.m:

 
I
DEFORMITIES AFTER  FRACTURES.
I 
DEFORMITIES  AETER FRACTURES.
BY
FEANK HASTINGS  HAMILTON.
  "That a 'cure' took place we do not doubt, but the information we should most desire would be on
the length of the cured limb, and on a few other matters of that sort."
                               Johnson's Replt to Radlet.
              ,0n Gei)/'s Q

              LIBSABY.   & ,


            EXTRACTED PROM THE

TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION,
         PHILADELPHIA:
T.  K. AND P. G. COLLIN'S, PEINTEES.
                1855. 
WEA




 1855 
PREFACE.
  I  propose  to deduce from my own experience, and from the
experience of  other surgeons, as recorded in this report, the true
prognosis of fractures.  This I shall endeavor to do with care and
fidelity, avoiding, on the one hand, if possible, the error of encou-
raging the practitioner with a prognosis too favorable, and, on the
other, the equal wrong of leaving him to expect too little.
  To this end, I shall draw from my hospital and private records
such cases as  have come under my immediate care, describing, as
briefly as will be consistent with my purpose, all those circum-
stances  connected with  each fracture which might  in  any way
modify the result, together with the plan of treatment, and finally,
the precise amount and character of the imperfection, or maiming,
if any, which remains.  I shall not, however, confine myself  to my
own cases; but, so far as I am able,  I shall record the cases  which
have been treated by other regularly qualified surgeons,  and  which
have subsequently passed under  my  own observation.  This is
necessary not  only as a vindication of my own practice and reputa-
tion, of which one must naturally feel jealous, but more especially
that my conclusions may have, what you have a right to demand
for them, the weight of authority.                    t
  I shall, therefore, ask the liberty of reporting the practice of my
contemporaries, and of mentioning their names, that you  may judge
for yourselves whether they constitute proper representatives of the
present condition of our art.  Of this, I trust, no one will complain,
since without such permission I would not have ventured upon the
duty assigned  me, nor do  I  believe any one else would have con-
sented to have occupied my place.
  It is certain that, up to this moment, no  one  has volunteered to
state fully what have been the results in his own practice, or in the
practice  of the hospital,  or other similar  institutions, which have
been under his immediate charge.   In hospital records, you may
find patients admitted with fractures, and reported as " dea'd," or as 
6
 dismissed  "cured," with  the  occasional interpolation of "a  good
 leg;"  and, upon  these records,  tables have been  constructed to
 determine the average fatality of such accidents, and the probabili-
 ties of cure;  but I have not yet seen any published reports declar-
 ing what  was the exact amount and  value of the "cure"—how
 much the  bone was shortened, or bent, or otherwise maimed and
 deformed.   In short, they still fail to inform us what are the " de-
 formities after fractures,"  which, under  fair treatment, may reason-
 ably be expected.
   Dr. "Wallace  published,  in 1839,  a statistical  account  of the
 eighteen hundred fractures which had been treated in the Pennsyl-
 vania  Hospital from its foundation up to the year 1838; and Dr.
 Norris published, soon after, a similar report of the fractures treated
 in the same institution between the years 1830and 1839, inclusive;
 but neither of these gentlemen make any reference to a shortening,
 or to any degree of deformity which may have occurred in the cases
 reported as cured.  Dr.  Peirson, in  his report of the statistical
 tables of all the fractures  which  had occurred in the Massachusetts
 General  Hospital  up  to the year 1840, notices, under the head of
 "Eemarks," many interesting  facts, such as delayed  or non-union,
 the occurrence of ulcers, gangrene,  &c. &c.; but there is nothing
 exactly pertinent to the subject of our inquiry.
   Dr. Lente, who has recorded the statistics of fractures treated at
 the New York  Hospital  for the twelve years preceding 1851, has
 attempted to supply the deficiency, which he declares does exist in
 the hospital records, upon this subject, by his own "personal expe-
 rience of several years in the practice of the hospital, and by con-
 versation with other surgeons who  have  been connected with it."
 But he has limited his statements to what he believes to have been
 the average results, as regards shortening, in the treatment of frac-
 tures of the femur.
  The statistics furnished by Lonsdale,  of the Middlesex  Hospital
 of London, and by Fricke, of the General Hospital at Hamburg, are
 equally silent  upon the subject of deformities or shortening.
  The same disinclination to approach this subject is manifested by
those who have written special or general  treatises upon fractures,
and who, with the single exception of Malgaigne, will be found
eith'er to have  ignored prognosis altogether, or they have seemed to
speak of it  only casually, and without any numerical basis for their
calculations, since, among writers of equal experience and reputa-
tion, there exist the widest discrepancies of opinion.  An example 
7
will illustrate what I have said.  Chelius, writing of fractures of the
thigh-bone, says: "Fracture  of the thigh-bone is always a severe
accident, as  the broken bones are retained  in proper contact with
great difficulty.  The  cure takes place most commonly  with de-
formity and shortening of  the limb, especially in oblique fractures,
and those which occur in the upper and lower third of the thigh-
bone."  To  which Mr. South, the translator, and Surgeon  to St.
Thomas's Hospital, appends  the following  note: "In simple frac-
tures of the thigh-bone, except with great obliquity, I have rarely
found difficulty in retaining the broken ends in place, and in effect-
ing 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
on his own carelessness or  ignorance."  (Chelius's Surgery, by South,
American edition, vol. i. p. 627.)
   Even Malgaigne, to  whose recent  work,  entitled,  Traite des
Fractures et des Luxations, I shall hereafter have frequent occasion to
refer, and who  speaks generally with a precision which indicates a
careful observation of the  facts, does not intimate the existence of
any  exact records, either in  his own practice or in the practice of
others, from which his conclusions have been deduced.
   In looking for an explanation of this seeming indifference, or
palpable  ignorance, upon  a  subject of such manifest importance
both to surgeons and to  their patients, I  find several  probable
causes.
   I  suppose that most practical surgeons have a tolerably correct
appreciation of prognosis  in fractures.   I say tolerably, because I
wish to imply a qualification.  I do not think  that a majority of
even "practical" surgeons have a full appreciation of the subject.
I am frank to confess that, until I commenced these investigations,
I  had not any just notions  of the frequency of deformities after
fractures.  Nor can I  now understand how any surgeon, who does
not  carefully measure limbs  with a rule or with a graduated tape-
line, can  have  possessed himself of any very accurate information
upon that point.  Yet I appeal to surgeons whether this has been
their constant or even their general practice? or whether they have
not usually adopted, in measuring the lower extremities, that more
simple, yet always unreliable method of placing the limbs parallel,
knee to knee and heel to heel ? or whether they have not  as often
contented themselves with the averment of the patient himself, that
the  limb was  perfect ? and, indeed, whether, in case of a fractured 
8
arm or radius and ulna, they have, in one case out of ten, instituted
any sort of inquiry or examination  by which their relative length
might be determined?*  I address  hospital surgeons  as  well as
surgeons in private practice.  Let them answer to themselves these
interrogatories.   If such examinations can be shown to have occa-
sionally been made, we still venture  to affirm that, in no instance.
for any considerable length of time, have  regular records of exact
results been kept.  Nor do  I expect that, upon my humble remon-
strance, such records, fairly made, will hereafter be kept.
   Surgeons who have the  charge of public hospitals understand
that the eyes of their pupils, their governors, their confreres, and of
the public even are upon them, and it is attributing to them nothing
more  than a common frailty  to  charge that  they dare  not  record
faithfully their results in the treatment of  fractures.  To be honest
in the admission of shortcomings in a branch of our art, where the
difficulties are so little understood  by those who constitute them-
selves our judges, would be suicidal.  Do  you not see that jealous
and designing colleagues would have no such discreditable results ?
Pupils would draw unfavorable comparisons, and desert the wards
where  failures were so common; rival hospitals would secretly or
openly seize upon such  records  to their own advantage; and the
patients  themselves  would, no doubt, often  return  the diligence,
skill, and honesty of their surgeons with imprecations and prosecu-
tions.
   There is, gentlemen, no  lack  of charity in these  suppositions.
We are to take men as they are, and as they are well enough known
to be, and not as we would have them; and it is in vain to deny that
such are the fair risks which strict honesty  in this matter must incur.
The instinct of self-preservation, therefore, prompts to  silence, or
to the most favorable representations.  Students will continue to
go out from our hospitals with a  belief that perfect union of broken
bones is  the rule, and that exceptions imply generally unskilful
management; and if, when  hereafter they have themselves occasion
to treat a fractured femur, the result falls short of their  standard of
perfect  success, they, taught also by the  same instinct  of self-pre-
servation which actuated their teachers, will conceal the truth from

  * " Le malheur de tous ceux qui  ont cru obtenir  de ces gu£risons miraculeuses,
c'est qu'ils n'ont pas meme songe  a me"surer comparativement les deux membres; je
dirai plus, c'est qu'ils ignorent le plus souvent les conditions d'une bonne et fidele
mensuration."—Traite des Fractures et des Luxations, par J. F. Malgaigne, torn. i. p.
724. A Paris, 1847. 
9
others, and  even from themselves, if possible.  Nay, I fear that
sometimes, under the same urgent promptings, and where the moral
sense is not  superior to all  other  considerations, they may hesitate
to regard the sanctity of an oath!  How else shall we explain the
testimony of that man who, with  uplifted hand, affirms that he has
" seen and treated ten fractures of the femur, in adult persons, and
not one of them is in any way shortened or deformed?"  Or what
less charitable construction will you place upon the published aver-
ment of  a hospital  surgeon in a neighboring province, who, in his
remarks upon  my "fracture tables," as  reported by my late pupil,
Dr. Boardman, some years ago, declares that he has lately treated
at the hospital under his care one case of fractured inferior maxilla;
three cases  of broken  clavicles,  two of which were at the outer
third;  seven of fractured femur,  one  of which was compound and
one comminuted ; eight cases of fracture of the tibia and fibula, two
of which were  comminuted and  one compound—in all nineteen
cases,  and that, with the  exception  of one who died, every case
resulted in a perfect cure ?
   It is more than probable that the writer will not escape  similar
criticisms hereafter, and that his report  may be regarded as giving
a true representation of American surgery, but as scarcely applica-
ble to the surgery of others.  In reply to a sentiment so illiberal, I
beg to say, in anticipation,  that having myself visited a majority of
the large hospitals of Great Britain, and very many upon the conti-
nent of  Europe, and  having observed carefully their methods of
treatment, and, in some  measure, noticed their success,  I am pre-
pared  to affirm that, in so far as I have yet seen, the practice of
American  surgeons,  in the management  of fractures,  compares
favorably with that of any other  people.  The English themselves
are constantly proclaiming their deficiency in this department of
surgery.  It  is  now more  than one hundred years since Pott, then
Surgeon to St. Bartholomew's Hospital,  inquired of his brethren if
it was not " notorious" that in England broken thighs and legs were
"often,  very often, left  deformed, crooked,  and shortened?"  But,
notwithstanding Pott believed that he  had discovered the true cause
of these deformities, and had devised a remedy which must in future
secure to his countrymen comparative eminence in this branch, yet
to-day Mr. Skey, the  very distinguished successor  of Mr. Pott in
the same great hospital, finds occasion to say : " One is therefore at
a loss to find any apology for those surgeons to whose want  of care,
and even of humanity, may be attributed the numerous examples of 
10
distorted and contracted members, ivhich have cast a reproach  on the
surgery  of Great Britain."  (Skeys  Operative Surgery,  American
edition,  p. 140.)
  For myself, while I take these admissions as evidence that Ame-
ricans are quite  as expert in the dressing of broken bones as the
English, I am nevertheless much more charitable to their failures
than they are themselves.  To me  these admissions  only confirm
a long-nourished conviction that neither in  Great Britain nor in
the United States, nor in any other part of the world, has the art of
treating fractures attained that  degree of perfection which surgeons
have almost universally claimed for it.
  If my reviewers deny the correctness of  my conclusions, I trust
they will do me  the justice to accompany their denial with proofs
of the  same specific character, and  obtained in the  same careful
manner, with those evidences which I shall present.
  Finally, no man can be more sensible than myself of the imper-
fect  manner in  which I have accomplished the  duty which  you
have imposed upon me,  and  especially since, while I  have only
contributed  a  limited experience to the elucidation  of a very im-
portant subject—the subject of Prognosis in Fractures—I  have, to
an extent still more limited, contributed suggestions or experience
in relation to better or more  successful modes of treatment.  Yet
I trust  no one will, for that cause, censure an humble  beginning.
Others  may yet complete what I have only commenced.  " Admit
that bones and  patients are and always have been contumacious
and refractory.  What then ?   " What good," do you ask, " can be
accomplished by exposing our failures, unless we have found the
remedy, in which alone  the world can claim a  final interest ?"  I
reply, that the first step towards improvement in any art or science
must be the faithful exposure of its wants and deficiencies. 
11
                       CHAPTEE  I.

                          OSSA NASI.

  Case 1. Simple displacement of left os nasi, laterally and backicards.
Partial restoration.
  S. L., of  Auburn, aged 10 years.  While playing, one of his
mates accidentally hit him 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  inevitable  by the  mere
separation of its serrated margins from the  bones adjoining.
  With a steel instrument,  introduced  into the  left  nostril, I  at-
tempted to  lift the  bone  to its place.   The membrane  was  very
sensitive, and the patient  very restless under my repeated efforts.
I pressed upwards with considerable force, and succeeded at length
in bringing  the bone nearly  into position.  In  this situation, with
some slight  deformity remaining, I was compelled to leave it.
  The hemorrhage, which was for a time profuse, soon ceased spon-
taneously.

  Case 2. Simple fracture or displacement of the ossa nasi.  Perma-
nent deformity.
  M. L. P. T., of Saratoga County, aged  5  years, was struck by a
boy's sled on the left side, completely flattening his nose, and turning
the bones across to the right. Dr. John Thompson, a distinguished
surgeon of  Saratoga County, was in  attendance, and,  as well  as  it
was possible to do so, lifted and  replaced the nasal bones.  For  some
months it was supposed that the restoration was  perfect, and not
until all swelling had disappeared was it ascertained to be still con-
siderably displaced.
  Thirty-six years after the  accident I examined the nose. I find
the ossa nasi are inclined over to the right, the deviation being in a
straight line, and commencing at their upper ends. It is, therefore,
a displacement, rather than a fracture.  The left nostril is very much 
12
obstructed, and has been all his life a source of much inconvenience.
Within a few years, also, a cartilaginous growth in the left nostril
has materially increased the obstruction.

  Case 3.  Simple fracture and displacement of the lower third of the
right os nasi.  Restoration after one week.
  D., of Attica,  aged 11 years.   The lower third of the right os
nasi was broken, and displaced to the right side.  The accident
occurred a week since, and an  attempt was immediately made, by
an  intelligent country surgeon, to replace the bones, but  without
success.  The doctor then directed him to call upon me.
  I introduced a strong steel instrument into the right nostril, and
pressed upward and  to the  left, while  with my thumb I pressed
forcibly upon the right  side of the nose.  My object was to lift the
bone, and carry it a little over to  the left side.   During  the effort,
the bones were felt to crack and  give way slightly, but not suffi-
ciently.   I then gave him  chloroform, as the manipulation had
proved very painful, and again pressed in the same manner and
with  great force.   The restoration now seemed nearly or  quite
complete.

  Case 4.  Simple fracture and displacement of the lower ends of the
ossa nasi to the left side. Attempts at reduction unsuccessful. Deformity
remains. CI ironic ulceration of the septum, &c.
  N. B. N., of Hunt's Hollow, aged 27 years.  Two years since he
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 occasion-
ally 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 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.  AVhen a child, he was very subject
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 
13
has lived in the country upon  a farm, and has accustomed himself
to much out-door exercise.

   Case 5.  Simple fracture, followed by deformity.
   Mrs. J. A., aged 23 years.  Fifteen years ago she fell on her nose
and broke down the ends of the ossa nasi.  A surgeon of St. Gallen
in Switzerland, replaced them.
   There has remained  ever  since a slight elevation of the ends of
the bones and of the cartilage,  giving to her nose an aquiline form.
The elevated portion is slightly tender, and occasionally, in damp
weather, it is painful.
   It  is probable that, in replacing the  fragments, they were lifted
too high.   Possibly, however, the slight deformity is due to  an  ex-
ostosis.

   Case 6. Simple displacement of both ossa nasi backwards.  No treat-
ment.  Deformity.
   Miss H. S., of Buffalo.  When three weeks old, a block of wood
fell upon her nose 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 appear to have been spread asunder.  This having occurred
when the bones were in a cartilaginous state, the parts must have
been rather bent than fractured, and in this condition they have
ossified.  The deformity is very striking.

   Case 7.  Simple displacement of the bwer ends of the ossa nasi back-
wards, complicated with  fracture of the cranium and osfemoris. Death
on the seventh day.  No attempt to restore the bones to place.
   W. W., aged 45  years, fell from a two-story building.  Drs. White
and Hamilton in attendance.
   The  ossa nasi were  displaced  rather than broken, being forced
backwards from their  articulations with the nasal processes of the
superior  maxilla, but not completely separated from their articula-
tions with the os frontis.
   As the injury to  his skull was likely to prove fatal in a short
time, no attempt was made to  adjust the ossa nasi.   He.died on the
 seventh day. 
14
   Case 8. Simple displacement of the lower ends of the ossa nasi to the
 left side.   No treatment.   Displacement remains.
   Miss S. W., aged 8  years.  She was struck accidentally, by a
 piece of iron, on the right  side of her nose.   Her parents did not
 suppose any serious injury was received, and no surgeon was called.
   Ten years after the accident she called upon me for the purpose
 of having the deformity remedied, if possible.  The lower ends of
 both ossa nasi are pushed over to the left side.  I advised no inter-
 ference.

   Case 9. Simple displacement of lower ends of ossa nasi to left side.
 No treatment.  Deformity remains.
   E. Jackson, aged 18 years.  No surgeon was employed.
   Ten years after the accident the deformity was very striking, both
 bones inclining to the left side.

   Case 10. Simple displacement backwards of the lower ends of the
 ossa nasi.   No treatment.  Deformity.
   Henry Orb, aged 11 years.   The accident occurred in Germany,
 and, his parents  not suspecting the nature of the injury, no surgeon
 was called.  Thirteen years after, he was  an inmate of the Buffalo
 Hospital, and I found the bones very much displaced backwards.

   Case 11. Simple displacement of lower ends of ossa nasi to the right.
 No treatment.  Deformity.
   Wrm. Hingston, aged  9 years.  No surgeon was called.  Eighteen
years after the accident the displacement still continued.

   Case 12. Simple fracture and displacement of hioer ends of the ossa
 nasi to the left side.  No  treatment.  Deformity continues.
   Mathew Powell, aged 19 years.  This case came under my notice
 nine years after the accident, and the displacement still continued.
 He did not, at the time, suppose his  nose was broken, and he did
 not consult a surgeon.

   Case 13. Simple fracture and displacement of lower ends of the ossa
nasi to the left and backwards.  Treated by a "handy man" in Ireland.
 Deformity remains.
   Michael Gibson, aged 15 years, of Ireland.   Michael called upon
 what, in that country, is known generally as a  " handy man," or an
 uneducated "bone-setter."
   Fifteen years after the accident, the fragments remained displaced 
15
1
i
  Case 14.  SimpJle displacement of ossa nasi backwards.  No treat-
ment.   Deformity continues.
  Jacob Kibbs, a German, aged 7 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 he became
an inmate of the Buffalo Hospital.  The nose was then almost fiat.
The ossa nasi  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 of the nose, rising
above the level of the ossa nasi.

   Case 15. Simple fracture and displacement of the lower ends of the
ossa nasi to the left  side.  Treated by a  " handy  man" in Ireland.
Deformity continues.
   Michael  Kane,  aged  30 years, of  Ireland.  This  patient was
treated also by  a  " handy man."  Twenty years  after the accident
he was an inmate of the  Buffalo Hospital.   The deformity was then
very striking.   Lower ends of both bones incline to the left.

   Case 16.  Compound fracture and  displacement of  lower  ends of
both ossa nasi to left side and backwards.   Complete restoration.
   George Eeid, of Erie County, aged  about 24 years.  "While em-
 ployed in a sawmill he was struck by some part  of the machinery,
 and was soon after found insensible.  I saw him four hours after
 the accident.   He could give no account  of the  injury, but it was
 evident that the blow which rendered him insensible had been re-
 ceived only upon his nose.
    The ossa nasi were loose, and easily made to move under the
 finders.  The lower ends were pushed to  the left side, and a little
 backwards.  There was a wound on the right  side communicating
 with the bones and with the nasal passages. The hemorrhage was
 profuse.
    I  introduced a  straight steel instrument—a  director—into the
 superior  meatus,  and,  assisted by my fingers  upon the  outside,
 easily replaced the bones.   With a small compress also placed upon
 the left side, supported by a strip of adhesive plaster, I sought to
 retain the bones in  place.   This was found necessary on account of
 a manifest  tendency to fall off whenever the pressure was removed.
 The nostrils were plugged  to arrest hemorrhages, and cold  applica-
 tions made to the outside of the nose. 
16
   I have never seen the patient since, and cannot declare positively
the result; but I have reason to suppose it is perfect.

   Case 17. Compound fracture of the ossa nasi.  Treatment unsuccess-
ful.   Deformity.
   Thomas Burns,  of Oppenheim, Fulton County, aged 3 years.
The accident occurred from the kick of a horse, producing also a
wound on the side of the nose which communicated with the frac-
ture.   Dr. Peter Yost,  of Oppenheim, was his surgical attendant.
The bones still remain  considerably displaced, fourteen years  after
the accident.

