulum. The gemellus inferior and the quadratus femoris had been torn, 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. 1 Amer. Journ. Med. Sci., vol. xvi. p. 226,1835. From Lond. Med. Gaz., vol. x. p. 19. Wormald, London Med. Gaz., 1836. ANOMALOUS DISLOCATIONS. 677 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 re- duced a sub-cotyloid, incomplete dislocation, in a man aet. 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 ascendantede l'ischion;" D'Amblard. " Inwards on the ramus of the os pubis ;" Skey. D'Amblard published an example of this accident in 1821, occa- sioned 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 three following examples, except that in the first case the toes were turned slightly inwards, while in each of the other cases they were turned outwards.2 Mr. E----, aet. 35, a calker by occupation. The injury was re- ceived 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 him- self 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, ac- companied with moderate rotation, was then made in a direction out- wards and downwards, bringing the head of the bone over the ascend- ing ramus of the ischium, beyond which it was lying, into the foramen thyroideum; and from this position the bone was replaced in the acetabulum, by carrying the dislocated limb forcibly across the oppo- site one. The patient soon recovered the use of the joint.3 J. B., an Irishman, aet. 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 under- mined a bank, it unexpectedly fell upon his back while he was stand- ing 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 peri- 1 Luke Med. News and Library, vol. xvi. p. 34, March, 1858; from Med. Times andi Gaz., Jan! 2, 1858. 2 Malgaigne, op. cit., torn. ii. p. 876. s W. Parker, New York Med. Gaz., 1841; N. Y. Journ. Med., March, 1852, p. 188 678 DISLOCATIONS OF THE TniGH. neum. 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 proba- bly 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."1 A man, set. 22, was admitted to the Toronto Hospital, under the care of Dr. E. W. Hodder, Jan. 15, 1855, having been injured by the fall of a bank of earth an hour before. The head of the right femur was found under the arch of the pubes, the neck resting upon the as- cending ramus. The thigh formed nearly a right angle with the body; it was also strongly abducted, and the toes were slightly everted. On the following day, the patient being placed under the influence of chloroform, extension and counter-extension were employed in the direction of the axis of the femur, that is, nearly at right angles with the body, while, at the same moment, the upper portion of the femur was lifted by a round towel. By this manoeuvre the head of the bone was carried into the foramen thyroideum. The force was now applied in a direction "more upwards and outwards; the ankle held by the assistant was drawn under the other and at the same time rotated." In a few minutes the complete reduction was accomplished. His re- covery has been steady, and three weeks later he was discharged being able to walk very well with the aid of a cane.2 § 6. Ancient Dislocations of 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 ad- vanced 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, i0UP0peioSQt- L°UiS Me,L and Surg- Journ., July, 1850 ; N. Y. Journ. Med., March, ±ooZt p. iy©. * Hodder, British Amer. Journ., March, 1861. ANCIENT DISLOCATIONS OF THE FEMUE. 679 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 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 re- cently 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 some- times 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 Com- mercial 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, adminis- tered 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 Dupierns, 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 be- fore 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 condi- tion, except the great gluteal, which was painful to the touch." Deem- ing the use of anaesthetics improper, on account of the boys feeble condition, these agents were not employed. Dr. Dupierris describes the method of reduction as follows: "The body being held by two i Malgaigne, op. cit., torn. ii. p. 185 ; from Gallicinium Medico-practicum, Ulm,1700, p. 28S. .... R.tn 2 Blackman, Ohio Med. and Surg. Journ., vol. vm. p. 5 — 630 DISLOCATIONS OF THE THIGH. assistants by means of two bands, one of which passed beneath the perineum, and the other under the axilla?, 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. " The following day, the patient having obtained a tolerable night's rest by means of a narcotic potion, I concluded to attempt the reduc- tion 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 ordinarily 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 redisplacement, the next morning I found that the dislocation had been reproduced. It was again reduced, but for three successive days there was a redisplacement. 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." In the comparison of the relative value and hazards of the different PARTIAL DISLOCATIONS OF THE FEMUR. 681 modes of reduction I have cited several examples of fracture of the neck of the femur in the attempt to reduce ancient dislocations. § 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- 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 par- tial dislocations, in which the head of the bone has fairly left the coty- loid 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 sup- posed 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 break- ing 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 682 DISLOCATIONS OF THE THIGH. 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 out- wards, and advanced in front of the body, with very slight motion of either flexion or extension, and almost no tenderness about the joint. Dr. Warren, also, was able to feel indistinctly the head 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 tis- sues 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 so incomplete as 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 con- dition 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.2 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 accom- 1 Warren, Bost. Med. and Surg. Jouru., vol. xxiv. p. 220. 2 Amer. Journ. Med. Sci., vol. xxxiii. p. 455, from Lond. and Edin. Month. Journ Of Med. Sci., Dec. 18-13. COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 683 panied 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 splints, one of which extended up 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 elevat- ed 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 symp- toms 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 Lmdon Medical Gazette for July, 1836, a case of fracture of the femur through its upper third, in a ' Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1S33. 634 DISLOCATIONS OF THE THIGH. man a?t. 40, with dislocation into the ischiatic notch ; which disloca- tion, he assures us, was reduced at the end of six weeks. But it is much more probable that, instead of reducing a dislocation, he re- fractured the bone. During more than one hour and a half, aided by pulleys, tractions and manipulations were made in almost every di- rection. 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 of nearly equal length with the other;" but there remained an "im- mense deposit" around the acetabulum.1 Malgaigne says that M. Eteve found a poor fellow with a disloca- tion of his left thigh backwards, a fracture near its middle, a penetrat- ing 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 direc- tion, M. Eteve pushed with all his strength the head of the bone into its socket. Of which case Malgaigne justly remarks, that the "exten- sion"' 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 aet. 8, who was admit- ted 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 back- wards 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 admis- sion, 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 anv other examples of fracture of the femur complicated with dislocation; and, rejecting at least Mr. Thorn- 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 lork Journ. Med., Jan. 1S55, p. 3U. VOLUNTARY DISLOCATIONS OF THE FEMUR. 635 hill'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 contractions 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.1 By seizing the moment then when the patient is laboring under the shock, or by placing him completely under the influence of an anaesthetic, no re- sistance 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 exten- sion ; nor do I think it will be best to wait until the femur has united, since such delay will probably render the reduction impossible. § 9. Voluntary Dislocations of the Femur. Examples in which persons, having suffered no disease of the hip- joint, have been able voluntarily to dislocate the femur, have, from time to time, been recorded, but I am not aAvare that any dissections have ever been made in these cases. I shall, therefore, not attempt any explanation of the facts, but simply record them as matters of curious interest, and for the purpose of inducing others to make of them a subject of investigation. Sir Astley Cooper mentions the case of a man, who could throw out the head of the thigh bone at pleasure, and reduce it with equal facility. A similar case is alluded to by Samuel Cooper, in his First Lines. Gibson mentions a case reported by Dr. Lewis, of North Carolina.2 The following case was reported to me in 1865, by John M. Forrest, M. D., of Portland, Maine, to whom the man presented himself as a " substitute," while Dr. Forrest was in the service of the TJ. S. Army. The application was rejected. " Wm. G. Gliddon, set. 37, farmer, says that he has been able to dis- locate and replace the femur at the left hip-joint since he was a boy. It is not the result of any injury or disease so far as he knows. He is in good health, and his muscular development is complete. He accom- plishes the dislocation by throwing the weight of his body upon the left leg, and then contracting certain muscles about the hip. The reduction is generally more difficult than the dislocation, sometimes requiring the aid of his hand. When the head of the bone is put there is a marked projection above and behind the trochanter major, apparently caused by the pressure of the head in this situation; the limb is very slightly if at all inverted; while out of place it causes pain; and after°a few repetitions the pain becomes so^ great as to com- pel him to desist. The limb was not measured while it was dislo- cated. AVhen the limb is in position he does not walk lame." 1 New York Journ. Med., March, 1854, p. 293: from Bullet, de Ther. 2 Gibson's Surgery, vol. i. p. 367, 6th ed. 686 DISLOCATIONS OF THE PATELLA. The following is the only case which has come under my personal observation: Dr. AVm. G. S., ast. 24, received an injury on the out- side of the right knee, in Feb., 1862, from the kick of a horse. There was no apparent injury of the hip. On the fourteenth day after the accident he rode forty miles on horseback, which was followed by some stiffness in the right hip. Two weeks later, in mounting his horse, he felt something slip in the hip-joint. From that day until this, a period of four years, he has been able to reproduce the same slipping volun- tarily, and which phemomenon I recognize as a dislocation upwards and backwards. I have examined him more than once, and he has dislocated ^and reduced the dislocation in my presence repeatedly. Planting his right foot firmly upon the floor a little in advance of the left, with his toes turned out, he throws his weight upon the right leg by carrying his pelvis well over to the right, and then contracts powerfully the gluteal muscles. Instantly the head leaves the socket, and seems to mount upon the dorsum; the trochanter major becomes rotated inwards, causing a slight inward rotation of the leg and foot. He can do the same when lying on his back, but not with the same ease. Reduction is accomplished without change of position, but by what precise manoeuvre I have not determined. The reduction is more quiet, and less sudden apparently than the dislocation. Both manoeuvres are accompanied with some pain. He is not lame, nor does the dislocation take place without his volition. CHAPTER XVII. DISLOCATIONS OF THE PATELLA.. § 1. Dislocations of the Patella Outwards. Causes.—In the majority of cases it has been occasioned by muscu- lar action; and especially is this liable to occur in persons who are knock-kneed, or whose external condyles have not the usual promi- nence 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 triflino- 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. ' DISLOCATIONS OF THE PATELLA OUTWARDS. 687 Pathological Anatomy.—Most frequently the dislocation is only par- tial, 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 cap- sule 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 luxa- tion 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 having become entangled in machinery. In addition to several frac- tures in other limbs, he was found to have a subluxation of his left 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 rup- tured, 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^ liga- mentum patellae in nearly its whole extent. There was almost no swelling, and the limb was moderately flexed. By firm pressure the patella could be re- stored to position, but as soon as the hand was re- moved 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 im- movable ; the breadth of the knee is considerably increased; the inner condyle projects unnaturally, and the patella is distinctly felt upon the outer side. tion 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 as lono- 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 bv dancino-. He says the knee was slightly but firmly flexed. It was reduced by a very slight pressure with the fingers, and although Dislocation of the pa- tella outwards. If the disloca- i Norris, Amer. Journ. Med. Sci., vol. xxv., Feb. 1840, p. 276. 688 DISLOCATIONS OF THE PATELLA. some inflammation with effusion into the joint ensued, the use of the limb was completely restored in a week or ten days.1 Prognosis.—Reduction is in general easily accomplished, but a re- luxation 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 in- fancy. 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 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.2 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 gene- rally be found sufficient to accomplish the reduction. A man, aet. 27, was sitting on a box and in jumping off tripped him- self with his right leg, causing a partial dislocation of the patella of the left leg outwards. Half an hour after the receipt of the injury I found him sitting, with the knee bent and in great pain. The patella lay upon the outer half of the articular surface, with its outer margin a little tilted upwards. Lifting the leg and thigh to a right angle with the body, and making very slight pressure upon the outer margin of the patella, it immediately resumed its place. Very little inflamma- tion ensued. 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. 1 Watson, New York Journ. Med., vol. i. p. 306. 2 Op. cit., vol. i. p. 2(j0. DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 689 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. _ v Not long since, a young gentleman aet. 25, residing in Somerset, N. Y., called upon me in consequence of having discovered a floating carti- lage 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 dis- covered 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 of the Patella Inwards. Causes.—Iieas frequent than dislocations outwards, they are occa- sioned generally by direct blows received upon the outer margin ot 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 posi- tion of the patella. § 3. Dislocations of the Patella upon its Axis. Syn.—." Semi-rotation;" Miller. "Luxation Verticale ;" Mal- gaigne. These accidents, of which up to the present mo- ment 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 in- complete lateral dislocations. In these latter acci- dents, 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 articulatino- 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-condylo- ldean fossa, the other or free margin would be compelled to rise until Dislocation of the patella inwards. 690 DISLOCATIONS OF THE PATELLA. 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 deter- mine 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 suc- ceed, 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 pres- sure also, upon both margins of the upright patella, but in opposite directions. AVatson, of New York, has related the following example of rota- tion of the patella upon its inner margin ("Luxation Verticale 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 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 attach- ments 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 con- ceived, 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 press- ing it against the condyles of the femur, by forcing the head of a key against the posterior, now the outer face of the patella (usino- 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 DISLOCATIONS OF THE PATELLA UPWARDS. 691 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., 1812, 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 at- tempt reduction, but failed, after having made repeated trials by lift- ing 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. 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.2 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, notwith- standing the surgeon finally had the temerity to sever completely the tendon of the quadriceps extensor, and the ligamentum patellae Ex- tensive 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 of the Patella Upwards. Occasionally the ligamentum patellae has been found so much elon- gated 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 dislo- . Watson, New York Journ. Med., Oct. 1839, p. 302. » Gazzam, Amer. Journ. Med. Sci., vol. xxxi. April, 1843, p. 363. 1)02 DISLOCATIONS OF THE HEAD OF THE TIBIA. cation as a result of a rupture of the ligamentum patellae, as the fol- lowing example will illustrate. On the 18th of Dec, 1850, Dennis Milliards, 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. Gibson has recorded a similar case, in which both patellae were dis- located upwards by a rupture of the ligaments, occasioned by the exercise of leaping. He recovered the use of his limbs almost com- pletely.1 (For examples of rupture of the quadriceps femoris, which some writers have incorrectly named Dislocations of the Patella Down- wards, 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.) CHAPTER XYIII. DISLOCATIONS OF 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, antero- laterally, or postero-laterally. . They may be either complete or incom- plete. 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 insuf- 1 Gibson; Surgery, vol. i. p. 395, 6th ed. DISLOCATIONS OF HEAD OF TIBIA BACKWARDS. 693 ficient 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. Fig. 280. § 1. Dislocations of the Head of the Tibia Backwards. Symj)tom,s.—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 con- dyles 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 some- times 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, 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- 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 ex- amples 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. Ano- ther 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 simi- lar case seen by Lassus, the patient was con- fined 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 Dislocation of the head of the tibia backwards. 691 DISLOCATIONS OF THE HEAD OF THE TIBIA. simple manipulation, as this is often found to succeed when the dis- location 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 ap- plication 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, rotat- ing or rocking the limb also occasionally from one side to the other, while at the same moment strong pressure is made upon the project- ing 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 upper 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 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. Immedi- ately, 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 » Rose, Amer. Journ. Med. Sci., vol. xxxi. p. 216, DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 695 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 re- covered until after five months; at which time the crutches were finally laid aside.1 Fig. 281. § 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 shorten- ing 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.2 It is quite probable, however, that these latter statements are somewhat exaggerated. In consequence of the pressure upon the popliteal artery,the pulsa- tions in the branches below are frequently interrupted, and in one instance this pressure was sufficient to produce finally a dry gangrene. Dr. Gorde relates a case in the Bulletin de Therapeutiaue, occurring in a woman nearly sixty years old. This woman was returning home 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 for- wards 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.3 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 1 Walsham, Sir A. Cooper on Disloc, &c, 2d Lond. ed., p. 188. 2 B. Cooper's ed. of Sir Astley Cooper on Disloc, &c, pp. 214-215. 3 Gorde, Amer. Journ. Med. Sci., vol. xvi. p. 225, May, 1835. Dislocation of the head of the tibia forwards. 696 DISLOCATIONS OF THE HEAD OF THE TIBIA. immediately effected. At the end of one month the patient was able to leave his bed; and sixteen years after, Dr. Toogood saw him walk- ing "with very little lameness."1 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.2 B. Cooper, Malgaigne, Little,3 and others, have recorded examples of this accident. March 9th, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, aet. 45, was caught by his sled, drawn by horses, in such a way that a beam pressed against the front and lower end of the femur while the heel was caught and arrested by a stump. The foot was thrown for- wards and the upper end of the tibia completely dislocated in the same direction. It was at once reduced by a person who was present, but on attempting to use the leg in walking it was reluxated immedi- ately. Mr. J. H. Harris, medical student, found the limb soon after completely luxated, with the leg thrown forwards in the position of dorsal flexion about 40°. The tendons of the hamstring muscles were not ruptured, but had slid forwards past the condyles of the femur. There was no external wound. Reduction was easily accomplished by simple extension. Pasteboard splints were then applied. On the third day the knee was considerably swollen and some ecchymosis existed about the popliteal region. On the fifth day these symptoms had much increased. Mr. Harris then applied extension to the foot, with the aid of adhesive plaster, pulley and weights, and by elevating the foot of the bed. The amount of extension employed was 9 lbs. This gave immediate relief to the pain, and was continued until the inflammation subsided. His recovery was steady, and in four months he walked with crutches or a cane. In 1864 a similar dislocation was presented at the Brooklyn City Hospital, in which reduction having been practised the patient died. The case is reported very fully by Dr. Le Roy M. Yale.4 Dr. White, of Buffalo, politely invited me to see with him a lad, aet. 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 in- flammation 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 Toogood, Amer. Journ. Med. Sci., vol. xxxi. p. 465. 3 Little, New York Med. Times, Aug. 17, 1861. 1 Yale, N. Y. Journ. Med., vol. ii. p. 124, Nov. 1865. 2 E. Parker, ibid. DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. 697 § 3. Dislocations of the Head of the Tibia Outwards. Occasionally, owing to a violent wrench of the knee-joint, the late- ral ligaments upon one side or the other are ruptured, and conse- quently 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 derange- ment 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 disloca- tion 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 articu- lating surface of the tibia. The signs which characterize this accident are such as cannot easily be mistaken. The limb is not shortened, nor is there anything espe- cially diagnostic in its position, since it has been found to be some- times 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 use- ful, they must be left to the judgment of the sur- geon 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 leg was partially flexed upon the thigh, with the toes everted. By moderate extension, made with my own hands, united with alternate flexion and ex- tension, 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 swol- len, the nature of the injury was easily determined. The knee was immovable, and the toes turned outwards. Mr. Hallam, the house 45 Subluxation of the head of the tibia outwards. 698 DISLOCATIONS OF THE HEAD OF THE TIBIA. surgeon, reduced it by extension and counter-extension made by his own hands." 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 con- trolled, and she regained the use of her limbs.2 In one case of subluxation, mentioned by Sir Astley Cooper, and in a second recorded by Bransby Cooper, the recovery of the func- tions of the joint did not seem to have been so rapid; the joint re- maining unstable and tender for a long time afterwards.3 Fig. 283. § 4. Dislocations of the Head of the Tibia Inwards. There is nothing peculiar in either the signs, condition, or treatment of this accident, as distinguished from a dislocation outwards to de- mand 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- 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 in- jury which the ligaments had sustained. The pa- tient 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 re- duced the bone by extension and pressure. Mr. Cooper thinks that not only the internal lateral ligament was torn, but also some fibres of the vas- tus 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 Subluxation of the head •of the tibia inwards. 1 Hallam, Amer. Journ. Med. Sci., vol. xix. p. 251. 2 Pitt, ibid., vol. xxxi. p. 465. 3 B. Cooper's ed. of 4 Ibid., pp. 211-13. 5 Fergusson, op. cit., p. 2S4. Mr Ast., op. cit., pp. 111-13. HEAD OF THE TIBIA BACKWARDS AND OUTWARDS. 699 Key, had each seen one similar example; and he also enumerates two additional cases of complete luxation attended 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 of the Head of the Tibia Backwards and Outwards. In June, 1853, Henry J., of Dansville, N. Y., aet. 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 the 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 his 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 un- fortunate condition; indeed they seem to have exercised throughout great ingenuity and skill in its management. I directed the young man to Mr. John C. 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. idt., torn. ii. p. 95 J. 7«~>0 DISLOCATIONS OF THE HEAD OF THE TIBIA. Thomas "Wells, of Columbia, South Carolina, has described a similar accident, the tibia being dislocated outwards and backwards, which terminated fatally on the fourth day in consequence mainly of ex- posure, 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 of the Knee-Joint. Syn.—" 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 neces- sary 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 exceed- ingly liable to occur from very slight causes, and eventually the knee- joint 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, K Y., aet. 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, 1832. INTERNAL DERANGEMENT OF THE KNEE-JOINT. 701 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 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 modification, belongs probably to several varieties of "in- ternal 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 car- tilages 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 hyper- trophied, 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, becom- ing 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 cartilagi- nous, 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 gene- rally 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 ex- amples in the course of my practice, and in no instance has the sudden flexion and extension of the limb failed to overcome the difficulty. As to the question of subsequent treatment, especially as to whether 702 DISLOCATIONS OF LOWER END OF THE TIBIA. 