REMARKABLE CASES OF FRACTURE. 
SURGEON TO THE HOUSE OF RELIEF OP THE NEWYORK HOSPITAL. 
W. T. BULL, M. D. 
[.REPRINTED FROM THE NEWYORK MEDICAL JOURNAL, JAN, 1878.] 
I. Multiple Fracture of the Pelvis.—Y. S., aged seventy, 
a native of Germany, fell through a hatchway, a distance of 
abmd fifteen feet, December 22, 1876, striking on the right 
side of the body. When seen at the hospital a few minutes 
later, he was found to have received severe injuries to the 
pelvis and right shoulder. The humerus was dislocated for- 
ward and inward, so as to be situated just within the coracoid 
process; and on replacing the head of the bone, which was 
done at once by gentle manipulation, a movable fragment of 
the coracoid process was plainly felt below and to the inside 
of its normal situation. 
The right lower extremity was completely helpless, but lay 
in a natural position. On careful measurement, a shortening 
of half an inch was made out. On rotation, abundant crepitus 
was felt in the region of the trochanter; the crest of the ileum 
was movable, and a fracture of the descending ramus of the 
pubis was felt on palpation. A pelvic girdle was applied, and 
the arm placed in a sling. A week later the patient was sent 2 
to liis residence at the Old Men’s Unsectarian Home, 521 East 
120 th Street. Dr. J. B. Campbell attended him, and has been 
kind enough to inform me that his general health continued 
pretty good for about two months, when an obstinate diar- 
rhoea set in, and he died from exhaustion, March 21, 18YY, 
three months from the day of the injury. Before the diar- 
rhoea began he had been about his room on crutches several 
times, having largely regained the use of his arm, and com- 
plaining only of pain in the hip, and inability to bear weight 
on the injured limb. Through the courtesy of Dr, Campbell 
and Mr. Ramscar, the superintendent of the institution, and 
with the help of Dr, W. A. Jayne, I was able to make an 
autopsy and remove the fractured bone. The organs were 
remarkably healthy, 
except some atheroma- 
tous patches in the 
aorta, and some tatty 
degeneration of the 
kidneys. The blad- 
der and urethra were 
quite normal. More ex- 
tensive fracture of the 
pelvis had occurred 
than was supposed. 
With the aid of the 
accompanying dia- 
gram the lines of frac- 
ture may be clearly 
seen, while Figs. 1, 2, 
and 3, will show the dis- 
placement of the frag- 
ments. Through the 
rami of the pubes and 
ischium there are two 
oblique lines of fracture, both directed from above, downward 
and from within outward (a and 5). The body of the pubes is 
fractured nearly vertically downward into the obturator foramen 
(c d'), and from the centre of this fracture there is a split through the centre of the acetabulum, extending to the greater sacro- 
ischiatic notch (cd). The anterior and upper two-thirds of the 
ileum are separated by two lines of fracture, one passing from 
beneath the anterior superior spine to the ischiatic foramen 
{ed), and joined at its posterior third by another, which de- 
scends nearly vertically from the crest, an inch in front of 
the sacro-iliac synchondrosis {f g). There are, consequently, 
six distinct points of fracture. 
The most striking deformity occasioned by the displace- 
ment of these fragments is seen in the acetabulum. An irreg- 
ular opening exists in its roof, owing to the portion ode 
being thrown upward and forward, while the fragment add' 
is displaced inward and slightly forward. The piece of the 
rami of the pubes and ischium ah is moved a little down- 
ward. There is quite firm union of all these fractures except 
in the line cd\ where slight motion can be made. Consid- 
erable callus existed, and the tissues covering the gap in 
the roof of the acetabulum were consolidated, so that the head 
of the femur rested in an apparently natural socket, the at- 
tachment of the ligamentum teres being intact. 
The head of the humerus wTas in place, and no rent dis- 
coverable in the capsule. From the tip of the coracoid pro- 
cess two fragments were broken off: one, attacked to some 
fibres of the pectoralis minor, was drawn halfway to the side 
of the chest; the other was displaced about an inch downward 
by the fibres of the coraco-brachialis. 