   Case 18. Compound fracture and displacement of the  lower ends of
ossa nasi to the right side, and  backwards, with fracture  of the nasal
process of the superior maxilla  on  the left side.   Treatment partially
successful.
   G. C,  aged about 40 years,  was kicked by  a  horse  on the left
side of his nose, producing insensibility  and convulsions, which
lasted an hour or more.  A clever surgeon attempted to restore the
bones by introducing into the nostrils a female catheter.   I think
the instrument was too large.
   When I saw Mr.  C, about two hours after  the accident, the
lower  ends of both  nasal  bones were displaced  to the right, and
backwards.  The nasal process of the superior maxilla on the left
side was also broken in.   With a straight steel director,  and with
only moderate force, I lifted the bones into place.   The hemorrhage
not having ceased, I introduced a lint plug  into the bleeding nos-
tril.  After two years, I find the form of the nose nearly, but not
quite, perfect.

   Case 19.— Compound fracture of the ossa nasi, complicated with other
severe injuries.  Death on the twelfth day.
   John Gallaghan, aged 31 years. The frontal,  with the superior
and inferior maxillary bones, were broken in at  the same time.   I
lifted both the ossa nasi and the fractured os frontis; the restoration
of the fragments was complete, but the patient gradually sank, and
died on the twelfth day.

   Case 20. Compound fracture of ossa nasi, complicated with fracture
of the cribriform plate of the ethmoid, os frontis, &c.   Death after about
three months.   (See skull in my private collection^)
   H. G., of Brockport, N. Y.,  aged about 14 years, was kicked  by 
17
a horse, breaking in the ossa nasi, os frontis, and  ethmoid bone.
Dr. Thatcher, of Brockport, was called and  dressed the wounds.
The lad was slightly comatose for a  short time.  A small portion
of brain escaped.  Dr. T. lifted the  depressed os frontis as well as
he was able, but only very partially.
  The lad recovered rapidly, and soon returned to school, where
his intellect  seemed as bright as before.  He could also cut and
split a cord of wood a day.
  About three months after the accident, and about eight days
after the discharge of pus had ceased altogether, he began to com-
plain of pain in his head, and in six days died comatose.
   The autopsy disclosed a fracture, with depression of the os frontis,
ossa nasi, nasal processes  of  the superior maxilla and ethmoid.
The processes of the superior maxilla were driven backwards and
laterally into the  orbits, and the  anterior half of the cribriform
lamella, with a portion of the os frontis, were driven quite up into
the brain.   The  septum  narium was broken across in several
 places, and  could  have been of no use in assisting to restore the
 ethmoid.  I allude to the suggestions occasionally made, that  in
 such cases we ought  to seize the septum with a pair of forceps,
 and attempt, in this way, to bring  down the septum and ethmoid
 together.
   Most of  the fragments were completely  united in their  new
 positions.
    CASE 21.  Compound fracture and displacement of ossa nasi. Union
 without deformity.
    H.  W., aged 13 years.   William fell while running, and struck
 upon the corner of a stone step, breaking the lower ends of both
 ossa nasi, and forcing them directly  backwards.  I saw him within
 an hour, and found the nose already much  swollen, and bleeding
 freely with a flesh wound on the right side reaching to the bones.
 The fracture was not  perceptible to  the eye, but a  crepitus was
 very manifest.
    I immediately lifted the bones with a straight  steel  director, and
 without difficulty.  Six months after  the  accident no deformity
 remained.
    Case 22.  Depression of ossa nasi,  and fracture, with depression of
 nasal process of superior maxilla on  the right side.   Union, with  de-
 formity, &c.
    Thomas  Kelly, aged 4 years, was kicked by a horse.  Dr. Pratt,
        2 
is
of Buffalo, was in attendance within two hours.   Nose and face
then much swollen.  It is probable that, owing to the swelling,
which the mother says was already considerable, the fracture was
not observed.   Dr. P. dressed a lacerated wound upon the upper
lip.
  One year  after the accident, I find bolh nasal bones depressed
through nearly their whole length, and  especially  in  their lower
halves.  The right nasal process is much depressed, and the  right
nostril obstructed.  The lachrymal canals upon this side are closed.
Ossa Nasi.
6 o	6 o					RESULT.	
I No. Age when it curred.		X	o u a b °s o	TREATMENT.			
					c ■o . -tf o a « P		O o <? 8
1 10 y'rs	1 y'r	M.	Simple	Lifted bones with a steel instru-ment	Unitec	Slight lateral displace-ment	Imp.
2 5"	36 y'rs	it	it	Treated by a sur-geon, but treat-ment unknown	it	Lateral displacement, na-sal obstruction, &c.	ii
3 11 "	1 w'k	a	u	Lifted bones with a steel instru-ment	a	Nearly or quite perfect	Per.
4 25 "	2 y'rs	n	n	Treatment un-known	a	Lateral displacement, ul-ceration, and catarrh	Imp.
5 8"	15 "	F.	a	Treatment un-known	it	Slight deformity	a
6 3w'ks	12 "	"	a	No treatment	n	Nose very flat	it
7 45 y'rs	7d'ys	M.	Compl'd	tt a	N. U.	Death on the seventh day	u
8 8" 9 18 "	10 y'rs 10 "	F. M.	Simple	a it	United a	Lateral displacement	n tt
10 11 "	13 "	"	"	it tl	n	Nose very flat	tt
11 9 " 12 19 "	18 " 9 "	<<	n tt	a n	"	Lateral displacement	ti a
13 15 "	15 "	it	"	Treated by a "handy man"	ti	Lateral and backward displacement	it
14 7 "	24 "	a	it	No treatment	tt	Nose almost flat	a
15 30 "	20 "		a	Treated by a " handy man"	ti	Lateral displacement	n
16 24 "	3 «	n	Comp.	Lifted bones with a steel instru-ment			Per.
17 3 "	14 "	"	u	By a surgeon; treatment unk'n	u	Bones displaced	Imp.
18 40 "	2 "		a	Lifted bones with a steel instru-ment	it	Nearly perfect	a
19 31 "	12 d'ys	a	Compl'd	Lifted bones		Died on twentieth day Bones remain depressed;	tt
20 14 "	3 m'os	tt	"		it		
						died in three months	
21 13 "	6 "	it	Comp.	Lifted bones with a steel instru-ment		No deformity	Per.
22 4 "	1 y'r	it	Compl'd	No treatment	a	Deformity, nasal obstruc-	Imp.
						tion, and fistula lachry-	
						malis	
 
19
                            REMARKS.

  " Hippocrate se plaint que les chirurgiens de son temps y vont avec une sorte de
timidite blamable, et les malades eux-memes, qui payeraient si cher pour eviter une
difformite, ne savent pas se preter a ce qui est necessaire.  Ces reflexions, pour etre
anciennes, n'en sont pas moins applicables a notre temps, et j'ai vu plusieurs frac-
tures du nez dont la reunion vicieuse temoignait a tous les yeux ou de la faute du
chirurgien ou de  l'impatience des malades."—Vidal (de Cassis).

   I have, at the very outset, deviated widely from the rule which
I had laid down for myself, not to report any cases except  those
which  had been  treated  by  regularly qualified  surgeons.  Of
the twenty-two cases of fracture of the ossa nasi, only thirteen were
seen by a surgeon in time to afford relief.   It seemed  to me neces-
sary that we  should be instructed how frequently the nature of this
accident was  overlooked by the friends, and even  by the surgeon
himself, to the end that we  might be thus admonished of the neces-
sity of always instituting in  such cases, careful and thorough exa-
minations.  In some of the cases reported,  where surgeons were
called  in time, and a deformity remains, it is not improbable that
the  accident was not recognized.   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 exa-
mination.  It ought, however, not to be forgotten that the omission
 on the part of the surgeon to do his duty will not always be excused,
 even  though the patient himself has protested against his inter-
ference, 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.
   No  one  will be led into a false  prognosis by a record of such
 cases so long as we are careful to point them out and separate them
 in our analysis, from those in which surgeons have been retained.  I
 shall think it necessary, also, to mention  several cases of fractures
 of the septum nasi, in which the character of the injury was not at
 first understood,  and no surgical aid was obtained; but in no other

   * « The diagnosis is often very difficult, even where  there exists considerable dis-
 placement on account of the swelling."—Malgaigne, op. cit., vol. i p. 366. 
20
bones shall I find such frequent occasions  to  record similar over-
sights.
   Of the thirteen cases to which a surgeon  was called at first, three
died within  a short  time, and no  attempt to restore the ossa nasi
was deemed necessary or  proper.  In two other cases it is probable
that  the nature of the injury was not recognized.  Of 'the eight
remaining cases, and in which attempts at  restoration were imme-
diately made by qualified surgeons, five are marked imperfect.
   When the ossa nasi are struck with considerable force, from be-
fore  and from  above, a transverse fracture  occurs usually  within
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 by
examinations of the  noses of those persons who have been the sub-
jects of this accident, both before and  after death, and 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 is so frequently advised by surgeons, may answer well enough
in a  few instances, but it  will much more often fail.  The diameter
of the meatus  at this  point, where the instrument must reach 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  at
this point is too firm and  unyielding to allow it to pass without the
employment of unwarrantable force.  In this  way it happens that
the operator is  occasionally surprised  to find how much resistance
is opposed to his efforts to lift the bones, and after repeated unsuc-
cessful attempts the case is not unfrequently given over.  If, how-
ever, 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 instrument with a
piece of cotton cloth as some have, I suspect, without much con-
sideration, recommended.
   What I have said  of the facility with which these  bones may be 
21
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.  It is remarkable how rapidly these bones unite.
In Case  3, the union was quite firm on the  seventh day, so  that
I was obliged to use great force to replace  the fragments;  indeed,
the fracture was reproduced.  Hippocrates thought the union was
generally complete  in six  days.   Boyer,  Malgaigne,  and others
have noticed the fact that these fractures were repaired with great
rapidity.   Nor has Malgaigne, whose observations are always very
accurate,  overlooked the fact,  also, that their repair is  effected
without the interposition of provisional callus, but as it were upa,r
premiere intention."  My own observation confirms this statement.
Among all the specimens which I have seen in the various college
and private collections illustrating fractures  of the ossa nasi, and
amounting in all to over forty, in no instance has there been de-
tected, after a careful examination, 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,  Case  16,  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, 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 nostril  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 adjustment 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.
   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
 superior maxillary bones may suffer slightly. 
22
  With neither of these accidents  is the cribriform plate of the
ethmoid likely to be broken or disturbed.  Indeed, in numerous ex-
periments made upon the recent subject, and in which the force of the
blow  was directed backwards and  upwards, breaking and commi-
nuting 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, unin-
jured.  The exceeding tenuity and flexibility of the septum nasi at
certain points, prevents effectually the concussion from being  com-
municated through it to the base of the brain.   If, therefore,  after
these  accidents, cerebral  symptoms are occasionally present, as
in Cases  16 and  18, they must  be due rather  to the  concus-
sive 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 inevitably  yield also.   Nor do
I think patients could often be expected to recover from  an  acci-
dent so severe.  To this class of fractures belongs Case 20, in which
not only the whole of the nasal bones were sent in—the nasal spine
being broken at its base—but also the os frontis was depressed, the
nasal processes of the upper maxillary bones broken and greatly dis-
placed, and the anterior half of the cribriform plate of the  ethmoid
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,  admitting  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 sufficient 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. 
23
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  dis-
placement, or a dislocation, than a fracture.  It  is more likely to
happen, I think, in childhood than in middle or  old age (Case  22),
and sometimes the lower ends only bend backwards or sideways.
If 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 condition, they are  very firmly locked in, and it  requires
considerable force, applied under their lower extremities, to restore
them to place. In Case 1, the bones were thus forced sideways,  and
without a  fracture.   In Cases  10 and  22, they are displaced back-
wards ; and probably, also, the same thing has happened in several
of the ancient cases, occurring  in infancy or childhood, and the  his-
tory of which is incomplete.
   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 superior maxilla, which deformity may become permanent,
as in Cases 6  and 14.
   The unusual morbid phenomena which followed in Case 4, such
as catarrh, ulceration, &c, ought to be regarded as accidents due to
the state of the general system, and as having no  connection with
the fracture, except as this injury served to awaken certain vicious
propensities.  Yet it is true  that Mr. Benjamin Bell and others have
spoken of "tedious ulcers," "polypi,"  impeded respiration, and im-
pairment of the sense of smell and of  speech, as  circumstances apt
to result from these injuries,  and  it is not improbable that such
consequences have often followed. 
24
                      CHAPTEB II.

                      SEPTUM NARIUM.

  CASE 1. Lateral displacement of cartilaginous portion.   No surgeon
employed.  Deformity remains.   Nasal catarrh.
  W. H. W., of Cherry Valley,  aged 15 years. Struck accidentally
by a brickbat.   The nose became immediately much swollen, and
no surgeon was called.  Eight years after the accident, the septum
remained displaced laterally and to the left  side, producing a slight
lateral displacement of the end of the nose.   He cannot blow freely
through the left  nostril, and he  has had a catarrhal  discharge from
the same nostril  from that time  to the present.

  Case 2. Cartilaginous portion broken down.  A surgeon employed.
Great deformity.
  Ledyard Littlefield, aged 19 years, was struck on the top of his
nose by a ball.   It became immediately much swollen.   A surgeon
was called, who said that no serious accident had occurred, but that
when the swelling should subside it would  be all right.
  The nose  is now, thirty-three  years after the accident, almost per-
fectly flat, the cartilaginous portion of the septum being pressed
entirely down and to one side.

  Case 3. Cartilaginous portion broken down.  A surgeon employed.
Marked deformity.
  John Baptiste, aged 26 years,  a Mexican by birth.  The nose was
broken by a blow.  Dr. Beecher, of New Haven, Connecticut, was
called.  Four years  after the accident, the septum remained dis-
placed, and the nose much flattened.

  Case 4. Fracture of the cartilaginous portion of the septum nasi.
Slight deformity remaining.
  James Murphy, aged 25 years. The accident occurred three years
ago, and the nose is slightly turned to one side by displacement of
the septum.   No surgeon was employed. 
25
  CASE 5. Fracture of septum nasi.  Deformity.  Curious effect upon
right side of face.
  A. A. C, aged 16 years, fell on his face upon the ice.  The nose
bled profusely.  Employed no surgeon.
  Seven years after the accident he called upon me, supposing that
he had a polypus nasi.   The septum is displaced to the right side,
so as to  almost completely close this nostril.   This obstruction has
existed from the  time of the  receipt of the  injury.  In very cold
weather, when the vessels of the membrane are  constringed, the
passage  is somewhat 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 perspirations.   It is almost constant in
summer, and frequent in winter.  The line of division between the
perspiring and non-perspiring portions  of the face  passes perpen-
dicularly 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.

  Case 6. Fracture of the cartilaginous portion of the septum nasi.
No surgeon.   Permanent  deformity.
  Shannon, of Buffalo, aged nine years, fell  on his face while run-
nine.  No  surgeon was  called.   The cartilaginous  portion  of the
septum is broken at its  junction with the perpendicular plate, and
from this point downwards it inclines to one side, carrying with  it
the whole of the lower portion of the nose.  Examined by myself
two years after the accident.

  Case 7. Fracture of the cartilaginous portion of the septum. Deform-
ity.   Successful operation  for its relief.
  H____C----, of Chicago, aged 18 years.   This young man fell,
while walking in his  sleep, from a two-story window, striking upon
his  face.   A surgeon was called, but he did not discover the nature
of the injury to his nose.
  One year  after the accident he called upon me for relief.  The
cartilaginous portion  of the septum was broken just at the ends  of
the nasal bones, and forced backwards about  three lines, producing
a striking 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 
26
was very unseemly, and annoying both to himself and to his friends,
who at first could  scarcely recognize  him.  From  a handsome
Grecian, his nose had been converted into an ugly " pug."
  Without promising much, I consented to operate.
  Operation.—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 septum  perpendicularly backwards  about  three
lines, and then making a gradual curve, with my knife, I cut down-
wards  about eight lines towards the  end of the  nose.  The inter-
cepted portion of cartilage  could now be easily lifted  with a
probe,  and the line  of the ridge of the  nose  completely  restored.
It was at once  apparent, also, that lifting the  cartilage would  de-
press the tip of the nose, and restore its symmetry.
  To retain  the cartilage in 'place, I constructed a gutta percha
splint,  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 carti-
lage, 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 cicatriza-
tion occurred, I pressed the sides of the splint firmly towards each
other, just below the incision, so as to  press as much as possible the
walls of the nares  into the fissure in the septum,  made  by lifting it
up.
  The result is a complete and perfect restoration of the nose to its
original form. 
27
Septum Narium.
6 If.	6 o d . * a So"	.9?	t/2	TREATMENT.	RESULT.		
					o •p . "S °		u .* o"g ** «£ <2 S - — $ a c* .a
1 2 3 4 5 6 1	15 y'rs 19 " 26 " 22 " 16 " 9 " 18 "	8 y'rs 30 " 4 " 3 " 7 " 2 " 1 "	M. a ti n u	Surgeon employed, but no treatment Surgeon employed, but no treatment Surgeon employed, but no treatment No surgeon employed, and no treatment No surgeon employed, and no treatment No surgeon employed, and no treatment Surgeon employed, but no treatment	United a tt tt a ti	Lateral displacement and ca-tarrh Backward and lateral dis-placement. Nose flattened Backward and lateral dis-placement. Nose flattened Lateral displacement, and nose turned to one side. Lateral displacement, and ob-struction of nostril. One-half of face subject to ab-normal sweats Lateral displacement of sep-tum and nose End of nose tilted upwards. Successful operation after one year	Imp. it a tt a
              .  .           REMARKS.

  Of the  "results of treatment" in cases of fractures or displace-
ments of the septum narium, we have no facts or conclusions to record.
In three of the seven cases no surgeon was employed, and in these,
also, no surgical treatment was adopted, and it is quite probable that
in only a small proportion  of  all the cases was the nature of the
accident recognized.  Such  at least  has been generally the state-
ment of the patients themselves.  The same causes will explain this
which have been invoked to explain 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
frequently displaced by violence, and then it is usually at the point
of its articulation with the bony  septum.  Next  in point of fre-
quency the perpendicular nasal plate is broken, and especially where
it approaches 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 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. 
28
  Where the deviation  is only lateral, the results are less serious,
yet sufficiently so in a few instances to demand our attention. Late-
ral  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 Case 1, a
permanent  catarrh  accompanied this obstruction, and in Case 5, a
curious sweating phenomenon, which is particularly detailed in the
report.  Neither  of these circumstances  ought, however,  to be re-
garded as probable results, but only as  rare instances of singular
morbid events.  Yet a catarrhal affection in the obstructed nostril
is  not very infrequent.   It  was observed not  only in Case  1 of
this chapter, but also  in Case 4 of the chapter  treating of broken
ossa nasi.   To what it may be due I shall not attempt to explain.
  A depression of the cartilage forming a portion of the ridge of
the nose is  necessarily accompanied with a corresponding  degree of
lateral displacement, with or without fracture of its perpendicular
portion, and produces, therefore, not only great deformity, some-
times a complete flattening of the end of the nose, but, also, in some
instances, complete obstruction of the nostrils.
  We conclude, from the limited experience which we are able to
present, that fractures and displacements of the septum narium are
generally followed by permanent deformity, and occasionally with
still more  serious results.  We suggest, therefore, a more careful
examination in recent injuries, with a view to  the ascertainment of
its  lesions,  and it would be well, certainly, if we could devise some
reliable mode of treatment.
   With  no actual experimental knowledge upon this subject, we
are left to the suggestions of others, and to our own speculations,
neither of  which are very satisfactory.  It is doubtful whether a
partition so thin and unsupported  can  ever  be well adjusted and
supported  by artificial means.  We possess, however, 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 
                              29

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
procedure  must  be varied according  to  the circumstances of the
case.   One instance of this kind I have related in Case 7, which
was highly satisfactory, and which may serve as an example of
what we may sometimes accomplish.*
                     CHAPTER III.

             OSSA  MAXILLARIA SUPERIORA.

  CASE 1. A compound fracture of the nasal process of the superior
maxilla, complicated with fracture of the ossa nasi.
  G-. C.  (See Case  18 of Fractures of the Ossa Nasi.)

  CASE 2. Fracture of both upper maxillary bones, with partial sepa-
ration at their articulations, and  depression  of the  right  malar bone.
Recovery with permanent depression of  the malar bone.
  Harvey, of Fond du Lac, aged twenty years.  Harvey was thrown
backwards from a loaded cart, one wheel of the  cart passing over
his  face.  He was taken  up unconscious.   I saw him next day.
Consciousness had then returned.
  The right malar bone was broken from  its  articulations, and
forced down  upon the antrum about three lines.  Both  superior
maxilla? were loosened from their articulations, and could be moved
laterally, the motion producing a slight  grating sound.  The  same
motion  and  grating occurred whenever he attempted  to  swallow.
No  effort was made to elevate the malar bones, nor did I find any
means necessary to  retain the maxillary bones in place, the amount
of displacement being very inconsiderable, and never sufficient to be
observed by  the eye.  Cool lotions  were  applied constantly to the

  *  See M. Dieffenbach's operation.—Gazette des Hopitaux, 22 Fev., 1842.  A Paris. 
30
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.