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. CHAPTEE 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 ex- amples 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 of the Lower End of the Tibia Inwards. Syn.—"Inward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot out- wards ;" 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 pro- duced also by a blow received directly upon the ontside of the leg just above the ankle, or by a violent twist or wrench of the foot out- wards. Pathological Anatomy.—I have already, in the chapter on fractures of the fibula, stated my opinion that a large majority of those acci- dents 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 astragalus simply rotates on its axis, or is displaced laterally and hori- zontally from the tibia. DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 703 Dislocation of the lower end of the tibia inwards. 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 articu- lating surface of the tibia; its upper and inner margin descends toward the extremity of the malleolus internus, and the out- FiS- 284- er face of the astragalus pre- sents 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 frac- ture of the internal malleolus is a very common circum- stance in connection with this form of dislocation. Much more frequently, however, the fibula 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. Earely it happens that instead of this lateral rotation of _ the astra- galus, 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 lacera- tion 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 fabula may remain unbroken and undisturbed, the tibia merely having become displaced inwards; or the fibula may give way also above the articula- tion 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 peroneotibial articulation. Svniptoms —The foot is more or less violently abducted, the sole ot the foot presenting downwards and outwards instead of directly down- wards • the malleolus internus projects strongly at the inner side of the ioint • and at the outer side there is a corresponding depression, generally'most marked a little above the articulation near the point 701 DISLOCATIONS OF LOWER END OF THE TIBIA. 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 m6ve it pretty 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. 285. Dislocation of the lower end 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 be- tween 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 ap- plied by placing the limb over a firm double inclined fracture splint, and making the extension by the aid of a screw attached to the foot- DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 705 board, 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. 286. Charles Sauer, 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 frac- turing 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 ot the astragalus upon its axis. Seizing the foot with my hands, and flexing the leg, while an assistant held up the thigh and made counter- extension, I had scarcely begun to pull upon the foot before the re- duction 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 anchy- ° 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 impos- sible 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, con- sulted me at my office a few years since in relation to the condition ot his foot I found the tibia dislocated inwards, and projecting more than an inch beyond the astragalus; the sole was turned outwards, compellino- 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 706 DISLOCATIONS OF LOWER END OF THE TIBIA. foot, he 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., aet. 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. Sweet- land, 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 some- what 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 pro- jecting 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 reunited. Not long since I had occasion to amputate a limb for a compound dislocation inwards at the ankle-joint, and the possibility of this frac- ture 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 dislo- cation, 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 OF LOWER END OF TIBIA OUTWARDS. 707 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 manage- ment 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 of the Lower End of the Tibia Outwards. Syn.—" Outward tibio-tarsal luxation;" Malgaigne. " Dislocations of the foot in- wards," of others. The causes are the same or similar to those which are known gene- rally to produce dislocations in- wards ; only that the force of the FiS- 287- concussion or the direction of the rotation must have been re- versed. The external lateral liga- ments, 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 out- wards 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 treat- ment subsequently, will not differ from those which we have mentioned as suitable for dis- locations in the opposite direc- tion The examples which have fallen under my observation are not numerous but the reduction has always been easily effected. Thus, a man, aet. 21, fell from a scaffolding, alighting upon his feet. He says ' Townsend Mass. Hosp. Reports, Bost. Med. and Surg. Journ., vol. xxxiii. p. 277. Dislocation of the lower end of the tibia ontwards. 708 DISLOCATIONS OF LOWER END OF THE TIBIA. that his left foot struck the ground obliquely and upon its outer mar- gin. 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 1816, Henry Wilson, aet. 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 ex- cept 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 recog- nized. § 3. Dislocations of the Lower End of the Tibia Forwards. Syn^—" Forward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot back- wards," 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 en- gaged under a piece of timber, the body falls backwards to the ground; or when, the leg remaining fixed, a heavy weight descends upon the foot, the foot resting upon an inclined plane; by a blow upon the front of the foot; or it may be caused by a fall upon the bottom or 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 dimi- nished, 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 OF LOWER END OF TIBIA FORWARDS. 709 in front of the astragalus; the extensor tendons of the toes are sharply defined, while the tendo-Achillis is curved forwards, and tense. At the regular meeting of the New York Pathological Society, Nov. 22, 1865, I presented a specimen obtained from the dissecting- room of the Bellevue Hospital College. The history of the case was unknown. Before dissection the foot was observed to be turned outwards, and shortened in front of the tibia, while there was a corresponding length- ening of the heel. The specimen, after dissection, disclosed a fracture of the internal malleolus half an inch above its lower end, and a frac- ture of the fibula a little above its lower end. The tibia was displaced forwards about three quarters of an inch, so that only the posterior half of its lower end rested upon the articular surface of the astragalus, and at the point of contact with the astragalus a new socket was formed in the tibia, concave upwards, half an inch deep, and pre- senting an appearance as if the posterior lip of the lower end of the tibia had been broken off and had become displaced upwards. It was supported by a broad buttress of bone. It is not certain, however, but that this appearance was occasioned solely by the long-continued pressure of the tibia upon the astragalus at this point. The fragments of the malleolus internus, and the lower fragment of the fibula re- mained attached to their upper fragments and to the two sides of the astragalus in their normal positions, consequently each fragment was inclined downwards and backwards at an angle of 45°. The lower fragment of the fibula was driven upwards, also, but both of the frac- tures were firmly united. This specimen is now in the museum of the Bellevue Hospital College. At the same meeting of the Pathological Society I reported the case of Mary Conlan, aet. 38, admitted to Bellevue Hospital, Nov. 13th, 1865, having been thrown three days before from a street car. She could give no account of the manner in which she fell. I saw her Nov. 16th. The limb was then much swollen and I diagnosticated a fracture of the lower end of the fibula. (It had been supposed to be a mere sprain up to this time.) The limb was directed to be wet with cool water and to rest upon a pillow. From this time I looked at it occasionally to see whether the swelling had sufficiently subsided to warrant the application of a splint. Nov. 20th it was examined again carefully by the house surgeon, Dr. Farrall, but no displacement was noticed. Nov. 23d I found the lower end of the tibia displaced for- wards, and ascertained, also, that the internal malleolus was broken at its base. The dorsum of the foot, measuring from the front of the tibia to the end of the great toe, was shortened half an inch. The heel was lengthened. There can be no doubt but in this case the dislocation occurred sub- sequent to the fracture, and that it was caused by the contraction of the gastrocnemii. I reduced the dislocation a day or two later and maintained it in position by the method which I shall presently describe. Dr. Voss reported to the Society a similar case which had come 710 DISLOCATIONS OF LOWER END OF THE TIBIA. under his notice, and Dr. Buck remarked that he also had met with such examples.1 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. 288. Fig. 289. Dislocations of the lower end of the tibia forwards. In general, the dislocation has been easily reduced, but in a ma- jority 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 back- wards. Generally it will be found necessary to make additional pres- sure 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 in consequence of this pressure, it also should be supported, or sus° pended by another band passing underneath the heel and fastened above to the top of the foot-board. New York Journ. Med., April, 1SG6, p. -10. OF LOWER END OF TIBIA FORWARDS. 711 Dupuytren relates the following example of this rare accident:— Pierre Froment, aet. 33, was carryinga 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 ankle- joint. 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 ex- tensor 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 con- cavity 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 displace- ment 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 back- wards. The first attempt succeeded partially, and the second com- pleted 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.1 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 aet. 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 frag- ment 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 repeat- edly 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 ' Dupuytren, Injuries and Dis. of Bones. London ed., p. 278. 2 Op. cit., p. 27 °? ^^ that tbe ^nces of the patien are m the average very greatly increased by this practice. Of thirteen amputations made for compound dislocations at the ankle-joint n the th7tt ^"^ii fdmh^h' ^ ^o resulted in theiecoVeryof the patients.1 Alluding to which, Mr. Fergusson remarks "An amount of mortality which may well incline the surgeon tact uptn tt HmbWredu'fl VV^ C°°Per'' t0 W£tto save which accordsveTl iBut -^ Fe^USSOn has added a sentiment n W C ^ry closely with my own experience and opinions I fear however, that m the attempts which have been made to save h6e Iteltt^ " aU the CaSGS haVe " ^ tne 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 myselfTen Iwoull 1 Edinb. Med. Monthly, Aug. 1844. COMPOUND DISLOCATIONS OF THE LONG BONES. 711 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 Dieffenbach in cases of ancient unreduced luxations; but Wm. Hey, Jr., was the first to make a prac- tical application of this suggestion in a case of compound dislocation. After cutting the tendo-Achillis, the ankle being dislocated, the re- duction was easily effected, but a strong tendency to displacement backwards remained, and he was obliged afterwards to cut the ten- dons 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 ab- surd measure. Nor do I think that in the point of view in which we are now considering this subject, having reference only to the ques- tion 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 considera- tion 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: "Com- plete 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 at- tended with danger, unless one be cut off at once by deliquium animi, or if continued fever supervene on the fourth day." To which pas- sage the translator adds the following note: " This paragraph on re- section 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 compound dislocations very briefly, as follows: "Si nudum os emi- net, impedimentum semper futurum est; ideo quod excedit, abscin- dendum 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 1 Hey, Trans, of Provinc. Med. and Surg. Assoc, vol. xii. p. 171,1844. 712 COMPOUND DISLOCATIONS OF THE LONG BONES. 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 ex- tremities of the bone" (tibia, at the ankle) " have been sawed oft; although I shall have occasion to mention some cases which termi- nated 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, accord- ing to Sir Astley Cooper's opinions, to lessen the suppurative process, by diminishing the synovial surface. This mode of practice is cer- tainly not commonly followed in reference to other joints, and the younger Cline was always opposed to its being resorted to in dislo- cated 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, aet. 24, was caught by the cable of a vessel, June 17, 1855, dislocating the left tibia at its lower end in- wards, 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 cartilagi- nous 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- 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, band- ages, 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 per- mitted to see him frequently. COMPOUND DISLOCATIONS OF THE LONG BONES. 713 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 slough- ing. 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 Trans- actions 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 re- corded 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 oc- curred 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 chance 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 ma- jority 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 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, 744 COMPOUND DISLOCATIONS OF THE LONG BONES. it is now a question only between reduction without resection, and reduction with resection. These two methods, one of which experi- ence 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 conspicu- ous, yet sufficiently marked. . First. In either case the inflammation consequent upon the injury may be violent, and the recovery slow and tedious. The same argu- ments, however, which we have applied to the question of the com- parative 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 re- section. It'will be observed that not only is the danger of maiming rendered more considerable by reduction without resection, because the inflam- mation 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 free- dom 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 ammonia? acetatis, without removing the bandage. In my very early life upwards of sixty years ago, I saw many attempts to reduce 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 men- tioned, I have generally succeeded in saving the foot, and in preserving a tolerable articulation." a 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 COMPOUND DISLOCATIONS OF THE LONG BONES. 715 caries of the articulating surfaces, and their results, add still more substantial proofs as to the usefulness of the joints after such opera- tions. "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 in- wards. 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 situa- tion. 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-carti- laginous 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 astra- galus. A free motion existed between the tibia and astragalus which was permitted by the length and flexibility of the ligamentous sub- stance 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, ossific action proceeds from the extremity of the tibia into the ligamentous substance, and thus produces an ossific anchylosis." . . Second. Is it 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 per- fectly? Even after simple dislocations, especially in those occurring at the ankle-joint, great deformity and much maiming are the not un- frequent results, and that too when all diligence and care have been employed. It has been impossible always to maintain a perfect appo- sition 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 resec- tion 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 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 recom- mend resection as a universal practice in cases of compound disloca- tions 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 48 716 CONGENITAL DISLOCATIONS. 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, fibula, and toes; in short, to a certain pro- portion 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. CHAPTEE XXYI. CONGENITAL DISLOCATIONS. § 1. General Observations and History. We have omitted, until this moment, to speak of Congenital Dislo- cations, 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 struc- tures as to separate them entirely from ordinary traumatic luxations, which alone constitute the proper subjects of consideration in the pre- sent 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 dis- locations. Exceptions to this rule will occur, in examples of intra- uterine 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, however, the attention of surgeons has been almost entirelv directed to congenital dislocations of the shoulder and hip. Hippocrates, in his treatise "De Articulis," speaks expressly of dis- locations of the hip occurring in the mother's womb, comprising them under the same order with the different varieties of club-foot GENERAL OBSERVATIONS AND HISTORY. 717 Avicenna and Ambrose Pare have each mentioned original disloca- tions 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 arti- culation, and the other at the coxo-femoral. In 1788, Palletta, of Milan^ published, under the title of Adversaria Chirurgica, a collection of observations, in which, among other things, he has described certain congenital malformations of the hipjoint; 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 de- formities. 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 obser- vations 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 investi- gation. From this time, various treaties have been written by eminent surgeons, many of which are characterized by profound thought, care- ful investigation, and practical experiment. Among those who have furnished us lately with elaborate treatises, or with more precise practical information upon this subject, the fol- lowing names deserve to be especially mentioned: Breschet,1 Caillard- Billioniere,2 Lehoux,3 Sandiforte,4 Duval and Lafond, Humbert and Jacquier, Bouvier/ Sedillot,6 Gerdy, Polinie're, Wrolik,7 Gue>in,8 Pa- rise/ Pravaz,10 Carnochan,11 and Bobert Smith.12 1 Breschet, Repertoire d'Anatomieet de Physiologic 2 Caillard-Billioniere, These Inaugurale, 1828. » 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 Pravftz. 6 Sedillot, Journ. de Connais. Med.-Chirurg., 1838. '• Gerdy, Poliniere, Wrolik. See Pravaz. A s Guerin, Recherches sur les Luxations Congenitales; par Jules Guerin, Paris, 1841. V 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 Spontanees; par Ch. G. Pravaz, Lyons, 1847. n Carnochan, A Treatise on the Etiology, Pathology, aud 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 Acci- dental and Congenital Dislocations, Dublin, 1854. 718 CONGENITAL DISLOCATIONS. § 2. Etiology. Hippocrates says that the bones of the extremities may be disar- ticulated 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 pome 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 ?<£™'a .Ce T Gu<5rin has Srea% extended the application of this doctrine, having embraced in the same etiologic formula all or nearly all congenital dislocations. GutSrin ascribe! 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 sphie He affirms, moreover, that he has established incontestably the depend- ence of this abnormal state of the muscular system upon the absence Breschet and Delpeeh maintained similar views esDeciallv in tp1» hon to the dependence of the several varieties ™lbC"p„ s™e ocations of the head of the femur from the cotyloid caX denend to a perverted condmon of the excito-motor apparatus of the mX.la spmahs, and more especially of that portion of it which is in direct relation w.th the reflex-motor nervous fibres, distributedI to the nelvi "tionT1" Sar™»di« * connection withX^lemtai Palletta ascribes these deformities solely to an original defect of the CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 749 germ; and Dupuytren also declares that, in the case of a congenital dislocation of the hip, the causes are coeval with the earliest organiza- tion 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, ima- gine 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 sup- posed 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 pre- pared 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 Gue>in upon a derence'phalous 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 examina- tion, 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 750 CONGENITAL DISLOCATIONS. the subject of especial examination, we shall feel compelled to accept of it as reported by Gudrin. As to the objection 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 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 charac- teristic, not indeed of a traumatic luxation, but of a congenital disloca- tion, 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, ret. 38, an idiot from in- fancy, 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 coro- noid 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 lhe motions permitted in the lower jaw were more extensive than those which it enjoys in its normal condition, that is, upon the rio-ht side the ramus could be removed 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 per- forming this motion, and the right side of the face was continually affected with spasmodic twitches. When the mouth was closed the CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 751 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 correspond- ing eminence is developed in proportion to the growth and develop- ment of the condyle. But Mr. Smith justly observes that although the development of the condyle does precede that of the glenoid cavity, " 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 back- wards instead of upwards and forwards, as in the adult. A diplace- ment 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 some- what displaced forwards. Chronic rheumatic arthritis is occasionally found in the temporo- maxillary articulation of old persons; and it may be important to distinguish it from congenital luxation, with which, owing to the ab- sorption of the articular eminence, and the consequent displacement of the condvle, it might possibly be confounded. _ ,,,-,. Says Mr."Smith: "In a majority of instances, this remarkable dis- ease attacks those of advanced age, and is symmetrical; but occasion- ally 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 lym- phat'c glands of this region are sometimes enlarged, and the progress 1 Robert Smith, op. cit., p. 2S3. 752 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 articula- tions 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 pro- ject beyond those of the upper jaw. As the disease progresses, the glenoid cavity enlarges by absorp- tion, 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 luxa- tion 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 be- yond those of the lower; the reverse is observed in accidental luxa- tion 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 condyle is not enlarged, as in some instances of chronic rheumatic arthritis."1 § 4. Congenital Dislocations of the Spine. Says GueVin, 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 ex- actly applied against the posterior part of the neck, and upper part 1 R. Smith, op. cit., p. 292. CONGENITAL DISLOCATIONS OF THE STERNUM. 753 of the back. 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 Gue'rin himself;9 and it will be noticed that he only speaks of the second as aprolalle subluxation forwards. Neither of them can there- fore be regarded as established. Gue'rin 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 occipito- atloidean displacement, a series of angular flexions in the antero-pos- terior direction, with sliding of the articular surfaces. In attempting to appreciate the value of GueVin's observations upon this point, it must be remembered that he regards all cases of congeni- tal torticollis, and other deviations of the spine, as examples of sub- luxation ; and, in some sense, we think the theory of this distinguished surgeon may be regarded as correct. The amount of articular dis- placement between each of the adjacent vertebras may be very incon- siderable in any such case, yet, however trivial, if it exceeds the limits of natural motion, it may properly enough be regarded as the com- mencement of a luxation. § 5. Congenital Dislocations of the Pelvic Bones. Bassius speaks of a diastasis or separation of the sacro-iliac sym- physis, 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 three examples, are not properly examples of con- genital dislocations, but only of diastases, the separated portions re- maining in their normal position 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 pubes upon the external face of the ischium.3 § 6. Congenital Dislocations of the Sternum. Seo-er 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 i Guerin, op. cit., 1841, p. 29. » Ibid., Gaz. Med., 1851, p. 227. » Ibid., op. cit., p. 32. 754 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 for- wards; this extremity of the clavicle tying 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 cor- responding 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 Gue'rin 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 accom- plished, 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..) Gue'rin affirms that he has established the existence of three varie- ties of scapulohumeral dislocations, namely:— 1. Dislocations of the head of the humerus downwards; of which variety he presented to the Academy a plaster cast taken from a boy ' Seger, Ephem. Nat. Curios., 1677, from Malg., op. cit., p. 410 Fergusson, System of Surg., 4th Amer. ed., 1853, p. 203. CONGENITAL DISLOCATIONS OF THE SHOULDER. 755 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 incom- plete upon the other, in the same person. The head of each humerus was applied against the ribs, and the arms maintained in an abduc- tion almost horizontal, under the influence of the retraction of the deltoid-muscles. " The same case," Gue'rin remarks, " has been con- firmed 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 pro- cesses."1 Malgaigne, who regards " all luxations in consequence of paralysis as essentially posterior to birth," will not admit the first example mentioned by Gue'rin; 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 Gue'rin 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 ex- amples. The first was in the person of Alexander Steele, set. 29, who pre- sented both a dislocation of the head of the humerus under the cora- coid 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 hume- rus 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 1 Guerin, op. cit., p. 30. 