I deem this case worthy of record on account of the extent 
of injury to the bone following a fall, part of whose force 
was spent upon the shoulder; and also from the absence of 
damage to the pelvic viscera. It is interesting, too, to note 
the elaborate reparative action in an old person. 
11. Multiple Fracture of Femur (compound). 
Case I.—S. M., an Irish woman of intemperate habits, and 
thirty-one years of age, fell from a fire-escape on the first story, 
July 11, 1877, and was brought at once to the hospital. 
She was in a semi-intoxicated condition, and suffered but 
little from the shock of the accident. The left lower extrem- 
ity was entirely helpless and shortened, and lay with the foot 4 
everted. On the outer side of the thigh, just below its middle, 
was a wound, made by projection through the skin of the 
Fig. 1. 
Fig. 2. 
External View. 
Anterior View. 
Fig. 3. 
Internal View. 
lower extremity of the upper half of the femur. There 
was little contusion about the hip, and no pain referred to 
that point. (The woman was short, and quite fat.) The fin- 
ger passed into the wound, after the bone had been re- 
placed, detected a transverse fracture an inch below the 5 
middle, and a loose fragment of small size, which was at 
once extracted. On measuring, the shortening was one inch 
and. a half. Buck’s extension was applied, and the wound 
dressed antiseptically, according to 
Mr. Lister’s method. On the fourth 
day the discharges were offensive. 
Open treatment was pursued, but the 
patient died on the sixth day, with 
symptoms of septicaemia. 
At the autopsy I was surprised to 
find a comminuted fracture of the neck 
within the capsule, in addition to the 
fracture of the shaft, which was found 
to be more extensive than was sup- 
posed, a fragment two inches long be- 
ing detached from the posterior and 
inner surface. There was, moreover, a 
longitudinal fissure, running from the 
transverse fracture toward the condyles.1 
The cut shows clearly these fractures. 
Case ll.—The second case is very 
similar to the above. C. S., aged fifty- 
five, an intemperate and ill-conditioned 
Irish woman, fell from the roof of an 
out-house to the ground, a distance of 
fifteen to twenty feet, on September 9, 
1877, and struck on the left side of 
the body. There was a wound on 
the outer side of the left thigh, com- 
municating with a transverse fracture 
about the middle of the femur. The 
shortening was three inches. The 
wound was explored with the finger, several small fragments 
of bone removed, a counter-opening made in the posterior 
surface of the thigh, and an antiseptic dressing applied, with 
Buck’s extension, A month later, a plaster-of-Paris splint 
was applied, there being but slight discharge and no bur- 
1 Specimen exhibited at the meeting of the Pathological Society, No- 
vember 28, 1877. 6 
rowing of pus. The patient’s general condition was, however, 
unsatisfactory, as she was troubled with cystitis and chronic 
bronchitis. After two weeks, Buck’s extension was applied. 
There was no union at all. Bed-sores developed, in spite of 
every effort; the general condition grew worse, and she died 
October 28, 1877, about three months from the receipt of the 
injury. 
At the autopsy the points of fracture corresponded in situ- 
ation to those of the first case; but at the neck there was no 
comminution, while in the shaft there was considerable. 
About the intra-capsular fracture there were no indications 
of reparative action, and in the shaft there was merely a mass 
of fibrous callus, half an inch in thickness, between the ends 
of the fragments; on their anterior surface, and about the 
end of the bones, which overlapped, some osteoplastic for- 
mation. 
Although these two cases were compound fractures they 
were produced by the sort of injury which is frequently fol- 
lowed by simple breaking of the femur at one point; and lam 
inclined to believe that fracture at two points, especially in 
persons in whom the neck of the femur has undergone change 
in structure and relations, may not be rare. In such a case 
the fracture at the neck would naturally be overlooked, as the 
symptoms would be explained by the solution of continuity in 
the shaft. Even if it were suspected, it might be difficult to 
assure one’s self that it existed, especially in short and fat 
persons.