  CASE 3. Compound fracture of right inferior maxilla.  Removal
of floor of antrum.   Recovery with slight depression of malar bone.
   M. P., of  Colesville,  Wyoming County, aged  about thirty-
four years, was thrown from a height, striking upon his face, and
forcing the right malar bone down upon the antrum of the superior
maxilla.  Dr. L. Potter, of Yarysburg, and myself were called.
  The deformity produced by the sinking of the malar bone was
very striking, and the patient, as well as ourselves, was 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, how-
ever, brought down several teeth, and the whole floor of the antrum.
The detachment of this fragment was also now so complete that we
believed it necessary to remove it entirely, a labor which was ac-
complished 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 pterygoid 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 our knife that  we could distinctly feel its
pulsation.  After its removal, the hemorrhage was  for an hour or
more quite profuse, and could only be restrained by  sponge com-
presses 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,
permitted the finger to enter freely.  The restoration of the  malar
bone was now accomplished without much difficulty, and with only
moderate force.
  Two years  after the accident, the face  presented, externally, no
traces of the original  injury.   The malar bone seemed to  be as
prominent as  upon the opposite side, and  there was no perceptible
falling in where the teeth and alveoli were removed. During several 
31
months after the removal of the bone, the antrum continued to dis-
charge 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.

   Case 4. Fracture of both upper maxillary bones, complicated with
fractures of  the nasal bones, and of the  lower maxilla.  Death on the
twelfth day.
   (See Case 19 of Fractures of the Ossa Nasi.)

   Case 5. Fracture of left  nasal process, compound  and complicated
with fracture of the os frontis, nasal bones, &c.   Death in three months.
   (See Case 20 of Fractures of the Ossa Nasi.)
   The nasal process upon the left side was  broken just above the
root of the  cuspid tooth, and its  upper end was inclined inwards
towards the nasal passage and  backwards, until it was completely
buried.  In this situation it had become firmly united to the bony
and soft tissues into which it was brought in contact.

   Case 6. Fracture of the right  nasal process, complicated with frac-
ture of the ossa nasi et cart.  Deformity remains.
   (See Case 22 of Fractures of the Ossa Nasi.)
Ossa Maxillaria Superiora.
6	o a . A g & a » g	O © .So is	7-	O f. g o	TREATMENT.	RESULT.			
						o a 0 P	73		o o OJ u *a S. J? s
1 2 3 4 5 6	40 y's 20 " 34 " 31 " 14 " 4 "	2 y's 4w's 2 y's 12 d's 3m's 1 y'r	M. a n tt	Comp. compl'd Comp. compl'd Comp. compl'd Comp. compl'd Comp. compl'd Comp. compl'd	Lifted with a steel in-strument Cool lotions and rest Elevation of malarbone through an opening made at the base of the antrum No treatment; but rest, <fcc. No treatment; but rest No treatment; but rest, &c.	United a u n it it	9 d's	Nearly perfect Slight depression of the malar bone No deformity Death on twelfth day Death in three months United with de-pression	Imp. a Per. Imp. n n
 
32
                           remarks.
                   " Fort rares et a peine e'tudie'es."
  These fractures assume so great a variety  in respect of form,
situation, and complications, that no general prognosis can be es-
tablished.
  When the harmonies of the  upper maxillary bones are only
slightly disturbed, as in Case 2, nothing but a contentive treatment is
necessary.  If the alveoli are extensively detached, they may be se-
cured by dentists' gold or  silver  thread, but it is not always that a
reunion of the fragments will occur. Ledran reports a successful case
of this  kind.   See Observations  Chirurgicales, torn. i. obs. 3.  And
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 de-
clared for these fractures a special exemption."  (Op. cit., vol. i. p.
376.  Paris ed.)
  Fractures and depressions of the nasal processes have been men-
tioned in connection  with fractures of the ossa nasi.  Such fractures
occurred in Cases 1, 4, 5, and 6.   It  is seldom,  unless they happen
to be so exposed that they may be seized upon with forceps, that
anything can be done for their relief.
  I wish to suggest an expedient for lifting the malar bone when it
has been thrust down upon the antrum of the  upper maxillary,
which may in certain cases be substituted 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 by the accident itself, will give an  opportunity for the per-
foration of the antrum through the open socket, and  for the intro-
duction of a suitable instrument for lifting the depressed bone.
Unless,  however, the opening is quite large, the instrument employ-
ed 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 
                              33

inflict serious injury upon the eye itself.  Yet, with some care, such
accidents may be avoided, and it is probable that, in the cases sup-
posed, where the sockets of the teeth opposite the base of the an-
trum 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 ante-
rior wall above the roots of the teeth, or we must  proceed to ex-
tract a  tooth.   The first  method gives an inconvenient opening,
and one through which it will be necessary to use a curved  instru-
ment ; 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 procedure were suggested  by our tedious
and painful operation  in  Case 3.  The first attempt to extract  a
tooth brought down the whole  floor of the antrum, with all its
corresponding teeth and the pterygoid process.   The tooth was
already loose, and we thought it might be easily 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 alveoli.  Nor do
we now very well see how this condition should not always  coexist
with a  depression of the malar bone, and why, therefore, an attempt
to  extract a tooth should not always, after these accidents, expose
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 deform-
 ity which it  is likely to produce,  and of the  severity and even
 danger of the operation.  Be assured that neither  myself nor my
 excellent counsel and  co-operator,  Dr.  Potter, will  ever again
 attempt a similar feat.
    I wish then to suggest a procedure, 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.  It is  only that we  should employ for the purpose
 of lifting the malar bone, a screw levator, an instrument which I
 find already constructed, in a case of trephining instruments made
 for me by Mr. Luer, of  Paris, and  which  I have  often used  and
 constantly recommended to my pupils, in certain caftes of fractures
        3 
34
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.  In case the surgeon is  not  provided with this excellent in-
strument, a joiner's gimlet might answer tolerably well.
                      CHAPTER  IV.

                     MAXILLA INFERIOR.

   Case 1. Comminuted fracture.   Union without deformity.
   Andrew Vandwie, aged twenty-four  years.  Fracture produced
 by a blow from a club.  On the right side the jaw  was broken
 just in front of the angle,  and  one molar tooth  partially dis-
 located.   On  the left it was  broken  near the anterior mental
 foramen,  and the  corresponding  tooth was  partially dislocated.
 Both fractures were oblique.
   I was called three  days after the accident.   The face was then
 much swollen.   Assisted by Dr. John Trowbridge, I applied a felt
 splint, which was moulded to the form of the chin and face.  I had
 previously extracted the loosened  tooth, situated in the line of the
 most anterior fracture, chiefly with a view of closing the jaws com-
 pletely, and  of  permitting him to imbibe  his food through the
 opening thus made.  I also replaced the loosened molar.  No inter-
 dental splints were employed.   On the sixth day we found that the
 sides of the felt  splint being  flexible, allowed, when the retentive
 bandages were applied, too much lateral pressure.  The posterior
 fragments were,  in consequence, made to fall inwards.   We there-
 fore substituted a  well-moulded  and well-padded  copper splint
 constructed with broad and slightly expanded wings.   This appa-
 ratus was continued to the close of the treatment.
  On the thirty-sixth day after the  accident, the dressings  were
 finally removed, and union was complete.   The form  of the jaw
 and the line of the teeth were perfect.  No provisional callus could
be felt.  During a part of the time the patient had applied fomen- 
35
tations of hops and vinegar, and without my knowledge.  In con-
sequence of this the acetate of copper had produced several slight
ulcerations upon the skin, which soon healed when the splint was
taken off.
  About  a week  later I  found the molar tooth,  which I  had
replaced, loose and troublesome. I therefore removed it altogether.
The cure was complete.

  Case 2.  Comminuted fracture.  Union delayed.   Result perfect.
  N----B----, aged fifteen years, was struck violently with the
heel of a man's boot, while lying upon the floor and upon his back.
Fracture near the anterior mental foramen upon both sides, oblique.
Suitable dressings were applied by a surgeon in Oswego, but con-
siderable difficulty was experienced in retaining  the fragments in
place.
  About two months after the accident he consulted  me, the bones
not  having  yet  completely united.    The  dressings  had  been
removed.  I advised  nothing but  careful use of the jaw, and in a
short time the union was complete and perfect.

  Case 3. Compound comminuted fracture.  Union without deformity.
  Jenks, a canal boatman, aged about twenty-five years, was struck
by a stone thrown with great violence, breaking the inferior max-
illa,  on the left side, near the anterior mental foramen.  A portion
of the alveolar margin was also broken off, containing  the  sockets
of three teeth.
  Dr. Maxwell, of Lockport, dressed the fracture.  Five days after
the accident, the patient called  on me, having continued upon his
boat until he reached Buffalo.  The face was then much swollen,
the  anterior fragment slightly displaced, and the portion of  the
alveoli, which  had been  secured  in place by wires  ingeniously
belted  upon the teeth, was  quite loose.  I removed  the teeth and
alveoli, placed cork  splints  between the  molars,  and applied a
moulded pasteboard  splint to the chin,  securing it in place with a
four-tailed bandage.
  I found that, with this apparatus, it was  impossible  to prevent
the anterior fragment from  being slightly displaced  backwards;
nor could I draw the bandage so tight that, in the  act of deglutition,
a motion and grating were not  perceptible between the fragments.
  The union was completed in a  few weeks.  I think in about
three, without any perceptible deformity. 
36
  Case 4. Simple fracture.   Union without deformity.
  ---- of Colesville, aged  about forty years.  Dr. Parker,  of
Wyoming  County, was in attendance.   On the  third  day, Dr.
Parker requested  me to see the case with  him, as  he had  some
difficulty in retaining the fragments in place.
  We found that, during the absence of Dr. Parker, he had carved
from a block of wood, a splint which fitted accurately the chin and
face, and served the purpose admirably for which it was intended.
The fragments were well in place, and without  interdental splints
he was able to receive nourishment between his  teeth.  The diess-
ings were permitted to remain.  Four years after, I learn  that the
jaw is perfect.

  Case 5.  Compound comminuted fracture.  Union without deformity.
  C---- B----, of Little Falls, aged  fifty-five years.  Fracture
through the shaft caused by  the kick of a horse.   A small frag-
ment of the alveoli  with  one  molar tooth was broken off, and
removed by the surgeon at the first dressing.
  Dr. Green, of Little Falls, dressed the  fracture with a four-tailed
bandage, pasteboard, &c, without interdental splints.
  Seventeen days after the accident, I re-dressed the fracture at my
college clinic.   I found the  fragments  nicely  in apposition, and
not movable.
  I applied an apparatus made entirely of leather, and of my own
construction.   The result I do not know  positively, but as it was in
place  and  united on the seventeenth day, I think I may assume
that it is perfect.

  Case 6. Compound comminuted fracture.   Slight permanent  de-
formity.
  John Keef, an  Irish  laborer, aged seventeen years.   John was
thrown from a wagon  breaking  his leg at the same time.  The
inferior maxilla was broken on both sides  through the shaft, and,
also, exactly in the centre, vertically, between the central incisors.
   I dressed  the jaw with a four-tailed  bandage, but found great
difficulty in bringing up the left fragment to a line with the right,
and therefore closed the jaws, and, finding that the left side fell
three  lines below the right, I placed a  pine-wood  wedge between
the teeth on the right  side, and drew the jaw up firmly.  It now
lacked only about half  a line  of being in place.
   I had  not thereafter much difficulty in maintaining quiet and 
37
apposition of the fragments, and I supposed, from repeated exami-
nations, 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 per-
ceptible, and the displacement seemed to be rather less  From this
time the dressings were discontinued.

   Case 7. Compound comminuted fracture.  Union without deformity.
   Augustus Cotesworth, aged eleven years, was  kicked  by a horse,
producing a fracture  on the left side of the jaw, between the first
and second incisors, with an external wound communicating with
the fracture.  There was also a fragment of nearly two inches  in
length broken off from its lower margin. Four teeth were knocked
entirely out from the upper jaw, and the face was badly cut and
bruised.  All  the  teeth  in  the lower jaw remained  firm.  The
fracture was oblique.   I removed immediately the  loose fragments
of bone.   Between  the  teeth  I placed  splints of  gutta  percha,
covered with cotton cloth.  A firm and well padded splint of gutta
percha was also applied to  the  under side of the chin,  with broad
wings, penetrated with fenestra, through which  bands were passed,
to be subsequently fastened  over the top of the  head.  Care was
taken that the sides of the splint should not press too snugly against
 the sides of the face and  jaw.  Corresponding to the  wound in the
 face, an opening was made in the splint, through which the wound
 could be dressed, and the matter be permitted to escape.
   Very little difficulty was  experienced  in  the treatment of this
 case.  The result  is  a cure  without any deformity except  what
 results from the  scar on the face.

   Case 8.  Compound comminuted fracture,  with fracture of the supe-
 rior maxilla, ossa nasi, &c.  Death on the twelfth day.
   John Gallaghan, an Irish laborer, aged thirty-one years, admitted
 to the hospital,  October 3, 1851, with a fracture of  the  inferior
 maxilla, on the right side, near  the centre of the  shaft.  Fracture
 compound,  oblique,  and comminuted.   The ossa nasi, and ossa
 maxillaria  superiora  were also broken   and displaced.   Patient
 partially conscious.
   I made  only  slight attempts to adjust the  fragments, as death 
"8
seemed inevitable.  He died comatose,  on the twelfth day.  (See
Case 19 of Fracture of the Ossa Nasi.)

   Case 9.  Simple fracture.  Result not perfect.
   R----B----, aged thirty-nine years.  Fractured obliquely across
the right  angle of the  jaw.   Dr. Billings, of Hamilton,  C.  W.,
dressed the fracture, and, as far as I can judge, skilfully, with a
four-tailed  bandage.  The bandage was continued three weeks.  On
the sixth  week, Dr. B. extracted the last molar upon that side,
finding that it interfered with the closure of his jaws.
   Seven weeks after the  accident, the patient called  upon  me.
The fragments were united, but there was a large amount of callus
upon the outside, and the posterior fragment was lifted up, so that
the teeth were not on a line.  The jaw does not close perfectly.

   Case 10. Comminuted fracture.  Union delayed.
   Andrew  Mahoney, aged twenty-six years, had his jaw broken by
a blow with a club.  On the right side, the fracture is between the
two last molars.  On the left side, it is broken just in front of the
first molar.   One of the molars was knocked completely out.  He
called on me seventeen days after the accident, and at this time no
dressings had been applied.
   The right side of the face continued much swollen.  The frag-
ments were loose and much displaced.  On  the left side, the anterior
extremity of the posterior fragment fell inwards towards the mouth,
and the whole anterior or central fragment  was depressed and
drawn backwards.
   Assisted  by Dr. Boardman, I applied a gutta percha splint to the
outside of the jaw and face, and moulded splints of the same mate-
rial between the teeth.   The whole was  secured by bandages very
carefully and accurately.  About ten  days after this dressing was
applied, he disappeared, and  I  have  not seen him since.  In the
mean  time, however, the  fragments  were  kept  tolerably well  in
place, but as the bones had not  united at the end of four weeks, I
suspect it has resulted in deformity.

   Case 11. Simple oblique fracture.  Result perfect.
   I. W. S., of Darien City,  aged twenty-six years,  was struck
by a club in the hands of some unknown person, while walking at
night in one of the streets of Buffalo.   He was for a moment bewil-
dered, but  never completely  unconscious.   The next  mornino- he 
39
 called upon me.   The inferior maxilla was broken obliquely, on
 the right side, just anterior to the last molar.  The anterior frag-
 ment was displaced downwards and backwards.
   Assisted by Drs. Nicholls  and  Pupikofer,  I  applied  a gutta
 percha splint to the outside of the chin and face, and between the
 teeth I placed gutta percha wedges, moulded to the teeth and gums.
 The fragments now seemed to be in place, and well  supported.  S.
 returned home the same day, and  soon after placed himself under
 the care of Dr. Ganson, of Batavia, who removed the gutta percha
 and substituted other dressings.  Four months after the accident, I
 found the fragments perfectly in place, and no remaining deformity.

   Case 12. Simple fracture.   Result perfect.
   Joseph McEllicott, aged twenty-two years.  Fracture near the
 angle of  the inferior maxilla, on the right side.
   It was  treated by Dr. Johnson,  of Cattaraugus.   Bony  union
 occurred in three weeks from the time of the fracture, and without
 deformity.  This case was examined by myself soon  after the cure
 was completed.

   Case 13. Fracture and union without deformity.
   Albin  Vanderheyden, aged thirty-seven  years.   The fracture
 occurred  through  the angle, on the right  side.  I  examined  the
 bone twenty-five years after the accident, and no deformity or im-
 perfection could be discovered.

   Case 14. Compound comminuted fracture, through  the symphysis.
 Union with slight deformity.
   Norman Mason, aged twenty-five years.   Broken by the kick of
 a  horse.   Left lateral  incisor completely displaced, and a  large
 piece of the alveoli 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 mentis.
 The  left half of the chin was  slightly elevated, and  the whole of
 that side of the shaft was smaller than  the right.  He cannot close
his teeth perfectly, yet he can  close them  sufficiently for the pur- 
40
poses of mastication.   There is no perceptible  external deformity.
It must have been the loosened fragments of the alveoli secured by
the wire, which subsequently came out through an opening below
the ramus.

   Case 15. Comminuted fracture.   Union without deformity.
   Frederick Win. Stephen, aged four years. His face was traversed
by the wheel of a loaded cart, breaking the inferior maxilla through
its shaft, on both  sides.   Assisted by  Dr. Jno. Boardman,  I  pro-
ceeded at once to adjust and dress the  broken  fragments.  To the
chin and face  we  applied gutta percha splints, moulded carefully
and accurately to  the surfaces upon which it  was laid.  A\re em-
ployed, also,  the same material as an  interdental splint, having
previously covered it  with cotton cloth.   It was observed that the
posterior fragment was much higher  on  the right side than on the
left, and it was found, also, exceedingly difficult, after the fragments
were replaced, to prevent the left side from falling.   We therefore
placed the gutta percha only between the molars of the  right side,
leaving the left without any similar support, and now, by the pres-
sure of the bandage, the left side was lifted and  retained.
   During several  days, the swelling about the neck and  face was
very  great, and the  apparatus had  to be frequently readjusted.
The interdental splint, also, became displaced several times.
   Bony union was much delayed, not having been complete until
about the forty-second day.  The dressings had been removed more
than two weeks before this.
   No perceptible  deformity remained  after the union was com-
pleted.

   Case 16. Simple fracture.   No treatment under fourteen  days.
Result unknown.
   Frederick Wm.  Mande, aged forty three  years.  Fractured by a
blow from a  man's fist.   The fracture was simple, and upon the
right side, between the first and second bicuspid.
   Frederick did not suppose his jaw was broken until  two weeks
after the injury was received, at which time he called upon me.  A
large swelling  existed then, on the outside of the jaw,  and the
fragments were out of place and movable.   The posterior fragment
was elevated considerably above the level of the anterior fragment.
   I applied a four-tailed bandage, and was  able  to bring the ante-
rior fragment nearly in line.  No  splints were placed  between the 
41
teeth.  I have never seen him since.  I have, however, thought the
case worthy of record, as illustrating how the patient himself may
fail to discover, for many days, a fracture of his  own jaw.  The
same thing occurred in Cases 10 and 18.

   Case 17. Comminuted fracture.   Union with deformity.
   John McNally, aged twenty-three years, a sailor, was struck on
the right side of his face by a block, breaking the  inferior maxilla
upon the same side in two places.  One fracture was through the
ascending ramus, and just above the angle; the other was obliquely
downwards and forwards through the shaft of the bone, and near
the symphysis.  No  teeth were displaced.  The intercepted frag-
ment was forced inwards and downwards.
   On the second day after the accident, Dr. Charles Wilcox, one of
the Buffalo marine surgeons, took charge of the patient, and on the
fourth day Dr. Wilcox invited  me  to present the  case before my
pupils.  It was then dressed with a well-made gutta percha splint,
secured with appropriate bandages to the chin and face.  The teeth
were all perfect, and the jaws were closed upon  each other without
 any interdental splint, as it was found that he  could still  draw
 nourishment between his teeth.  The fragments were in place.
   The bone  united  in about  three weeks, but he left the hospital
 and  removed the  dressings without authority, at the  end  of the
 second week.  The intercepted fragment is displaced  downwards
 and inwards, in the  same direction in which it was when he first
 applied for treatment.

    Case 18. Simple fracture.  Delayed union.
    Daniel Moriarty, of Chicago, aged twenty-five years.  Daniel was
 kicked by a fellow-countryman, on the left side of his  face, break-
 ing the lower jaw on that side  just at the angle.   The fracture was
 oblique.  No teeth were displaced.  The face immediately became
 much  swollen, and  he did  not suspect the existence of a fracture.
 Two months after the accident he called upon me  for advice.  The
 left side of  his  face still  remained  much swollen,  and motion
 between the fragments was  very perceptible, especially in opening
 and shutting his jaw.   The anterior  fragment was carried to the
 left about one-quarter of an inch.
    The failure to  unite was probably  due  to the condition of his
 system, rather than to the neglect of surgical treatment.  He was
 pale and feeble, having had intermittent fever more or less for nine 
42
months.  It is  possible, however, that a small fragment  remains
loose at the point of fracture, and that this has, in some measure,
caused the delay and swelling.
  At my instance, he soon  after placed himself under  the care of
Dr. Rano, of Pembroke, N. Y.  Dr. R. extracted the last molar,
and evacuated considerable pus.  He has also taken measures at
once to improve his  general health.   At the end of seventy days
from the time  of fracture, Dr. Rano  informs me that  it  has  not
united.
                        Maxilla Inferior.
	5	6 o		o o &	o	6 1		RESULT.			
											