7o6 CONGENITAL DISLOCATIONS. year before the condition of the limb attracted attention, which was then excited, not by the deformity of the shoulder, but by the atro- phied condition of the muscles of the arm. The child had never complained of pain about the joint, nor had he ever met with any ac- cident. 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 defor- mity existing in both shoulders. This was in the person of a female, ast. 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 condi- tion 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 im- mediately 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 some- what 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 defor- mity upon each side, all indicate the original nature of the malforma- tion." The only example of backward luxation seen by Mr. Smith was also symmetrical, 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 con- vulsions, 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. CONGENITAL DISLOCATIONS OF THE SHOULDER. 757 The two shoulders resembled each other so perfectly, both in ex- 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 a 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 tubercle 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 im- movable, and only at the end of four years was the dislocation recog- nized ; but no attempt at reduction was then made. When sixteen years old, she was seen by Gaillard, who found the head of the hume- rus 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 im- mediately 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 com- Aristide Rodrigue, of Hollidaysburg, Penn., in a letter to the editor of the American Journal of Medical Sciences, gives the following brief ' Robert Smith, op. cit. * Gaillard, Mem. de l'Acad. deMed., 1841, from Malg., p. 569. 758 CONGENITAL DISLOCATIONS. account of a case of intra-uterine dislocation of the shoulder, compli- cated with a fracture of the forearm. "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; frac- ture of both bones of the forearm of left side, lower third. Dislocation could not be reduced ; union of the bones of the forearm by ossific 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 cap- sule. 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, Cru- veilhier, 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. ' Rodrigue, loc. cit., Jan. 1854, p. 272. * Uueriii, op. cit., p. 31. * Chaussier, from Malgaigne, op. cit., t. ii. p. 268. CONGENITAL DISLOCATIONS OF THE WRIST. 759 Loir: "The abnormal position which the head of either radius had 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 Jan. 1866, John Fitzmorris, aet. 19, was admitted to the Bellevue Hospital, laboring under a general scrophulous cachexy, in whose person I found a congenital dislocation of the heads of both radii, out- wards. The luxations are complete. The ulnae are in place and of natural form, but their articulations at the wrist are loose. The same remark applies to all the other joints in the body. The power of pro- nation and supination is unimpaired, as well, also, as the power of flexion and extension. 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 Gue'rin, 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 coro- nary fossettes.3 §11. Congenital Dislocations of the Wrist. Gue'rin 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 Gue'rin has also seen three examples of dislocation outwards in foetal monsters, and one of dislocation inwards, as the result of arrest of development. Robert Smith believes that the case of simple dislocation of the wrist or of the carpus forwards, mentioned by Cruveilhier in his Anatomie 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 dislo- cation 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 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. « Ibid., p. 717. 760 CONGENITAL DISLOCATIONS. 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 develop- ment also.1 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 first range of the carpal bones; the hand being strongly turned in- wards.2 § 12. Congenital Dislocations of 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.3 A. Be'rard speaks of an incurvation backwards of the last two pha- langes 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 back- wards to an angle of 135°, leaving the heads of the phalanges project- ing forward under the skin.4 Robert has seen, in a girl six years old, a congenital lateral luxation of the phalangette of the index ringer, 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.5 § 13. Congenital Dislocations of 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 oftener in females than in males. Of forty-five examples mentioned by Du- puytren 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 Delpec'h found in 1 R. Smith, op. cit., pp. 238, 251. * Marrigues, Malgaigne, from Journ. de Med., 1775, t. ii. p 31 Chaussier, Malgaigne, op. cit., t. ii. p. 751. • Berard, Malgaigne, op. cit., p. 773. * Robert, from Malg., op. cit., p. 773. CONGENITAL DISLOCATIONS OF THE HIP. 761 an infant, born paralytic, the head of the femur lodged habitually near the foramen thyroideum. Directly upwards; seen by Gue'rin, Pravaz, and others; the head of the femur being placed immediately without the anterior inferior spinous process of the ilium. Gue'rin 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 edge of the cotyloid cavity: " Observed often in newly-born children, and with those in whom the muscular dislocations are effected sponta- neously after birth." Through the courtesy of Dr. Davis, of this city, I was permitted in March, 1865, to see a child, the daughter of a gentleman residing in Victor, Monroe Co., N. Y., who was born in 1860, with dislocation of both knees and both hip-joints. The legs at the time of birth were doubled forward upon the thighs, the heads of the tibias resting upon the front of the femurs, one inch above the condyles, the thighs being at right angles with the body and the feet touching the abdomen. The knees were drawn closely together. The dislocation of the heads of the femurs was not at this time recognized. By constant pressure Dr. J. B. Palmer had succeeded at the end of one year, in restoring the legs to position, the thighs remaining flexed; but when two years old she began to walk with her body bent forwards. The displace- ment of the hip-bones was then first discovered. When four years old the sartorius and tensor vaginae femoris were severed, but with very little benefit. At the time of my examination she was five years old. The thighs were still flexed and adducted; by pressure upon the knees the femurs could be slid upwards and backwards upon the ilium one inch : on rotating the femurs the trochanters were observed to move upon a very short radius, indicating the entire absence of head and neck. She walked with the gait peculiar to these conditions. Both Delpech and Gue'rin 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 is 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. 49 762 CONGENITAL DISLOCATIONS. 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 back- wards, 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 di- rectly 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 thigh- bones, 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 the mobility of the heads of the femurs is appreciably less than in slow progression, which is explained by the more constant and vigor- ous 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, accord- ing 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, there- fore, 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 altera- tions in its size, form, direction, &c; at other times the head fs 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 acetabu- CONGENITAL DISLOCATIONS OF THE HIP. 763 lum 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 remain- ing 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 conse- quence 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 hvpertrophied, or degenerate into a fibrous tissue. Treatment—Say a Dupuytren : " Of what possible utility can it be to practise extension of the lower extremities in these cases, even sup- posing 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 employ- ment 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 casing which requires much standing and walking about would dan^usly aggravate their deformity. Yet one would scarcely be willing to condemn such individuals to per- petual repose; and to avoid this it is necessary to discover some means 7o4 CONGENITAL DISLOCATIONS. 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 min- utes, 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 cata- menial 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 in- dications, certain precautions are necessary in the construction of this cincture; in the first place, it should occupy the narrow interval be- tween 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 tro- chanters 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 get- ting rid of the inconveniences of congenital dislocations of the thigh- bones, but I have 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 charac- ter ; 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 admission: "I at first thought that no benefit would be derived in these cases from the employment of con- tinual 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 orthopasdic in- stitution, 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 bene- ficial results remained for several weeks undiminished. It would be idle, it is true, to generalize on this single case; but as an isolated CONGENITAL DISLOCATIONS OF THE HIP. 765 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 applica- tion. The means recommended and practised by Gue'rin, are: first, pre- paratory extension destined to elongate the muscles as much as possi- ble ; second, subcutaneous section of the muscles which mechanical extension has not sufficiently elongated; third, extension of the liga- ments, and even, if extension does not suffice, their subcutaneous sec- tion ; fourth, manoeuvres destined to effect reduction; fifth, treatment designed to consolidate the reduction, and consisting in the applica- tion 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 physio- logical 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 Gue'rin has gone a step farther, and has sought to es- tablish a new socket upon some point of the pelvic bones as near as 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 that 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 ab- normal 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 beo-innino- 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 lux- ated extremity, in this place of election, I practise all about deep scari- fications which tend to excite the same work of organization and to 1 Dupuytren, op. cit., pp. 176-8. 7«• 0 CONGENITAL DISLOCATIONS. establish fibro-cellular adhesions between the incised borders of the capsule and the contiguous bony surfaces. " Finally, when the fibro-cellular adhesions are supposed to be suf- ficient! v sol'id to resist the movements of the new articulation, I pro- voke, 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 fre- quent movements of this articulation."1 The treatment ought to be commenced as early as possible, no ex- amples of success having been recorded in persons over fifteen years of age; while the youngest child whose treatment is reported as suc- cessful was three years of age. For the purpose of making the requisite extension, and of main- taining 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 sur- geon who understands fully the principle upon which the cure is sup- posed 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 is unnecessary to say that where the accomplishment of the cure de- mands 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 appli- ances 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.2 § 14. Congenital Dislocations of the Patella. Palletta found a dislocation of the patella in the cadaver of a youno- man, which he supposed to be congenital.3 Michaelis has reported 1 Guerin, op. cit., pp. 81-3. 2 Snuth, Note to Chelius, op. cit., vol. ii. p. 245. 3 Palletta, Exercitationes Pathologicse, p. 91. CONGENITAL DISLOCATIONS OF THE KNEE. 767 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.1 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 walk- ing, and in relation to the authenticity or pertinence of which Mal- gaigne seems also to entertain a doubt.2 South says that he has seen a congenital dislocation on both legs, in an aged man. The patellae 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.3 The most remarkable example, however, has been reported by Dr. E. J. Caswell, of Providence, R. L, inasmuch as no less than five members of the same family have double congenital dislocations of the patellae. The man who was the subject of Dr. Caswell's special examination is 43 years old, and possessed of a good constitution. The patellae lay upon the outer condyles, and are movable, performing their functions nearly as well as if placed in their proper positions. He walks without difficulty upon level ground, or upon an ascending plane, but great caution is required in descending. The right patella is longer and less movable than the left, and the muscles of both of his lower extremities are small. "In addition to his labor as an operative, he cultivates a small farm." Dr. Caswell examined his son and found the same malposition, but less marked than in the case of the father. The father then stated that his own father, his sister, and the son of his half brother by the same father, had a similar de- formity.4 § 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 dis- location forwards has been observed much the most often. A subluxation forwards of the head of the tibia has been seen by Gue'rin in a foetal monster, accompanied with extreme retraction of the extensor muscles of the leg.5 Cruveilhier has dissected a foetus affected with a similar subluxation.6 ■ Michaelis, Rev. M£d.-Chirurg., torn. xv. p. 56. 2 Periat, Malgaigne, op. cit., torn. ii. p. 932. ' South, Note to Chelius, op. cit., vol. ii. p. 247. 4 Caswell, Amer. Journ. Med. Sci., July, 1865. 6 Guerin, op. cit., p. 33. 6 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 70S CONGENITAL DISLOCATIONS. 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 com- pletely. 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.1 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 thigh near the groin. Dr. Youmans immediately took hold of the limb and brought it to its natural form, but as soon as he relin- quished 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 particular attention is called to the disposition on the part of the limb to resume its unnatural position with a spring show- ing 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.2 I have mentioned a case of congenital forward dislocation of both tibiae which came under my observation, in the section on congenital dislocations of the hip, and I have recently seen a case of congenital subluxation of both tibiae backwards, occasioned by contraction of the hamstrings. Section of the muscles restored the bones nearly to their normal positions. NoV^'itsL1"' J°urn'Med'Sci" Feb- 1835,p'555, from Bost-MecL and Sure-Journ- 2 Youmans, Bost. Med. and Surg. Journ., Oct. 25, 1860, vol. 63, p. 250. CONGENITAL DISLOCATIONS OF THE KNEE. 769 Chatelain 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 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 (ex- tended) 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 correspond- ing 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 painfui. The treatment was commenced by securing the limb in a straight position by means of a splint and roller; subsequently, Kleeberg car- ried 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.3 Chaussier found both tibiae displaced backwards in an infant other- wise deformed." 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.* 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 man- ner 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 intra- uterine life. The case quoted from Robert, by Malgaigne, as an example of dis- location 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. ' Chatelain, Bibliotheque Med., torn. lxxv. p. 85. 2 Kleeburg, Malgaigne, op. cit., p. 983. 5 Robert, Malg., op. cit., p. 985. » Guerin, sur les Lux. Congen., p. 33. B Guerin, sur les Lux. Congen., p. 33. « Chaussier, Malgaigne, op. cit., p. 884. i.O CONGENITAL DISLOCATIONS. § 16. Congenital Dislocations of the Tarsal Bones. Under this general term may be included all those varieties of sub- luxation 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. Although these deformities may properly enough claim a place in a chapter on congenital dislocations, they have so long been the sub- jects of special treatises as to justify their exclusion from the present volume. § 17. Congenital Dislocations of 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 1 Guerin, op. cit., p. 34. INDEX. PART I.—FRACTURES. Abscess in fracture of the sternum, 169 Acetabulum, 339 Acromion process, 206 Amesbury's thigh splint, 407 Anatomical neck of humerus, 313 Anaplasty in fractures of the septum narium, 97 Anchylosis after Colles's fracture, 278 after fractures of elbow, 253 excision for anchylosis of knee, 452 Apparatus immobile, 54 in fractures of the leg, 474 Arytenoid cartilages, fractures of, 135 Ashhurst, fracture of astragalus, 483 Astragalus, 480 Atlas, 163 and axis, 164 Axis, 161 Ayres, compound fracture of clavicle, 186 Badly united fracture of leg, 479 Bartlett's apparatus for broken clavicle, 195 Barton's bran dressing, 61, 478 bandage for fractured jaw, 130 trephining vertebrae, 149 fracture of lower end of radius, 277 fracture-bed, 430 Base of acetabulum, 339 Bauer's wire splints, 476 Beans, lower jaw, 125 Bending of bones, 72 Bigelow, fracture of axis, 161 stellate fracture of lower end of radius, ' 275 Boardman, fracture of zygoma, 107 perineal band, 414 Body of the scapula, 200 Bodies of the vertebrae, 152 Bond's elbow splint, 248 radius splint, 280 Box for leg, 476 Boyer's thigh splint, 407 Brainard, perforator, 69 Buyk, lower jaw, 120 thigh splint, 415 Burges's thigh apparatus, 411 Calcaneum,485 Carpal bones, 323 Cartilages, 176 Carved splints, radius, 287 Cervical ligaments, strains of, 158 Cervical vertebrae, bodies of five lower, 156 axis, 161 atlas, 163 atlas and axis, 164 Chnpin's thigh apparatus, 417 . Children, fracture of femur, 402, 414, 420 422 Chronic rheumatic arthritis, 374 Clark's case of fracture of pelvis, 332 Clavicle, 177 partial fractures, 178 repair of fractures, 185 Cline, trephining vertebrae, 149 fracture of atlas, 163 Coates, fracture bed, 430 bran dressings, 61 Coccyx, 347 Colby, neck of femur within capsule, 371 Colles's fractures, examples, 271 Common signs of fracture, 33 Compress, pasteboard, for fractured jaw, 127 Compound fractures, 60 forearm, 314 thigh, Gilbert on, 423 patella, 447 tibia and fibula, 462 Concussion of spinal marrow, 158 Condyles of humerus, 252 internal, 258 external, 260 base, 242 base and between condyles, 250 of femur, 437 external, 437 internal, 438 base, 394 between condyles, 440 Congenital, 31, 233, 453 Cooper, Sir Astley, fracture of olecranon pro- cess, 309 neck of femur within capsule, 349 patella, 451 Coracoid process, 209 Coronoid process of ulna, 297 Cotyloid cavity, 339 Counter-extension by adhesive plaster, 415 Cradle for leg, 477 Crandall, extension, fracture of leg, 473 Cricoid cartilage, 141 Crosby, neck of femur within capsule, 371 external condyle, 437 INDEX—FRACTURES. Dalton. John O, fracture of neck of femur, 360 Daniels' fracture-bed, 431 Deformities of legs, 479 Delayed or non-union, 61 humerus, 234 Dextrine, 55 Diagnosis, general, 33 Dieffenbach, tenotomy in fracture of olecranon process, 313 Dislocation of humerus, differential diagnosis, 226 Division of fractures, general, 27 Dorsal vertebrae, 155 Dorsey, fracture of patella, 450 Dudley, treatment of fractures by bandages, 419 Dugas, sign of dislocation of humerus, 226 thigh apparatus, 415 Dupuytren's case of fracture of a dorsal ver- tebra, 155 body of a lower cervical vertebra, 156 dressing for fracture of fibula, 460 Elbow splint, Physick's 246 Kirkbride's, 247 Rose's, 247 Welch's, 247 Bond's, 248 the author's 249 Ellis, fracture of lower jaw, 111 Else, fracture of axis, 161 Emphysema in fracture of ribs, 174, 175, 176 Endless screw for extension of thigh, 428 Epicondyle of humerus, external, 257 internal, 253 Epiphyseal separations, 28 acromion, 207 humerus, upper end, 221 lower end, 242 femur, upper end, 352 lower end, 383, 428, 441 trochanter major, 391 Epiphyses, sternum, 166 scapula, 208 humerus, 220 radius, 292 ulna, 301 os innominatum, 331 femur, 347 tibia, 453 fibula, 457 Epitrochlea, 252 Etiology, general, 29 Eve, non-union of ribs, 173 patella, 444 Exciting causes, general, 29 Experiments on bending, 72 on partial fractures, 79, 82 External epicondyle of humerus, 257 condyle of humerus, 260 femur, 437 Extension of thigh by adhesive plaster, 422 Fauger, Colles's fracture, 282 Felt splints, 51 Femur, 347 neck, within capsule, 349 neck, anatomy of, George K. Smith, 373 differential diagnosis, 386 without capsule, 383 trochanter major and base of neck, 390 Femur— epiphysis of trochanter major, 391 shaft, 393 external condyle, 437 internal condyle, 438 between condyles, 440 base of condyles, 394 Fibula, 457 Fingers, 327 Fissures, 85 neck of femur, 351 Flagg's thigh apparatus, 414 Floating cartilages, in knee-joint, 700 Forearm, 314 Fore's case of fracture of hyoid bone, 135 Four-tailed bandage for broken jaw, 131 Fracture beds, 43i Jenks, 431 Hewson, 430 Barton, 430 Coates, 430 Daniels, 432 Burges, 411, 430 Crosby, 432 Fracture-box, 478 Gangrene, after fracture at base of condyles of humerus, 246 Dupuytren's cases after fracture of radius, 288 Robert Smith's cases, 289 Norris, 291 after fracture of forearm, 317 leg, from tight roller, 419 patella, 450 from tight bandages, 456 leg from tight bandages, 469 from use of " apparatus immobile," 475 Gibson, bandage for fractured jaw, 130 fracture of clavicle, 187 of coracoid process, 210 Gilbert, apparatus for broken femur, 423 leg, 472 Glenoid cavity of scapula, comminuted, 205 Granger, fracture of epicondyle, 253 Greater tubercle of humerus, 227, 230 Gunning's interdental splint, 125 Gunshot fractures, 487 treatment in, 490 Gutta-percha splints, 52 Harris, separation of upper maxillary bones. 102 J ' Harrold, lumbar vertebrae, 155 Hartshorne, thigh apparatus, 416 Hays, radial splint, 281 Hayward, lower-jaw, 122 Head of femur, 349 of radius, 266 and anatomical neck of humerus, 213 and neck of humerus, longitudinal frac- ture, 218 Hewson, fracture-bed, 430 Hodge, thigh-splint, 424 Hodgen's fracture cradle, 491 " wire, suspension splint, 477 Horner, thigh apparatus, 416 Humerus, 212 anatomical neck, 213 head and neck, 213 tubercles, 217 longitudinal fracture of head and neck, 218 INDEX—FRACTURES. 773 Humerus— surgical neck, 220 upper epiphysis, 221. differential diagnosis, 226 shaft, 232 lower epiphysis, 242 base of condyles, 242 with splitting of condyles, 250 condyles, 252 internal epicondyle, 253 external epicondyle, 257 internal condyle, 258 external condyle, 260 delayed union, 263 dislocation of, 226 Hutchinson, leg splint, 471 Hutchinson, J. C, fracture of spine, 150 Hyoid bone, 134 Ilium,336 Immovable apparatus, 54 leg, 475 Impacted fractures, 28 head and neck of humerus, 213 tubercles, 217 neck of femur within capsule, 349 without the capsule, 383 Incomplete fractures, 72 Inferior maxilla, 109 Interstitial absorption of neck of femur, 374 Intra-uterine fracture, 30, 233, 453 fracture of tibia, 453 Internal condvle of humerus, 258 femur, 438 Interdental splints, 123 Ischium, 334 Jackson, acromion process, 207 Jarvis's adjuster, 471 Jenks, fracture-bed, 430 Johnson, neck of femur, 359, 364 Key, lumbar vertebrae, 155 Kimball, fracture of femur, 415 Kirkbride, elbow splint, 247 Metallic splints, 48 Monahan, fracture of astragalus, 481 Morbus coxae senilis, 374 Morland, statistics of fracture of tibia and fibula, 463 Mott, prognosis in Colles's fracture, 279 fracture of femur, 408 electricity in non-union, 67 Mussey, fracture of coracoid process, 210 neck of femur, 363 Mutter's "clamp," 125 neck of radius, 265 Neck of femur, 348 within capsule, 349 prognosis, 355 G. K. Smith on, 373 without capsule, 383 Neck of humerus, anatomical, 213 surgical neck, 220 Neck of lower jaw, 113 Neck of radius, 265 Neck of scapula, 205 signs of fracture, 227 Neill, maxilla superior, 105 coracoid process, 209 fracture of patelia, 449 thigh, 412 leg, simple fracture, 471 compound fracture, 472 Nelaton, radial splint, 281 Non-union, 61 humerus, 237 lower jaw, 118 ribs, 173 Norris, delayed and non-union, 62 astragalus, 484 gangrene from bandages, 291 tibia, 456 Nose, fracture of, 90 Nott, wire splints, 48 thigh apparatus, 409 Odontoid process of axis, 161 Olecranon process, 306 tenotomy, 313 Ossa nasi, 90 Partial fracture, 76 Patella, 442 Pelvis, 380 Phalanges of fingers, 327 toes, 487 Pubes, 331 Radius, 264 Radius and ulna, 314 Reduction of fractures : general considera- tions, 44 Refracture of badly-united legs, 479 Repair of fracture, 37 Resection for badly-united fractures, 479 Ribs, 171 cartilages of, 171 Rim of acetablum, 342 Rodet, neck of femur, 350 Rogers, trephining vertebrae, 150 Roller, 46 Rose, elbow splint, 247 Sacrum,345 Sacro-iliac symphysis, 345 Larynx, fracture of, 139, 141 Lente, fracture of dorsal vertebra, 155 femur, 424 non-union, 67 pelvis, 331 Lewitt, patella, 447 Liston, thigh splint, 404 leg splint, 475 Lockwood, fracture of humerus at birth, 233 Long splints, 48 Lonsdale, extension in fracture ofhumerus,236 patella, 451 Lower jaw, 109 Malar bone, 98 McDowell, remarkable displacement of head of humerus, 214 separation of upper epiphysis, 221 Malgaigne, apparatus for fracture of leg, 478 Many-tailed bandage, 47 March, acromial separations, 207 neck of femur, 367 Maxilla, superior, 101 inferior, 109 Metacarpus, 324 Metatarsus, 4S5 RACTURES. 771 INDEX — F Salter's cradle for leg, 177 Sargent, separation of upper maxillary bones, 101 Scapula, 200 bodv, 200 neck, 198, 205 acromion process. 206 coracoid process, 209 epiphyses of, 207 Scultetus, bandage, 46 Semeiology, general, 33 Septum narium, 94 Setting bones, 44 Seutin, dressing, 54 anaplasty, 97 Shaft of humerus, 232 radius, 269 ulna, 293 femur, 393 Shoulder-joint: differential diagnosis of acci- dents, 226 Shrady, radius splint, 282 thigh splint, 416 Side splints, 48 Slin HENRY C. LEA, Philadelphia. THE SCIENCE AND ART OF SURGERY: BEIXCi A TREATISE ON SURGICAL INJURIES, DISEASES, AND OPERATIONS. By JOHN ERICHSEX, Professor of Surgery in University College, London. New and improved American, from the Second enlarged and carefully revised London edition, gltosirairb britlj obtt gam fmtbreb ffiHoob C-ngrabi'ngs. In one large and handsome octavo volume o/lOOO closely printed pages ; extra cloth, $6; lea- ther, raised bands, $7. We are bound to state, and we do so without wish- ing to draw invidious comparisons, that the work of Mr. Erichsen, in most respects, surpasses any that has preceded it. Mr. Erichsen's is a practical work, combining a due proportion of the " Science and Art of Surgery." Having derived no little instruction from it, in many important branches of surgery, we can have no hesitation in recommending it as a va- luable book alike to the practitioner and the stu- dent.—Dublin Quarterly. Gives a very admirable practical view of the sci- ence and art of surgery.—Edinburgh Med. and Sur- gical Journal. We recommend it as the best compendium of sur- gery in our language.—London Lancet. It is, we think, the most valuable practical work on surgery in existence, both for young and old practitioners.—Nashville Med. and Surg. Journal. The limited time we have to review this improved edition of a work, the first issue of which we prized as one of the very best, if not the best text-book of Bingery with which we were acquainted, permits us All that the surgical student or practitioner could desire—Dublin Quarterly Journal: It is a most admirable book. We do not know when we have examined one with more pleasure.— Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the- principles and the practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic. The fact that twelve editions have already been called for, in these days of active competition, would of itself show it to possess marked superiority. We have examined the book most thoroughly, and can say that this success is well merited. His book, moreover, pu*sesses the inestimable advantages of having the subjects perfectly well arranged and classified, and of being written in a style at once clear and succinct.— Am Journ. of Med. Sciences. Whether we view Druitt's Surgery as a guide to operative procedures, or as representing the latest to give it but a passing notice totally unworthy of its merits. It may be confidently asserted, that no work on the science and art of surgery has ever re- ceived more universal commendation or occupied a higher position as a general text-book on surgery, than this treatise of Professor Erichsen.—Savannuh Journal of Medicine. In fulness of practical detail and perspicuity of style, convenience of arrangement and soundness of discrimination, as well as fairness and completeness of discussion, it is better suited to the wants of both student and practitioner than any of its predeces- sors.—Am. Journal of Med. Sciences. After careful and frequent perusals of Erichseu's surgery, we are at a loss fully to express our admi- ration of it. The author's style is eminently didac- tic, and characterized by a most admirable direct- ness, clearness, and compactness. These traits have enabled him, in a volume of about 1000 pages, large- ly occupied by wood-cuts, to present what is, in many respects, the most full and complete system- atic treatise on the subject of which it treats in the English language.—Ohio Med. and Surg. Journal. theoretical surgical opinions, no work that we are at present acquainted with can at all compare with it. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserves the estimate placed upon it.— Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among our best text-books on elementary sur- gery.— Columbus Rev. of Med. and Surg. We must close this brief notice of an admirable work by recommending it to the earnest attention of every medical student.—Charleston Med. Jour. and Review. A text-book which the general voice of .the profes- sion in both England and America has commended as one of the most admirable "manuals," or "vntte mecum," as its English title runs, which can be placed in the hands of the student. The merits of Druitt's Surgery are too well known to every one to need any further eulogium from us.—Nashville. M<(licnl Journal. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, By ROBERT DRUITT, M. R.C. S., &c. A. new and revised American, from tha eighth enlarged and improved London edition, |llnstratcb foitjj <#our f)unbab anb olljirtji-tfcoo S&oob ©ngrabhtgs. In one very handsome octavo volume of nearly 700 large and closely printed pages ; extra cloth, St; leather, $5. Besides the careful revision of the author, this work has had the advantage of very thorough editing on the part of a competent surgeon to adapt it more completely to the wants of the American student and practitioner. Many illustrations have been introduced, and every care has been taken to render the mechanical execution unexceptionable. At the very low price affixed, it will therefore be found one of the most attractive and useful volumes accessible to the American practitioner. HENRY O. LEA, Philadelphi HEISTRY O. LENA'S (LATE LEA & BLANCHAED's) CLASSIFIED OA.T.A LOGrUB OF MEDICAL AND SUEGICAL PUBLICATIONS. In asking the attention of the profession to the works contained in the following pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. It will be observed that the prices during the last four years have not been advanced in anything like proportion to the increased cost of manufacture, and there is no pro- bability of a decrease of cftst that will warrant a reduction during the current year. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, postpaid, on receipt of ten cents. HENRY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, September, 1866. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. WITH THE MEDICAL NEWg_AND LIBRARY. TEKMS—FREE OF POSTAGE. The American Journal of the Medical Sciences, ") published quarterly, each number of 288 pp. f Five Dollars per annum, The Medical News and Library, C in advance. published monthly, each number of 32 pp. ) The Medical News and Library, separate, One Dollar per annum, in advance. Notwithstanding that the cost of manufacture of the "American JouTtxAi of the Medical Sciences " has more than doubled during the last four years, the publishers have felt a pride in maintaining it at the very moderate price at which it has remained for nearly half a century. To accomplish this, it has been found necessary to adopt the plan of strict payment in advance The r-nnrobation of this by the profession has been manifested by an unexampled increase in the sub- scription list, and the efforts of the friends of the "Journal" in extending its circulation among their acquaintances are thankfully acknowledged. . Bv reference to the terms, it will be seen that for Five Dollars per annum m advance the sub- scriber receives free of postage, both the "American Jouunal op the Medical Sciences and thP" Medical News and Library," containing in all about fifteen hundred large octavo pages, contributed by the leading minds of the profession. For cheapness, this is believed to be almost without a parallel in scientific literature. The appreciation manifested by the profession has been such as to exhaust within a few months of DubHcation each successive number for the last two years, notwithstanding the printing of con- st wtW enlarged editions. The number for January, 1866, is now exhausted; while but few copies rf the April number are still on hand. New subscribers can, therefore commence with the July number, which is the first of Vol. LII. To prevent disappointment in this, however, early remit- tftThV>-SrarTDepartment" of the "Medical News" for 1866 will be occupied with the com- i *• nf Dr C Handfield Jones' "Clinical Observations on Functional Nervous Dis- orders" which'has attracted so much commendation during 1S65. The portions of the work which have appeared previous to the time of subscribing can be procured. 2 ITk.nry C. Lea's Publications—(Am. Jourv. Med. Sciences). New subscribers may rely that no exertion will be spared by the editor and publisher to main- tain the high character enjoyed by the "Journal" throughout its long career of usefulness. It has arrived at the position of a National Organ of the American Medical Profession, solely devoted to the advancement of scientific medicine, and the liberal support which has been unfailingly ex- tended to it is gratefully acknowledged as a stimulus to increased exertion in the effort to render it worthy a continuance of favor. Identified as it has been with the professional advancement ot the last half century, every effort will be made to keep it as heretofore on a level with the most ad- vanced condition of medical progress and to maintain its position as a medium of inter-commum- cation between the profession of America and Europe. To accomplish this, communications are invited from gentlemen in all parts of the country. All elaborate articles inserted by the Editor are paid for by the Publisher. For many years, the list of contributors has embraced the leading names of the profession in every part of the United States, and it is hoped that the "Original Department"' of the "Journal" will continue, as heretofore, to represent, both in its variety and practical character, the highest development of scientific medicine in America. As the aim of the "Journal" is to combine the advantages of all the different kinds of periodi- cals, its "Review Department" will be found an important feature. Extended and impartial reviews of all important new works are given, together with very numerous bibliographical notices, including nearly all the medical publications of this country and Great Britain, together with the more important continental works. The reader is thus kept thoroughly informed as to the progress and direction of medical literature. This is followed by the "Quarterly Summary of the Improvements and Discoveries in the Medical Sciences," which presents in a condensed form an abridgment of all facts and in- vestigations of interest which have been made public during the preceding quarter at home and abroad. It is the object of especial care on the part of the Editor, and the ample materials at his command enable him to render it exceedingly complete. It is classified and arranged under appro- priate heads, thus facilitating the researches of the reader in pursuit of particular subjects. The extent and variety of the matter thus laid before subscribers may perhaps best be shown by a very condensed summary of the contents of the last two numbers of the "Journal." SUMMARY OF CONTENTS OF No. 101, NEW SERIES, FOR JANUARY, 1866. MEMOIRS AND CASES. I. Researches on Typhus Fever. By J. M. Da Costa, M. D , of Philadelphia. II. On the Cause of Intermittent and Remittent Fe- vers, traced to certain species of Palmellie. By J H. Salisbury, M. D , of Cleveland, Ohio. Ill On tho Causes of Certain Diseases on Ships of War. By Edgar Holden, M. D., of Newark. N. J. IV Comparative advantages of Pirogoff's, Syme's, and Chopart's Amputations, and Excision of the Ankle- joint, by Hancock's Method, with the proposition of another Method for Excision. By James M. Hol- loway, M. D . of Louisville, Ky. V. On Symptomatic Bronchial Irritation. By A. P. Merrill, M. D., of Now York City. VI On Puerperal Tetanus. By Wm. A. Gordon, M.D., New Bedford, fllasa. VII The Use of the Artificial Membrana Tympani. By D B Si John Roosa, M.D , of New York. VIII. Successful Kemoval of the Uterus and both Ovaries by Abdominal Section. By Horatio R. St ore r, M. D , of Boston. IX. Cases of Excision of Bones. By James B Cnfter, M D, of Newark, N. J. (With two wood-cuts.) X. Amputation of Right Shonlder-.Toiut. By W P Moou. M. D , Chestnut Hill. Pa (W.th a wood-cut ) XI. A Peculiar Case of Hematocele. By Charles M Ailiu, M. D., of New York. XII. Instruments for Facilitating Surgical Opera- tions. By D. Prince, M. D., of Jacksonville, 111. AVith two wood-cuts ) XIII. Reduction of an Ioverted Uterus of Seven Months'Standing. By Thomas Addis Emmet, M.D., of New York. TRANSACTIONS OF SOCIETIES X!V. Summary of the Transactions of the College of Physicians of Philadelphia M.immary Cancer. By John Ashhurst, Jr., M D. —Report on Meteorology and Epidemics for the year ending January 1st, IStS.V By James M Corse, M D —Cancer of the Ascending Colon By Alfred Stille, M. D —Regeneration of Bone By William Hunt, M.D.— Tumor on the Poste- rior Portion of the Tongue. ByWra Hunt MD —Fatal Peritonitis iu Typhoid Fever, wi'lhout Perforation of the Bowel. By Alfred Stille, M. D. REVIEWS. XV. Cliuiqne Medicale de l'Hotel-Dieu de Paris Par A. Trousteau. Deuxieme edition, revue et aue- mentee. " XVI. Lectures on the Pathology and Treatment of £a'^!,and other Forms of Curvature of the Spine By William Adams, F. R. C. S. BIBLIOGRAPHICAL NOTICES. XVTI. Transactions of the Medical "Society of the State of Pennsylvania, at its Sixteenth Annual Ses- sion, held at Altoona, June, 1860 XVIII. Reports of American Hospitals for the Insane. XIX. The Practice of Medicine and Surgery applied to the Diseases and Accidents incident to Women. By Wm. H Byford, A.M , M.D. XX Materia Medica for the Use of Students. By John B. Biddle, M.D. XXI. On the Direct Influence of Medicinal and Mor- bific Agents upon the Muscular tissue of tbe Blood- vessels. By R. Cresson Stiles, M D., etc. XXII. Obscure Diseases of the Brain and Mind By Forbes Winslow, M D., D.C L. XXIII. An Inquiry into the Possibility of Restoring the Life of Warm-Blooded Auimahs in certain case* By Benjamin Ward Richardson, M A., M.D ' XXIV. The Practice of Medicine. By Thomas Hawkes Tanner, M D.. F L S. Xv\ Th6 Principles of SllrgeiT- By James Syme, XXVI. The Essentials of Materia Modica and Thera- peutics. By Alfred Baring Garrod, M.D . F.R S XXVII. Lectures on the Diseases of the Stomach F.y William Brinton, M D. F R.S. •" XXVIII A Report upon tbe Epidemic occutrirg at Maple wood Young Ladies' Institute, Pittsfaeld, Mass., in July and August, 1861. X£IXV. Lectuiv« 0Q Epilepsy, Pain, Paralysis, &c. By Charles Bland Radcliffe, MI). •» XXX/ ^>atoloSia e Terapia delle Malattie Veueree di F. J Bumstead —Buinsteau's Pathology aud Treat- ment of Venereal Diseases. Translated into the Italian by Dr. Cirillo Tarabutiui. QUARTERLY SUMMARY. FOREIGN INTELLIGENCE. Anatomy and Phtsioloot. 1. On Life. By Dr Beale. 2. Experiments to determine the Activity of the Spleen. By MM Estor and St. Pierre. 3. Deglutition as observed by Autolaryngoscopy Bv M Guipier. i. Influence of Galvanism on the Heart By Dr Flies 5. Experiments on Congelation of Animals Bv M Pouchet. ' 6. Cell-Pathology. By Dr. Bennett. Materia Medica and Pharmact. 7. Danger of Subcutaneous Injections. By Pi0f Nassbaum. 8. Action of Certain of the Amyl Compounds Bv Dr B. W. Richardson ' Henry C. Lea's Publications—(Am. Journ. Med. Sciences). 3 9. Modification in Canquoin's Caustic Paste. 10. New Anaesthetic Mixture. By M. Brown, Jr. Medical Pathology and Therapeutics, a:nd Pbactical Medicine. 11. The Use of the Thermometer in Acute Disease. By Dr. Ringer. 12. Hydatids of the Liver, their Diagnosis, and their Treatment. By. Dr. Murchison 13. Children's Diseases. By M. Roger. 14. Aphthae of the Mouth and Throat. By Dr. Wilks. 15. Malignant Pustule. By M. Davaine. 16. Animal Parasite Diseases of the Skin. By Dr. Squire. 17. Degeneracy of Vaccine Lymph by Frequent Transmission. By Mr. Harding. 18. Assimilation of Fat in Consumption. By Dr. Dobell. 19. Inhalation of Oxygen in Phthisis and Anaemia. By Dr. Wolff. 20. Use of Phenic Acid for the Cure of Phthisis. By Dr. Wolff. 21. Instantaneous Cure of Coryza. By M. Luc. 22. Bronzing of the skin for Seven Years—Disease of Supra-renal Capsules. 23. Climacteric Insanity in the Male. By Dr. Skae. Surgical Pathology and Therapeutics, and Operative Surgery. 2t. Osteo-myelitis. By Dr. Fayrer. 25. .Treatment of Hereditary Syphilis without Mer- cury. By Mr. Dunn. 26. Traumatic Tetanus successfully treated by Opium Smoking, Chloroform, and Hemp. By Dr. Fayrer. 27.' Subcutaneous Section of Carbuncle. By Mr. Heath. 2S. Enlarged Spleen Removed by Excision. By Mr. Wells. 29. Entire Tongue Successfully Removed. By Mr. Nunneley. 30. Congeuital Luxation of the Patella. By Mr. William Stokes. 31. Compound Dislocation of the Astragalus—Reduc- tion. By Dr. Grant. 32. Fissured Fracture of the External Table of the Skull. By Mr. Teevan. 33. Fracture of the Larynx; Tracheotomy; Reco- very. By Dr. Maclean. t Ophthalmology. 34. Strumous Ophthalmia. By Mr. Johnson. 35. Blennorrhagic Conjunctivitis treated by Alcohol. By M. Go*selin. 36. Sympathetic Ophthalmia. By MM. Guepin and Wecker. 37. Retinal Disease occurring in the Course of Kidney Disease. By Mr. Hulke, Mr. Hart, and Mr. Hutch- inson. 38. Graves' Disease. By Dr. Reith. 39. Black Cataract. By Mr. Nunneley. Midwifery. 40. Mortality of the Childbed as Affected hy the Num- ber of theLabor. By Dr. Duncan. 41. Fatal Case of Accidental Hemorrhage. By Dr. Young. 42. Rupture of the Uterus; Abdominal Section ; Sub- sequent Pregnancies. By Dr. Dyer. 43. Extra-Uterine Foetation. By Dr. Hicks. 44. Intra-Uterine Variola. By M. Legros. 45. Retention of Urine in the Foetus. By M. Depaul. . Hygiene. 46. Ozone. Bv Dr. Richardson. 47. On the Effects of Scanty and Deficient Food. By Dr. Davy. 48. Does a Diet of Animal Food Conduce to Lean- ness? By Dr. Davy. 49. Beef and Pork as Sources of Entozoa. By Dr. Cobbold. AMERICAN INTELLIGENCE. Original Communications. Exsection of two and one-half inches of the Right Tibia. By W. Kempster, M D. Paralysis of the Median Nerve. By J. W. Moor- man, M.D. Sycosis cured by Sulphite of Soda. By J. Y_Dale, M.D. Domestic Summary. Dermoid Tumour of the Conjunctiva. By Dr. Sprague. Action of the Bromide of Potassium. By Dr. Bartholow. Treatment of Paralysis in Children. By Dr. Wm. A. Hammond. Uterine Tumors. By Dr. Sands. Bifid Uterus and Double Vagina. By Dr. Hoyt. SUMMARY OF CONTENTS OF No. 102, NEW SERIES, FOR APRIL, 1866. MEMOIRS AND CASES. I. Microscopic Researches on the Histology and Mi- nute Anatomy of the Spleen and Lacteal and Lym- phatic Glauds. By J. H. Salisbury, M. D., Cleve- land, Ohio. (With a plate.) II. Reflections upon the Epidemic of Yellow Fever at Pensacola in 1863. By B. F. Gibbs, M.D , U. S. N. III. Hospital Gangrene at Patterson Park Hospital, Bait. By W. Kempster, M.D., of Syracuse, N Y. IV. On Ether as a Local Application. By J J. Black, M.D., of Philadelphia. V. On Chloroform and Ergot in Ohstetric Practice. By Charles C. Hildreth, M.D.,-of Zanesville, Ohio. VI On some of the Diseases prevailing among the Freedpeople in the Dist. of Col. By Robert Rey- burn, M D , Washington, D.C. VII.. On Torpedo Wounds. By 8. W. Gross, M.D., of Philadelphia. VIII. Case of Neuralgic and Paralytic Affection fol- lowing Labor. By Isaac G. Porter, M. D., New London, Coun. IX. On Fractures of the Larynx and Ruptures of the Trachea. By Wm Hunt, M.D., of Philadelphia. X. Report of Eight Cases of Lithotomy. By Paul F Eve, M D , of Nashville, Tenn. XI. On Ilvpersulphiteof Soda in Intermittent Fever. By T l»" Leavitt, M D., of Germantown, Pa. XII On the Treatment of Certain Chronic and Acute Affections of the Skin by Chloride of Iron. By Bedford Brown, M D., of Washington City, D. C. XIII Shoulder Presentation in Four Successive La- bors. By Charles C. Hildreth, M. D., of Zanesville, O. XIV. Case of Orariotomy. By James E. Reeves, M.D., Fairmont, W. Va. XV Reduction of an inverted Uterus of Eight Months' Duration. By Thomas Addis Emmett, M.D., Now York. TRANSACTIONS OF SOCIETIES. XVI. Summary of the Proceedings of the Patkological Society of Philadelphia. Remittent Fever.; Pigment in all Tissues of Body. By Wm. Pepper, M. D— Acute Infiltrated Tu- bercle Associated with Malaria. By Wm. Pep- per, M.D.— Remittent Fever; Pigment in the Brain, &c. By Wm. Pepper, M.D.—Tubercular Meningitis. By T. H. Andrews, M. D —Spina Bifida; Fatty Kidney. By Dr. Packard.— Fracture of Base of Skull. By Dr. Wm. Pepper. —Fracture of Right Temporal Bone. By Dr. Wm. Pepper—Gunshot Wound through Thy- roid Glaud. By Wm. Pepper, M.D.—Medullary Cancer. By S. W. Mitchell, M.D.—Examination of Tumour. By Wm. Pepper, M.D.—Lithotomy. By John Ashhurst, Jr., M.D.— Polypi of the Vocal Chords. By S. W. Mitchell, M.D —Sup- purative Meningitis following Comminuted Fracture of the Nasal Bones. By Wm. Pepper, M. D.— Abscess of the Spleen. By George Pep- per, M. D. REVIEWS. XVII. Hypodermic Injections in the Treatment of Disease. XVIII. Stimulants and Narcotics. By Francis E. Anstie, M.D., M.R.P.C. XIX. Laryngoscopy. BIBLIOGRAPHICAL NOTICES. XX. Transactions of American StateMedical Societies. XXI. Reports of American Hospitals for the Insane. XXII. Guy's Hospital Reports. XXIII. On the Arrangement of the Muscular Fibres iu the Ventricles of the Vertebrate Heart. By James Bell Pettigrew, M. D. On the Relation, Structure, and Function of the Valves of the Vascular System in Vertebrata. By Ju.jies Bell Pettigrew, m!d. XXIV. Essay on the Use of the Nitrate of Silver in the Treatment of Inflammation, Wounds, and Ulcers. By John Higginbottom, F R. S. XXV. Contributions to Bone and Nerve Surgery. By J. C. Nott, M.D. 4 Henry 0. Lea's Publications—(Am. Journ. Jfed. Sciences). XXVI. Ou Wakefulness. By Wm. A. Hammond, M.D. XX VII. Anuual Report of the Surgeon-Qeneral U.S. A. 1SQ5. XXVIII. The Student's Book of Cutaneous -Medicine. By Erasmus Wil.-on, F. R.S. XXIX. On the Diseases, Injuries, and Malformations of the Rectum and Anus. By T. J. Ashton. XXX. Lectures on the Diseases of Infancy and Child- hood. By Charles West, M.D. QUARTERLY SUMMARY. FOREIGN INTELLIGENCE. Anatomy and Physiology. 1. The Functions of the Nucleus. By M. Balbiani. 2. Decomposition of Air by the Tissues. By M. De- marquay 3. Production of Animal Heat. By M Berthelot. 4. Existence of Glycogen in the Tissue of Entozoa. By Mi*! Foster. Materia Medica and Pharmacy. 5. New and Ready Mode of Producing Anaesthsesia. By Dr. B. W Richardson. 6. Anaesthetic and Sedative Properties of Bi-Chloride of Carbon. By Prof. Simpson. 7. Solanum Paniculatum By M. Martin. 8. Physiological Action of Iron. By Dr. A. Sasse. Medical Pathology and Therapeutics, and Practical Medicine. 9. The Polymorphism of Disease. 10. Medical Statistics. By M. Bernard. 11. Morbid Anatomy and Early Signs of Pneumonia By Dr. Waters. 12. Certain Forms of Haemoptysis. By Dr. Cotton. 13 snow's Theory of the Causes of Cholera. By Dr. RU -hard son. 14. i;tlk;uy of Lemon-Juice in Diphtheria. By M. (iucrsant. 15. Hyposulphite of Soda in Diphtheria. By Mr. J. C. Maynard. 16. Treatment of Articular Rheumatism, &c. by the subcutaneous Injection of Sulphate of Quinia Bv Dodenil. J 17 The Hot Mustard Hip-bath in Diarfhoea and Choleraic Diarrhoea. By Dr. Joseph Burlar. is Atropia in Constipation. By Dr. Fleming. 19. Cumbility of Blight's Disease. By Dr. Hassall. 20. Entozoa in the Muscles of Animals Destroyed bv Cattle Plague. By Mr. Beale. 21. Outbreak of Trichinosis at Hedersleben. By Dr Kratz. 22. Diagnosis by the Ophthalmoscope. ByM. Bouchut. Scroical Pathology and Therapeutics and Operative Surgery. 23. Use of Chloride of Zinc for Removal of Cancerous Tumors. By Mr. De Morgan. 24. Subcutaneous Ulceration. By Mr. Paget 25. Cancer of the Testis in Children. By M. Guersant 26. Artei«- Venous Cyst in the Popliteal Nerve. By Mr. Moore. 27. Removal of the entire ifongue by the Ecraseur. By Mr. Paget. 28. Excision of the Tongue. By Prof. Jas. Syme. 29. Foreign Bodies in the Air-Passages of Children. ' By M. Guersant. 30. Polypi of Larynx. By Dr. Gilewski. 31. Wounds of Joints. By Dr. Rutherford. 32. The Sequel in Excision of Joints. 33. Trephining the Spine. By Dr. Gordon. 34. Ovariotomy in Relation to Disease of both Ova- ries. By M. Scanzoni. Ophthalmology. 35. Changes in the Eye in Progressive Myopia. Mr. Rouse. By 36. Physiology and Pathology of Dilated Pupil. By Dr. Bell. 37. Atropia Points. By Mr. Laurence. Midwifery. 38. Use of the Wire-Ribbon in Difficult Turning. By Dr. Heyerdahl. * 39. Influence of Chlorate of Potash on the Foetus in Utero. By Dr. Bruce. 40. Procidentia Uteri. By Dr. Sims. Hygiene. 41. Ozone for Sanitary Purposes. By Dr. Day. 42. Deodorization and Disinfection. By Dr. Baker. 43. Utilization of Fecal Matter. By Dr. Lecadre. Medical Jurisprudence and Toxicology. 44. Death from Chloroform. By Dr. Gillespie. 45. Respiration and Signs of Life in a Five Months' Foetus. By Dr. Moore. AMERICAN INTELLIGENCE. Original Communications. Case of Prolapsus Recti. By John Peach, M D • Case of Tapeworm Probably Contracted by Eatine Beef or Veal. By J. H. Beech, M D Poisoning by the Fruit of Rhus Toxicodendron. Bv J. W. Moorman. ' Spontaneous Umbilical Hemorrhage. By J. H. Pooley, Domestic Summary. Aphasia. By Prof. Austin Flint. Gutta-Percha Shoe in Talipes. By Dr Post Amputation at Hip-Joint. By Dr. Fauntleroy Colotomy for Cancer of the Rectum. By Prof Black- Gunshot Wound of the Brain. By Dr. Hutchinson Dislocation of the Patella on its Axis. By Dr Ro- chester. ' " DDr°Pauntlefroye ^^ UP°n "" D°rSUm I11L B? COBulloUcekntS °f ^"er,itrum Viride- By Mr. Charles The late Professor Chandler R. Gilman. prSip^ «* large amount of valuable THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo paees Its N>w« n™ . „ rent information of the day, and for some month™V ♦(, i. I DepARTMENT presents the cur- to the subject of Cholera. y'lts Librae? CSe^e in the Univ. of Penna. AX ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination) of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12tno. volume, of about one thousand pages, with 374. wood cuts, extra cloth, $4 ; strongly bound in leather, with raised bands, $1 75. T'.ie Compeud of Drs. Neill and Smith is incompara- bly the most valuable work of its class ever published in this country Attempts have been made in various quarters to squeeze Anatomy, Physiology. Surgery, the Practice of Medicine, Obstetrics, Materia Medica, and Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of" Neill and .Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class.— N. 0. Med. and Surg. Journal. This popular favorite with the student is so well known that it requires no more at the hands of a medical editor than the annunciation of a new and improved edition. There is no sort of comparison between this work and any other on a similar plan, and for a similar object.—Nash. Journ of Medicine. There are but few students or practitioners of me- dicine unacquainted with the former editions of this unassuming though highly instructive work. The whole science of medicine appears to have been sifted, as the gold-bearing sands of El Dorado, and the pre- cious facts treasured up in this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion.— West- ern Lancet. To compress the whole science of medicine in less than 1,000 pages is an impossibility, but we think that the book before us approaches as near to it as is pos- sible. Altogether, it is the best of its class, and has met with a deserved success. As an elementary text- book for students, it has been useful, and wiil con- tinue to be employed in the examinatioa^)f private classes, whilst it will often be referredMo by the country practitioner.— Va. Med. Journal. | As a handbook for studeuts it is invaluable, con- taining in the most condensed form the established [ facts and principles of medicine and its collateral sciences.—N. H. Journal of Medicine. In the rapid course of lectures, where work for the studeuts is heavy, and review necessary for an exa- mination, a compeud is not only valuable, but it is almost a sine qua non. The one before us is, iu most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and sound- est doctrines and the latest improvements and dis. coveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recom- mend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the gradu- ates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not ex- actly now what it was when they left it olf. — The Stethoscope. Having made free use of this volume in our exami- nations of pupils, we can speak from experience in recommendiugit as an admirable compend for stu- dents, and especially useful to preceptors who exam- ine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be examined. A work of this sort should be in the hands of every one who takes pupils into his office with a viewof examining them ; and this is unquestionably the best of its class. Lot every practitioner who has pupils provide himself with it, and he will find the labor of refreshing his knowledge so much facilitated that he will be able to do justice to his pupils at very little cost of time or trouble to himself.—Transylvania Med. Journal. JjUDLOW (J.L.), M.D., A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy Irid TherapeutHs. To which is added a Medical Formulary. Third edition, thorough y re'vised and greatly extended and. enlarged. With 370 illustrations. In one handsome roval 12mo. volume of 816 large pages, extra cloth, S3 25; leather, $3 75 nandsome r°yal The arrangement of this volume in the form of question and answer renders it especiallv suit- able for the office examination of students, and for those preparing for graduation We know of no better companion for the student during the hours spent in the lecture-room, or to re- fresh, at a glance, his memory of the various topics crammed into his head by the various professors to whom he is compelled to listen.—Western Lancet. As it embraces the whole range of medical studies it is necessarily voluminous, containing 816 large duodecimo page3. After a somewhat careful exami- nation of its contents, we have formed a much more favorable opinion of it than we are wont to regard such works. Although well adapted to meet the wants of the student in preparing for his final examination, it might be profitably consulted by the practitioner aiS?\W-, ° i8 m0st apt t0 become rusty in the very kind ot details here given, and who, amid the hurry of his daily routine, is but too prone to neglect the study of m,°'e. elaborate works. The possession of a volume ot this kind might serve as an inducement for him to seize the moment of excited curiosity to inform him- self on any subject, and which is otherwise too often allowed to pass unimproved.