II		■s i		4.1 £. £	> ~	0	TREATMENT.	O	8*8		-I
dl u^		I 3	«! e S.'s \		53 £ 0	.S = '0 -^		-" 0 2 0	*%		t §'
«s	<	H	''■	Commin.	E-1	a.		t->			Per.
1	24 y'r»	3 y'rs	M.		Oblique	Angle	Copper splints to out-	United	5 w'ks	No deformity	
						and	side. No interdental				
						shaft	splints				
2 15 "		6 "	"	"	"	Shaft	Unknown	u	3mo's	No deformity	'"
a 25 "		4 w'ks		Comp. commiu.			Pasteboard splint to outside, and inter-dental splints ol cork	a	3wk's	No deformity	
4 40 " 1		4 y'rs	n	Simple	«	16	Carved wooden splint. No interdental splints	it		No deformity	it
5 55 "		17 d'ys	"	Comp.	u	11	Pasteboard splint,	it	17 d'ys	No deformity	16
				commin.			and subsequently a leather apparatus. No interdental splints				
017		1 y'r	"	Comp.	Oblique	Shaft	Four-tailed bandage,	a	6 w'ks	Slight defor-	Imp.
				commin.	and trans.	and symph.	and interdental splints of pine wood			mity	
	11 "	4 y'rs		Comp. commin.	Oblique and trans.	Shaft	Gutta percha splint on the outside, and the same as in inter-dental splint	tt		No deformity	Per.
8		12 d'ys		Comp. commin. comp I'd.	Oblique	tt	No treatment	Non-united		Died on the 12th day	Imp.
9	39 "	7 w'ks		Simple		Angle	Four-tailed bandage	United		Excess of cal-lus and slight deformity. Probably de-	tt
10	26 "	4 "	«	Commin.	"	Angle	No treatment for 17	Delay-			(<
						and	days. After this a	ed		formed	
						shaft	gutta percha splint outside, and the same between the teeth				
11 26 "		Imo's	u	Simple		Shaft	For a few days with guttapercha splints within and without	United		No deformity	Per.
12,22 "		3 w'ks	"	C(		Angle	Treatment unknown	"	3 w'ks	No deformity	«
l:: 11 -2 "		25 y'rs	"			" | Treatment unknown		"		No deformity	«
u	25 "	10 "	"	Comp.	Trans.	Symph. Pasteboard splint on		"	7 w'ks	Slight defor-	Imp.
				commin.			outside. No inter-dental splints			mity	
15	4 "			Commin.	Oblique	Shaft	Gutta percha splints within and without	tt	6 w'ks	No deformity	Per.
16	13 "			Simple	it		No surgeon, and no treatment under 14 days				
17	23 "		"	Commin.	it	Shaft	Gutta percha splint	tt	3 w'ks	Slight defor-	Imp.
						and	on outside. No inter-			mity	
						symph.	dental splint				
IS-	25 "	2mo'8 i	" j Simple			Angle j No treatment under 70 days		Non-united	70 d'ys	Lateral dis-placement, ulcers, &c.	
 
43
                           REMARKS.
   "La reduction assez facile a opdrer est souvent difficile a maintenir."— Vidal
                            [de Cassis).
  It is  difficult, sometimes, and  especially  where the fracture is
near the angle, to say whether  it is oblique or transverse, but  I
have been unable to recognize a  transverse fracture, except where,
as in Cases 6, 14, and 17, the fracture was at the symphysis mentis.
Of eighteen fractures, only three are recorded  as quite or nearly
transverse.
   Fractures through the symphysis are rare, but it is quite common
to find a fracture  immediately in  front  of the angle, and at any
point of the shaft between the anterior  attachment of the masseter
and the symphysis.  I have  seen no fracture of the coronoid pro-
cess, and but one of a condyle.
   In seven cases  the bone  was broken at two points, in one of
which the two fractures were upon the same side.  In one case the
bone was broken  at three points.   Considerable fragments of the
alveoli were  detached in  Cases 3, 5, and 14, and a  fragment  from
the lower margin of the jaw in Case 7, but in neither instance was
the effort to save the fragment successful.
   It ought to be observed, also, that when the fracture has occurred
at or near  the angle, as in  Cases 1, 9, and 18, and the second or
third molars were disturbed, it has always become  necessary  even-
tually to remove them, and chiefly because they  have interfered
with the closure of the mouth.
   In no instance has the bone finally refused to unite, although  in
a few instances it has been delayed,  six, seven, ten, and even twelve
or more weeks (Cases 15, 14,  2, and  18).   I  regard thiS> fact  as
worthy of more especial attention, because of the extreme difficulty,
if not actual impossibility, of preventing motion between the frag-
ments, by any mode of dressing yet adopted.   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  neces-
 sary acts of  deglutition, or  to speak, even, without inflicting some
 motion upon the fragments.
   Indeed, the rapidity with which this  bone unites has, I  think, 
44
been observed by other surgeons, and  I have myself noticed one
instance, in an adult person, Case 5, in  which the bone was immov-
able at the seat of fracture on the seventeenth day,  and, perhaps,
earlier.  In other  instances, the union has been speedily effected
after the removal of all dressings.
  It would be very unsafe from these few cases to deduce any con-
clusions as to the effect of slight motion in retarding the union of
broken bones.   Yet I shall  take the liberty of referring to some
remarks upon this subject, published  by myself, in the Buffalo
Medical Journal, vol. x. p. 142, in connection with an  article entitled
" New Mode of Treating Ununited Fractures of the Humerus."
  The amount of deformity resulting, also, from these fractures is
usually very trifling, whatever treatment has been adopted.  Seven
are marked imperfect, but one of these cases was  complicated with
other injuries of which the patient died in a few days, and one was
a case of delayed union, at the time  of writing this report.  Only
five of the united  fractures are  imperfect, and in none of these is
the imperfection such as  to be noticed  in  a casual examination of
the face.  The deformity which is usually found, is a slight irregu-
larity  of the teeth, produced, in most cases, by a falling of the
anterior  fragment, and  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.
  Where the prognosis is so  favorable we shall,  perhaps, feel less
necessity for suggesting any modifications or improvements in rela-
tion to the surgical treatment.  We  cannot refrain, however, from
making a few practical hints.
  It  will be seen  that the  few cases in which attempts have been
made to restore a dislocated tooth to its socket, or to retain it when
much  loosened, have  generally proved  abortive, and  especially
where the fracture is near the angle,  and a molar has been  disturb-
ed.   I believe  it would  be better practice always to remove this
latter when it is much disturbed, and in cases where teeth farther
forward are loosened, we might be  somewhat less  perseverinc in
our efforts  to retain them.
  The same  remark applies,  also, to  fragments  of alveoli,  which
have been detached completely, and are held only by the soft tissues 
45
about them.   Complete exfoliation has sooner or later occurred, or
the surgeon  himself has  found it  at length  necessary to  remove
them.  (See Remarks on Fractures of the Upper Jaw.)
  As to  the  employment of interdental  splints, every one knows
how inconvenient they are, both to the patient and to the surgeon,
and I need not say that they ought  to be dispensed with whenever
it is possible to do so.
  They are soon covered with an offensive sordes, and, as  usually
made, they irritate the  mouth with their rough surfaces, and  are
constantly liable to displacement.   Yet instances must occur in
which these wedges are indispensable, and I wish to call your atten-
tion to  the advantage  which gutta percha  possesses over every
other material, in its adaptation to this purpose.  I have already
employed it in four instances, and I find  no practical objections to
its use.
   The mode of preparing gutta percha,  and of adapting it between
the  teeth is as follows: Dip a couple of pieces of the  gum, of  a
proper  size, into boiling water, and when  they are  sufficiently
softened, mould them into wedge-shaped  blocks, and, having wrap-
ped each block  with  a piece of cotton  cloth, carry them to their
appropriate places between the back teeth.   Immediately press up
each horizontal ramus  of the jaw  until  the mouth is  sufficiently
closed, and the line of the inferior margin is straight.  In this posi-
tion retain the fragments a few minutes, until the gum has suffi-
ciently  hardened.  Meantime,  it will  be practicable, generally, to
introduce the fingers into the mouth, and to press the gutta percha
laterally on each side towards the teeth,  and thus to make its posi-
tion more secure.   When it is sufficiently  hardened, remove the
splints for the purpose of determining more precisely that they are
properly shaped and fitted.
   The superiority  of this splint  is  now  at once  perceived.  If
properly made, it is smooth upon its surface, and  not, therefore, so
liable to irritate the mouth as wood or cork,  and it  is so moulded
to the teeth  that it will  never become  displaced.  My friend, Dr.
Ganson, of Batavia, believes that the  gutta  percha will itself irri-
tate the  mucous membrane, and he, therefore, removed the splints
which I had inserted in Case 11.   I think he is  probably correct,
although I have never observed this effect myself.  But in Case 11
the gutta percha was not covered with cloth, a precaution which I
have since always adopted, and which I  desire to recommend.
   I have found the same material,  also,  particularly convenient as 
46
an outside splint, since it is so easily moulded to the face, and  its
form may be readily changed from  time to  time as the swelling
increases  or subsides.   In compound fractures, also, where the
wound  is external, an opening can  be made through the  splint
suitable  for the dressing of the wound, and the discharge of pus.
The piece from which this splint is made should be two or three
lines in thickness, covered with cloth, and padded under the chin.
It will be found convenient to cover it with cloth before immersing
it in the hot water. The water should be nearly at a boiling tempera-
ture, so that the splint may become perfectly pliant;  and it should
be laid upon the face and allowed to mould itself while  the patient
lies upon his back.
  Having long experienced  the insufficiency  of the ordinary  dress-
ings to resist the tendency in the anterior fragment  to  fall  down-
wards and backwards, when oblique fractures exist upon both sides,
I devised some years since a leather dressing, which  may be found
useful hereafter in some cases.
  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, called,  respectively,  occipital  and frontal,  made of strong
linen webbing.   One  of these, the  occipital, is  attached to the
posterior margin of the maxillary strap about  half an inch above the
ear, and being carried around  behind and under  the  occiput, it  is
finally buckled to the maxillary strap upon the  opposite side, and
at a point exactly corresponding to its  origin.   The frontal stay
simply antagonizes the occipital; and having its origin and  termi-
nation at the anterior margins of the maxillary strap, it is buckled
horizontally across the forehead, and just above the eyebrows.
  The maxillary strap is narrow under the chin to avoid pressure
upon the front of the neck, but immediately becomes wider  so  as
to cover the sides of the inferior maxilla and face, after which it
gradually diminishes to accommodate the buckle upon  the  top of
the head.  The anterior  margin of this  band, at the point corre-
sponding to the symphysis mentis, and for about two inches on each
side, is supplied with thread holes, for the purpose of attaching a
piece of linen which, when the apparatus is in place, shall  cross  in
front of the  chin, and prevent  the  maxillary strap  from  sliding
backwards against the front  of the neck.   (Fig. 1.) 
                              47

  The advantage of this dressing over any which I have yet seen,
consists in its capability to lift the anterior fragment almost verti-
The Author's Apparatus.
cally, and at the same time it is  in  no danger of falling forwards
and downwards upon the forehead.  If, as in the case of most other
dressings, the occipital stay had its attachment opposite to the chin,
its effect would be to draw the  central fragment  backwards.  By
using a firm piece of leather as a  maxillary band, and attaching the
occipital stay above the ears, this difficulty is completely avoided.

   Note.—At  my request,  Dr. Mutter, of Philadelphia, has fur-
nished me with the following engraving of an  instrument  recom-
mended and occasionally used by him in  the  treatment of  such
fractures of the inferior maxilla as are not  easily retained in place
by the usual apparatus.  The instrument is a silver clamp, and it
is intended to be placed over the teeth and alveoli in such a way as
to traverse the seat of fracture.   It is more simple  than the appa-
ratus of Lonsdale, while the principle upon which it acts is nearly
the same.  (Fig. 2.)
                             Fig. 2.
Matter's Clamp for Fractured Jaw. 
48
                      CHAPTER V.

                         CLAVICLE.

                 SEC. I.—INCOMPLETE FRACTURES.

  Case 1. Partial fracture through the middle third.   Result perfect.
  M. K., aged four years, fell down a flight of stone steps.   Dr. G.
Burwell  and myself being  called,  found the  right clavicle  bent
forwards at the outer end of the middle third.
  We immediately applied Fox's apparatus.
  Twenty-six days after the accident we examined the clavicle, and
ascertained that the cure was completed, and without any deformity.
During most of this time, however, the dressings were quite loose.
  Eight years later I examined the arm, and there remained no-
thing to indicate the place where it had been broken.

  Case 2. Fracture through the inner third.  Result imperfect.
  Miss McN., aged nineteen years, broke her left  collar-bone, by
coming  in contact with a bridge while riding  on the  Erie Canal.
The fracture  occurred at the outer end of the inner third.  I saw
her the day following.   The fragments were not completely sepa-
rated from each other, but bent forwards at the point of injury.
  By pressure, I attempted to restore  the ends to place, but with
only partial success.   I dressed the arm with Fox's apparatus.
  Ten years afterwards, I find the bone still bent forwards at the
point of fracture.  The arm is  often  painful, and the clavicle is
tender where the bend occurred.  In other respects it is as sound
as it was before.

  Case 3. Fracture through the middle.   Result not perfect.
  A. B., aged three years, fell from the sofa on to 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 of
the clavicle.
  She was brought to me three  days after the  second fall.  There 
49
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 think, however, there existed a
partial fracture, or that the  bone having been bent, had at once
resumed its original  place spontaneously, and that the projection
consisted of provisional callus.
   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.

   Case 4.  Fracture through the middle.  Result perfect.
   H. S., aged six years, was  thrown from a horse, bending his  left
clavicle near its middle.  Surgeon, Alden S. Sprague, of Buffalo.
The projection in front was for several days very apparent, and was
examined by myself  at  Dr. Sprague's request.  The  bone did not
seem to be out of line.  Dr. Sprague used no dressing.  Five years
after the accident, at the date of this report, I have examined the
lad, and cannot find any trace of the original injury.

   Case 5. Fracture through the middle third.   Result perfect.
   Robert  M. Frazer, aged  twelve years, was run  against by  a
wagon, breaking or bending  both clavicles  at about  their centres.
Dr. Wyckoff examined the  fractures, and directed a simple sling,
with cool lotions.  He had  previously attempted  to straighten the
bones, but was unable to do  so completely.
   On the second or third day, Dr. Wyckoff sent the lad  to the
college dispensary.   I was unable,  also, to restore the bones,  and  I
recommended  a continuance of the  same  simple plan.  He  was
advised, however, to lie a few days  upon his back.  Six years after
the accident, Dr. Mendenhall, of Cincinnati, examined the clavicles
at my request, and informs  me that no  traces of the accident can
be found.   The projections remained some time, but just how long
the mother does not remember.
   I assume that this  was a case of  bending, in which the  bones
immediately resumed their places, and that what we supposed to be
a projection of the fragment was provisional callus.

   Case 6.  Fracture  through  the middle third.  Result perfect.
   Robert M. Frazer.   (Same as Case 5 ;  opposite arm.)
       4 
50
  Case 7.  Fracture through the middle third.  Result perfect.
  T. D. S., aged two years, fell and broke  or  bent his collar-bone
near its middle.   Dr. II. O. Harmon, of Montpelier, \t, dressed the
arm.
  Twenty-four years after the accident  no traces of the  accident
can be discovered.   The arm is perfect.

  Case 8.  Fracture through the middle third.  Result perfect.
  E. M., aged fourteen years.
  After  thirty-one years  I find it perfect, but Mr. M. says that a
projection existed at the seat of the fracture about five years.

  Case 9.  Fracture through the middle third.  Result nearly perfect.
  Samuel Chapin, aged five  years, fell down a flight of steps and
broke his clavicle, at the outer end of the middle  third.  The frac-
ture was rather more complete than interstitial fractures are usually,
the deformity being very manifest, and the projection quite angular
and slightly movable.
  Assisted by Dr.  Barnes, I dressed  the fracture carefully with
Fox's apparatus, but we could not completely restore the fragments
to place, neither at this nor at the subsequent dressings.
  The fragments became firm in  about  twenty days, but  a slight
deformity remained at the seat of fracture.

  Case 10. Fracture through the middle third.  Result nearly perfect.
  (This fracture occurred in the  same person as Case 19, but was
not discovered until the twenty-fourth  day.  No treatment was,
therefore, adopted, except so far as the treatment of the fracture  in
the opposite arm might influence this.)
  Wm.  Hefferman, aged fourteen years.   Fracture  of the  right
clavicle, at the outer end of the middle third.  No displacement,
and only a slight bend.   On  the  twenty-fourth day this bend was
accidentally  discovered,  surrounded  with  a  distinct  and perfect
provisional callus.   The bone was at this time so firm that it  could
not be bent by any moderate force applied at its two extremities.

  Case 11. Fracture through the  middle  third, resulting in a  slight
deformity.
  E. A. W., aged twenty-three months.   This child fell  from her
bed, a height of about two feet.  The parents did  not discover that
any injury had been done to the collar-bone until  about  five days 
51
after the accident.  Dr. George Burwell was then requested to see
it, and found the  same deformity existing as at present, and  pro-
nounced it a fracture.  On the fourteenth day, at the instance of
Dr. Burwell, the child was brought to me.  The  right clavicle was
bent abruptly forwards, at about its middle.  The projection was no
greater now than on the fifth day,  when it was first discovered.
She used her arm freely.
   We immediately  made an attempt to straighten the bone by
pressing upon the projecting angle, while, at the same moment, the
scapula was drawn forwards.   The efforts  were repeated, and  at
each time the pressure made was firm, steady, and long continued.
We could, however, produce no change in the form of the  bone,
and our efforts were discontinued.
   No dressings had been previously applied, and I did not advise
their application now.
   After three years, I have again examined the bone, and find the
projection has become smaller, but it is still quite manifest.  The
functions of the arm are in no ways impaired.

   CASE 12. Fracture  through the middle third.  Result imperfect.
 (See cast in my private collection.)
   B., aged seven years, of Rochester, fell and bent her right collar-
 bone, near its middle.   Her parents did not discover the accident
 until after three weeks, when they immediately brought her to me.
 The bone was then firm,  and by no  reasonable pressure could it be
 made to yield;  it was slightly bent  forwards at the seat of fracture,
 and in this condition we were obliged  to leave it.  I advised no
 treatment.

    CASE 13. Fracture through the middle third.  Result imperfect. (See
 cast in my private collection.)
    The cast of this case was furnished to me by Dr. Caleb Green, of
 Homer N. Y. the very intelligent surgeon who treated the fracture,
 and I shall take the liberty of quoting his own account of it.
    "Dec. 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 ex-
 tremity of the external curvature, a  point which was swollen, tender, 
52
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 diagnosed
bending of the clavicle forward with a splitting out of the posterior
edge, and that the bone, by its elasticity, had resumed its 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 dis-
placement.  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  swelling 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 swell-
ing and  inflammation should  in a measure subside.  In three  ox
four  days he was about.   The callus left is not large, still it is quite
evident.   I have  had one well-marked case  of bending of the
radius  and ulna, in  a boy  eight years  of age, and other surgeons
have detailed similar accidents to  the forearm, and, more rarely,
cases of incomplete fracture, with bending of the humerus, leg, and
thigh; but as a like bending of the clavicle is  much  less common
than either of the others, I  have thought this  case possessed suffi-
sient interest to make it worthy of being reported.

   Case 14. Fracture through the middle third.   Result perfect.
   W.  P.  L.,  aged thirteen years.   The fracture occurred  at  the
outer  end of the  middle third.  Dr. John Thompson, of Scipio,
Cayuga Co., N. Y., was employed.   Soon after the union had been
completed, it was refractured by accident, and  it was re-dressed by
the same surgeon.
   Of the treatment adopted in this case I have no information.
   I examined the clavicle thirteen years after  the accident, and no
trace of the original fracture could be seen.
   I believe it proper to assume that this was a partial fracture.

   The following case I  have thought was of sufficient  interest to
authorize its  introduction  at  this  place, but  as some doubt may 
53
exist as to the character of the fracture, I shall not include it in my
tables.
  Fracture through the middle third.   Union with great  deformity.
(Specimen found in dissecting-room.  See cast in my private collec-
tion representing  the thorax  before the bone was removed, and,
also, cast representing the bone after it was removed.)
  The deformity, as seen before the integuments were removed, was
very remarkable—the  left clavicle being  bent downwards and
forwards at a point just two inches and  a half from the  sternum,
and deviating from its proper line about one inch.   The  patient
was an adult.
   The bone, on examination,  was found firmly united at the point
of  fracture, but expanded into a  sort of round knob,  smooth and
uniform upon its surface.
   I suspect that this fracture occurred in early life,  as it was trans-
verse, and its knob-like projection resembled that which is so com-
monly found to exist for a long time upon any fractures or bendings
of  the bones in children.  The nodose swelling,  also, at the seat of
fracture, was formed entirely at  the  expense of the  anterior and
superior surfaces of the clavicle. Posteriorly and inferiorly, the
surface of the bone was only  slightly,  if at  all elevated,  and I pre-
sume this  side of the bone was never completely broken.
   It would  have  been  impossible for the ends of  a complete frac-
 ture of  the clavicle, such as occur in adult persons, to  have been
 retained in apposition until union was effected, while  at  the  same
 time the fragments were so much out of line.


                  SEC. II.—COMPLETE FRACTURES.

                     DlVlS. 1.—Middle Third.

    CASE 15. Simple oblique fracture.   Union with deformity.
    G. W. R., of Lockport, aged about fifty years.  While residing
 temporarily in  Buffalo, he fell and broke  his left clavicle at the
 outer end of the  middle  third.   Fracture simple and oblique.  Dr.
 Barnes and myself were employed as his surgical attendants.  We
 found  the sternal fragment projecting and overriding  the acromial
 fragment.   Before applying any dressings, we attempted to reduce
 the fragments, so as to determine its practicability, but we did not
 succeed.  Having assured Mr. R, that an overriding would be the
 result, we applied Fox's apparatus.   After the  application of the 
54
dressings, reduction still remained impossible.  We observed, also,
that whether the dressings were applied snugly or loosely, the frag-
ments constantly moved upon each other, whenever he turned his
neck or changed the position of the opposite arm.
   On  the  eighth day, the callus around  the fragments was  very
abundant.
   On the twenty-first day, motion at the seat of fracture had nearly
ceased, and at the end of four weeks the union was completed, but
with the usual deformity.
   Having  been  advised, subsequently, by a surgeon, that such  a
result was  unnecessary,  and that it implied unskilfulness or neglect
on my part, he talked of withholding payment for my services, and
this notwithstanding he had been from the first fully warned of the
certainty of  such a  result.   Until surgeons learn by their own
experience, or from the testimony of others, what  may be accom-
plished after these accidents, they will, no doubt, continue to regard
such  results  as were  obtained in this case, as evidence of wrong
practice.

   Case 16. Simple  oblique fracture, and union with deformity.   (See
cast in my  private collection.)
   Hugh Sarsfield,  aged fifty-seven years;  an Irish laborer;  fell
upon the outside of the left shoulder,  breaking his left clavicle.
Fracture at the outer  end of the middle third. Simple and oblique.
   I immediately applied a figure of 8 bandage,  with  a sling  and
axillary pad.  The fragments were brought nearly to their proper
places.
   On  the  two following days the bandages were found slightly
loosened, and the fragments displaced.
   On the third day  I  applied a dressing after the  method described
and recommended by M. Velpeau* except that  I employed flour
paste instead of dextrine.   The dressing was very carefully laid on,
and when completed the fragments were in place, and the patient
expressed himself as being quite  comfortable.
   On the following  day he complained greatly of its tightness.  On
the third day after its application, I found he had himself cut away
the principal parts  of the bandages, and  that  the fragments were
again displaced.  I therefore removed them entirely, and substi-
tuted the figure of 8.

  * Nouveau  Elements de MeMecine Op6ratoire. Par A. L. M. Velpeau, a Paris, 1839
torn. i. p. 229. 
55
  The result has been that the bone has united, shortened about
three-quarters of an inch, but the arm  is as strong and as useful
as before the accident.

  CASE 17.  Simple oblique fracture, and union with deformity.
  Baby Golden Condy (female), Irish, aged forty years.   By a fall
she broke her right clavicle at  the junction of the outer with the
middle third.   Fracture simple and oblique.
  On the following day I dressed the fracture with a sling, axillary
pad, and bandages.  These were removed on the fourth week,
when the bone was found united and shortened half an inch.

  Case 18.  Simple oblique fracture, and union with deformity.
  H. M., of Angelica, aged about thirty-five years.  Fracture at the
outer end of the middle third; oblique, occasioned by the kick of
a horse.
  Five days after the accident, Drs. Charles and Smith, of Angelica,
both men of excellent reputation as surgeons, dressed the  fracture
with the eleven yard bandage of S. Brown, and with a pad in the
axilla.
   On  the eleventh day from the accident, and six days after the
first dressing, Mr. M. himself directed the bandages to be removed.
It was done without the knowledge of his surgeons, because, he said,
he  could not endure the pain.  The pain was chiefly on the outside
of  his humerus, near its middle.
   Dr. Charles  reapplied the same  dressings, but  with  a  smaller
axillary pad.
   About the twenty-third day, Mr. M. again removed the whole of
the dressings, and from this time forward the bandages were seve-
ral times applied, and as often removed, after a short time, by the
patient.
   Four months from the date of the fracture, Mr. M. consulted me.
   The bone had then united, and with the usual deformity.  It was
shortened  three-quarters of an inch.  He could, at this time, raise
his arm but slightly from the side of his body.

   CASE 19.  Simple oblique fracture, and union with slight deformity.
   Wm. Heffeman, aged fourteen years, was admitted into the hos-
pital with a fracture of the left clavicle, having been run over by a
horse and buggy.  Fracture at the  outer end of the middle third;
simple and oblique, with the usual  overlappings.   He could raise 
56
his arm  perpendicularly over  his  head, as  easily as before the
accident, •
  I  replaced the fractured  ends, and then dressed with  a  sling
under the forearm and elbow, and a well-padded board across the
back, to which the shoulders were securely laced.  The retention of
the fragments was complete.
  On each successive day, however,  I  found the board displaced
more or less to the right or  left shoulder, and during  most of the
time the dressings  were completely inoperative.  Still they were
continued with  occasional slight modifications, until the cure was
consummated.
  On the thirteenth day I noticed callus upon the upper margins of
the  broken ends, but none in front or below.  The same was
noticed, also, on the twenty-first day, but it was less in amount.
  The union was complete about the twentieth day, as motion was
perceptible on  the  eighteenth,  and  it was lost on the  twenty-first.
It united with a slight overlapping and projection.

  CASE 20. Simple oblique fracture, and union with deformity.
  Almond D. Loomis, aged twenty-three years, fell, while wrestling,
upon his left shoulder, breaking the  left clavicle at the outer end  of
the middle third.   Fracture  simple and oblique, with the usual dis-
placement.  It was shortened one inch.
  Assisted by Drs. Thompson and Hunt, I applied a sling with an
axillary pad, &c. &c, but we could not retain the fragments in place.
We  then covered the elevated fragment with long and broad strips
of adhesive plaster, which, for a time, brought the  bone to its
place.
  I never saw the patient again, but I have been told that it finally
united with the usual deformity.

  CASE 21. Simple oblique fracture, and ligamentous union.
  Edmund Nugent, aged twenty-five years, was admitted to the
hospital  in March, 1854.  The  house surgeon called  my attention
to his clavicle, and in presence of Drs. Winnie, Rochester, and Davis,
I made the following examination and notes:—
  Nugent is a stout Irish laborer.  Sixteen years ago, when only
nine years old, 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 his work, holding the tail of  the plough, nor from that day for- 
57
ward 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 success-
ful treatment, except that it is not united by bone.  The outer end
of the inner fragment rides  upon the inner end of the outer frag-
ment 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 whicji
he had suffered from the ligamentous union, we directed him to lift
weights placed  on a table before him, while he was seated upon a
chair.  We ascertained from this experiment that with his left arm
he could lift as much, within three ounces, as he could with his
right,  and he  was not himself conscious of any difference.   The>
muscles of the  left  arm seemed as well  developed as those of the
right.

  Case 22. Simple  oblique fracture, and union with slight deformity.
  Mary Beaumont, aged seventeen years, broke her left clavicle at
the outer end  of the middle  third.   Dr. Brodie, of Caven, C. W.,
treated the fracture.
  Nine years after the accident she became an inmate of the Buffalo
Hospital, and was under my care.
  The outer end of the inner  fragment is displaced upwards about
half an inch.   There is no shortening.   The functions of the  arm
are perfect.

  Case 23. Simple oblique fracture, and union with deformity.
  H. B. H., of Gaines,  Orleans Co., aged forty-four years, a carriage
maker by trade.  Health generally pretty good, yet not very vigor-
ous.  Mr.  H. fell down a flight of steps, about four  feet, striking
upon his right shoulder, and fracturing his right clavicle at the
outer  end  of the middle third. He  was not  stunned by the fall,
and his right shoulder and side were only slightly bruised.
  Dr.  Alfred Babcock, of Orleans Co., was employed.   He applied
a jacket (Brasdor's) with shoulder-straps, and a sling; no axillary
pad.   The jacket had no purpose except to attach the shoulder-
straps, which were buckled  over each shoulder.   That on the right
side was intended to keep  down the  inner fragment; and it was
therefore buckled so tight that he was compelled constantly to in- 
58
cline his head and body to the right side.  He was unable to lie
down completely, but, most of the time, he half reclined upon his
back.
  On the twenty-first day, Dr. Babcock removed the dressings, and
found the fragments displaced, but united.  Dr. B. offered to " break
it over again," but the patient declined.  The same dressings Avere
reapplied, and continued one  week longer.
  Two  years,  after the accident, Mr. H. consulted me at Buffalo.
The place  of  union  of the broken clavicle  was very perceptible;
the inner fragment lying entirely in front,  and not at  all above the
outer fragment.  It is shortened three-quarters of an inch.  A nar-
row ring of ensheathing callus can be distinctly felt.
  Three months after the accident, and about two months after the
dressings were removed, the upper dorsal vertebra? began to fall off
to the left side.  Soon, his left hand became tremulous and weak,
and now his left arm and hand  are completely paralytic, and his
left leg is also partially paralyzed. Sensation remains undiminished.
His spine is also very much curved to the left.  The  right arm is
sound, and its strength is in no degree abated.   His health is some-
what impaired.
  It is not clear what has occasioned the spinal distortion and the
paralysis, but  I  suspect it is  due to some  injury done to the verte-
bral column at the time of the accident, although he is  not conscious
of having received any such injury.
  To charge these results to the peculiar mode of dressing the  frac-
ture, the facts and circumstances will scarcely warrant.

  Case 24. Simple oblique fracture, and union with deformity.
  Daniel Sullivan, of Buffalo, aged fourteen years, fell from a  scaf-
folding, striking upon the back of the left shoulder, and breaking
the left clavicle at the outer end of the middle third.  I first applied
Day's splint, and, subsequently, Fox's apparatus, but  I soon found
that the fragments were only temporarily kept in place by either of
these dressings;  yet  with various modifications, and frequent read-
justments,  Fox's apparatus was  continued  throughout  the treat-
ment.   On the eleventh day the fragments were immovable, and no
provisional callus could  be felt.   The  boy was  a restless, active
fellow, and was incessantly going about.
  It has united with the inner fragment riding upon  the outer one
a quarter of an inch.  Three months after the union was effected, the
arm was as useful  as before.  The dressings  remained on the arm 
59
about thirty days.  As is usual with good-natured people, the mother
ascribes the deformity to his own carelessness ;  she  says, " he had
the dressings loose nearly all the time."

  Case 25. Simple oblique fracture, and union with deformity.
  M. W., of  Angelica, aged twenty-two years, was thrown  from a
carriage, breaking her right collar-bone.  Fracture oblique, at the
outer end of  the middle third.
  Dr.  Haines, of Portage, dressed the fracture immediately, and I
met him in counsel on the third day after the accident.   The inner
fragment was then riding upon the outer in the usual manner.   Dr.
Haines had  attempted repeatedly to restore the fragments to  an
exact apposition, but he had  been wholly unable to do so ; nor did
we succeed any better after my arrival.  We were unable, even for
one moment, to bring them into place.
  We applied Fox's apparatus moderately tight, and I left the case
in the hands  of Dr. Haines, with an assurance that overlapping and
some deformity must be the  result; and I have since learned that
such was the fact.   It is shortened about half an inch.

   CASE 26. Simple oblique fracture—union not perfect.
  James  Elwood, of Rochester,  aged thirty-five years.  Fracture
occurred at the outer end of the middle third:  right clavicle.   Dr.
----} of Rochester, in attendance.
   Five years after the accident, I found the clavicle  shortened half
an  inch, and  slightly deformed at the seat of fracture.   The right
shoulder falls about half an inch; his arm  is,  however, in all  re-
spects as well and as useful as before.   It was dressed, he says, by a
surgeon in Rochester, but he cannot give the name of the surgeon,
nor have I any notes of the mode of treatment.

   CASE 27. Simple oblique fracture, and union with deformity.
   Hiram Gay lor, aged thirty-three years, broke one of his collar-
bones at the  outer end of the middle third.   Dr. Stanberg, of Palen-
tine, Montgomery Co., was in attendance.
   Fourteen years after the accident, I found the usual displacement
at the seat of fracture, with a shortening of half an inch.  The arm
has been occasionally painful from that time to the present.   Its
functions were, however, unimpaired.   My notes do  not declare the
mode of treatment. 
60
  Case 28. Simple oblique fracture, and union with deformity.
  Mrs. T. M., aged thirty years, was thrown from a carriage, striking
upon the outer end of the left acromion process.  The left clavicle
was broken at the outer end of the middle third, or about two and
a half inches from the acromion process.
  The outer end of the inner fragment was lifted upwards and for-
wards, and made to override, very slightly, the acromial fragment.
By pressure alone it was easily replaced.
  Assisted by my  son, Theodore, I  adjusted the fragments,  and
secured the arm with a sling, axillary  pad, and bandages.
  On the third day, I found the dressings loose, and the fragments
displaced, although the usual care had been taken to prevent this
result.  I removed, therefore, the dressings, and substituted a care-
fully made Fox's apparatus.
  On the seventh day, the patient having been seen by me, and the
dressings tightened on each intervening day, I removed the appa-
ratus, finding  that it had no influence  in retaining the fragments in
place, and I substituted a dressing made entirely of adhesive plas-
ters.  For this purpose I used, at this single dressing, about  two
yards of plaster, made into strips of from three to four feet in length
by one or two inches in breadth.  A pad was placed in the axilla,
and the arm and shoulder were then secured by various turns of the
adhesive strips, some of which served as a sling for the elbow, some
bound the elbow to the body,  some drew back the shoulders,  and
some crossed the broken clavicle to bear down the  outer end of the
sternal  fragment.  When the  whole was  finished, the patient ex-
pressed herself as very comfortable, and the fractured ends were in
place.   The next day, the straps had slipped and loosened, and the
fracture was again deranged.
  On the thirteenth day, I becamed satisfied that no amount of care
and diligence, short of a reapplication  of them every few hours, was
sufficient to prevent the straps from becoming loose, a circumstance
mainly due to the warmth of the body, and to the motions of respi-
ration.  I therefore removed the straps, and applied the very beau-
tiful and ingenious  splint for fractured  clavicles, invented  by Mr.
Day.  This is a carved splint, made to fit the back, shoulders,  and
neck, and furnished with sling, straps,  loops, etc.  Before applying
this splint, I had a large and soft cushion constructed and placed on
the concave  surface of the splint.  Its application was easy and
simple, and promised to be efficient.
  The patient wore this apparatus five days, during which time  it 
61
required daily, indeed  almost  hourly, readjustment, as the splint
would constantly slide upwards against the neck and head, and the
shoulder-straps would roll and excoriate the axilla.  To remedy the
latter difficulty, I had large circular tin plates constructed, furnished
with pads, which were placed in front of the axilla, and over which
the shoulder-straps were made to pass.  The sliding upwards of
the splint, however, still continued, and was irremediable; and, on
about the twenty-first day, this also was removed, and no dressings
were  subsequently employed, except a sling for  the forearm.  At
this time no union had occurred.  No provisional callus could be
felt;  the fragments remained slightly displaced, just  as when I first
saw her.  In short, the treatment had accomplished nothing.
   Soon after union occurred, and, two months from the time of the
fracture, I found the bone firm, with an overlapping of three-quar-
ters of an inch.  The functions of the arm were  also already com-
pletely restored.  At the end of one year, no changes have occurred.

   CASE 29. Simple oblique fracture, and union with deformity.
   John Moran, a sailor, aged twenty years, fell upon his left shoulder,
and broke the left clavicle at the outer end of the middle third.
   At the end of fourteen days, he  consulted Dr. Charles Wilcox,
Surgeon to the Marine Hospital at Buffalo.   This was his first appli-
cation for surgical advice.  Dr. Wilcox applied the figure of 8 dress-
ing ;  on the following day, it had become loosened and drawn  into
strings, and, on the third day, John  removed it altogether, and has
had  no  treatment or dressing since, except  that he has  generally
kept his hand in the bosom of his coat.
   The bone united in about twenty-one days, and, at the end of six
 weeks, when  I examined it carefully, the clavicle  was shortened
 one-quarter of an inch; provisional callus could  be  detected.   The
 arm  was as strong and as useful as before.

   Case 30. Simple oblique fracture, and union with deformity.
   Daniel Sharp, get. 16 years, broke his right  clavicle, at the outer
 end of the middle third.  A surgeon of respectability in New York
 city  dressed and treated the fracture.
   Seventeen  years after  the  accident, I  examined the arm, and
 found a projection and overlapping of the fragments, to the  extent
 of three-quarters of an inch.  Its displacement upwards was rather
 greater than is ordinarily seen, yet the arm was as strong  and as
 useful as before.  Patient cannot describe the treatment. 
62
  Case 31. Simple oblique fracture, and union with deformity.
  Henry West, aged 25 years, broke  his left clavicle at the outer
end of the middle third.  Surgeon Williams, of Liverpool, England,
dressed the fracture, and continued his  charge until the cure was
completed.
  Two  years after the fracture  had occurred, West came under
my care at the hospital.  The clavicle is shortened  one-quarter of        g
an inch, and a slight deformity remains at the seat of fracture.  The
functions  of  his arm are perfect.   I have no knowledge  of  the
treatment.

  Case 32. Simple oblique fracture, and union with deformity.
  James Roach, aged about 40 years.  A barrel of flour fell against
his left  shoulder, breaking  the left clavicle at the outer end of the
middle  third: oblique and  simple.  The fragments were displaced
in the usual manner.
  Assisted by Drs. Eastman and  Vanderventer, I applied dressings
consisting of a  sling, axillary  pad, and bandages.   Over each
shoulder I placed a moulded compress, made of numerous layers of         t
cloth  and  paste; this, when dry,  was to  serve as a point d'appui for
bandages, tapes, &c.
  The whole being arranged, we made  an  attempt to  reduce  the
fragments, but we were unsuccessful.
  The same thing happened, indeed, which has several times hap-
pened to  me before.  I could not, nor  could the gentlemen with
me bring  the fragments into  apposition, and this notwithstanding
we placed our knees  against the back, and drew forcibly upon the
shoulders; and notwithstanding  also we placed  a firm pad in  the
axilla, and made use of the arm as a lever until  the patient could
no longer endure the pain.  Each gentleman satisfied himself that         *
it was not practicable to reduce the fragments  by either of these
modes, and on the following day Dr. Myers, of the U. S. Army,
and Dr. Pupikofer repeated the  attempt in my presence, and with
like success.
  In  one way alone  could the  fragments  be brought even tem-
porarily into contact, viz: by  pressing the  acromial  end of the
sternal  fragment downwards and backwards, which fragment we
found, when  left to itself,  constantly  projecting  upwards and for-
wards, while  the opposing fragment was  inclined, at  its sternal end,
backwards.
   The  patient was assured that  overlapping was  inevitable;  the 
63
dressings were carefully applied, and, with slight modifications, were
continued until the cure was completed.
  The fragments united about  the thirtieth day, with half an inch
of shortening, and with projection of the  outer end  of the inner
fragment.

  CASE 33. Simple transverse fracture, and union without deformity.
  Patrick Rowan, aged 26 years, fell while wrestling, and broke the
right clavicle at the outer end of the middle third.   The  fracture
was complete, but transverse.
  I reduced the fragments soon after the accident, and noticed that
unless disturbed, they would remain in place for a few seconds, at
least.
  I applied .the cross described  in  Case 21; on the  seventh day,
motion between the fragments had ceased, and on the twenty-eighth
day the apparatus was removed, and  the union found to be complete
without shortening or deformity.

   CASE 34.  Simple oblique fracture, and union with deformity.
   S. E., of Buffalo, aged about 25 years.  Mr. E. was thrown upon
 his shoulder, by jumping from the cars while they were in motion.
 The fracture was at  the  outer end of the  middle third, simple and
 oblique.
   During the first four days, I applied a figure of 8  bandage with
 an  axillary pad  and a  sling.  Finding,  however, that  the  frag-
 ments  could not  by these means be kept in place, I directed our
 ingenious instrument maker, Mr. Seiffert, to construct,  under my
 direction,  an apparatus such as I hoped might  prove more efficient
 in  the management of these fractures.  It consisted essentially of
 an upright and a  transverse plate of brass, secured upon each other
 in  the form of a cross, and  intended to be placed  against the back.
 The transverse bar extended from acromion to  acromion,  to which
 the shoulders were to be securely fastened back by leather shoulder
 caps and  straps,  with buckles.  This  bar was padded, especially
 along its middle,  where it was intended  to rest between the blades
 of the scapulas.   The vertical  bar was only designed as  a support
 for the crossbar, its lower end being received into a pocket made
 in a broad leather belt, the belt to be fastened around the hips.
    This apparatus I applied on the fifth day, and I continued to see
 him daily  until  the cure  was  completed.  Motion between  the
 fragments had ceased on the fourteenth day after the accident, and 
64
on the twenty-fifth day I removed the apparatus entirely, the bone
being quite firm.  There was, however, the usual overlapping and
deformity at the seat of fracture, but rather  less than occurs in a
majority of cases.
  I cannot say that the apparatus answered my expectations, since
it was constantly inclined to fall off from the shoulders, either to
the right or to the left, and this  defect I have not yet succeeded in        >
remedying.