—Si. Louis Med. and Surg. Journal. rpAXXER (THOMAS HAWKES), M.D., \osif UTird aF CLIIJIC\L MEDICINE AND PHYSICAL DIAG- Henry C. Lea's Publications—(Anatomy). 7 QRA Y (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H- V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissec- tions 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, $b 00; leather, raised bands, $7 00. The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding its exceedingly low price, the work~will be found, in every detail of mechanical execution, one of the handsomest that has yet been offered to the American profession; while the careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed in the English edition. Tlius it is that book after book makes the labor of the student easier than before, and since we have seen Blanchard & Lea's new edition of Gray's Ana- tomy, certainly the finest work of the kind now ex- tant, we would fain hope that the bugbear of medical students will lose half its horrors, and this necessary foundation of physiological science will be much fa- cilitated and advanced.—N. O. Med. News. The various points illustrated are marked directly on the structure; that is, whether it be muscle, pro- cess, artery, nerve, valve, etc. etc.—we say each point is distinctly marked by lettered engravings, so that the student perceives at once each point described as readily as if pointed out on the subject by the de- , rnonstrator. Most of the illustrations are thus ren- dered exceedingly satisfactory, and to the physician they serve to refresh the memory with great readiness and with scarce a reference to the printed text. The surgical application of the various regions is also pre- sented with force and clearness, impressing upon the student at each step of his research all the important relations of the structure demonstrated.—Cincinnati Lancet. This is, we believe, the handsomest book on Ana- tomy as yet published in our language, and bids fair to become in a short time the standard text-book of our colleges and studies Students and practitioners will alike appreciate this book. We predict for ii a bright career, and are fully prepared to endorse the statement of the London Lancet, that "We are not acquainted with any work in any language which can take equal rank with the one before us." Paper, printing, binding, all are excellent, and we feel that a grateful profession will not allow the publishers to go unrewarded.—Nashville Med. and Surg. Journal. OMITH (HENRYH), M.D., and TJORXER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna., &c. LateProf of Anatomy in the Univ. ofPenna., &er AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. ■ In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pecu- I the kind that has yet appeared; and we must add, liarly convenient for the studeut, and its superb ar- | the very beautiful manner in which it is "got up" tistical execution, have been already pointed out. We I is so creditable to the country as to be flattering to must congratulate the student upon the completion our national pride.—American Medical Journal. of this Atlas, as it is the most convenient work of I H VRNER (WILLIAM E.), M.D., SPECIAL ANATOMY AND HISTOLOGY. Eighth edition, exten- sively revised and modified. In two large octavo volumes of over 1000 pages, with more than 300 wood-cuts; extra cloth, $6 00. OHARPEY ( WILLIAM), 21.D., and Q UAIN (JONES fr RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Lkidv, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. ALLEN (J. M.), M.D. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting Room. With 266 illustrations. In one very handsome royal 12mo. volume, of over 600 pages; extra cloth, $2 00. One of the most useful works upon the subject ever written.—Medical Examiner. Henry C. Lea's Publications—(Anatomy). lyiLSOX (ERASMUS). F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and revised American, from the last and enlarged English edition. Edited by W. H. Go- buecht, M.D., Professor of General and Surgical Anatomy in the Medical College of Ohio. Illustrated with three hundred and ninety-seven engravings-on wood. In one large and handsome octavo volume, of over 600 large pages; extra cloth, $4 00; leather, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to. render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contain? over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. The publisher has felt that neither care nor expense should be spared to render the external finish of the volume worthy of the universal favor with which it has been received by the American profession, and he has endeavored, consequently, to produce in its mechanical execution an im- provement corresponding with that which the text has enjoyed. It will therefore be found one of the handsomest specimens of typography as yet produced in this country, and in all respects suited to the office table of the practitioner, notwithstanding the exceedingly low price at which it has been placed. T>Y THE SAME AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Ana- tomv. Third American, from the last revised and enlarged English edition. Modified and rearranged by William Hunt, M.D., late Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, of 582 pages, with 154 illustrations; extra cloth, $2 00. one TiTACLISE (JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In . volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. As no complete work of the kind has heretofore been published in the English language the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas: of Surgical Anatomy, to which the student and practitioner can at aH times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface as well as their abnormal deviations. The importance of such a work to the student, in the absence of anatomical material, and to practitioners, either for consultation in emergencies or to refresh their recollections of the dissecting room, is evident. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that thi price is so low as to place it within the reach of all members of the profession. refreshed by those clear and distinct dissections, which every one must appreciate who has\ particle ot enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. Those who have any curiosity to gratify, in reference to the perfectibility of the We know of no work on surgical anatomy which can compete with it.—Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the library of any medical man, while the student could scarcely make a better investment than this.—The Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. While the operator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is .. .s. «v. ---«-~..s/s. w i.uo ycucut.iuiiitj' oi me lithographic art in delineating the complex mechan- ism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-similes of nature.— Boston Med. and Surg. Journal. pEASLEE (E.R.), M.D., ' ------- Professor of Anatomy and Physiology in Dartmouth Med. College', N. H. HTp?tIbA1X HISTOLOGY in its relations to Anatomy, Physiology, and Pathology; for the use of medical students. With four hundred and thirty-four il u tra toons. In one handsome octavo volume of over 600 pages, extra cloth $3 75 ofTll «,.??, rnrn^fheSm^SScts'rhicn fi^nd wV* ^™»M »™^ °f ™di" it treats: of all that is in the great works of Shnon an honor t, th? ?° L°81tatlon jn »7»»»8 that it is *nd Lehmann, and the organic chemists in eeneral %r Tn»T.f at U ,A™encarn medical profession. - Master this one volume, and you know aYX is ' " and Swa' JourliaL Henry C. Lea's Publications—(Physiology). 9 (JARP ENTER (WILLIAM B.), 21. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations 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 Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 ; leather, raised bands, $6" 50. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges.—Virginia Medical Journal. We have so often spoken in terms of high com- mendation of Dr. Carpenter's elaborate work on hu- man physiology that, in announcing a new edition, it is unnecessary to add anything to what has hereto- fore been said, and especially is this the case since every intelligent physician is as well aware of the character and merits of the work as we ourselves are. —St. Louis Med. and Surg. Journal. The above is the title of what is emphatically the great work on physiology; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority.—Atlanta Med. Journal. The greatest, the most reliable, and the best book on the subject which we know of in the English lan- guage. —Stethoscope. The highest cpmpliment that can be extended to this great work of Dr. Carpenter is to call attention to this, another new edition, which the favorable regard of the profession has called for. Carpenter is the standard authority on physiology, and no physi- cian or medical student will regard his library as complete without a copy of it.—Cincinnati Med. Ob- server. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tioi^ already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology in its reference to tbe institutes and practice of medicine.—Am. Jour. Med. Sciences. ■ A complete cyclopaedia of this branch of science.— N. Y. Med. Times. DF THE SAME AUTHOR. ---- PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- can, 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 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. DF THE SAME AUTHOR. . THE MICROSCOPE AND ITS REVELATIONS. With, an Appen- dix 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, $5 25. rpODD (ROBERT B.), 31. D. F.R.S., and JgOWMAN (TV), F.R.S. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on w od. Complete in one large octavo volume of 950 pages, extra cloth. Price $4 75. The names of Todd and Bowman have long been familiar to the student of physiology. In this work we have the ripe experience of these laborious physi- ologists on every branch of this science. They gave each subject the most thorough and critical examina- tion before making it a matter of record. Thus, while they advanced tardily, apparently, in their publica- tion, the work thus issued was a complete exponent of the science of physiology at the time of its final appearance. We can, therefore, recommend this work as one of the most reliable which the student or practitioner can consult relating to physiology.—N. Y. Journal of Medicine. To it the rising generation of medical men will owe, in great measure, a familiar acquaintance with all the chief truths respecting the healthy structure and working of the frames which are to form the subject of their care. The possession of such know- ledge will do more to make sound and able practi- tioners than anything else.—British and Foreign Medico-Chirurgical Review. J7-IRKES (WILLIA2I SENHOUSE), 21.D., A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition. With two hundred illustrations. In one large and hand- some royal 12mo. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2 75. By the use of a fine and clear type, a very large amount of matter has been condensed into a comparatively small volume, and at its exceedingly low price it will be found a most desirable manual for students or for gentlemen desirous to refresh their knowledge of modern physiology. It is at once convenient in size, comprehensive in design, and concise in statement, and altogether well adapted for the purpose designed.—££. Louis Med. and Surg. Journal. The physiological reader will find it a most excel- lent guide in the study Of physiology in its most ad- vanced and perfect form. The author has shown himself capable of giving details sufficiently ample in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not lengthened.—Edinburgh Med. and Surg. Journal. 10 Henry C. Lea's Publications—(Physiology). JJALTON (J. C), M.D., Professor of Physiology in the College of Physicians and Surgeons, X* w York. A-r. A TREATISE ON III MAX PHYSIOLOGY, Designed for the use of Students and Practitioners of Medicine. Third edition, revi-ed, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $5 2,"> ; leather, $(> 25. " In the present edition of this work the general plan and arrangement of the two former ones are retained. The improvements and additions which have been introduced consist in the incor- poration into the text of certain new facts and discoveries, relating mainly to details, which have made their appearance within the last three years."—Author's Preface. The rapid demand for another edition of this work sufficiently shows that the author has suc- ceeded in his efforts to produce a text-book of standard and permanent value, embodying within a moderate compass all that is definitively and positively known within the domain of Human Physiology. His high reputation as an original observer and investigator is a guarantee that in again revising it he has introduced whatever is necessary to render it thoroughly on a level with the advanced science of the day, and this has been accomplished without unduly increasing the size of the volume. No exertion has been spared to maintain the standard of typographical execution which has rendered this work admittedly one of the handsomest volumes as yet produced in this country. We believe we fully recognize the value of Draper and Dunglison, Carpenter and Kirkes, and Todd and Bowman, and yet we Unhesitatingly place Dalton at the head of the list, for qualities already enumerated. In the important feature of illustration, Dalton's work is without a peer, either in adaptedness to the text, simplicity and graphicness of design, or elegance of artistic execution.—Chicago Med. Examiner. In calling attention to the recent publication of the third edition of this book, it will only be necessary to say that it retains all the merits and essentially the same plan of the two former editions, with which every American student of medicine is undoubtedly familiar The distinguished author has added to the text all the importaut discoveries in experimental physiology and embryology which have appeared during the last three years.—Boston Med. and Surg. Journal, June 30, 1S64. The arrangement of the work is excellent. The facts and theories put forward in it are brought up to the present tiinp. Indeed, it may he looked upon as presenting the latest views of physiologists in a con- densed form, written in a clear, distinct manner, and in a style which makes it not only a book of study to the student, or of reference to the medical practi- tioner, but a book which may be taken up and read with both pleasure and profit at any time.—Canada Med. Journal, October, 1861. In Dr. Dalton's excellent treatise we have one of the latest contributions of our American brethren to medical science, aud its popularity may be estimated by the fact that this, the second edition, follows upon the first with the short interval of two years. The author has succeeded in giving his readers an exceed ingly accurate and^at the same time most readable I Chirurgical Review risttmi of the present condition of physiological science ; and, moreover, he has not been content with mere compilation", but has ably investigated the func- tions of the body for himself, many of the original experiments and ohservations being of the greatest value—London Med. Review. This work, recognized as a standard text-book by the medical schools, and with which the members of the profession are so familiar, demands but a brief notice. Its popularity is attested by the rapidity with which former editions have been exhausted.— Chicago Med. Journal, April, 1864. To the student of physiology, no work as yet pub- lished could be more satisfactory as a guide, not only to a correct knowledge of the physiological subjects embraced in its limits, but, what is of far greater importance, it will prove the best teacher of the modes of investigation by which that knowledge can be acquired, and, if necessary, tested.—The Columbus Review of Med and Surgery. Until within a very recent date, American works on physiology were almost entirely unknown in En- rope, a circumstance solely due to the fact of their being little else than crude compilations of European works. Within the last few years, however, a great change has taken place for the better, and our friends on the other side of the Atlantic can now boast of possessing manuals equalled by few and excelled by none of our own. In Dr. Dalton's treatise we are glad to find a valuable addition to physiological lite- rature. With pleasure we have observed throughout the volume proof of the author not being a mere compiler of the ideas of others, but an active laborer in the field of science.—The Brit, and For. Medico- J)UXGLISOX (ROBLEY), M.D., Professor of Institutes of Medicine in 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 of about 1500 pages, extm cloth $7 00 JTjERMAXX (C. G.) ---------------~ plete in two 1mm and h2S Physiological Chemistry, and an Appendix of plates. Com- l^^\7^o^^t^^°^lU^ ^^^ 12°° ^ wit» —ly two £Y THE SAME AUTHOR. ____ Vania. WithmMilJlZAT*™ JaCKS?*' M D-> of «"> University of Pennsyl- extra cloth$21 25 In °ne Tery hand*o^ octavo volume of 336 pages, Henry C. Lea's Publications—(Chemistry). 11 J^RANDE (W21. T.), D. C.L., and rTAYLOR (ALFRED S.), 31.D., F.R.S. CHEMISTRY. In one handsome 8vo. vol. of 696 pp., extra cloth. $4 50. The passage of this volume through the press has been superintended hy a competent chemist who has sedulously endeavored to secure the accuracy so essential to a work of this nature. No additions have been made, but the publishers have been favored by the authors with some correc- tions and revisions of the first twenty-one chapters, which have been duly inserted. _ A most comprehensive and compact volume. Its information is recejit, and is conveyed in clear lan- guage. Its index of sixty closely-printed columns shows with what care new discoveries have been added to well-known facts.—The Chemical News. The Handbook in Chemistry of the Stddent.— For clearness of language, accuracy of description, extent of information, and freedom from pedantry and mysticism, no other text-book comes into com- petition with it.^-The Lancet. The authors set out with the definite purpose of writing a book which shall be intelligible to any educated man. 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.— Medical Times. We can cordially recommend this work as one of the clearest, and most practical that can be put in the hands of the student.—Edinburgh Med. Journal. It abounds in innumerable interesting facts not to be found elsewhere ; and from the masterly manner in which every subject is handled, with its pleasing mode of describing even the dryest details, it cannot fail to prove acceptable, not only to those for whom it is intended, but to the profession at large.—Canada Lancet. We have for a long time felt that the preparation of a proper chemical text-book for students would be time better spent than in the invention of a novel system of classification or the discovery of half a dozen new elements ending in ium. We believe this want has at last been satisfied in the book now before us, which has been prepared expressly for medical students by two of the most experienced teachers of the science in England.—Boston Med. and Surgical Journal. J$OW3IAN (JOHN E.),M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fourth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. £2 25. The fourth edition of this invaluable text-book of Medical Chemistry was published in England in Octo- ber of the last year. The Editor has brought down the Handbook to that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in the science which have come to light since the previous edition was printed. The work is indispensable to every student of medicine ox enlightened practitioner. It is printed in clear type, and the illustrations are numerous and intelligible.—Boston Med. and Surg. Journal. The medical student and practitioner have already appreciated properly this small manual, in which instruction for the examination and analysis of the urine, blood and other animal products, both healthy and morbid, are accurately given. The direcTTSns for the detection of poisons in oi'gauic mixtures and in the tissues are exceedingly well exposed in a con- cise and simple, manner. This fourth edition has been thoroughly revised by the editor, and brought up to the present state of practical medical chemistry. —Pacific Med. and Surg. Journal. B Y THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Third American, from the third and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. One of the molt complete manuals that has for a long time been given to the medical student.— Athenaum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. It is by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign Medico-Chirurgical Review. The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Jour. This little treatise, or manual, is designed espe- cially for beginners. With this view the author has very judiciously simplified his subjects and illustra- tions as much as possible. aDd presents all of the details pertaining to chemical analysis, and other portions difficult for beginners to comprehend, in such a clear and distinct manner as to remove all doubt or difficulty. Thus a subject which is usually regarded by students as almost beyond their com- prehension, is rendered very easy of acquisition. Several valuable tables, a glossary, etc., all combine to render the work peculiarly adapted to the wants of such; and as such we commend it to them.—The Western Lancet. f1RAHA2I (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. $5 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 $3 00. From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to me. 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 aflTord to be without this edition of Prof. Graham's Elements.—Sillirnan's Journal, March, 1SJS. 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. 12 Henry C. Lea's Piblicatioxs—(Chemistry and Pharmacy). T > WXES (GEORGE), Ph. D. A MVXUVL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. Ecjited ^ |!^«^ B'U^oES M. D. In one large royal l2mo. volume, of 600 pages, extra cloth, *2 00 ; leather, . i ■ Wo know of none within the same limits wlncli has higher claims to our confidence as a college class- book, f/oth for accuracy of detail aud scientific ar- rangement.— Augusta Medical Journal. We know of no text-book on chemistry that we would sooner recommend to the student than this edition -of Prof. Fowues' work.— Montreal Medical A new and revised edition of one of the best elemen- tary works on chemistry accessible to the American and English student.— N. Y. Journal of Medical and Collateral Science. We unhesitatingly recommend it to medical stu- dents.—^. W. Med. and Surg. Journal. This is a most excellent text-book for class instruc- tion in chemistry, whether lor schools or colleges.— Silli'man's Journal. We know of no treatise in the language so well calculated to aid the student in becoming familiar with the numerous facts in the intrmsic science on which it treats, or one better calculated as a text- book for those attending Chemical lectures. * * * * The best text-book on Chemistry that has issued from our press.—American Medical Journal. We again most cheerfully recommend It as the best text-book for students in attendance upon Chem- ical lectures that we have yet examined.—III. and Ind. Med. and Surg. Journal. A flrst-rate work upon' a first-rate subject.—St. Louis Med. and Surg. Journal. No manual of Chemistry which we have met comes so near meeting the wants of the beginner.— Western Journal of Medicine and Surgery. ABEL AND BLOXAM'S HANDBOOK OF CHEMIS- TRY, Theoretical, Practical, and Technical. With a recommendatory Preface, by Dr. Hoffman. In one large octavo volume of 662 pages, with illus- trations, extra cloth, $1 50. GARDNER'S MEDICAL CHEMISTRY, for the Use of Students, and the Profession. In one royal 12mo. volume, with woodcuts; pp. 396, extra cloth, $1 00. KNAPPS TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. Edited, with "numerous notes and additions, by Dr. Edmund Ronai.s, aud Dr. Thomas Richardson. With Amer- ican additions, by Prof. Walter R Johnson. In two very handsome octavo volumes, containing about 1000 pages, and 500 wood engravings, extra cloth, $6 00. pARRISH (EDWARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the ,? Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00. The rapid progress made in the science and art of Pharmacy, and the many changes in the last edition of the Phartnaoopoeia have required a very thorough revision of tins work to render it worthy the continued confidence with which it has heretofore been favored. In effecting this, many portions have been condensed, and every effort has been made to avoid increasing unduly the bulk of the volume, yet, notwithstanding this, it will be found enlarged by about one hundred and fifty pages. The author's aim has been to present in a clear and compendious manner every- thing of value to the prescriber and dispenser of medicines, and the work, it is hoped, will be found more than ever a complete book of reference and text-book, indispensable to all who desire to keep on a level with the advance of knowledge connected with their profession. The immense amount of practical information condensed in its pages may b^ estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36; Extracts, 159 j Lozenges, 25; Mixtures, 55; Pills, 56; Syrups, 131; Tinctures, 138; Unguentum, 57, &c. not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, aud we must conclude by a simple expression of our hearty appreciation of its merits.—Dublin Quarterly Jour, of Medical Science, August, 1864. We have in this able and elaborate work a fair ex- position of pharmaceutical science as it exists in the United States ; aud it shows that our transatlantic friends have given the subject most elaborate con- sideration, and have brought their art to a degree of perfection which, we believe, is scarcely to be sur- passed anywhere. The book is, of course, of more direct value to the medicine maker than to the physi- cian ; yet Mr. Parrish has not failed to introduce matter in which the prescriber is quite as much interested as the compounder pf remedies. In con- clusion, we can only express our high opinion of the value of this work as a guide to the pharmaceutist, and in many respects to the physician, not only in America, but in other parts of the world.—British Med. Journal, Nov. 12th, 1864. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats ; a more complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay.—Canada Med. Journal, Nov. 1864. The medical student and the practising physician will find the volume of inestimable worth for study and reference.—San Francisco Med. Press, July, 1jo4. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do not wish it to be understood as very extravagant praise. Iu truth, it is not so much the best as the only book.—The London Chemical News. An attempt to furnish anything like an analysis of Parrislfs very valuable and elaborate Treatise on Practical Pliarmacy would require more space than we have at our disposal. This, however, is not so much a matter of regret, inasmuch as it would be difficult to think of any point, however minute and apparently trivial, connected with the manipulation of pharmaceutic substances or appliances which has The former editions have been sufficiently long before the medical public to render the merits of the work well known. It is certaiuly one of the -most -complete and valuable works on practical pharmacy to which the student, the practitioner, or the apothe- cary can have access.—Chicago Medical Examiner, March, 1S64. Henry C. Lea's Publications—(3Iateria 3Ied. and Therapeutics). 13 QRIFFITH (ROBERT E.), 31.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring 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 of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. In this volume, the Formulary proper occupies over 400 double-column pages, and contains about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable receipts for the preparation of essences, perfumes, inks, soaps, varnishes, &c. Ac. In addition to this, the work contains a vast amount of information indispensable for daily reference by the prac- tising physician and apothecary, embracing Tables of Weights arid Measures, Specific Gravity, Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific Gravities of some of the Preparations of the Pharmacopoeias, Relation between different Thermometrical Scales, Explanation of Abbreviations used in Formulae, Vocabulary of Words used in Prescriptions, Ob- servations on the Management of the Sick Room, Doses of Medicines, Rules for the Administration of Medicines, Management of Convalescence and Relapses, Dietetic Preparations not included in the Formulary, List of Incompatibles, Posologieal Table, Table of Pharmaceutical Names which differ in the Pharmacopoeias, Officinal Preparations and Directions, and Poisons. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseases and their Remedies, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formulae containing them—while another of Pharmaceutical and Botanical Names, and a very thorongh General Index afford the means of obtaining at once any information desired. The Formulary itself is arranged alphabetically, under the heads of the leading constituents of the prescriptions. _ This, is one of the most useful books for the prac- We know of none in our language, or any other, so tising physician which has been issued from the press comprehensive in its details.—London Lancet. of late years, containing a vast variety of formulas ... for the safe and convenient administration of medi- 0ne of the most complete works of the kind in any cines, all arranged upon scientific and rational prin- language.— Edinburgh Med. Journal. ciples, with the quantities stated in full, without We are not cognizant of the existence of a parallel signs or abbreviations.—Memphis Med. Recorder. work.—London Med. Gazette. &TILLE (ALFRED), 31. D., Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Second edition, revised and enlarged. In two large and handsome octavo volumes, of 1592 pages. Extra cloth, $10 00; leather, raised bands, $12 00. Dr. Stillfe's splendid work on therapeutics and ma- I We have placed first on the list Dr. Stille's great teria medica.—London Med. Times, April 8, 1865. j work on therapeutics.— Edinburgh Med. Journ., 1865. TfLLIS (BENJA31IN), 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 Ob- servations. Eleventh edition, carefully revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one volume 8vo., of about 350 pages. $3 00. We endorse the favorable Opinion which the book has so long established for itself, and take this occa- sion to commend it to our readers as one of the con- venient handbooks of the office and library.—Cin- cinnati Lancet, Feb. 1864. The work has long been before the profession, and its merits are well known. The present edition con- tains many valuable additions, and will be found to be an exceedingly convenient and useful volume for reference by the medical practitioner. — Chicago Medical Examiner, March, 1864. The work is now so well known, and has been so frequently noticed in this Journal as the successive editions appeared, that it is sufficient, on the present occasion, to state that the editor has introduced into the eleventh edition a large amount of new matter, derived from the current medical and pharmaceutical works, as well as a number of Valuable prescriptions furnished from private sources. A very comprehen- sive and extremely useful index has also been sup- plied, which facilitates reference to the particular article the prescriber may wish to administer; and the language of the Formulary has been made to cor- respond with the nomenclature of the new national Pharmacoposia.—Am. Jour. Med. Sciences, Jan. ISol. T\UNGLISON (ROBLEY), 31.D., -*~^ Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-Book. AYith 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, of about 1100 pages, extra cloth. $G 50. T>Y THE SAME AUTHOR. ---- NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARA- TION AND ADMINISTRATION. Seventh edition, with extensive additions. In one very large octavo volume of 770 pages, extra cloth. $4 00. 14 IIknry C. Lea's Publications—(Materia Med. and Tlierapenfirs). JJ ERE IRA -(JONATHAN 21. P., F.R.S. and L.S. MATERIA MEDICA AND THERAPEUTICS being an Abridg- ment of the late Dr. Pereira's Elements of Materia Medica? arranged in conformity with the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemist? and Druggists, Medical and Pharmaceutical Students, Ac. By F. J. Farre, M.D., Senior Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; assisted by Robert Bentlev, M.R.C.S., Professor of Materia Medica and Botany to the Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S., Chemical Operator to the Society of Apothecaries. With numerous additions and references to the United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the University of Pennsylvania. In one large and handsome octavo volume of over 1000 closely printed pages, ^ith 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. {Now Ready.) The very large size attained by the great work of Dr. Pereira, in its successive revisions, has seemed to render desirable an abridgment of it in which should be omitted the commercial and physical details which possessed more interest for the druggist than for the practitioner. In the effort at condensation, however, the English editors have confined the work almost wholly to the articles embraced in the British Pharmacopoeia, thus omitting much that is of primary importance to the American practitioner. The aim of Professor Wood has been to restore from Pereira's original work whatever may seem necessary, and to add notices of such American remedies as elaim a place in a volume designed alike for the student and physician. In this, he has had the advantage of the valuable notes of the former American editor, Professor Carson, and his additions will be found to constitute from one-fourth to one third of the whole work. Their importance may be estimated from the fact that he has introduced notices of nearly one hundred articles not alluded to in the English edition, among which will be found detailed accounts of such remedies as Bismuthi Sub-Nitras, Monsell's Salt, Pyro-Phosphate of Iron, Iodide of Lead, Glauber Salts, Cyanide of Mercury, Pepsin, Prunus Virginiana, Eupatorium, Veratrum Viride, Apocynum, Tapioca, Arrow-Root, Sago, Euphorbium, Helleborus, Coffee, Spigelia, Salix, Rhus, Rubus, Ca- labar Bean, Succinium, etc. etc. The series of illustrations has been largely increased, and the object of the work will be to present a thorough and condensed view of the whole subject in its most modern aspect. Of the many works on Materia Medica which have appeared since the issuing of the British Pharmaco- poeia, none will be more acceptable to the student and practitioner than the present. Pereira's Materia Medica had long ago asserted for itself the position of being the most complete work on the subject in the English language. But its very completeness stood in the way of its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, aud its pe- rusal required an amount of time which few had at their disposal. Dr Farre has very judiciously availed himself of the opportunity of the publication of the n<>w Pharmacopoeia, by bringing out an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, but contains ma- ny improvements, both in the descriptive and thera- peutical departments. We can recommend it as a vory excellent and reliable text-book.— Edinburgh Med Journal, February, lb66. Dr. Farre has conferred on both students and prac- titioners a real boon in presenting in a comprehensive form, and within the limits of a moderate octavo volume, the more important and more practical por- tions of his predecessor's great work. That Dr. Farre has spared no endeavor to perform his task in every department, in the most perfect manner, mav be al- ready inferred from the fact of his having associated with himself in the work, the two distinguished gen- tlemen whose names appear with his own upon the title-page.—Dublin Quarterly Journal, May, 1S66. With their able co-operation he has succeeded not only in reducing Dr. Pereira's work to a convenient size, but in producing a very reliable and instructive work on the authorized British Materia Medica.— Britten Medical Journal, December 2, 1865. Only 592 pages, while Pereira's original volumes included 2000, and yet the results of many years' ad- ditional research in pharmacology and therapeutics are embodied in the new edition. Unquestionably Dr. Farre has conferred'a great benefit upon medical students and practitioners. And in both respects we think he has acted very judiciously. And the work is now condensed—brought fully into accordance with the pharmacological opinions in vogue, and can be used with great advantage as a handbook for exami- nations.— The Lancet, December, 1865. ft ARSON (JOSEPH), M.D.. CTrv^"" °/-W"«™ ^.ica «nd Pharmacy in the University of Pennsylvania, &c. ■ SYNOPSIS OF THE COURSE OF LECTURES ON MATFRTV octavo volume. $2 50. Medicines. Third edition, revised. In one handsome ROYLE'S MATERIA MEDICA AND THERAPEU- TICS; including the Preparations of the Pharma- copoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M D. With ninety-eight illus- trations, in one large octavo volume of about 700 pages, extra cloth. $3 00. C^ItShTISp?T'S DISpESSATORY; or, Commentary r„5 , ^afrraac°P«'as of Great Britain and the Lnited States; comprising the Natural History, Description, Chemistry, Pharmacy, Actions, Uses < a A?* the Article« of the Materia Medica econd edition, revised and improved, with a Sup- plement containing the most important New Reme- ■ nTtbirtiln f°PI°aS additions- and two hundred ana thuteen large wood-engravings. By R Ehip*. fkld Ge.fht.1, M. D. In one very handsome o tavo volume of over 1000 pages, extra cloth. $i 00 CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquors in Health and Disease New edition, with a Preface by D. F. Condie, M.D , and explanations of scientific words. In one neat 12mo volume, pp. 178, extra cloth. 60 cents. BEALE ON THE LAWS OF HEALTH IN RELATION to Mind and Bodt. In one vol. royal 12mo., extra cloth, pp. 296. 80 cents. De JONGH ON THE THREE KINDS OF COD-LIVER Oil, with their Chemical and Therapeutic Pro- perties. 1 vol. 12mo., cloth. 75 cents. MAYNE'S DISPENSATORY AND THERAPEUTICAL Remembrancer With every Practical Formula FHU.Ted-A\he "T.!? Bri,tish Pharmacopceias. ?t c iuWlth the addltl0n of the Formula; 0f the U. S. Pharmacopoeia, by R. E. Griffith M D In one 12mo. volume, 300 pp., extra cloth. 75 cent« Henry C. Lea's Publications—(Pathology). 15 QROSS [SAMUEL U.), 31. D., Professor of Surgery in the Jefferson Medical College of Philadelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra cloth. $4 00. _ The very beautiful execution of this valuable work, and the exceedingly low price at which it is offered, should command for it a place in the library of every practitioner To the student of medicine we would say that we know of no work which we can more heartily com- mend than Gross's Pathological Anatomy.—Southern Med. and Surg. Journal. The volume commends itself to the medical student; it will repay a careful perusal, and should be upon the book-shelf of ev/fvj American physician.—Charles- ton Med. Journal: It contains much new matter, and brings down our knowledge of patliology to the latest period.—London Lanat. JONES (C. HAND FIELD), F.R.S., and SI EVE KING (ED. H), M.D., Assistant Physicians and Lecturers in St. Mary's Hospital. A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three .hundred and ninety-seven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. Our limited space alone restrains us from noticing more at length the various subjects treated of in this interesting work; presenting, as it does, an excel- lent summary of the existing state of knowledge in relation to pathological anatomy, we cannot too strongly urge upon the student the necessity of a tho- rough acquaintance with its contents.—Medical Ex- aminer. We have long had need of a hand-book of patholo- gical anatomy which should thoroughly reflect the present state of that science. In the treatise before us this desideratum is supplied. Within the limits of a moderate octavo, we have the outlines of this great department of medical science accurately defined, and the most recent investigations presented in suffi- cient detail for the student of pathology. We cannot at this time undertake a formal analysis of this trea- tise, as it would involve a separate and lengthy consideration of nearly every subject discussed ; nor would such analysis be advantageous to the medical reader. The work is of such a character that every physician ought to obtain it, both for reference and study.—N. Y. Journal of Medicine.. Its importance to the physician cannot be too highly estimated, and we would recommend our readers to add it to their library as soon as they conveniently can.—Montreal Med. Chronicle. JffOKITANSKY (CARL), 31. D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna. A MANUAL OF PATHOLOGICAL ANATOMY. Translated by W. E. Swaine, Edward Sieveking, C. H. Moore, and G. E. Day. Four volumes octavo, bound in two, of about 1200 pages, extra cloth. $7 50. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D. In one volume, very large imperial I quarto, with 320 copper-plate figures, plain and colored, extra cloth. $1 00. I SIMON'S GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. In.one octavo volume of 212 pages, extra cloth. $1 25. TJ/'ILLIAMS {CHARLES J. B.), 21. D., Professor of Clinical Medicine in University College, London. PRINCIPLES OF MEDICINE. An Elementary View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume of about 500 pages, extra cloth. $3 50. The unequivocal favor with which this work has been received by the profession, both in Europe and America, is one among the many gratifying evidences which might be adduced as going to show that there is a steady progress taking place in the science as well as in the art of medicine.—St. Louis Med. and Surg. Journal. No work has ever achieved or maintained a more deserved reputation. — Virginia Med. and Surg. Journal. One of the be'st works on the subject of which it treats in our language. It has already commended itself to the high regard of the profession ; and we may well say that we know of no single volume that will afford the source of so thorough a drilling in the principles of practice as this. Students and practitioners should make themselves intimately familiar with its teachings— they will find their labor and study most amply repaid.—Cincinnati Med. Observer. There is no work in medical literature which can fill the place of this one. It is the Primer of the young practitioner, the Koran of the scientific one.— Stethoscope. A text-book to which no other in our language is comparable.—Charleston Med. Journal. The lengthened analysis we have given of Dr. Wil- liams's Principles of Medicine will, we trust, clearly prove to our readers his perfect competency for the task he has undertaken—that of imparting to the student, as well as to the more experienced practi- tioner, a knowledge of those general principles of pathology on which alone a correct practice can be founded. The absolute necessity of such a work must be evident to all who pretend to more than mere empiricism. We must conclude by again ex- pressing our high sense of the immense benefit which Dr. Williams has conferred on medicine by the pub- lication of this work. We are certain that in the pi-esent state of our knowledge his Principles of Medi- cine could not possibly be surpassed. While we regret the loss which many of the rising generation of practitioners have sustained hy his resignation of the Chair at University College, it is comforting to feel that his writings must long continue to exert a powerful influence on the practice of that profession for the improvement of which he has so assiduously and successfully labored, and in which he holds so distinguished a position.— London Jour, of Medicine. Ifi Henry C. Lf.a's Publications—(Practice of Medicine). TALI NT (A US TIN), 21. D., -L Professor of the Principle and Practice of Medicine in Bellevue Med. College, N. 1. A TREATISE OX THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. In one large and closely printed octavo volume of 867 pages; handsome extra cloth, JO 00; or strongly bound in leather, with raised bands, §7 00 A book of inestimable value, as the recorded expe- rience of one of the clearest and best educated minds ever devoted to the theory and practice of medicine. Dr. Flint's Theort and Practice of Medicine will be eagerly perused by all our readers—will be re- garded as tbe Bible of practical medicine.—Buffalo Med. and Surg. Journal, May, 1S66. In following out such a plan Dr. Flint has suc- ceeded most admirably, and gives to his readers a work that is not only very readable, interesting, and concise, but in every respect calculated to meet the requirements of professional men of every class. The student has presented to him, in the plainest possible manner, the symptoms of disease, the prin- ciples which should guide him in its treatment, and the difficulties which have to be surmounted in order to arrive at a correct diagnosis. The practitioner, besides having such aids, has offered to him the con- clusion which the experience of the professor has enabled him to arrive at in reference to the relative merits of different therapeutical agents, and different methods of treatment. This new work, as a whole, will add not a little to the well-earned reputation of Prof. Flint as a medical writer and teacher. The number of years i n which he has been engaged in the active duties of his profession, both in public and private life, have given him an amount of experi- ence which has eminently fitted him for the produc- tion of a work which must necessarily extend over such a wide range of subjects. We cannot see how it can fail to meet withsuniversal favor.—N. Y. Med. Record, April 2, 1866. It presents a brief, but concise and reliable sum- mary of those pathological and therapeutical views that are most generally accepted by the profession at tin' present time; and consequently it is well adapted for a text-book in the hands of students. It will also form a valuable addition to the library of the practi- tioner.—The Chicago Medical Examiner, April, 1866. The Practice of Medicine of Prof. Flint is, un- doubtedly, a most excellent work, and is much better suited to the special needs of the American student and practitioner than any other accessible to them. We predict for the book a very great, and, as we be- lieve, well deserved popularity.—Ginciunoii Jour- nal of Medicine, March, 1866. Contains all that has recently been added to our knowledge of this department of medicine.—Detroit Review, April, 1S66. From J. Adams Allen, M. D., LL. D., Professor of Princi/iles and Practice of Medicine, Rush Medical. College, Chicago. I shall take great pleasure in recommending this work as a text-book in our college, and also for the libraries of the profession generally. It is a timely and absolutely indispensable contribution to the literature of the profession. , [Now Ready.) ■ From Walter Carpenter, M. D., Professor of Theory and Practice of Medicine,' Univ. of Vermont. I consider " Flint's Principles and Practice of Medicine" as the best book upon the subject, that has yet come under my notice, for many other rea- sons as well as the one above mentioned. I shall most surely recommend the work to my class, and only wish every member had a copy. From Richard McSherrt, M. D., Prof, of Practice of Medicine, Univ. of Maryland. I am much pleased with this work, and I take pleasure in recommending it to the students who attend my lectures. From Israel T. Dana, M. D., Prof, of Theory and Practice of Medicine in Bowdoin College, Brunswick, Me. On examination I am much pleased with the book, and shall warmly recommend it to our college stu- dents, next month, when my lectures at Brunswick commence again. .From E. E. Phelps, M. D., Prof, of Theory and Practice of Medicine in Dart- mouth Med. College, N. H. I have given it an examination, and am prepared to recommend it to my classes as a text-book. From J. A. Murphy, M. D., Prof, of Theory and Practice of Medicine in Miami Med. College, Cincinnati, Ohio. I am well pleased with it, and shall recommend it to the class of Miami Medical College. From A. P. Dutcher, M.D., Prof, of Principles and Practice of Medicine in Charity Hasp. Med. Coll., Cleveland, 0. As a text-book for students it is superior to any work lam acquainted with, and as such I hope it will be adopted by every medical college in the laud. From Geo. C. Shattuck, M. D., Professor of Theory and Practice of Medicine, Mass. Med. College. I have recommended the book to the students and adopted it as a text-book. From Thomas F. Rochester, M. D., Professor of Principles and Practice of Medicine, University of Buffalo. I am much pleased with the work; during the winter, I advised the class to use it, and regret that it only arrived in this city just at the close of the term. I shall employ it as a text-book. JJUXGLISOX, FORBES, TWEED IE, 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. Y THE SAME AUTHOR. ---- A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume of nearly 500 pages, with a plate; extra cloth, $3 50. We question the fact of any recent American author in our profession being more extensively known, or more deservedly esteemed in this country than Dr. Flint. We willingly acknowledge his success, more particularly in the volume on diseases of the heart, i n makingan extended personal clinical study available for purposes of illustration, in connection with cases which have been reported by other trustworthy ob- servers. The work of Dr Flint, which has received this short notice at our hauds, in connection with his other Volume, whose title we have placed at the head of our observations, may be regarded as constituting a complete guide to the diagnosis of diseases of the chest; and for this purpose we have much pleasure and every confidence in recommending them.—Brit. and For. Med.-Chir. Review. BLAKISTON ON CERTAIN DISEASES OF THE CHEsT. In one Wlume octavo. $1 2.5. BUCKLER ON FIBRO-BROXC1UTIS AND RHEU- MATIC PNEUMONIA. In one octavo vol., extra cloth, pp. 1.30. $1 25. F1SKE FUND PRIZE ESSAYS—LEE ON THE EF- FECTS OF CLIMATE ON TUBERCULOUS DIS- EASE • A.YD WARREN ON THE INFLUENCE OF PltEfjNANCY ON THE DEVELOPMENT OF TU- BERCLES. Together in one neat octavo volume, extra cloth, $1 00. HUGHES' CLINICAL INTRODUCTION TO AUS- CULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS. Second edition. One volume royal 12mo., extra cloth, pp. 304 $1 25. WALSHE'S PRACTICAL TREATISE ON DISEASES OF THE LUNGS. Third American, from the third revised and much enlarged London edition. In one neat octavo volume of nearly 500 pages, extra cloth. Price *.i 00. WALSHE'S PRACTICAL TREATISE ON THE DIS- EASES OF THE HEART AND GREAT VESSELS. Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 120 pages, extra cloth. $3 00. V21ITH ED WARD), 31. D. CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. one neat octavo volume of 254 pages, extra cloth. $2 25.. gALTER (H. H), M.D. ASTHMA; its Pathology, Causes, Consequences, and Treatment. one volume, octavo, extra cloth. $2 50. In In gLADE (D. D.), 31. D. DIPHTHERIA; its Nature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised edition. In one neat royal 12mo. volume, extra cloth. $1 25. (Just issued.) B RIXTOX (WILLIA3I), M.D., F.R.S. LECTURES ON THE DISEASES OF THE STOMACH; with an Hon w-T -T I*8 i4natomy and Physiology. From the second and enlarged London edi- Mt™ oZ£ l*£ ?r °n •W00d/ In one flandsome octavo volume of about 300 pages, extra ciotn. $d 25. (Just issued.) and^ructrve MstoiW Zl^"' aCCUrate plaiD' I , The mosf coraPlete ™rk ln °™ 1*WW «P<>n the tiou^^w^^inl^r^fZ^*' P.?0™ ra_ dia«nosis "d treatment of these puzzlinglnd impor- ^-A^yXS^^g^XwSF ^^^■-^^^■^aSurg.jLrnal, N°ov. •ft" ItspuMfc^ These l%Cturea COmPrise a brief but condensed and eases, functiona ana organic of*rhSr!rim-i "> I qmte perfeCt aCCOunt of what i8 at Vie"*at Unown the human machine iTfs unnece saVv Cre\7r?Z°J TcerninS leases of the stomach. The anatomy, the praise which we formerly Wto^dI on' the book ^tlt^^^Z' "t treatment *re *° P^ wben it was a debutant, solicitinVm^fessionalf^ aS t0 "f6 the. Tork a very instructive and -*■«. and For. M^Cl^Zf^S^^^ I ^^S^J^^^^-*W*> JJABERSHOX (S. O.), M.D. PATHOLOGICAL AND PR ACTIO \L OBSERVATIONS OY m<3 f^T?$™ ALIMENTARY CANAL, (ESOPHAGUS ~ ^ IMLSTIM.s. With illustrations on wood. pages, extra cloth. $2 50. , STOMACH, CECUM, AND In one handsome octavo volume of 312 Henry C. Lea's Publications—(Practice of 3Iedicine). 19 "OUMSTEAD (FREEMAN J), 21. D., -*-J Lecturer on Materia Medica and Venereal Dixeaseg at the Col. of Phys. and Surg., New York. &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EAS^S. Including the results of recent investigations upon the subject. A new and re- vised edition, with illustrations. In one large and handsome octavo volume of 640 pages, extra cloth, $5 00. (Lately Issued.) During the short time which has elapsed since the appearance of this work, it has assumed the position of a recognized authority on the subject wherever the language is spoken, and its transla- tion into Italian shows that its reputation is not confined to our own tongue. The singular clear- ness with which the modern doctrines of venereal diseases are set forth renders it admirably adapted to the. student, while the fulness of its practical details and directions as to treatment makes it indispensable to the practitioner. The few notices subjoined will show the very high position universally accorded to it by the medical press of both hemispheres. Well known as one of the hest authorities of the present day on the subject.—British and For. Med.- Chirurg. Review, April, 1S66. A regular store-house of special information.— London Lancet, Feb. 24, 1866. A remarkably clear and full systematic treatise on the whole subject.—Lond. Med. Times and Gazette. The best, completes!, fullest monograph on this subject in our language.—British American Journal. Indispensable in a medical library.—Pacific Med. and Surg. Journal. We have no doubt that it will supersede in America every other treatise on Venereal.—San Francisco Med. Press, Oct. 1864. A perfect compilation of all that is worth knowing on venereal diseases in general. It fills up a gap which has long been felt in English medical literature. —Brit, and Foreign Med.-Chirurg. Review, Jan., '65. We have not met with any which so highly merits 21. D. our approval and praise as the second edition of Dr. Bumstead's work.—Glasgow Med. Journal, Oct. 1864. We know of no treatise in. any language which is its equal in point of completeness and practical sim- plicity.—Boston Medical and Surgical Journal, Jan. 30, 1864. The book is one which every practitioner should have in his possession, and, we may further say, the onlytbook upon the subject which he should acknow- ledge as competent authority.—Buffalo Medical and Surgical Journal, July, 1864. The best work with which we are acquainted, and the most convenient hand-book for the busy practi- tioner —Cincinnati Lancet, July, 1864. The author has spared no labor to make this edition worthy of the reputation acquired by the last, and we believe that no improvement or suggestion worthy of notice, recorded since the last edition was published, has been left unnoticed.—Dublin Quarterly Journal of Medical Science, August, 1864. T>ICORD (P.), LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M.D. In one neat octavo volume, of 270 pages, extra cloth, $2 00. L ALLE2IAND AND WILSON. l PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by Henry J. McDougall. Fifth American edition. To which is added-----ON DISEASES OF THE VESICULiE SEMINALES, and their associateo organs. With special reference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M.D. In one neat octavo volume, of about 400 pp., extra cloth, $2 75. JOUDD (GEORGE), 31.D. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beautifully colored plates, and numerous wood-cuts. pp. 500. §4 00. TA ROCHE (R.), M.D. YELLOW FEVER, considered in its Historical, Pathological, Etio- logical, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes, of nearly 1500 pages, extra oloth, $7 00. JDT THE SAME AUTHOR. ---- PNEUMONIA ; its Supposed Connection, Pathological, and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. T YOXS (ROBERT D.), K. C. C.y A TREATISE ON FEVER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth. $2 25. BARTLETT ON THE HISTORY, DIAGNOSIS, AND Treatment op the Fevers of the United States. A new and revised edition. By Alonzo Clark, M,D., Prof, of Pathology and Practical Medicine in the N V. College of Physicians and Surgeons, &c. In one octavo volume, of 600 pages, extra cloth. $1 25. CLYMER ON FEVERS; THEIR DIAGNOSIS, PA- tholoot and Treatment. In one octavo volume of 600 pages, leather. SI 75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pages, extra cloth. *2 50. 