  Case 35. Simple oblique fracture, and union with deformity.
  Mrs.  ----, of England,  aged 28 years, fell and broke her  left
collar bone obliquely at the outer  end of the  middle  third.   A
surgeon in London dressed the fracture.
  Twelve years after the accident, I found the usual deformity and
a shortening of half an inch; the arm in other respects, perfect.
No record of treatment.

  Case 36. Simple oblique fracture, and union with deformity.
  Mary McCarty, aged 12  years, of Ireland.  Mary broke  one of
her collar bones, by a fall upon her shoulder.  The fracture was
complete, and occurred at  the outer  end of the middle third.  She
says that a skilful  Swiss surgeon dressed the fracture.   Twenty-
three years after the accident, she became an inmate of the Buffalo
Hospital,  and I examined the arm.
  The  clavicle is shortened half an inch, and slightly bent at  the
seat of  fracture.  For many years, Mary says, the deformity was
very striking.  Functions of arm not impaired.

  Case 37. Simple oblique fracture, and union with deformity.
  Silas  Usher, aged 46 years, fell from  a scaffolding about fifteen
feet, striking upon his shoulder,  and breaking the left clavicle, near
the junction of the outer third with the inner two thirds.  Dr. Peter
Knox,  of Watervleit, dressed  the fracture immediately, with  an
axillary pad, sling and. bandages.  On the third day, the  fragments
were discovered  to be displaced,  and  Dr. Thorn, of  Troy, was sum-
moned.
  Dr. Thorn removed the  dressings  and substituted an  apparatus
composed  of bandages, and without any axillary pad.   He also
placed an adhesive plaster  over  the fracture;  on the tenth day Dr.
Thorn removed all the dressings, and did not reapply them; but the
plaster was continued until it fell off. 
65
  Eleven years after the fracture, I found the bone united, but
overlapped one-quarter of an inch ; the inner fragment overriding
the outer,  the functions  of the  arm perfect.  He thinks it  was
united in about two weeks after it was broken.

  Case 38. Simple transverse fracture, occurring at the seat of an old
comminuted fracture.   Union without additional deformity or maiming.
Prosecution of the  surgeon, and successful  defence.  (See cast in my
private collection.)
  Burgess,  aged about 30  years, of Buffalo, N. Y.  (This is the
same man whose first fracture is reported in Case 52.)  Burgess was
riding in a buggy, when the horse became frightened by the pas-
sage of a train of cars, and he was thrown upon the ground, striking
upon his right shoulder.
  Dr. George Burwell, an intelligent and skilful surgeon of Buffalo,
was called to dress the fracture.
   On the eighth day, Dr. Burwell requested me to see Burgess with
him.  I found him wearing Fox's apparatus, which had been care-
fully made  and applied, but which was now loose from his  own
interference.  The clavicle was broken at  the seat of the old frac-
ture, but only at one point—at the point nearest the shoulder.  The
vertical or intercepted fragment remained firmly fastened  to the
inner portion  of the bone.  Burgess had not  told  Dr. Burwell, nor
did he tell me that the clavicle  had ever been  broken before, and
we did not suspect the intended  imposition.  Wre were  unable  to
explain satisfactorily the fixed and immovable condition of the
central fragment, which we repeatedly attempted to restore to place.
On attempting to  adjust the portions which were movable, also, we
found that no force applied to the shoulders was sufficient to make
any sensible impression upon them. They still continued to occupy
almost precisely the position in  which we first found them.  We
assured him, therefore, that deformity was inevitable, and that we
would  apply  the  dressings only so as to  maintain some degree of
rest between the fragments, but that we should not attempt to over-
come the shortening, &c.  To this Burgess assented with a readiness
which at that time surprised us, but which subsequent developments
rendered consistent.   We observed, also, the emaciated condition of
the arm, and the deformity of his hand and  wrist.   These conditions
he ascribed to a dislocation of the shoulder which, he said, occurred
when he was twelve years old.
        5 
66
  Dr. Burwell continued to attend him until the union of the bone
was completed, about twenty-one days.
  Soon after his recovery, Burgess commenced his well-planned and
systematic  conspiracy, by prosecuting the Niagara  Falls Railroad
Company, for having been the cause of his accident, and of all the
deformity and maiming  from which he was now suffering.
  This suit resulted in a verdict in favor of the company.                 }
  A few months later, Burgess refused to pay his bill for  surgical
services, and threatened to prosecute Dr. Burwell for damages. Dr.
Burwell immediately gave the account to his attorney for collection,
and  Burgess, through Mr. Williams, his counsel, put in a defence
of "unskilful treatment." The cause was tried October 3d, 1846, in
a Justice's  Court, Justice Childs presiding, and when the testimony
was  partly before the magistrate, Burgess's counsel withdrew the
defence, and Dr. Burwell's account was allowed.  Burgess, however,
had no property, and the judgment was  never paid.
  The matter did not  rest here.  He at once commenced a suit
against  Dr. Burwell for mal-practice.  The first trial of this suit
occurred in June of 1847, in the Erie County Circuit, Judge Stevens
presiding.
  The evidence was most conclusive  in favor of Dr.  Burwell, but
the jury could not agree, and were dismissed.  Eleven of the jurors
wished to return a verdict for the  defendant, Dr. Burwell, and one
insisted upon damages to plaintiff.
  The second trial  occurred in June, 1849.  The same facts were
elicited here as on the two former trials, viz: That he had repeatedly
falsified his own statements in relation to the cause of his maiminar.
That he had at one  time ascribed it solely to an injury of the wrist,
received when he was twelve years old;  at another, to an old dislo-
cation of the shoulder;  at another, entirely to his recent accident.        '
He never  admitted, so  far as we could learn, that the clavicle had
ever been broken until  recently, but it will be seen at once  that,
with the knowledge of his character and motives now disclosed, no
other supposition is probable.  The jury having heard the testi-
mony, promptly returned a verdict for the defendant.

   Case 39.  Simple fracture, and union with very little deformity.
   Francis Carpenter, aged thirty-two years, of Lille, France.  Francis
fell sideways upon  the ground, striking upon  the outer end of his
left shoulder, and breaking the left clavicle at  the outer end of the
middle third. 
67
  Dr. Barras, of Lille, dressed the  fracture with bandages and a
sling, using no axillary pad, and no band to draw the shoulders
back.  The dressings were continued eight weeks.
  Ten years after, while an inmate of the Buffalo  Hospital, I ex-
amined the arm.  The clavicle had united without  shortening, but
only bent forwards at the  seat of fracture.   He thinks it never
overlapped, nor was there ever any sharp projecting point of bone,
the arm is as strong as before the accident.  Probably it was a
transverse fracture, and possibly not complete.

  CASE 40. Simple oblique fracture, and union with deformity.
  Joseph Price, aged about twenty years, broke his clavicle at the
outer end of the middle third.   Oblique  and simple.
  I  applied Fox's apparatus, but did not see him but once or
twice after the first dressing, as he soon left town.  Two years  from
the date of the accident, I examined the arm again.  The fragments
had united, overlapped, and with the usual  deformity.  It is short-
ened  half an inch.  He  is a good-natured fellow, and ascribes all
the unfortunate result to his own negligence.  His  arm is not yet
quite as strong as before the clavicle was broken.

  CASE 41. Simple and oblique fracture, and union with deformity.
  C. A.  W., aged forty-seven  years, was  struck by the hawser of a
vessel, breaking the  right clavicle, and, at  the  same time, several
ribs on the right side of his body.  Dr. Sprague, a very experienced
surgeon of Buffalo, was called, and applied dressings consisting
essentially of a sling and axillary pad, bandages, &c. The condition
of his side, however, did not permit the dressings to be applied very
snugly.
  Some person having suggested to Mr. W. that the arm  was not
properly in place, that the shoulder was out of joint! and the cla-
vicle not united! he consulted me in June,  1851, about four years
after the accident.
  The fracture had occurred at the outer end of the  middle third,
and the inner fragment was still overriding the  outer fragment.
The clavicle was united, but shortened one inch.   The projecting
point of the inner  fragment was quite sharp and  prominent, and
occasionally tender and painful.  The right humerus is properly in
its socket,  but the muscles about the joint are atrophied, leaving a
flatness upon the outside and behind.  In front, there exists rather 
68
an unusual fulness.  He is unable to raise his arm to a right angle
with his body.

  CASE 42.  Simple oblique fracture.   Union with deformity, and pa-
ralysis of the arm.
  Mrs.----, aged 51 years, of New York.  Mrs.----was thrown
from her carriage, breaking the right clavicle obliquely at the outer         )
end of the middle third.  Dr. Congar, of Niagara Falls, dressed the
fracture with Fox's apparatus.  This dressing was continued three
weeks, and was not particularly painful.
  At this time, by a change of residence, she became the patient of
Dr. J., a very excellent surgeon  of  Erie County, N. Y. The frag-
ments were found to  be overlapped, and Dr. J., with  a hope of re-
storing them to place, applied a figure of 8 bandage, with an axillary
pad.  During the  short time these dressings were continued, the
pain was excessive; and, notwithstanding the free use of anodynes,
they became wholly insupportable, and were removed at the end of
fourteen hours.
  Dr. C, of  the same county, removed the dressings,  and reapplied
Fox's apparatus, which, with -occasional removals, remained on four
weeks longer. In all this time, repeated efforts were made to bring
the fragments into place.
  Forty-eight daj^s after the accident, she consulted me.  The cla-
vicle  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 of the hospital, there was a gra-
dual improvement in the condition of her arm, in respect of swelling
and tenderness, but the paralysis did not much abate.                     ^

  Case  43.  Fracture and union, with slight deformity.
  Miss A. W. R., of Westfield, Chatauque County, aged 5 years, by
a fall broke  her right clavicle near its middle.  Dr. Jones, of West-
field,  dressed the fracture.  It was found impossible  to retain the
fragments in place, although Dr. Jones  readjusted them at three
separate times.   Union occurred, with a palpable deformity, which
was still manifest thirty-five years after the accident, when I had an
opportunity of examining the bone.  The  arm, also, during the
whole of this period, has  been  occasionally painful.   In  all other
respects it is well. 
69
  Case 44.  Fracture and union, with deformity.
  John Lewis, of  Painted Post, N. Y., aged 32 years, fractured his
clavicle near its middle. Simple and oblique.  Dr. Hoyt, of Painted
Post, was employed.
  Eight years after the fracture, I found the clavicle shortened one
quarter of an inch, and pushed forward at the seat of fracture. The
arm was not as strong as before the accident.  I find no mention in
my records  of the treatment.

  Case 45.  Fracture and union, without deformity.
  S., aged 15 years, fell on the ice, breaking his left clavicle.   The
fragments were never much  displaced.  Dr. John  Trowbridge, of
Buffalo, and myself, in attendance.
  We applied at first a  back-board splint, which  seemed to keep
the fragments, for a day or two, very well in place; but, after this
date,  it was found too troublesome, and we substituted a simple
sling.
   Five years after the accident, I examined the arm carefully, and
find it neither shortened nor displaced.  Yet the line of fracture can
be  distinctly felt.  It  occurred at the outer end of the middle third,
and was oblique.

                     DiViS. 2.—Inner Third.

   Case 46. Simple transverse fracture half an inch from sternum.
 Union without deformity.
   Mrs. Winfield Dunmoody, aged 80  years,  fell down  a flight of
 steps,  breaking the right clavicle about one inch from its sternal end.
   Dr. John Trowbridge, who was in attendance, invited me to see
 the case  on the  day following  the accident.  Motion and crepitus
 were  distinct,  but the displacement was very inconsiderable, and
 scarcely perceptible.   We applied  no dressings, but directed only
 that the patient should be kept quiet.  The bone united in the usual
 time,  and without either deformity or maiming.

                      DiViS. 3.—Outer Third.

   Case 47. Fracture between the coracoidprocess and  acromion.  Union,
 with slight deformity.
   J. H., aged about 21 years, in jumping from the cars while they
 were  in motion, broke his left clavicle at a point between the cora- 
70
   coid process and the acromion, viz: about half an inch to the acro-
   mial side of the coracoid process.  The outer end of the inner or
   sternal fragment was slightly elevated, and overlapped the acromial
   about one-quarter of an inch.   The displacement and  deformity
   were slight, as compared with those cases in which the fracture had
   occurred on the  sternal side of  the coracoid process.   Dr. Wilcox
   and myself in attendance.
     We laid across the back a broad, thick plate of gutta percha, pre-
   viously covered with cotton cloth, and  to this, as a back splint, we
   secured  the shoulders.  A sling and axillary pad were also used,
   with bandages.  The fragments were very easily brought into place
   and retained.
     The next day I found the dressings  loose, and I readjusted them
   with care.   On the sixth day, the whole being loose, the bandages,
   &c, were reapplied,  and he was  dismissed for his  home, where he
   came under  the  care of Dr. Lansing Briggs,  of Auburn.   Dr. B.
   continued the dressings, but the  bone has  united with a slight pro-
   jection and a shortening of about one-quarter of an inch.

     Case 48. Simple oblique fracture, and delayed union.
     Michael Connor, aged 55 years, fell from a scaffolding and broke
   his left  collar-bone,  about one  inch from  the  acromial  end.   He
   was sent immediately to the Bellevue Hospital, New York City.
   "Dr. Murdock  dressed  the fracture," says  Michael, "with a collar
   upon my right shoulder, a pad under my left shoulder, and a sling
   under my elbow."  The apparatus was retained upon the arm and
   shoulder about five weeks.
     At the end of six weeks, Michael became an inmate of the Buffalo
   Hospital, and, upon  examination, I found that  the fragments were
   overlapped one-quarter of an inch,  and that bony union had not
   yet taken place.  Moving the fragments upon each other, produced
%  an audible click  at the seat  of  the fracture.   He could not lift his
   arm.

                       DiViS. 4.— Comminuted.

     Case 49. Union with  deformity.
     R. L., aged thirty-three years, was thrown from a horse, and broke
   his right clavicle in two places.  One fracture was at the inner end
   of the outer third, and the other at a point nearer the sternum.
     I was  called to dress it on the third  day, and, on the fourth day, 
71
I applied Fox's apparatus.  I could not, however, retain the frag-
ments in place, nor prevent motion.
  On the twenty-second day, one fragment had united, but the other
remained loose.  I substituted the figure of  8  bandage for  Fox's
apparatus, and applied a compress, &c, over the fracture.
  On about the twenty-eighth day, union was effected  throughout,
but with overlapping and the usual deformity.
  Eight years after  the accident, I examined  the  arm, and find
the bone united with a shortening of half an inch.   The arm is as
strong and  as useful as before.   The overlapping is in front, and
not above.

   Case 50.  Union with deformity.
   ----, aged twenty-nine years, of Buffalo, was thrown backwards
from a wagon, striking upon his shoulder.  I saw the  man soon after
the accident, and dressed the fracture at my college dispensary. The
right clavicle was broken at two points, the intercepted piece being
about one inch and a half in length, and considerably displaced.
 The outer fracture was at the  inner end of the outer  third  of the
 clavicle.
   It was noticed that, contrary to what has been supposed to  be the
 general fact in such cases, he could easily raise  his  arm and hand
 to his head,  and  also, that by no  force or art could the fragments
 be made to resume their places.  Fox's apparatus was then applied,
 and the patient distinctly informed that  shortening and deformity
 were inevitable.   I have never seen the  patient since.
   I have learned, however, that the results which I predicted have
 occurred.  It is shortened about half an inch.

   CASE 51.  Union with deformity.   (See  cast in  my private  collec-
 tion.)
   Charles Clarke, of Otisco, aged forty-six years, was  thrown from
 his horse, breaking  his left collar-bone  at two points, viz: at its
 middle, and at a point about one inch nearer the sternum.
   Dr. Ashbel Searle, of Otisco, was in attendance. Dr. Searle placed
 the arm in a sling, and secured it with bandages, but  used no axil-
 lary pad.  The dressings were at first exceedingly painful, and Dr.
 Searle was obliged to loosen them.
   The bones united, and,  fourteen years after the accident, I ex-
 amined the arm, and found a very marked deformity in consequence
 of the displacement of the intercepted fragment.   The clavicle is 
72
shortened half an inch.  His  left shoulder is lower than his right.
Functions of the arm perfect.

  Case 52.  Union with deformity, and maiming.  (See Case 38.)
  Burgess, aged twelve years, then a resident of London, England.
The right clavicle was broken at two points, viz: at the junction of
the outer third with the inner two  thirds, and also at a point one         \
inch and a  half nearer the  sternum, the intercepted piece being
thrown at right angles with the line of the clavicle, and  remaining
in that position until bony union was accomplished.
  The vertical, intercepted piece projected a little more than half an
inch both above and below, and the  opposite fragments united with
it on its anterior and posterior surfaces.  Clavicle is shortened one
inch.
  I have not been able to  ascertain what treatment was adopted by
the London surgeon, but the result has been a general marasmus of
the arm, inability to lift the arm, and a permanent abduction of the
hand to the ulnar side, with flexion  of the fingers.
  He continued, however, to follow his occupation as a carpenter,
shoving the plane more by the motions of his body than of his arm.

  Case 53.  Union with deformity.
  B. L. Derrick, aged about fifty years, a feeble, non-muscular man.
Mr. D. fell about fifteen feet, striking upon the back and outer part
of the left shoulder.  Dr. Smith, of the Army, Dr. Wyckoff, and
myself, made the first dressing.   The clavicle was broken obliquely
at the inner end of the outer third, and also at a point  about one
inch nearer  the  sternum.   The intercepted fragment  was  quite
movable.   The acromial end of the sternal fragment was lifted up-
wards and carried forwards, and also rode  upon the other fragment         ^
one inch.
   We first  attempted to replace the fragments before the dressings
were applied, but we could not.
   We then placed a very  broad and firm gutta  percha splint upon
the back and shoulders well moulded and covered with cotton cloth.
To this we drew  back firmly the shoulders, but without effecting
an adjustment of the fragments.
   We then elevated the elbow and shoulder with a properly con-
structed sling, suspended from the  opposite shoulder.   The  effect
was to approximate and partially conceal in the tissues the  project- 
73
ing ends, but a careful examination showed that the riding still con-
tinued.
  Finally, we adapted a large and pretty firm pad to the axilla, and
using the arm as a lever, we attempted to carry out the shoulder.
When great force was  applied, the fragments  moved  about three
lines, but no force which we could apply was sufficient  to carry out
the shoulder so as to accomplish exact reduction.
  Relaxing, therefore,  our  efforts, and bringing the arm  to that
position in which the pressure  ceased to be painful, we applied the
requisite retentive bandages, and left the patient, assuring him that
a shortening was inevitable.
   After a few days, I became satisfied that the back splint was in-
sufficient, and only burdensome, and I substituted for the whole
dressing a simple figure of  8, with a sling, &c.
   The result has been a union, with  a  shortening of one inch, the
same as before any dressings were applied.  There is also the usual
projection of the fragments. 
74
 Fractures of the Clavicle.
INCOMPLETE FRACTURES.
	o	6 o		<M |	■o	a5 p. 9 1		RESULT.				
												
	a f u	|-3		"5 3	i	c	TREATMENT.	O T3		3-s.s		o 3 « a.
c is 1	< °	S s	X	u'~	R.	"3 PK			■" s			a a i."
	i y'rs	8 y'rs	V.	Simple		Outer	Fox's apparatus	United		No	Cannot trace the	Per.
				and		third				short-	fracture	
				trans.						sning.		
2	19 "	10 "	"		L.	Inner third	Fox's apparatus	a			Slight projection in front	Imp.
3	3 "	7mo's	it	k	R.	Middle third	Elandkerchief sling	"		n	Slight projection at time of death	
4	6 "	5 y'rs	SI.	it	L.		Surgeon employ-ed, but no treat-ment adopted	it			So trace of the fracture	Per.
5	12 «	6 "	K	"	R.	K	Sling and supine position	"		tt	No trace of the fracture	
6 12 '		6 «	«	u	L.	"	Sling and supine	«		"	No trace of the	'■'
							position				fracture	
7	2 "	24 "		»		Jliddle	Surgeon employ-ed, but treatment unknown	u		n	Cannot determine the point of frac-ture	tt
8	14 "	31 "		a		u	Unknown	a		a	A projection exist-ed at seat of frac-ture about five years, but it has now entirely dis-appeared	
9	5 "		"	ti		Mid. 3d	Fox's apparatus	it	20 d'ys	u	Slight projection	Imp.
10	14 "	4 w'ks		it	R.		No treatment, but rest		21 "	it	At the end of four weeks there was a slight projection	
11	2 "	3 y'rs	F.	u	66	Middle	Unsuccessful at-tempts to straigh-ten the bone on the 5th and 14th days. No other treatment		14 "		Slight projection	
12	7 "	2 w'ks	«	it		«	Not seen by a sur-geon until the 14th day. No treatment	a	14 "	u	Slight projection on the 14th day	
13	7 "	6mo's	M.	«		Outer third	"Dressed as for a complete frac-ture"	tt		«	Slight projection	a
14	13 "	13 y'rs				Middle third	Surgeon employ-ed, but treatment unknown.	it			No trace of the fracture	Per.
COMPLETE FRA								CTUR	ES.			
MIDDLE THI]								ID.				
15 50 y'rs 2 y'rs			M.	Simple	L.	Outer	Fox's apparatus	United.	24 d'ys	5 inch	Inner fragment	Imp.
				and		end of					projects forwards	
				ob.		middle third					and upwards	
16	57 "	1 "		<(			Figure of 8. Vel-peau's bandage	tt		$ inch	Inner fragment projects. Arm as strong as before	u
17	40 "	5 w'ks	F.	a	R.	(i	Sling; axillary pad, &c.	it	28 "	4 inch		a
18	35 "	4mo's	M.	ti			Brown's bandage; axillary pad, Ac. &c.	tt		$ inch	Considerable pro-jection of inner fragment. Ina-bility to lift the arm	
19	14 «	4 w'ks	«	a	L.	u	Back splint; sling; no axillary pad	a	20 d'ys	J inch	(Could lift his arm above his heat] before it was dressed.) Frag-ments project slightly	
20	1	ly'r	a			it	Sling, &c.				Fragments over-ride	a
 
75
Fractures of the Clavicle.—Continued.
6	k	l|	6 3		RESULT.				
o d	I		C3						
					u		J.		
No. Age who curred.	S S * H ° CO	Characte fracture Right or	o "3 '3	TREATMENT.		When united. Amoun of shor ening. 1		I!	
21 9 y'rs 1	5 y'rs M.	Simple L. and ob-	Outer No treatment United end of by liga-			*	inch Fragments move Imp. freely upon each		
		lique	middle	ment				other. IN o impair-	
			third					ment of functions	
								}f arm	
22 17 "	9 " F.	Simple " and	" Treatment un- United known 1				*fone Fragments displac-ed in direction		(C
		trans.						of diameter ol bone half an inch	
23 44 "	1 " M	Simple R	" Brasdor's jacket;]		" 21 d'ys 1 ""* Paralysis of arm;				tt
		and ob-		sling; no axillary			curvature ui		
24 14 "	3mo's "	lique " L.	pad " Day's splint. Fox's apparatus		" 11 " =		spine, &c. inch Fragments ride, but do not pro-ject much		"
25 22 " 26 35 "	4 " F 5 y'rs M	" R	" Fox's apparatus. " Treated by a sur-ereon. but treat-		66		■ inch Slight projection : inch Right shoulder falls. Arm asuse-		"
				ment unknown				ful as betore	
27 33 "	14 " '	"		rreated by a sur-geon, but treat-	66		i inch	iVrm occasionally painful	
				ment unknown					
28 30 " "< " *		. " L	«	Fox's apparatus;	it	26 "	} inch	'rejection of inner	
				adhesive plaster				fragment. Func-	
				dressing; Day's				tions of arm per-	
				splint, with ax-illary pad, &c. Fox's apparatus during three days, and after				fect	
29 20 "	6 w'ks J	' " '	if		ft	21 "	J inch	Arm as useful as before. No more projection than is	u
				third day no				usually found	
				treatment					
30 16 "	17 y'rs	i « R	u	Surgeon employ-	U		} inch	Remarkable pro-	"
				ed, but treatment				jection of inner	
				unknown				fragment. Func-tions of arm per-fect	
31 25 "	2 "	i « i		Surgeon employ-ed, but treatment unknown	11		I inch	Slight projection. Functions of arm perfect	
32 40 "	2mo's	66 (6	6 «	Sling; paste com-presses ; axillary	66	30 "	J inch	Projection of in-ner fragment	
33 26 "	4 w'ks	" Simple 1 and	t. "	pad, &c. Back splint; sling-no axillary pad	tt	7 "	Not any	Line of bone per-fect	Per.
34 25 "	2mo's	trans. " Simple and ob-	"	Back splint; sling no axillary pad	"	14 "	| inch	Slight projection	Imp.
35 28 "	12 y'rs	lique F. "	a	Surg^Jn employ ed,buttreatmen unknown	«		i inch	Slight projection at seat of frac-ture. Functions of arm perfect	u
36 12 "	23 "	.. a	u	Surgeon employ ed, but treatmen	It		i incl	Slight bend at seat of fracture. Foi many years thi deformity wa	u
				unknown					
								much greater	
								Functions perfec	t
37 46 "	11 "	M. "	L. "	Bandages; adhe sive straps; n	it	14 "	J incl	i Slight projection use of arm per feet This was a secon( fracture at th	a
38 30 "	1 "	" Simple	R. "	axillary pad Fox's apparatus	61	21 "			1 B
		and						same point. Th	e
		trans.						original deform ty was not in creased. (See cas 52.) Prosecutio	--e a
39 32 " 40 20 "	10 " 2 "	16 " Simple and ob. 1	L. "	Sling; bandages no axillary pads Fox's apparatus	ti		Not any £ inc	A slight forwar displacement h Slight iui pah-men of strength	i t "
L---									
 
76
Fractures of the Clacirh-.—Continued.
	6 o			4	3		RESULT.				
	c	a _;			o	TREATMENT.					
							o ■3	■3 c2	3 A 0		?l
											
41	< ~	6 3	■j!	51™ ~	'o		c ° . a P	0	a*£		Uip.
	17 y'rs	4 y'rs	M.	Simple K	i lutor end	31ing; band-	United		l inch	Considerable pro-	
				and ob-	of middle	ages; axillary				jection of inner	
				lique	third	pad, &c.				fragment. Use of arm impaired, <fcc. &c.	
42	51 "	3mo's	F.			Fig. of 8; Fox's apparatus; ax-illary pad, &c.	u		\ inch	'rejection of frag-ments, paraly-sys, and swell-ing of arm	
43	5 "	35 y'rs		Simple '	"	Surgeon em-ployed, but treatment un-known	66			Slight projec-tion ; occasion-ally painful	
44	32 "	8 "	M.	Simple and ob-lique	«	Surgeon em-ployed, but treatment un-known	16		j inch	Slight projec-tion. Arm not as strong as be-fore	
45	15 "	6 "		" t		Back board splint, &c.	a			No deformity	Per.
INNER THIRD.											
40	80 y'rs	2mo's	F.	Simple B and trans.	. One inch from ster-num		United		Not any		Per.
OUTER THIRD.											
47	21 y'rs	1 y'r	M.	Simple I	. Outside ofGutta percha		United		i inch	Inner fragment	Imp.
				and	coracoid	back splint				projects slightly	
				trans.	process						
48	55 "	6 w'ks		Simple ' and ob-lique	One inch from acro-mion pro-cess	Fox's appara-tus	Delay-ed 6 w'ks		i inch	Unable to lift his arm	
COMMINUTED.											
49	33 y'rs	8 y'rs	M.	Com- 1 min. and ob-lique	I. Inner end of outer third and middle	Fox's appara tus; fig. of 8 &c.	United	22 and 28 d'ys	i inch	Use of arm not impaired	Imp.
50	29 "	1 "		Com-min.		Fox's appara tus	«		i inch	He could raise his arm to his head before it was dressed	tt
51	46 "	14 "	66	it	L. Middle, and one inch nearerster num	Sling, &c. Nc axillary pad	"		i inch	Remarkable de-formity. Shoul der falls. Func-tions of arm perfect.	a
52	12 "	18 "		"	R. Inner end of outei third, anc H inches nearer sternum.	Employed t surgeon, bu treatment un known	"		1 inch	Wasting and pal sey of arm. Con traction of hanc and fingers	ti
53	50 «	3 "		it	L. "	Gutta perchs back-splint; fig. of 8, etc.	i "		linch	Inner fragmen projects	li
 
77
                                   REMARKS.

         "Yet it is lamentable, even at the present day, to see how some fashionable doctors
       torment their patients, in cases of fracture  of the clavicle, with tight bandages,
       which, after  all, have little or no  power in  keeping the bones in situ."—Note to
       Works of Hippocrates, Sydenham Society's ed., vol. ii. p. 585.

*          I have found it convenient to divide fractures of the clavicle into
       " Incomplete" and " Complete," and again to arrange complete frac-
       tures under several  heads,  according as they may be simple or
       comminuted, or  as they  may  have  occurred through the middle,
       inner or outer thirds.
          Boyer denied the existence of the incomplete or  partial fracture,
       and calls  it " an occurrence utterly impossible."  (Boyer on Bones,
       Amer. ed., vol. i. p. 17, 1805.)   But Boyer had  reference, no  doubt,
       to what has been called sometimes a partial fracture in adult bones,
       and not at all to that accident which we are now considering.
          Mecling,  Turine, Dupuytren, Malgaigne,  South, Chelius,  Syme,
       Miller, B.  Cooper,  Norris,  Barton, Gibson, with others,  recognize
       its existence, and no one, perhaps,  at the present day, doubts its
       possibility.  J. Rhea Barton, of Philadelphia, has also written upon
       this subject a very interesting  memoir,  entitled, "Remarks on
       certain Injuries of the Bones in Children."   (See Philadelphia Med-
       ical Recorder, vol. iv. p. 13, 1821.)
          Fergusson  compares it  to  the fracture  of  a "walking stick;"
       South to the cracking of a " fresh willow," but  it is more generally
       known as the " green stick" fracture.
          It is necessary, I think, to admit at least two forms or degrees of
       incomplete fractures, the first of which is unaccompanied with any
       lesion of the periosteum, and the second is attended with this addi-
       tional circumstance.   A "refinement" which, I ought  to say, Mr.
       Erichsen thinks  unnecessary.
          I am disposed, however, not only to admit these divisions, but even
       to extend them, and to regard interperiosteal fractures as existing in
       three  conditions.  First, as a mere bend, in which the  fibres upon
       the one side are compressed, and upon the other side expanded,
       without any actual disruption, except what may be interstitial, and
       too trivial to be reckoned.  Second, as  a  fracture of the central
       fibres of the  bone, while the outer, more completely cartilaginous
       and more elastic fibres, preserve  their integrity, a  condition which
       M. Blandin claims to have first explained, and which he considers,
       without sufficient reason, it seems to me, as the sole cause why, in 
78
 partial fractures, the fragments do not separate.  Third, as a fracture
 of the  middle and  outer fibres, generally upon one side only, but
 within the periosteum.
   It is certain that these  several  injuries do occur;  the  bone
 being  sometimes  merely bent,  as  happens most frequently in in-
 fancy.   In  such cases, the  bone will often resume its form  spon-
 taneously, as does the twig of willow after having been bent upon       »
 itself.  I have reported seven of these cases, and  the oldest patient
 was ten years, while of the second and third variety the oldest child
 was fourteen years.
   Since, however, they possess this feature in common, namely,
 that the periosteum is not broken, and there are, consequently, no
 abrupt angles or sharp spiculse  pushing out at the seat of  fracture,
 but only a smooth, knuckle-like projection, it is proper to speak of
 them as one form.
   In the other form of incomplete fracture, the periosteum yields
 more or less, and  a  thin fragment of the outer fibres of the  bone
 may be made to  fly off from the point of fracture, as in Case 13.
 Or it may break  transversely to its  diameter (as occurs most fre-        '
 quently), but not completely across.   No crepitus can, therefore, be
 discovered, unless, by imprudent efforts to examine or to straighten
 the bone, it should  be entirely  separated, and then at  once  both
 crepitus and displacement will be manifest.  To this  form of acci-
 dent belong Cases 2, 9, 13, and 14, the oldest of which patients was
 nineteen years.
   Unlike complete fractures of  the clavicle, a considerable propor-
 tion of these  occur  rather to the sternal side  of the middle,  and
 they are seldom oblique.
   The direction of the displacement is usually forwards and a  little
 downwards.  It will be observed, however, that the amount of dis-        ♦
 placement existing in a bone broken in this way, and for  some time
 united,  cannot always be measured by the amount of anterior pro-
jection at the seat of fracture, since in Case 3, as well as in Case 13,
 reported to  me by Dr. Green, and I  think, also, in several other
 cases which have come under my observation,  the line of  the axis
 of the bone is completely restored, and there exists only a node-like
 projection in front, with no corresponding depression behind,  indi-
 cating,  as Dr.  Green  has very  properly suggested, one of  those
 fractures in which the bone has been for the moment bent forwards,
 but has also  immediately, in consequence of its elasticity, resumed its
 original position. The projection, which is soon after found to exist, 
79
        is probably, therefore, an effusion under the periosteum—a callus.
        This may explain,' also, why, in some instances, the parents do not
        discover the fracture until after several days, in one  instance, Case
        11, not  until after five days, and in  Case 12, not until after three
        weeks.  There was at first no deformity, because no effusion had
        yet occurred.
t                                     Fig. 3.
Incomplete Fracture. Case 12.
  Even in those cases where the bone remains bent, most, if not all
of the callus will be found in front, or in the direction in which the
bone has yielded.  This was very marked in the specimen obtained
from the dissecting-room* where the angular deviation was extra-
ordinary, but there was no callus behind  the point of fracture.  A
circumstance which, may so easily mislead us as to the amount of
actual bending, ought not to be forgotten.
  The prognosis in these simple accidents is generally very favora-
ble.  Where the bone is broken, but has by its own elasticity resumed
its former position, the deformity, depending only upon the presence
of callus, will  sooner or later disappear, yet not entirely, I think,
until after several months or even years.  Where the fracture is a
little more complete, and the fragments are not immediately restored
spontaneously, the restoration  can  sometimes be accomplished with
ease by moderate pressure upon the projecting  point, but this only
when the case is early  presented to the surgeon, and  not always

  * This case follows Case 14, but it is not included in the tables, or in the general
enumeration. 
80
even then, as some of my cases have proven.  In partial fractures
of the bones of the forearm, occurring in children, I  have not ex-
perienced much difficulty in straightening the bones at any time
within a week or two, but the same observation will not hold good
with  regard to the clavicle.  The forces cannot be so conveniently
applied, and its repair and consolidation are much more rapid.
  I agree Avith Syme, that, in cases of partial fracture, Avhether  it
occurs in the  clavicle  or elsewhere, when the fragments are once
restored, mechanical support will hardly be required; at least only
in a few cases.  If, however, such support becomes necessary, the
treatment ought to be essentially the same as for complete fractures.
  The division of complete fractures of the clavicle, according as
the accident occurs through  the inner, outer, or middle third, has
been adopted for the convenience of prognosis.  By the outer third,
I mean all that portion of the clavicle included between its scapular
extremity and the internal margin of the conoid ligament, be it more
or less than one-third.  The remaining  portion  is intended to be
divided equally into two separate thirds.   The peculiarities of these
several portions, in respect of anatomical relations, liability to frac-
ture, results, &c, will explain the propriety of the divisions.
  Fractures which are complete occur  mostly after the bones have
become firm and unyielding.   They are also  generally oblique, sel-
dom comminuted, still more rarely compound.  The point of a bone
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 ligament.  It might be more exact to say that the fracture
commences usually at this  point, and from thence extends, more or
less obliquely, downwards and inwards  towards the sternum, the
entire length of the fracture, including, sometimes, nearly one third
of the bone.
  Bransby Cooper, Miller, Liston, Fergusson, and  many others, have
spoken of this fracture as occurring most frequently at about its
" middle," and in the last American edition of Fergusson's Surgery,
is a plate, intended, I suppose, to indicate the point where the frac-
ture usually takes place, and it is here represented as a little to the
sternal side  of the centre. The fact is, however, that it generally
gives way at  what Syme calls  "the beginning of  the acromial
curvature,"  and near the junction of the outer third with the inner
two-thirds.
  Why the  bone should break more frequently at this point, espe-
cially in the adult, it is not difficult to understand.  It  is smaller 
81
here than elsewhere, and less supported by muscular and ligament-
ous attachments.   At this point, also, the axis of the  bone begins
pretty abruptly to curve forwards, more abruptly in the adult  and
male than in the child and female.
  When, therefore, a blow is received upon the point  of the
shoulders—and it  is in this way, by a contre coup, that the fracture
most frequently occurs—the force of the blow conveyed through the
outer portion of the clavicle is suddenly arrested, and expends itself
upon the point where the.direction of the axis is changed.
  Of 48 simple fractures of the clavicle recorded by  me, 40 have
occurred through the middle third, and a great majority, about 35,
at the acromial end of this third; and of  58 fractures, including
the incomplete and comminuted,  which latter are always broken
twice, 39 have occurred at or near this point.
  The direction of the displacement is almost always such, that the
inner end of the outer fragment is  depressed, and falls  below the
outer end of the inner fragment.  It is also found often a little be-
hind the inner fragment.
  Syme has seen a case in which the outer fragment  overrode the
inner ; and M. Gueretin reports another case, in the Presse Medicate.
Hippocrates  also speaks of this accident as known to him.  Desault
saw several cases, and has recorded one.  (Treatise on Fractures and
Dislocations, Amer. ed., p. 16.)
  An overlapping and consequent shortening of from one-quarter
of an inch to one inch, is almost always present in oblique frac-
tures, occurring at the outer end of the middle  third,  and not un-
frequently in fractures occurring at other points, and in  transverse
fractures.
  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.
(Cases 5, 6, 10.)
  Malgaigne says it has only happened to him to see it once in 2,358
cases, at the Hotel Dieu, and he can recollect only five other examples.
And of  158  cases of broken clavicles reported from the New York
Hospital, it is stated to have occurred in only four.  These gentle-
men  however, ronly report hospital  cases, and they have reference,
doubtless, to complete fractures.  Incomplete fractures are not so
likely to be seen in such institutions, but are more common, I  sus-
pect, in private practice.
  Prognosis in this fracture deserves especial attention.  In no other
       6 
82
bone, except the femur, does a shortening so uniformly result.  Of
39 complete fractures, only 7 have united without shortening; and
of 25 simple, oblique, complete fractures, which have occurred at or
near the outer end of the middle third, only one has united without
any shortening (Case 45); 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 had anything to do with the result.  Three        I
cases of complete transverse  fracture, occurring at the  same point,
have united without shortening.
  The shortening varies from  one-quarter of an inch to one inch,
and the fragments are almost always found lying in the position in
which we have described them to be at the first—the outer end of
the inner fragment  being above, and often a little in front of the
outer: sometimes, especially in lean persons, and when the fracture
is very oblique, presenting a sharp and unseemly projection.

                             Fig. 4.
Complete Fracture.  Case 16.
  The presence of a small amount of ensheathing callus soon after
the cure is completed, sometimes increases the deformity.  It is
rarely seen to encircle the  bone completely,  but, if present, it is
usually 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 inter-
cepted fragment turned at right angles to the axis of the bone.  In 
83
the case of partial fracture, reported by Dr. Green, a similar cir-
cumstance was observed, but which his natural shrewdness soon
enabled him to explain.
  Complete fractures  through the  sternal third of  the bone are
exceedingly rare, and I have been able to record, from my own
observation, but  one case, which  occurred in an old lady, eighty
years of age.  The fracture was within half an inch of the sternum)
transverse, and it united without  any dressings,  and without defor-
mity.  The rhomboid ligament must, in such accidents, generally
prevent any considerable displacement.
  It is not quite so rare to find a complete fracture through the
acromial third of the clavicle, or through that portion beginning at
the acromion process, and terminating at the sternal margin of the
internal fasciculus of the coraco-clavicular ligament.
  I have  recorded two cases, in both of which a  slight riding, about
one-quarter of an  inch, has resulted; and in one, the union was
delayed at least beyond six weeks. ■ The deformity, or projection,
was in both cases very trifling.
   Comminuted fractures have been observed by  me five times.  The
intercepted fragment generally falls off  from  the line of the  other
fragments, and cannot easily be restored.  I have never seen a corn-