20 Henry C. Lea's Publications—(Practice of 2fedieine) 7 > '> Ii Eli TS ( WILLI A M i, 21. D.. ■*-' Lecturer on Medicine in the Manchester School of Medici ne, *UCKNILL (J. C.),M.D., •*-■* Med. Superintendent of the Devon . and T)ANIEL H. TUKE, M.D., of the Devon Lunatic Asylum.-*S Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of In- sanity. With a Plate. In one handsome octavo volume, of 536 pages, extra cloth. £4 25. A work alike characterized by great classical ele- gance and a careful and judicious discrimination on the diagnosis, pathology and treatment of this dread- ful malady.— Va. Med. and Surg. Journal. We do not know where anything can be found in the literature of the specialty to compare with these essays, in complete and logical treatment, and the clear, practical manner in which their subjects are discussed. They will be cited as authority wherever the language is used, and will, no doubt, be exten- sively translated.—Amer. Journal of Insanity. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume of 292 pp. $1 50. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of 500 pages, with 120 wood-cuts; extra cloth. $2 50. J( 'ONES (C. HAND FIELD), M. D., Physician to St. Mary's Hospital, &c. CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Publishing in the "Medical News and Library," for 1865 and 1866. To form one handsome octavo volume of about four hundred pages. This work, which is now passing through the "Library Department" of the Medical News and Library, will he completed during the present year, and will be issued separate in a handsome volume in December. The author is known as a physician of large experience and scientific re- search, and his ample opportunities of investigating the symptoms and treatment of this obscure and intractable class of diseases have been turned to good account. Few disorders occur more fre- quently in practice or prove more embarrassing than these, and the profession has long felt the want of an authoritative practical treatise devoted especially to them. The subjects discussed by t *ut£or.are :0 General Pathology—Cerebral Anaemia—Anaemia of the Spinal Cord—Hyperaemia ot the Brain—Spinal Hyperaemia—Cerebral Paresis (or Paralysis)—Spinal Paresis—Cerebral Ex- citement—Delirium Tremens —Tetanus—Catalepsy—Epilepsy —Headache—Vertigo—Chorea- Paralysis Agitans—Spasmodic Affections—Sleeplessness—Facial Neuralgia—Facial Paralysis— Ketmal Hyperesthesia— Throat Dysaesthesia—Lingual Neuralgia—Brachial Neuralgia—Sciatica- Angina Pectoris—Respiratory Neuroses—Myalgia—Abdominal Neuralgia—Neuroses of Urinary Urgans and Intestines—Uterine Neuroses-Cutaneous Neuroses—Malarioid Disorder—Secretion ^u^—Hysteria—Syphilitic and Rheumatic Nerve Affections—Remedies. lhe wide scope of the treatise, and its practical character, as illustrated by the large number ot cases reported in detail by the author, can hardly fail to render it exceedingly valuable to toe profession. For terms of the "American Journal of the Medical Sciences" and the "Medical Wews, see p 1. Henry C. Lea's Publications—(Diseases of the Skill). 21 ^yiLSON (ERAS21US), F.R.S., *ON DISEASES OF THE SKIN. The sixth American, from the fifth and enlarged English edition. In one large octavo volume of nearly 700 pages, extra cloth. $4 50. Also— A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume, extra cloth. Price $9 50. This classical work has for twenty years occupied the position of the leading authority on cuta- neous diseases in the English language, and the industry of the author keeps it on a level with the advance of science, in the frequent revisions which it receives at his hands. The large size of the volume enables him to enter thoroughly into detail on all the subjects embraced in it, while its very moderate price places it within the reach of every one interested in this department of practice. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his hook on diseases of the skin has long been re garded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this.edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases treated of in the body of the work.—Cin- cinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work. — Canada Lancet. August, 1863. We can safely recommend it to the profession as the best work on the subject now in existence in the English language.—Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.—British and Foreign Medical Review. These plates are very accurate, and are executed with an elegance and taste which are highly creditable to the artrstic skill of the American artist who executed them.—St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indis- pensable companion to the book it illustrates and completes.—Charleston Medical Journal. Df THE SAME AUTHOR. ---- THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royal 12mo. volume. S3 50. (Now Ready.) This new class-book will be admirably adapted to I Thoroughly practical in the best sense. —Brit. Med. the necessities of students.—Lancet. \ Journal. T>Y THE SAME AUTHOR. ---- HEALTHY SKIN; a Popular Treatise on the Skin and Hair, their Preservation and Management. One vol. 12mo., pp. 291, with illustrations, cloth. §1 00. JYELIGA N (J. 310ORE), 31. D., 31. R. I. A., A PRACTICAL TREATISE ON DISEASES OF THE SKIN. , Fourth American edition. In one neat royal 12mo. volume, extra cloth. $1 50. Dl' THE SAME AUTHOR. —--- ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Extra cloth, $5 50. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are inclined to consider it a very superior work, com- bining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. It possesses the merit of giving short and condensed descriptions, avoiding the tedious minuteness of many writers, while at the same time the work, as its title implies, is strictly practical.—Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis. Taken with the beautiful plates of the Atlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man.—Buffalo Med. Journal. TJILLIER (TH031AS), M.D., ■*-*- Physician to the Skin Department of University College Hospital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. In one neat royal 12mo. volume of about 300 pages, with two plates; extra cloth, $2 25. (Just Issued.) The work of Dr. Hillier will unquestionably serve the student as a useful and faithful guide to the ac- quirement of a knowledge of skin diseases. The treatment laid down by the author is simple, rational, and in accordance with the results of an extended experience. Dr. H. avoids all unnecessary multipli- cation of remedies, and rejects all of doubtful value. __jm. Journal Med. Sciences, July, 1S65. A text-book well adapted to the student, and the information contained in it shows the author to be au niveau with the scientific medicine of the day.— London Lancet, Feb. 25, 1S675. In the 3,50 pages, the practitroner will find scattered a great deal of very valuable information not to be met with in more pretentious and extensive works — Med. and Surg. Review (Australasian), Oct. 1, I860. IIknry C. Lea's Publications—(Disease* of Children). 1VEST (CHARLES). M.D., Physician to the Hospital for Sick Children, Ac. » LECTURES ON THE DISEASES OF INFANCY AND CHILD- lloOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. (Just issued.) This work may now fairly claim the position of a standard authority and medical classic. Five editions in England, four in America, four in Germany, and translations in French, Danish, Dutch, and Russian, show how fully it has met the wants of the profession by the soundness of its views and the clearness with which they are presented. Few practitioners, indeed, have had tbe opportunities of observation and experience enjoyed by the Author. In his Preface he remarks, "The present edition embodies the results of 1200 recorded cases and of nearly 400 post-mortem examinations, collected from between 30,000 and 40,000 children, who, during the past twenty- six years, have come under my care, either in public or in private practice." The universal favor with which the work has been received shows that the author has made good use of these unusual advantages. infancy and childhood.—Columbus Review of Mtd. and Surgery. To occupy in medical literature, in regard to dis- eases of children the enviable position which Dr. Watson's treatise does on the diseases of adults is now very generally assigned to our author, and his book is in the hands of the profession everywhere as an original work of great value.—Md. and Va. Med. and Surg. Journal. Dr. West's works need no recommendation at this date from any hands. The volume before us, espe- cially, has won for itself a large and well-deserved popularity among the profession, wherever the Eng- lish tongue is spoken. Many years will elapse before it will be replaced in public estimation by any similar treatise, and seldom again will the same subject be discussed in a clearer, more vigorous, or pleasing style, with equal simplicity and power.—Charleston Med. Jour, and Review. There is no part of the volume, no subject on which it treats which does not exhibit the keen perception, the clear judgment, and the sound reasoning of the author. It will be found a most useful guide to the young practitioner, directing him in his management of children's diseases in the clearest possible manner, and enlightening him on many a dubious pathological point, while the older one will find in it many a sug- gestion and practical hint of great value.—Brit. Am. Med Journal. Of all the English writers on the diseases of chil- dren, there is no one so entirely satisfactory to us as Dr. West. For years we have held his opinion as judicial, and have regarded him as one of the highest living authorities in the difficult department of medi- cal science In which he is most widely kuown. His writings are characterized by a sound,"practical com- mon sense, at the same time that they bear the marks of the most laborious study and investigation. We commend it to all as a most reliable adviser on many occasions when many treatises on the snme subjects will utterly fail to help us. It is supplied with a very copious geueral index, and a special index to the for- mula scattered throughout the work.—Boston, Med. and Surg. Journal, April 26, 1866. Dr. West's volume is, in our opinion, incomparably the best authority upon the maladies of children that the practitioner can consult. Withal, too—a minor matter, truly, but still not one that should be neglected—Dr. West's composition possesses a pecu- liar charm, beauty and clearness of expression, thus affording the reader much pleasure, even independent of that which arises from the acquisition of valuable truths.—Cincinnati Jour, of Medicine, March, 1866. We have long regarded it as the mofet scientific and practical book on diseases of children which has yet appeared in this country— Buffalo Medical Journal. Dr. West's book is the best that has ever been written in the English language on the diseases of QONDIE (D. FRANCIS), 31. D. A PRACTICAL TREATISE ON Fifth edition, revised and augmented. I printed pages, extra cloth. 84 50. Dr. Condie's scholarship, acumen, industry and practical sense are manifested in this, as in all his numerous contributions to science.— Dr. 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 great- est satistaction — Western Journal of Medicine and Surgery. We pronounced the first edition to be the best work THE DISEASES OF CHILDREN. n one large octavo volume of over 750 closely- on tbe diseases of children in the English language, and, notwithstanding all that has heeu published, we still regard it in that light.—Medical Examiner. The value of works hy native authors on the dis- eases which the physician is called upon to combat will he appreciated by all, and the work of Dr Con- die 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. QIIURCHILL (FLEETWOOD), 31.D., M.R.I.A., Prof, of Midwifery and Diseases of Women and Children in the Dublin College of Physicians ON THE DISEASES OF INFANTS AND CHILDREN. Second k"a™M D°ninTiSid and ^^f by the auth0r- Edited> with Notes, by W V seating, M. D. In one large and handsome volume of over 700 pages, extra cloth. $4 50. J) E WEES (WILLIAM P.), 31. D., ■ Late Professor of Midwifery, Ac, in the University of Pennsylvania, &c. A ™5o?CHLDRFrTTSE PfcHYSICAL AND MEDICAL TREAT- , r^,0'*0™^^ last improvements and cor- Henry C. Lea's Publications—(Diseases of Women). 23 ]\/[EIGS (CHARLES D.), 31. D., ' Late Professor of Obstetrics, &c. in Jefferson Medical College, Philadelphia. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lectures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume of over 700 pages, extra cloth, $5 00 ; leather, $6 00. That this work has been thoroughly appreciated i mend with great pleasure a much improved edition by the profession of this country as well as of Europe, ' of a work in which we saw little room for improve- is fully attested by the fact of its having reached its ment.—Nashville Medical Journal. fourth edition in a period of less than twelve years, j We t tMs new ertition 0f Dr. Meigs* work on Its value has been much enhanced hy many impor- I woma° wlth m„ch pleasure, and commend it to the tant additions, and it contains a fund of useful in- protession, especially to the younger members, who formation..conveyed in an easy and delightful style. ' receive much valuable instruction from its Every topic discussed by the author is rendered so 'es conveyed in a pleasing stvle. The teaching plain as to be readily understood by every student: throughout the work reflects the highest credit upon and, for our own part, we consider it not only one of tke h(fad and heart of the author.-CTtica^o Medical the most readable of books, hut one of priceless value journai to the practitioner engaged in the practice of those i ' ' ■ , , ., , ., • , , . . , diseases peculiar to females.— N. Am. Med.-Chir. Re- , The rille3 of the art here described, the obstetrical xtitw. opinions here expressed, the general directions and j advice given and suggested, are, beyond any cavil, We read the book and find him more—an original | unexceptionably sagacious and prudent. They are thinker, an eloquent expounder, and a thorough • founded on a large practice, have been tested by a practitioner. The book is but twelve years old, but I long experience, and come from lips to whose teach- it has been so much appreciated by the profession ' ing thousands have listened for many years, and that edition after edition has been demanded, and ! never without profit.—Charleiton Med. Journal and now the fourth is on the table by us. We recom- j Review. Df THE SAME AUTHOR. ---- 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 of 365 pages, extra cloth. $2 00. /IHURCHILL (FLEETWOOD), 31. D., M. R. I A. 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 of " A Practical Treatise on the Diseases of Chil- dren." With numerous illustrations. In one large and handsome octavo volume of 768 pages, extra cloth, $4 00; leather, $5 00. From the Author's Preface. In reviewing this edition, at the request of my American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches ; in addition to which the publishers have been fortunate enough to secure the services of an able and highly esteemed editor in Dr. Condie. As an epitome of all that is known in this depart- present day. To Dr. Churchill, then, are the pro ment of medicine, the book before us is perhaps the fullest and most valuable in the Euglish language. ■—Dublin Medical Press. It was left for Dr Churchill to gather the scat- tered facts from their various sources, and reduce them to a general system. This he has done with a masterly hand in the volume now before us; in which, to the results of his own extensive observa- tion, he has added the views of all British and for- eign writers of any note; thus giving us in a com- plete form, all that is known upon this subject at the T>Y THE SAME AUTHOR. ---- . ESSAYS ON THE PUERPERAL FEYER, AND QTHER DIS- EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. -DRO WX (ISAAC BAKER), 31. D. ON SOME DISEASES OF WOMEN ADMITTING OF SUP GICAL TREATMENT. With handsome illustrations. One volume 8vo., extra cloth, pp. 276. $1 60. fession deeply indebted for supplying them with so great a desideratum—the achievement of which de- servedly entitles his name,.already intimately asso- ciated with the diseases of women, to rank very high as an authority upon this subject. We would briefly characterize it as one of the most useful which has issued from the press for many years. To all it bears its own recommendation ; and* will be found to be invaluable to the student as a text-book, no less than as a compendious work of reference to the qualified practitioner.—Glasgow Med. Journal. An important addition to obstetrical literature. The operative suggestions and contrivances which Ittr Frown describes, exhibit much practical sagacity and skill, and merit the careful attention of every surgeon-accoucheur.—Association Journal. We have no hesitation in recommending this book to the careful attention of all surgeons who make female complaints a part of their study and practice. —Dublin Quarterly Journal. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised Lon- don edition. In one octavo volume, extra cloth, of 52S pages. $3 50. RIGBY ON' THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc- tions. In one octavo volume of 536 pages, with plates, extra cloth, $3 00. COLOMBAT DE L'ISERE rtN THE DISEASES OF FEMALES. Translated by C. D. Meigs, M. D. Se- cond edition. In one vol. Svn, extra cloth, with numerous wood-cuts. pp. 720. $3 75. 21' Henry C. Lea's Publications—(Disease* of Women). JfODGE (HUGH L.), M.D. ON DISKASKS PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume of nearly 500 pages, extra cloth. £3 75. CONTENTS. PART I. Diseases of Irritation.—Ch.vptek I. Nervous Irritation, and its ponscjuences. II. Irritable Uterus—Complications. III. Local Symptoms of Irritable Uterus. IV. Local Symptoms of Irritable Uterus. V. General Symptoms of Irritable Diseases. VI. General Symptoms of Irritable Uterus—Reflex Influences of Cerebral and Spinal Irritation. VII. Pro- gross and Terminations of Irritable Uterus. VIII. Causes arid Pathology of Irritable Diseases. IX. Treatment of Irritable Uterus—Removal or Palliation of the Cause. . X. Treatment of Irritable Uterus—to Diminish or Destroy the Morbid Irritability. XI. Treatment of Irritable Uterus—modified by Menstrual Disorders and Inflammations. XII. Treatment of Irritable Uterus Complicated with Secondary and Sympathetic Symptoms. PART II. Displacements op the Uterus.—Chapter I. Displacement of the Uterus. II. Causes and Symptoms of Displacement of the Uterus. III. Diagnosis of Displacement of the Uterus. IV. Treatment of Displacement of the Uterus. V. Treatment, continued—Internal Supporters. VI. Treatment, continued—Lever Pessaries. VII. Treatment, continued. VIII. Treatment of Complications of Displacements. ^PART III. Diseases op Sedation.—Chapter I. General and Local Sedation. II. Sedation of Uterus. III. Diagnosis and Treatment. J.J777ST (CHARLES), M.D. LECTURES ON THE DISEASES OE WOMEN. Second American, from the second Lqtodon edition. In one neat octavo volume of about 500 pages, extra cloth. $3 25. We have thus embodied, in this series of lectures, one of the most valuable treatises on the diseases of the female sexual system unconnected with gestation, in our language, aad one which cannot fail, from the lucid manner in which the various subjects have been treated, and the careful discrimination used in dealing only with facts, to recommend the volume to the careful study of every practitioner, as affording his safest guides to practice within our knowledge. We have seldom perused a work of a more thoroughly practical character than the one before us. Every page teems with the most truthful aud accurate infor- mation, and we certainly do not know of any other work from which the physician, in active practice, can more readily obtain advice of the soundest cha- racter upon the peculiar diseases which have been made the subject of elucidation.—British Am. Med. Journal. We return the author our grateful thanks for the vast amount of instruction he has afforded us. His valuable treatise needs no eulogy on our part. His graphic diction and truthful pictures of disease all speak for themselves.—Medico-Chir urg. Review. i Most justly esteemed a standard work.....It bears evidence of having been carefully revised, and is well worthy of the fame it has already obtained. —Dub. Med. Quar. Jour. JfiY THE SAME AUTHOR. _____ AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. gIMPSOX (SIR JAMES Y.), M.D. CLINICAL LECTURES ON THE DISEASES OF WOMEN. With numerous illustrations. In one handsome octave volume of over 500 pages, extra cloth. $4. TW PrifciPa'1t0P.ics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus, Jf th ™v° • ^r,ln-?-manby Caus*iTcs' Dysmenorrhea, Amenorrhea, Closures, Contractions, Ac. Dolenl Og a'7 iS^aT110^Peath after S^g^l Operations, Surgical Fever, Phlegmasia OvSn?.^^ *',a'1PelV1nCellullti^ ?elvio H«atolM. SPurio^ Pregnancy, Ovarian Dropsy, S^feS^lruSS^0'*?6 FaU°Pian Tub6S' Puer*eral Mania> Bub Involution^ RENNET (HENRY), 21. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE ^^yiLSJ;? A*VP™^S, and orlits^^ connection'with Uterine IS tsj^szzz^ %rt^=^ES4dition-In one octavo volume t, . ,, From the Author's Preface. Indeed, the entire volume is so replete with infor- mation, to all appearance so perfect in its details that we could scarcely have thought another page or para- graph was required for the full description of all that " __, *—- — "**« »«•" u^vuiruuu ui an ma .m»» >■ Tn Wlth regard t0 the diseases under con- sideration if we had not been so informed by the au- £Y THE SAME AUTHOR. thor. To speak of it except in terms of tbe highest approval would be impossible, and we gladly avail ourselves of the present opportunity to recommend it in the most unqualified manner to the profession. —Dublin Med. Press. A loFgyIEtW °F nHE PRESE^T STATE OF UTERINE PATHO- LOGY. In one small octavo volume, extra cloth. 50 cents. J^iAXlIU- Henry C. Lea's Publications—(Midwifery). 25 TJODGE (HUGH L.), 31. D., Late Professor of Midwifery, &c. in the University of Pennsylvania, &c. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with-large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. (Late- ly published.) From the Author's Preface. " Influenced by these motives, the author has, in this volume, endeavored to present not simply his own opinions, but also those of the most distinguished authorities in the profession; so that it may be considered a digest of the theory and practice of Obstetrics at the present period." In carrying out this design, the ample space afforded hy the quarto form has enabled the author to enter thoroughly into all details, and in combining the results of his long experience and study with the teachings of other distinguished authors, he cannot fail to afford to the practitioner what- ever counsel and assistance may be required in doubtful cases and emergencies. . A distinguishing feature of the work is the profuseness of its illustrations. The lithographic plates are all original, and, to insure their accuracy, they have been copied from photographs taken expressly for the purpose. Besides these, a very full series of engravings on wood will be found scattered through the text, so that all the details given by the author are amply elucidated by the illustrations. It may be added that no pains or expense have been spared to render the mechanical execution of the work in every respect worthy of the character and value of the teachings it contains. *^* Specimens of the plates and letterpress will be forwarded to any address free by mail on receipt of six cents in postage stamps. The work of Br. Hodge is something more than a simple presentation of his particular views in the de- partment of Obstetrics; it is something more than an ordinary treatise on midwifery; it is, in fact, a cyclo- pedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle is left unstated or unexplained.—Am. Med. Times, Sept. 3, 1864. We should like to analyze the remainder of this excellent work, but already has this review extended heyond our limited space. We cannot conclude this notice without referring to the excellent finish of he work In typography it is not to be excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books The engravings and lithographs are most beautifully executed. The work recommends itself for its originality, and is in every way a most valu- able addition to those on the subject of obstetrics.— Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the work:s of great obstetricians. Of the American works on the subject it is decidedly the best.—Edinb. Med. Jour., Dec. 64. We have examined*Professor Hodge's work with great satisfaction; every topic is elaborated most fully. The views of the author are comprehensive, and concisely stated. The rules of practice are judi- cious, and will enable the practitioner to meet every emergency of obstetric complication with confidence. —Chicago Med. Journal, Aug. 1S64. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by far the most original, complete, and carefully composed treatise on'the principles and practice of Obstetrics which has ever been issued from the American press.— Pacific Med. and Surg. Journal, July, 1864. We have read Dr. Hodge's book with great plea- sure and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly instructive, and in the main, we believe, correct. lhe great attention which the author has devoted to the mechanism of parturition, taken along with the con- clusions at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. —Glasgow Med. Journal, Oct. 1S64. MONTGOMERY (W. F.), 21. D., M Professor of Midwifery in the King's and Queen's College of Physicians xn Ireland. \N EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- \ aIhTV With some other Papers on Subjects connected with Midwifery. From the second N i^T;Jl FnHkh edition With two exquisite colored plates, and numerous wood-cuts. S'oE^bS&^SS volume of nearly 600 pages, extra cloth. *3 75. 7] TILLER (HENRY), 31. D J-'-*- Professor of Obstetrics and Di 1. JJ; *- Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PT5TNOIPLES AND PRACTICE OF OBSTETRICS, &c; including PRl^JUll L.UO ^;~, Inflammation of the Cervix and Body of the Uterus considered ;?aT!^e£^ »• rdriiu^t*a on wood-In one very handsome octavo volume of over 600 pages, extra cloth. $o - 5. m-vr vv SMITH ON PARTURITION, ANn THE PRIN- TVtf>TVF^AND PRACTICE OF OBSTETRICS. In 21 royaSo volume, extra cloth, of 400 pages. $1 50. RIGBY'S SYSTEM OF MIDWIFERY. With Notes K and Additional Illustrations. Second American | edition. One volume octavo, extra cloth, 422 pages. $•2 50. DEWEES'S COMPREHENSIVE SYSTEM OF MID- WIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the au- thor's last improvements and corrections. In one octavo volume, extra cloth, of 600 pages. $3 50. 26 IIknry C. Lka's Publications—(Midwifery). J>.\M.1 render this new edition »™S.Tf,ry t0 *•;? .obMtotric student than were either of the former editions at the date of their appearance No treatise on obstetrics wUt which w are acquainted can compare favorably with this in Krel'fro116 am°Unt °f material which has been Journal "ery source— *"to» Med. and Surg. flf™fTe ,a no b*tter text-book for students, or work of reference and study for the nrartiBino. Ai,„ • • than this. It «lm,.lH .a '1 '? Pract'S.ng physician These additions render the work still more com Plete and acceptable than ever; and w th the excel" m :'* vsr chh.«hii?publishers have *""■"* inr . ii i„n of Churchill, we can commend it to the R^^.8™ C^'^ P'easure.i-°^- Few works on this branch of medical science are the physician, studeut, or lecturer, all of whom will Br^A^jZ^iT^ *"** <*»' ™^*7- than this. It shou.d ado",, and e^Tch'8very^eS library.—Chicago Med. Journal. 7 medlea, Henry C. Lea's Publications—(Surgery). 