                             Fig. 5.
Comminuted Fracture. Case 52.
pound fracture of the clavicle, although the outer end of the inner
fragment often projects in such a way as to excite a serious appre-
hension that it will push through the skin. 
84
  The clavicle usually unites with great rapidity, generally within
twenty days.  In one instance (Case 33), a transverse fracture, the
union seemed to be tolerably firm at seven days.  Wallace reports
one case from the Pennsylvania Hospital, which was cured in eight
days, and another in nine days (Amer. Med. Journ., vol. xv. p. 115).
Velpeau says the clavicle will unite in from fifteen  to twenty-five
days ; Benjamin Bell, in fourteen.
  I have only once seen a case of ligamentous union (Case 21), and
in one other instance, already referred to, union was delayed at least
six  weeks.
  It is seldom that the arm suffers any serious ultimate injury,
whatever  may be the mode of union.   This  is most remarkably
confirmed by the instance of ligamentous union, in which the func-
tions of the arm are very little, if at all, impaired.  Chelius, how-
ever, quotes a case of artificial joint of the clavicle where " the use
of the limb Avas not destroyed, but impaired." (Op. cit., vol. i. p. 603.)
The paralysis in Case 23 was not due certainly to the fracture, nor
is it probable  that it was due to the treatment, but only to some in-
jury entirely foreign to the fracture. In Case 42, also, no paralysis
existed previous to the repeated attempts which were made to over-
come the riding of the fragments.  I have no censure for the excel-
lent surgeon who sought thus to accomplish an end so desirable.
He was attempting to do only what others claimed to have done in
similar cases,  and with the same apparatus. A failure, therefore,
Avas certain to bring discredit upon his  skill, or to  subject him to
the  charge of not having  employed proper diligence  and care in
the use of the means at his command.   But it  has added another
instance  to that mentioned by Dr. Parker, in which  the use of the
axillary  pad  has resulted  in at least temporary paralysis of  the
arm, and  to this class,  also, probably belongs  the  case  treated by
Desault himself,  and reported  by Bichat, in which the  paralysis
began only on the  third day,  and was complete  on the seventh.
Hoav many more the records  of private or  hospital  surgery, if
carefully  examined,  might  show,  I cannot  tell.   In  Case  38,
where the bone had been  previously comminuted, a paralysis  ex-
isted, but whether it was due to the severity of the original injury
or  to  the treatment,  could not be satisfactorily  learned.   Mr.
Earle has recorded a case in which the clavicle was comminuted,
and the  " nerves  converging to form  the  axillary plexus" Avcre
so  injured that paralysis  of the  arm ensued. (Samuel Cooper's
Surg., Amer.  ed., vol. ii. p. 323.) 
85
  In a case where conclusions must be drawn so mortifying to our
professional pride, it is but fair that the Avriter should be permitted
to defend the value of his evidences by a reference to the opinions of
other practical surgeons.
  " Great difficulty has been experienced in treating this fracture."
(Syme's Principles of Surgery, p. 266, Philadelphia ed., 1832.)
  " The  indications of  treatment are plain, but, unfortunately, not
very  easily  fulfilled."  (Miller's Practice of Surgery, 3d Amer. ed.
from  2d  Edinburgh, p.  309.)
  "Fractures of the clavicle will often cause greater trouble than
those which are considered of a more serious character, and the
utmost pains will not, on all occasions, sufirce to prevent a slight
prominence  of the inner  fragment."  (Practical  Surgery.  By Wm.
Fergusson.  4th Amer. ed. from 3d London, p.  215.)
   " Setting of this fracture is  easy, yet only in very rare cases is
the cure possible without any deformity."   (System of Surgery. By
J. M. Chelius, of Heidelberg, with notes by South.  1st Amer. ed.,
vol. i. p. 603.)
   " It is considered, also, that the close union of the fracture of the
oollar-bone depends less on the apparatus than  on the position and
direction  of the fracture;  (therefore,  in spite  of the most careful
 application of this apparatus, some deformity often remains.") (Ibid.,
p. 605.)
   The following statements of M.  Yelpeau are  found in a letter ad-
 dressed  to the editor of the Boston Medical and Surgical Journal, by
 J. Willis Fisher, dated Paris, Sept. 16, 1846.
   Mr. Fisher remarks that  the report is drawn in part from his own
 notes," and partly from  " the  report  published in  the Gazette des
 ffdpitaux."  It is the  annual summary of M. Velpeau's practice at
 La Charite", for the year  ending Sept. 1846.
   " The fractures of the clavicle, less numerous than ordinarily,
 have been only four.  They have  proved these three often repeated
 propositions:  First,  that  contrary  to the general  opinion, the
 patients can carry the  hand to the head when they have a fractured
 clavicle. Secondly, that the consolidation of the bone demands only
 from fifteen to twenty-five days, and not six weeks or  two months.
 Thirdly, that with all the bandages imaginable, we cannot prevent
 fracture'of  the two internal and oblique thirds from leaving a de-
 formity " (Bost. Med. and Surg. Joum., vol. xxxv. p. 212.)
    « Fracture of the clavicle is almost always followed by deformity, 
86
whatever may be  the perfection of the apparatus and the care of
the surgeon."  ( Vidal (de Cassis). Paris ed., vol. ii. p. 105.)
   " Hippocrates has observed that some degree of deformity almost
always accompanies the reunion of a fractured clavicle; all Avriters
since his time have made the same remark; experience has  con-
firmed the truth of it."  (Treatise on Fractures and Luxations. By P.
J. Desault.  Edited by Xav. Bichat, and translated by Charles Cald-
well, M.  D.  Philadelphia, 1805, p. 9.)
   " 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, ivithout
obvious deformity."   (Reyiiel Coates, Amer. Med. Journ., vol. xviii. p.
62.  Old series.)
   I need not say that  the  "venerable gentleman" to Avhom Dr.
Coates refers in this passage, was the late Dr. Physick, of Philadelphia.
   If evidence Avere needed beyond that Avhich has been furnished,
of the  difficulty  of bringing to a successful issue the treatment
of this fracture,  it  might be supplied, one Avould think, by a refer-
ence 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.
Such are the  names of Paulus iEgineta, Petit,  Duverney, Boyer,
Boettcher, Desault, Ledran,  David, Moscati, Dupuytren, Ravaton,
Cruveilhier, Lasere, Delpech, Flamant, Reynaud, Meyer, Mayor, Mes-
lier,  Glaucius, Kluge, Heister,  Evers, Brunninghausen, Wilhelm,
Eberl,  Brefeld, Eicheimer, Koppenstaedter,  Brasdor, Earle, Chap-
man, Keal, Ellis, Lee, Amesbury, Wattman, Hancock, Coates, Fox,
BroAvn, Hunton,  Day, Keckerly, Guillou, Cabot, Coleman, Bartlett,
Welch, &c.
   All these  surgeons, however, have admitted the same indications
of treatment, viz:  That  in order  to a  complete restoration of the
outer fragment, Avhich alone is  supposed to be much displaced, we
are to carry the shoulder upwards, outwards and backwards.   But
as to the  means by which these  indications can be most easily, if at
all accomplished, the widest  differences of opinion have prevailed;
and in the debate it may be seen that while on the one hand no in-
vention has  wanted for  both advocates and admirers, on the other
hand, no  method has escaped its equivalent of censure. 
87
  Hippocrates, Celsus, Dupuytren, and others simply directed  the
patients to lie upon their backs, with the spinal column so support-
ed and lifted with pillows, as that the shoulders would, by their own
weight, fall  backwards;  and from the account given by Dr. Lente,
it may be inferred that a similar plan is generally adopted in  the
New York City Hospital.  " But this result (deformity) rarely hap-
pens when the  patient has strictly followed  the  directions of the
surgeon, as to position especially, for it is by position more than by
any other remedial means, that a good result is to be effected. *  *  *
The persevering continuance of the  supine position in bed, with
the head low, and, if necessary, a pad between the shoulders. This
is the treatment uniformly adopted by  Dr. Buck, in the hospital,
and the results of his treatment  are certainly such as to recommend
it highly."   (Lente.)
   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; and Dr. Post mentions a case treated in this man-
ner which terminated with very little deformity. (JV. Y. Journ. Med.,
vol. ii. p. 266.)
   Albucasis, Lanfranc, Guy de  Chauliac,  Petit, Parr, Syme, Skey,
Brunninghausen, Parker, and very many  others,  especially among
the English, have preferred, in order to  carry the shoulders back, a
 figure  of 8, while  Desault, Colles, South, Samuel  Cooper, have
represented  this bandage as  useless, annoying, and mischievous.
   Heister, Chelius, Miller, Brefeld, Keckerley, prefer for this  pur-
 pose, some  form of back-splint, extending  from  acromion to acro-
 mion, against which the shoulders may be  properly secured. Parker
 says that splints of this kind, with a figure of 8 bandage, are " bet-
 ter than all  the apparatus ever invented."   While Mr. South gives
 his testimony in  relation to all dressings of this sort, as folloAVS:
 " 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."
 (Note to Chelius, vol. i. p. 605.)
    Fox, Desault and  others bring the elbow a little forwards, and
 then lift the shoulder upwards and  backwards.   Wattman carries
 the elbow  still further  forwards, so  as  to lay the hand across the
 opposite shoulder,  Avhile Guillou carries the  hand  and  forearm
 behind the patient, and then proceeds to lift the shoulder to its place. 
88
  Thus Desault, Fox, and Wattman accomplish the indication to
carry the shoulder back, by lifting the humerus while the elbow is
in front of the body, and Guillou accomplishes the same indication
by lifting the humerus when the elbow is a little behind the body.
Chelius, also (vol. i. p. 603), 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.  (Note to Miller's Practice, p. 311.)
  Hollingsworth has also treated one case successfully by Guillou's
method, and adds his testimony  in its  favor.  But how shall we
explain these equal results from opposite modes of treatment?  Is
the indication to carry the shoulders back, which Fox sought to
accomplish  by  pressing the elbow upwards and  backwards, as
easily attained by pressing the  elbow upwards and forwards?  Or
are we not compelled to infer that there  has been some mistake as
to the precise amount of good accomplished  by the apparatus in
either case?  Moreover,  Coates, 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  iEgineta,  Boyer, Desault, Pecceti, Liston, Fergusson,
Samuel Cooper, Erichsen, Miller, Skey, Fox, Smith, Norris, Sargent,
recommended an axillary pad, while Richerand, Velpeau, Dupuy-
tren,  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"—(Samuel Cooper's Surgery, with notes
by  Parker, vol. ii. p. 328), and I have myself recorded another.
  Desault's plan, which took its origin, as Velpeau thinks, in  the
spica of Glaucius, under various modifications, is recommended by
Delpech, Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson,
Liston, Cutler,  Physick, Coates,  and Gibson; while by Velpeau,
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 use-
less." (Op. cit., vol. ii. p. 328.)
   The dextrine bandages, or apparatus immobile, of Blandin, Vel- 
                               89

peau, and  others, constitute only  another  form of  the bandage
dressing of Desault.
  The sling, in  some of its forms,  is employed by Richerand, Hu-
berthal, Colles, Miller, Fox, Smith, Sargent, Norris, Neil, Benjamin
Bell, Bransby Cooper, Earle, Chapman, Keal, and by a large ma-
jority of the English surgeons;  while Dr. Gibson declares the sling
bandage employed so much by the English, "the most inefficient,
contemptible, and injurious of all contrivances for  such purposes."
  No apparatus, perhaps, has been so generally employed, among
American  surgeons, as that form  of the sling introduced  by Dr.
George Fox into the Pennsylvania Hospital in 1828,  since which
time no other has ever been used  in that institution for the treat-
ment of broken clavicles.
  Sargent  says  of it: "Fractures of the  clavicles,  treated by this
apparatus,  are daily dismissed from the Pennsylvania Hospital, and
by  surgeons  in  private practice, cured Avithout perceptible deform-
ity." (SargenCs Minor Surgery, p. 180.  1848.)
  Norris, in a note to  Listorfs Practical Surgery, affirms that "the
chief indications in the treatment of fracture of the  clavicle are
perfectly fulfilled by the use of this apparatus." (Op. cit, Am. edit.,
p. 47.)
  Smith, in his Minor Surgery, declares that  Fox's apparatus accom-
plishes "perfect cures" in very many cases,  and that it is "a very
rare thing  for a  simple case to  go out of the house (Pennsylvania
Hospital) with any other deformity save that which time cures, viz:
the deposition of the provisional callus."  (Op. cit., p. 209.)
  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 mea-
sure this general preference is due fairly to the intrinsic excellences
of  the dressing.  But I must be permitted to express a doubt whe-
ther it has made deformities of the clavicle "the  exception, instead
of the rule," with us. I have used this dressing, as may be seen by
a reference to my cases, oftener than any other form, and yet my
success has by no means been so flattering  as  has been the success
of  these gentlemen.  I have seen  others employ it, also, and with
pretty much the same results.  Nor ought it to be forgotten that, in 
90
Great Britain, by far the greater majority of surgeons employ an
apparatus essentially the same.   I have seen it in many of the hos-
pitals, and Mr. Bickersteth, one of the surgeons of the Liverpool
Infirmary, informed me, in 1844, that it had been in use Avith them
as long  as thirty years.  All that has  justly been said against the
English mode  of dressing 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 Pennsylvania Hospital, the axil-
lary pad employed is not so large, and, especially, not so thick, as
that recommended by Desault, and in this respect  it is plainly an
improvement; but then, in the same proportion that it is made  less
thick, it is less poAverful to accomplish the indication in question;
and if it merely fills the axillary space, then it is no longer a fulcrum
upon which the arm  is to operate as a lever, but it is only, in its
effect "retentive."
  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 dress-
ing, is it asking too much of these gentlemen, that they will present
us some more  precise statistical testimony ?  It will be  observed
that its  advocates claim for it what is  not to-day, at least, claimed
for any other apparatus, viz: that, under its use in the Pennsylvania
Hospital, and in the  hands of private  practitioners, so far as they
have seen, deformities have become the "exception."   It is affirmed
to answer " perfectly" all the indications.  By which it must be in-
tended to  say, that, in addition to both of the other indications, that
also, which has always heretofore been found so  difficult, if not im-
possible, 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 be-
longs to a multitude  of other forms of dressing as well as to  that in
question, than upon that which forces the shoulder  out, and it may
be accomplished, in a majority of cases, as well without an axillary
pad, with  a mere sling, as with it.   But, in fact,  my experience has
convinced me  that the absence or presence of  such a projection, 
91
after union, is due  more to the circumstances of the fracture, as to
whether it is more or less oblique;  and still more especially, to the
degree of roundness, or emaciation of the patient, than to any form,
or part, or condition of the apparatus.  It will be found  more  dis-
tinct in oblique fractures than in transverse, and much more marked
in thin persons than in plump, or fat persons, and more so in mus-
cular than in non-muscular.   In short, I affirm that  such a projec-
tion has occurred as often under my observation, when this dressing
has been used, as it has when other forms have been  employed.
   Finally, while I deprecate incautious assumptions in regard to
the capabilities of any form of dressing for  broken  collar-bones, a
disposition to  which is manifested by more than one advocate of
special plans* I  am ready to bear my humble testimony in favor
of that one of whose claims I have taken the liberty to speak so
freely, and which is usually  known in this  country by the name of
Fox's apparatus, consisting essentially of a sling, axillary pad, and
bandages to secure the arm to the chest, and to which the stuffed
collar is a convenient accessory, but admits of various modifications,
answering the same ends.  Among the considerable variety of dress-
ings which I  have used, this, either with or without  such slight
modifications  as I shall presently suggest, has seemed to be most
 simple in its construction, the most comfortable to the  patient, the
 least liable to  derangement (if I except Velpeau's dextrine bandage),
 and  as capable as any other of answering  the several  indications
 proposed.
   No apparatus is better able to answer the first indication, namely,
 " to carry the shoulder up,"  and thus to bring the fragments in line.
 If, as not unfrequently happens, the outer end of the inner fragment
 is also carried a little  upwards  and forwards, it may be, in some
 measure, replaced by inclining the head to the injured side, or by a
 carefully adjusted compress  and bandage.   But it is not probable
 that any patient will consent to remain a long time in a position so
 unnatural and constrained;  nor is it very easy, as the experiment

   * The bone will be found to  lie quite smooth, to remain of its proper length, to
 unite, generally,  within twenty days, and without any unseemly exuberance of callus.
 —Liston.  At length, Desault proved that a feeble and unskilful mode of treatment
 was the sole cause of a want of success, and that, by being more correct and judicious,
 art might be as successful here as  in other fractures.  They supposed that to be a
 superabundant callus, which was nothing but a displacement of the fragments.  These
 visionary hypotheses ceased to exist as soon as this displacement was prevented by a
 proper apparatus.—Ibid. 
92
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 Avhich I have  seen described, I see       }•
no alternative but to trust to that action of  the muscles attached to
the scapula, by  which, as Desault first explained, when the shoulder
is lifted perpendicularly, it is also in some degree carried backwards,
and that, too, it has occurred to me frequently to observe, just as
much as when the upward pressure is made Avith  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 unac-
complished ; that it cannot be claimed for this, or for any other ap-
paratus yet invented; that, in a certain class of cases which I have
sufficiently indicated, constituting a vast majority of the whole num-
ber, 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 sought, will ever be attained.
Yet it is presumptuous, perhaps, to say what the skill and ingenuity
of a profession  whose  labors never cease, may 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, calls atten-
tion to the danger of making too much pressure upon the brachial
artery and nerves, when the  axillary pad is  used, and the arm is, at
the same  time,  carried forwards upon the body.  In bringing the
elbow forwards  so as to lay the forearm across the body, the humerus
is made to rotate inwards, and  the brachial artery and nerves are
brought into more direct apposition with the pad.  The same ob-
jection must hold, only in a greater degree, to M. Guillou's  method
of carrying the forearm across the back.
  The humerus ought then to be permitted to hang perpendicularly
beside the body, and thus the nerves and bloodvessels will be re-
moved in  a great measure,  yet not entirely, from pressure. The
pad (to be employed  only as a part of the contentive means, and
not as a fulcrum) should be  firm, but scarcely thicker than is ne- 
93
      cessary to fill completely the axillary space, when the elboAV is made
      to press snugly against the side of the body.
         In consequence of having placed the elbow further 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 direc-
|      tions—before and behind the body—towards the stuffed collar; and
      each set of front and back tapes, attached to the humeral portion of
      the tray, must be in pairs, for the convenience of tying.  I find it
      convenient also to secure the arm to the body by two or  three turns
      of a roller, applied always with great  care, so that its pressure shall
      be in no degree painful or uncomfortable. 
94
APPENDIX.
AMERICAN  INVENTIONS  AND MODIFICATIONS OF  AP-
  PARATUS  FOR  THE  TREATMENT  OF  FRACTURED
  CLAVICLES.
  Fig. 6.  George Foxh Apparatus.—" Consists of a firmly stuffed pad of
a wedge shape, and  about half as long as the humerus, having 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's Minor Surgery, p. 149.)

                              Fig. 6.
George Fox's Apparatus.
  Fig. 7. E. BartleWs Apparatus.—" For an axilla pad, roll a strip of
woollen flannel, four or five inches wide, around the axilla  strap, to the
size required. 
95
  " Put on the  collar.  Apply the  pad, and  pass the strap  under the
collar, thus securing each in its place.

                                  Fig. 7.
E. Bartlett's Apparatus.
  " The sling, being  first  attached to the collar by the forward strap, is
made to receive the arm of the side affected, when the straps at the back

                                  Fig. 8.
The Author's Apparatus. 
96
of the sling should  be buckled, one behind, the other  forward, to the
ends  of the  collar with  requisite tightness to reduce the fracture and
maintain the ends in apposition.
   " The apparatus  may  be used for either side, by changing the attach-
ment of the  sling."  (Dr. Bartlett.)
   Fig. 8.  The Author's Apparatus.
   Fig. 9. E. C. Keclceley's Apparatus.—"The splint, of which the accom-
panying  figures give a representation, is two feet three inches  long and
three and a half inches wide.

                                 Fig. 9.
                          E. C. Keckeley'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, 66, 66. 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 a
handkerchief, doubled into a triangular form, in such a manner over the
arm, the front and back  parts of the  thorax, as  that  it shall draw and
confine the arm of the injured side close to the body, give it  support, and
prevent its falling down." (Am. Journ. of Med. Sciences, xv. 115,  1834.)
   Fig. 10.  Welch's Apparatus.—Back view, complete,  with the exception
of the sling and axillary cushion.
   Fig. 11. Front view, complete, as it appears when applied.   The frame,
consisting of the  dorsal  piece with the thoracic  and  cervical arms, is
formed of flexible metal, which yields sufficiently to adapt it always to the 
97
motions of the spine and chest.  The lateral or thoracic arms encircle the
body, and  the vertical or  cervical  arms, passing upwards, outwards and

                                   Fig. 10.
                          Back View of Welch's Apparatus.
  A. Vertical or dorsal piece.  6, b. Lateral or thoracic arms, c, c. Oblique or cervical arms,  d, d. Trans-
verse or acromial arms,  e, e. Leather shoulder-caps and straps.
Fig. 11.
Front View of Welch's Apparatus.
forwards, conform  to the  sides of the neck.   The  whole are well  and
thickly padded.
        7 
   The transverse or acromial arms, running parallel with the spine of the
scapula to the acromion process, are made of elastic steel, slightly curved
backwards at their outer extremities, so that, when the shoulders are
made fast to them by the shoulder-straps, they will tend  constantly to
pull the shoulders outwards and backwards.
   The several parts of the apparatus are adjusted to persons of different
sizes.
   1st. The cervical arms can  be  made to approach or to separate from
the arch,  and they can also be made longer or shorter.
   2d. The acromial arms can be lengthened or shortened  upon  either
side, and  when in use the  arm opposite the broken bone should be longer
than the one opposite the  sound bone, to give greater freedom to the arm
upon this  side.
   In the front view of the apparatus is seen " a padded metallic ring, the
upper edge of which is placed nearly as high as the upper edge of the
sternum.   Above are straps connecting it with the  cervical arms.   Late-
rally is  a  strap  connecting with  the shoulder-cap  of the sound  side, to
prevent the central  ring from inclining toward the injured side ; opposite
this is another strap attached  also to the sling supporting the arm and
drawing the arm of the injured side inwards;"  below these are  straps
connecting with  the thoracic arms, and at the inferior point of the ring
is a strap  designed to support the hand and forearm.
Fig. Ii
Hunton's " Yoke Splint," modified by Day.
  " The sling in which the arm rests has thin strips of metal sewed into
the cloth, at the sides of the arm both above and below the elbow, with 
                                 99

rings for the straps, in order to give a uniform and unyielding support to
the arm the entire length of the sling,"
  The axillary pad may be made in the usual form, and secured  in  the
ordinary mode.
  The inventor claims for this apparatus that it possesses, in common with
no other apparatus, the essential and distinguishing feature of accomplish-
ing the three indications through  supports resting and depending  almost
exclusively upon the spine and sternum, and but slightly if at all depend-
ing upon the shoulder of the sound side, of whose motions therefore it is
entirely independent.   He  believes  that there  is no motion of the body
which can more than slightly change their relative position.
  Fig. 12.  A. Hunton's "yoke splint,^ modified by Day,*—New  Jersey*
Medical Reporter, vol, v. p, 146, 1852. 
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