21 QROSS (SAMUEL D.), 21.D., Professor of Surgery in the Jefferson Medical Colleae of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, carefully revised, and improved. In two large and beautifully printed royal octavo volumes of 2200 pages, strongly bound in leather, with raised bands. $15 00. The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. Though but little over six years have elapsed since its first publication, it has already reached its fourth edition, while the care of the author in its revision and correction ha-? kept it in a constantly im- proved shape. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long remain the most comprehensive work on this important part of medicine.—Boston Medical and Surgical Journal, March 23, 1S65. We have compared it with most of our standard works, such as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure «our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer it.is upon the shelves of our library.—Canada Med. Journal, September, 1865. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so higtflvprized, that it would be idle for us to speak in praise of this work.— Chicago Medical Journal, September, I860. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance.—British and Foreign Medico-Chirurgical Revieno, Oct. I860. The most complete work that has yet issued from the press op the science and practice of surgery.— London Lancet. ^ This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent "Pfcce, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, aud equal to the best systems of surgery in any language.— N. Y. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority abroad.__Am. Journal Med. Sciences, Jan. I860. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- tioner shall not seek in vain for what they desire.— San Francisco Med. Press, Jan. I860. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratiiude of the future of surgical science.—Edinburgh Med. Journal, Jan. 1865. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country.—St. Louis Med. and Surg. Journal, April, 1865. The third opportunity is now offered during our editorial life to review, or rather to indorse and re- commend this great American work on Surgery. Upon this last edition a great amount of labor has been expended, though to all others except the author the work was regarded in its previous editions as so full and complete as to be hardly capable of improve- ment. Every chapter has been revised; the text aug- mented by nearly two hundred pages, and a con- siderable number of wood-cuts have been introduced. Many portions have been entirely re-written, and the additions made to the text are principally of a prac- tical character. This comprehensive treatise upon surgery has undergone revisions and enlargements, keeping pace with the progress of the art and science of surgery, so that whoever is in possession of this work may consult its pages upon any topic embraced within the scope of its department, and%est satisfied; that its teaching is fully up to the present standard of surgical knowledge. It is also so comprehensive that it may truthfully be said to embrace all that is actually known, that is really of any value in the diagnosis and treatment of surgical diseases and acci- dents. Wherever illustration will add clearness to the subject, or make better or more lasting impression, it is not wanting; in this respect the work is eminently superior.—Buffalo Med. Journal, Dec. 1864. A system of surgery which we think unrivalled In our language, and which will indelibly associate his name with surgical science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which cau be put into the hands of the student seeking to know the principles and practice of this f^Hnns 7nd onerations It is a' complete Thesaurus branch of the profession which he designs subse- rt' modern su^eryrwbere the student and practi- I quently to follow.-^ Brit. Am. Journ., Montreal. T>Y THE SAME AUTHOR. ---- 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 eighty-four illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth. $4 00. Whoever will peruse the vast amount of valuable I guage which can make any just pretensions to be its practical information it contains will, we think, agree equal.-*: Y. Journal of Medicine. with us, that there is no work in the English ian- | , nY THE SAME AUTHOR. ---- A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations. pp. 468. $2 75. 2^ Henry C. Lea's Publications—(Surgery). JAi:iCHSEN (JOHN), Professor of Surgery in University College, London. THE SCIENCE AND ART OF SUROERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. New and improved American, from the Second enlarged and carefully revised London edition. Illustrated with over four hundred wood engravings. In one large and handsome octavo volume of 1000 closely printed pages; extra cloth, $6; leather, raised bands, §7. We are bound to state, and we do so without wish- | to give it but a passing notice totally unworthy of its ing to draw invidious comparisons, that the work of merits. It may be confidently asserted, that no work Mr. Erichsen. in most respects, surpasses any that I on the science and art of surgery has ever received has precedent. Mr Erichsen's is a practical work, more universal commendation or occupied a higher combining a due proportion of the "Science and Art position as a general text-book on surgery, than this of Surgery." Having derived no little instruction treoti-e of Professor Erichsen.—Savannah Journal of from it, in many important branches of surgery, we Medicine. can have no hesitation in recommending it as aValu- | In fn, of practical detall and perspicuity of - n ,w/« o « I 1, the Praetltloner and tue student' style, convenience of arrangement and soundness of uuoun vuaneny. ( discrimination, as well as fairness aud completeness Gives a very admirable practical view of the sci- of discussion, it is better suited to the wants of both ence and art of surgery.—Edinburgh Med. and Surg, student and practitioner than any of its predecessors. Journal. —Am. Journal of Med. Sciences. We recommend it as the best compendium of sur- After careful and frequent perusals of Erichsen's gery in our lauguage — London Lancet. | surgery, we are at a loss fully to express our admira- It is, we fhink, the most valuable practical work ' tioa of 4t- Tlle author's style is eminently didactic, on suriterv in existence, both for young and old prac- and characterized by a most admirable directness, titioners.— Nashville Med. and Surg. Journal ■ clearness, and compactness. These traits have en- abled him. in a volume of about 1000 pages, largely The limited time we have to review this improved occupied by wood-cuts, to present what is, in many edition of a work, the first issue of which we prized respects, the most full and complete systematic trea- as one of the very best, if not the best text-book of tise on the subject of which it treats in the English surgery with which we were acquainted, permits us language.—Ohio Med. and Surg. Journal M ILLER (JA2IES), Late 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 of 700 pages with two hundred and forty illustrations on wood, extra cloth. $3 75. • JJY THE SAME AUTHOR. T1Vr kPRkVC^ICEv°F S^GERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and ciol'h 0$3e7n5gravings °n In one large octavo volume of nearly 700 Paees>extra It is seldom that two volumes have ever made so i acquired The author is an *>mi„„„*i,, „*, i i profound an impression in so short a time as the tical and weiMnfl™ ^an.eminently sensible, prac- P IRRIE ( WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen THE PRINCIPLES AND PRACTICE OF SURGFPY TYiif.i i John Neill, M. D., Professor of Surgery in the Penna Mediae 7. ' c ^ ^ Pennsylvania Hospital, &c. In one vlv hanrlsnm«!,^ ,Cal Co"ege, Surgeon to the illustrations, extra cloth. $3 75 * handsome octavo vol«me of 780 pages, with 316 We know of no other surgical work of reasonable I «- ,„i___ v , size, wherein there is so much theory and pracUce! I -The KSj,?" more soundly °r clearly taught. gARGENT (F. IE), M.D. ON BANDAGING AND OTHER OPERATION ni? -rTW^ r,T „ GERY. New edition, with an additionXhanter^Mrr * 0F :vfIIS OR SUR- 12mo. volume, of nearly 400 pageTS wK^^S^?^ #?*»*«»" "»* Exceedingly convenient and valuable to all mem- Me[y,°1862e professl?n—OMeago Medical Examiner, The very best manual of Minor Surgery we have seen.—Buffalo Med. Journal. 6 ' ave MALGAIGNE 5 OPERATIVE SURGERY. With nu- merous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly 600 pp «2 50 SKEY'S OPERATIVE SURGERY. In one very hand^ s.„ne octavo volume, extra cloth, of over 6.30 na/es with about 100 wood-cats. $3 2.3. P g ' t\J™ c°rd;iU'y commend this volume as one which olh^t Ca' StUdent should most closely stucfy and to the surgeon in practice it must prove Use fins ir net B.//0n,man7 V°'mts which hfi may haveZgotten- Brit. Am. Journal, May, 1862. lorgotten.— F wST'8 S'YST,EM °F PRACTICAL SURGERY some illustrations. Leather, *f ' J hand- Henry C. Lea's Publications—(Surgery). 23 * jyRUITT (ROBERT), 21.R. C.S., frc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated with four hundred and thirty-two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, §4 00; leather, $5 00. theoretical surgical opinions, no work that we are at present acquainted with can at all compare with it. All that the surgical student or practitioner could desire.—Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure.— Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic. The fact that twelve editions have already been called for, in these days of active competition, would of itself show it to possess marked superiority. We have examined the book most thoroughly, and can say that this success is well merited. His book, moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and clas- sified, and of being written in a style at once clear and succinct.—Am. Journal of Med. Sciences. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserves the estimate placed upon it.—Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among our best text-books on elementary sur- gery.—Columbus Rev. of Med. and Surg. We must close this brief notice of an admirable work by recommending it to the earnest attention of every medical student.—Charleston Medical Journal and Review. A text-book which the general voice of the profes- sion in both England and America has commended as one of the most admirable ''manuals," or, "vade mecum," as its English title runs, which can be placed in the hands of the student. The merits of Druitt's Surgery are too well known to every one to Whether we view Druitt's Surgery as a guide to need any further eulogium from us.—Nashville Med. operative procedures, or as representing the latest Journal. H AMILTON (FRANK H), M.D., Professor of Fractures and Dislocations, &c. in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume, with several hundred illustrations. (Preparing for early publication.) The demand which has so speedily exhausted two large editions of this work shows that the author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad as well as at home, has pronounced it the most complete work to which the surgeon can refer for information respecting all details of the subject. In the preparation of this'new edition, the author has sedulously endeavored to render it worthy a continuance of the favor which has been accorded to it, and the experience of the recent war has afforded a large amount of material which he has sought to turn to the best practical account. 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.—Edinburgh Med. and Surg. Journal. " From the great labor and time bestowed upon its preparation, we had beeu led to anticipate a very this work; to do so would carry us far beyond the limits which we have assigned to us, to say nothing of the fact that it would be a matter of supererogation, inasmuch as no intelligent practitioner will be likely to be without a copy of it for ready use. No library, however extensive, will be complete without it.— North American Medico-Chirurgical Review- This is a valuable contribution to the surgery of thorough and elaborate monograph, and an attentive j most important affections, and is the more welcome, perusal of its pages'has satisfied us that our expecta- tions have been fully realized. The work is by far the most complete disquisition on fractures and dis- locations in the English language. It is not our in- tention to present anything like a.forinal analysis of inasmuch as at the present time we do not posses 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.—London Lancet. PURLING (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, from the second and enlarged English edition. In one handsome octavo volume, extra cloth, with numerous illustra- tions, pp. 420. $2 00. B AR WELL (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 j extra cloth, BRODIF.'S CLINICAL LECTURES ON SURGERY. i vol. Svo., 350 pp.; cloth, $1 25. • COOPER OX THE STRUCTURE AND DISEASES OF the Testis, and on the Thymus Gland. One vol. imperial Svo., extra cloth, with 177 figures on 29 plates. $2 50. COOPER'S LECTURES ON THE PRINCIPLES AND Practice of Suruery. In one very large octavo volume, extra cloth, of 750 pages. $2 00. GIBSON'S INSTITUTES AND PRACTICE OF SUR- bery. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- umes, about 1000 pages, leather, raised bands. $6 50. 50 Henry C. Lea's Publications—(Sure/cry). rjiOYXREE (JOSEPH). F.R.S., Aural S»rgeon to and Lecturer on Surgery at St. Mary's Hospital. THE DIS MASKS OK THE EAR: their Nature, Diagnosis, and Treat- ment. With one hundred engravings on wood. Second American edition. In one very handsomely printed octavo volume of 440 pages; extra cloth, $4. The appearance of a volume of Mr. Toynbee's, there- fore, in which the subject of aural disease is treated in the most scientific manner, and our knowledge in respect to it placed fully on a par with that which we possess respecting most other orgaus of the body, is a matter for sincere congratulation. We may rea- sonably hope that henceforth the subject of this trea- tise will cease to be amoug the opprobria of medical Bcien^ce.—London Medical Review. The woi"k, as was stated at the outset of our notice, is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Con- sidered all in all—as an original work, well written, philosophically elaborated, aud happily illustrated with cases and drawings—it is by far the ablest mo- nograph that has ever appeared on the anatomy aud diseases of the ear, and one of the most valuable con- tributions to the art and science of surgeiy iu the nineteenth century.—N. Am. Med.-Chirurg. Review. £A UREXCE (JOIIX Z.), F. R. C. S, and 1JOON (ROBERT C), Editor of the Ophthalmic Review, &c. "^ "* House Surgeon to the Southwark Oph- thaiui ic Hospital, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. With numerous illustrations. In one very handsome octavo volume. (Just Ready.) (from the authors' preface.) " In writing these pages it has been our aim to bring the principles and practice of modern ophthalmic surgery within a small compass, to supply the wants of the busy practitioner who may have neither time nor opportunity to read the innumerable contributions that ophthalmic surgery and sciBnce have received within the last fifteen years. "In describing symptoms, we have limited ourselves to those which are essential for the recog- nition tf disease; in describing operations, &c, to those details which are essential for its treat- ment. J 'ONES (T. WHARTON), F.R.S., Professor of Ophthalmic Med. and Surg, in University College, London THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDI- CINE and SURGERY With one hundred and seventeen illustrations. Third and re- ^7^^^^°^*™* L-d- «™°- I- one handsome octavo onn^i,^^ I j^^^^t^^ioa ^ ric»; commend the book to the American physician and me- to the want, both of ?L . 7 \ a " Wel -adapted dical Undent.-^* Francisco Mel Press. ^ | Chicago Md Exatinlr. "^ "* »"M!lltl0ner- J\[A UKENZIE ( W.), 31. D., ' Surgeon Oculist in Scotland in ordinary to her Majesty &c A TPHE^YFrrCT;VwliThREAfiTIpE a°X LEASES AND INJURIES OF 0f io27 p^jtTSh?xji£i & ois oVs^srd as- octavo ™i- JjJORLAND (W. IP.), 31. D. DISEASES OF THE URINVPY orpwq „n Diagnosis, Pathologv, and Treatment With U, t r ' \C°mPendl™ ©f their octavo volume of about 6^0 pages extra cToth. $3 50 ^ ^ 0M *"*> &M hands0me Taken as a whole, we can recommend Dr Mmlanj'. i „r ,. , co^pendiumasaverydesirableadditionto theT^ry8 | ^KK^JH""-^ and J^SHTOX (T. J.)------------ ^^TH^cT^^^s^r^^ AuXD ^FORMATIONS OF from the fourth and enlarged Lond^Uon ^Vith^1 f°nstiPf °- Second American, beautifully printed octavo^oiumfof abou °300 pig s ^\T ?r^?™t , In •»• very We can recommend this volume of Mr m ■ • m g * {Just Issued.) the strongest terms, as containing all the latest T*J? I sho1*} pfiriod whicu has elapsed since the an- of the pathology and treatment of disease^ ^ of *h" fo''>»" American reprint and the withtherectum.-Canarfa^^.^t^Mirrch^"^^^^f^^^^^^^ This is a new and carefully revised edition f bts^s r »„„ " "Ue'' °,' the "'eiiU> and ot the use- Henry C. Lea's Publications—(3Iedical Jurisprudence, &c). 31 r£AYLOR (ALFRED S.), 21.D., Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. MEDICAL .JURISPRUDENCE. Fifth American, from the seventh improved and enlarged London edition. With Notes and References to American Decisions, by Edward Hartshorne, M.D. In one large octavo volume of over 700 pages, extra cloth. £4 00. We have the more pleasure in expressing our Taylor's Medical Jurisprudence has been the text- book in our colleges for years, and the present edi- tion, with the valuable additions made by the Ameri- can editor, render it tlie most standard work of the day, on the peculiar province of medicine on which it treats. The American editor, Dr. Hartshorne, has done his duty to the text, and, upon the whole, we cannot but consider this volume the best and richest treatise on medical jurisprudence in our language.— Brit. Am. Med. Journal. The presentation to the profession of a new and im- proved edition of this well-known and deservedly popular work cannot be looked upon otherwise than as a subject of congratulation. The book has many merits. It is brief, it is comprehensive; it treats in a clear aud satisfactory manner upon a large number of medico-legal subjects, the most interesting and im- portant that can be presented to the attention of the physician, and the completeness of the work is en- hanced, especially to the American reader, by the appropriate though not very copious notes and re- ferences to recent American cases, by Dr. Hartshorne. —Chicago Med. Jour. We need hardly say that this work is quite beyond the pale of criticism; and that all we have to do is to congratulate the profession on having its conteuts again laid before them, in istil, in a thoroughly re- vised condition.—British Med. Journal. hearty coincidence with the general verdict of the two professions, medical and legal, in favor of this admirable treatise, which, like the one just men- tioned, although printed in tbe manual form, is really the most elaborate work on the subject that our lite- rature possesses, and will unquestionably hold its ground as the standard of medical jurisprudence in this country so long as it shall be kept by its author so completely up to the mark as it now is.—The Brit- ish and Foreign Medico-Chirurgical Review. Without materially increasing the bulk of this most admirable work, we have a new edition brought close up to the present day, with old errors removed and very many new discoveries added. This is a work well worthy the high position of its author, and a fair representative and exponent of the state of foren- sic medicine in this country, second to none, we ven- ture to say, in the world. To attain this every chapter has undergone a close revision, and many new cases and observations have been added; at the same time no extensive changes have been made because un- called for. It would be a waste of time to attempt any description of this work, which must have found its way to the bookshelf of almost every practitioner in the kingdom; those who have it not should pos- sess it forthwith. There is no more useful work of reference on this or any subject.—London Medical Review. JOY THE SAME AUTHOR. ---- ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume of 755 pages, extra cloth. $5 00. TJJINSLOW (FORBES), M.D., D.C.L., frc. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, extra cloth. $4 25. (Just Issued.) SUMMARY OF CONTENTS. Chapter I. Introduction—II. Morbid Phenomena of Intelligence—III. Premonitory Symp- toms of Insanity—IV. Confessions of Patients after Recovery—V. State of the Mind during Recovery__VI. Anomalous and Masked Affections of the Mind—VII. Stage of Consciousness— ■ VIII. Sttige of Exaltation—IX. Stage of Mental Depression—X. Stage of Aberration—XI. Im- pairment of Mind—XII. Morbid Phenomena of Attention—XIII. Morbid Phenomena of Memory —XIV. Acute Disorders of Memory—XV. Chronic Affections of Memory—XVI. Perversion and Exaltation of Memorv—XVII. Psychology and Pathology of Memory—XVIII. Morbid Pheno- mena'of Motion—XIX. Morbid Phenomena of Speech—XX. Morbid Phenomena of Sensation— XXL Morbid Phenomena of the Special Senses—XXII. Morbid Phenomena of Vision, Hearing, Taste Touch, and Smell—XXIII. Morbid Phenomena of Sleep and Dreaming—XXIV. Morbid Phenomena of Organic and Nutritive Life—XXV. General Principles of Pathology, Diagnosis, Treatment, and Prophylaxis. Of the merits of Dr. Winslow's treatise the profes- sion has sufficifntly judged. It has taken its place in the front rank of the works upon the special depart- ment of practical medicine to which it pertains.— Cincinnati Journal of Medicine, March, 1866. It is an interesting volume that will amply repay for a careful perusal by all intelligent readers — Chicago Med Examiner, Feb. 1866. A work which, like the present, will largely aid the practitioner in recognizing and arresting the first insidious advances of cerebral and mental disease, is one of immense practical value, and demands earnest attention and diligent study on the part of all who have embraced the medical profession, and have thereby underlakeu responsibilities in wh.ch the welfare and happiness of individuals and families arelar-ely involved. We shall therefore close this brief and necessarily very imperfect notice of Dr. Winslow's great aud classical work by expressing our conviction that it is long since so important and beautifully written a volume has issued from the British medical press. The details of the manage- ment of confirmed cases of insanity more nearly in- Jeiest those who have made mental diseases their Special study; but Dr. Winslow's masterly exposi- tion of the early symptoms, aud his graphic descrip- tions of the insidious advances of incipient insanity, together with his judicious observations on the treat- ment of disorders of the mind, should, we repeat, be carefully studied by all who have undertaken the responsibilities of medical practice.—Dublin Medical Press. It is the most interesting as well as valuable book that we have seen for a long time. It is truly fasci- nating—Am. Jour. Med. Sciences. Dr. Winslow's work will undoubtedly occupy an unique position in the medico-psychological litera- ture of this country.—London Med. Review. Henry C.Lea's Publication; INDEX TO CATALOGUE, Abel and Bloxam's Handbook of Chemistry Allen's Dissector and Practical Anatomist American Journal of the Medical Seiences Anatomical Atlas, by Smith and Horner Ashton on the Kectum and Anus . Ashwell on Diseases of Females . Blakiston on the Chest .... Brinton on the Stomach Barclay's Medical Diagnosis . Harlow's Practice of Medicine Bartlett on Fevers of the United Stat9s Barwi 11 on the Joints .... Ik ale on the Laws of Health Benuet (Henry) on Diseases of the Uterus Benuet's Review of Uterine Pathology Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Brando & Taylor's Chemistry Brodie's Clinical Lectures on Surgery . Brown on the Surgical Diseases of Women Buckler on Bronchitis .... Bucknill and Tuke on Insanity Budd on Diseases of the Liver Bumstead on Venereal .... Carpenter's Human Physiology . Carpenter's Comparative Physiology . Carpenter on the Microscope Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Christisou and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Diseases of Females Churchill on Diseases of Children Churchill on Puerperal Fever Clymer on Fevers..... Colombat de l'lsere on Females, by Meigs Coinlte on Diseases of Children . Cooper'- i U. Ii ) Lectures on Surgery . Cooper iSir A. P.) on the Testis, &c. .. Curling ou Diseases of the Testis . Cyclopedia of Practical Medicine . DaltonV Human Phvsiology . De .lough ou Cod-Liver Oil Dewees's System of Midwifery Dewees on Diseases of Females . Dewees on Diseases of Children . Dickson's Practice of Medicine Druitt's Modern Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . I'i: igti-on on New Remedies Dinglisou's Therapeutics and Materia Med Lliis s .Medical Formulary, by Thomas ].:.!-,. .! s System of Surgery F.o_"i--,m's Operative Surgery Flint on Respiratory Organs . F:int oil the Heart..... Flint's Practice of Medicine . Fownes's Elementary Chemistry . Frick on Renal Affections Gardner's Medical Chemistry Gibson's Surirerv..... Gluge's Pathological Histology, by Leidy Graham'- Elements of Chemistry . Gray's Auatomy..... Griffith's (R. E.) Universal Formulary . Griffith's (J. W.) Manual on the Blood, &c. Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy Habershon on Alimentary Canal . Hamilton on Dislocations" and Fractures Harrison on the Nervous Sy-tein . Hoblyn's Medical Dictionary Hodge on Women . - . Hodg.i's Obstetrics ....'. Holland's Medical Not<\s and Reflections Horner's Anatomy and Histology Hughes on Auscultation aud Percussion Hillier's Handbook of skin Diseases . PAQB . 12 . 7 1 . 7 . 80 . 23 . 18 . 13 . 17 . 16 . 19 . 2il . 14 . 21 . 2t . 11 . 11 . 11 . 29 . 23 . 18 . 20 . 19 . 19 Jones's iT. W.) Ophthalmic Medicine and Surg. Jones and Sievekiug's Pathological Anatomy Jones (C. Haudfield) on Nervous Disorders . Kirkes' Physiology ...... Knapp's Chemical Technology Lallemand and Wilson on Spermatorrhoea . La Roche ou Yellow Fever .... La Roche on Pneumonia., &c. Laurence ami Moon's Ophthalmic Surgery . Laycock ou .Medical Observation . Lehmann's Physiological Chemistry, 2 vols. Lehmaun's Chemical Physiology . Ludlow's Manual of Examinations Lyons ou Fever...... Maclisp's Surgical Anatomy .... Malgaigne's Operative Surgery, by Brittan . Marwick's Examination of Urine . Mayne's Dispensatory and Formulary Mackenzie on Diseases of the Eye Medical News and Library .... Meigs's Obstetrics, the Science and the Art . Meigs's Letters on Diseases of Woineu Meigs on Puerperal Fever .... Miller's System of Obstetrics Miller's Practice of Surgery . . . . Miller's Principles of Surgery Montgomery on Pregnancy .... Morlaud on Urinary Organs .... Morland on Ursemia..... Neill and Smith's Compendium of Med Science Neligan's Alias of Diseases of the Skin Neligan on Diseases of the Skin . Prize Essays on Consumption Parrish's Practical Pharmacy Peaslee's Human Histology , Pirrie's System of Surgery .... Pereira's Mat. Medica and Therapeutics, abridged Quain and Sharpey's Anatomy, by Leidy . Roberts ou Urinary Diseases .... Ramsbotham on Parturition .... Reese on Blood and Urine * Ricord's Letters on Syphilis, by Lattimore . Rigby on F'emale Diseases .... Rigby's Midwifery...... Rokitansky's Pathological Anatomy . Royle's Materia Medica and Therapeutics . Sargent's Minor Surgery .... Sharpey and Quain's Anatomy, by Leidy . Simon's General Pathology .... Simpson on Females..... Skey's Operative Surgery .... Slade on Diphtheria ..... Smith (H. H.) and Horner's Anatomical Atlas Smith (Tyler) on Parturition Smith (Edward) on Consumption . Solly on Anatomy and Diseases of the Brain Still6's Therapeutics ..... Salter on Asthma...... Tanner's Manual of Clinical Medicine '. '. Taylor's Medical Jurisprudence . Taylor on Poisons...... Todd and Bowman's Physiological Anatomy Todd on Acute Diseases..... Toynbee on the Ear ..... Walshe on the Lungs..... Walshe on the Heart..... Watson's Practice of Physic . . . . West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . . Wilson's Dissector.....\ Wilson on Diseases of the Skin . ! '. Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Healthy Skin .... Wilson on Spermatorrhoea . Winslow on Brain and Mind PAOB 30