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D., PROFESSOR OF ANATOMY IN THE ECLECTIC MEDICAL INSTITUTE SECOND ^EDITION. CINCINNATI; JOHN M. SCUDDER, Publisher. 1873. H? 5 E p 1973 FJ-i-frlJi. U-^,; tf Entered According to Act of Congress in 1870, by John M. Souddeb, in the Clerk's office of the District Court for the Southern District of Ohio. CONTENTS. PART I, FRACTURES. PAGE. Preface.............................................................................. 11 Chapter I. General Observations upon the Nature and Treatment of Fractures... 17 Chapter II. Signs of Fracture........................................................................ 22 Chapter III. Process of Union....................................................................... 29 Chapter IV. Non-union, or False-joint after Fracture......................................... 36 Chapter V. Defective Union......................................................................... 41 Chapter VI. General Remarks in Regard to the Treatment of Fractures............... 43 Chapter VII. Reduction of Displaced Fragments................................................ 49 Chapter VIII. Apparatus for the Treatment of Fractures........-............................ 52 Chapter IX. Re-dressings.............................................................................. 64 Chapter X. Movements allowed a Patient........................................................ 66 Chapter XI. Management of Compound Fractures............................................. 67 Chapter XII. Diastasis, or Separation of an Epiphysis........................................ 72 Chapter XIII. Fracture of the Cranium.............................................................. 74 Chapter XIV. Fracture of the Inferior Maxillary................................................. 80 Chapter XV. Fracture of the Hyoid Bone and Laryngeal Cartilages..................... 88 Chapter XVI. Fracture of the Vertebrae.........................................................•• 91 (iii) iv Contents. PAGE, Chapter XVII. Fracture of the Ribs and Costal Cartilages..................................... 95 Chapter XVIII. Fracture of the Clavicle............................................................... 1C4 Chapter XIX. Fracture of the Scapula............................................................... 110 Chapter XX. Fracture of the Humerus............................................................ 117 Chapter XXI. Fracture of the Ulna................................................................... 137 Chapter XXII. Fracture of the Radius................................................................ 145 Chapter XXIII. Fracture of the Bones of the Hand............................................... 161 Chapter XXIV. Fracture of the Pelvic Bones....................................................... 165 Chapter XXV. Fracture of the Femur................................................................. 171 Chapter XXVI. Fracture of the Patella................................................................ 215 Chapter XXVII. Fracture of the Leg................................................................... 221 Chapter XXVIII. Fracture of the Bones of the Foot............................................... 249 ♦ «►»■■ PART Ii: DISLOCATIONS, Chapter I. General Considerations................................................................ 225 Chapter IT. Dislocation of the Jaw................................................................. 290 Chapter III. Dislocation of the Vertebrae....................................................... 297 Chapter IV. Dislocation of the Ribs.................................................... 3qo Chapter V. Dislocation of the Clavicle.......................................................... 305 Chapter VI. Dislocation of the Scapula........................................................... o^n Chapter VII. Dislocation of the Humerus......................................................... 314 Contents. -s PAGE, Chapter VIII. Dislocation of the Radius and Ulna at the Elbow............................ 335 Chapter IX. Dislocation of the Wrist.............................................................. 349 Chapter X. Dislocation of the Phalanges........................................................ 355 Chapter XI. Dislocation of the Femur............................................................. 359 Chapter XII. Dislocation of the Patella........................................................... 388 Chapter XIII. Dislocation of the Tibia............................................................... 391 Chapter XIV. Dislocation of the Tibio-fibular Articulations................................. 397 Chapter XV. Dislocation of the Ankle............................................................ 399 Chapter XVI. Dislocation of the Bones of the Foot.............................................400 ILLUSTRATIONS. FRACTURES. FIGURE. pAQE 1. Partial or "green-stick" fracture.......................................... 27 2. Specimen of broken ribs....................................................... 33 3. Method of union when fragments overlap................................. 35 4. Brainard's perforator or drill................................................. 39 5. Method of making a " reverse " in a spiral reversed bandage...... 53 6. Bandage of strips................................................................. 55 7. Lined splint material............................................................ 58 8. Moulded gutta-percha splints................................................. 58 9. Carved wooden splints.......................................................... 58 10. "Wire breeches"................................................................ 59 11. Adhesive strips to make fast to the leg, for purposes of extension. 60 12. Double inclined plane fracture box.......................................... 61 13. Welch's double inclined apparatus.......................................... 62 14. Burge's fracture bed............................................................ 63 15. Compound fracture of the leg................................................ 67 16. Separation of the lower epiphysis of the humerus..............,....... 73 17. Fracture of the lower jaw.................................................... 80 18. Pasteboard splintfor moulding to the chin................................ 84 19. Moulded pasteboard splint for the chin.................................... 84 20. Dressing for fracture of the inferior maxillary........................... 84 21. Application of silver wire to adjacent teeth.............................. 85 22. Fractured rib....................................................................... 69 23. Union of broken ribs........................................................... 100 24. Fracture of the Sternum.............••......................................... 102 25. Fracture of the Clavicle...,..................................................... 105 26. Deformity after fracture of the clavicle.................................... 107 27. Posterior view of Fox's dressing for fracture of the clavicle........ 108 28. Anterior view of Fox's dressing for fracture of the clavicle........ 108 29. Fracture of the shoulder blade............................................... Ill 30. Fracture of the acromion...................................................... 112 31. Fracture of the coracoid process............................................. 113 32. Fracture of the neck of the scapula......................................... 114 33. Humerus, divided into thirds............................................... 117 34. Carved and hinged splintfor the shoulder................................. 119 35. Fracture of the surgical neck of the humerus........................... 120 36 Woven wire splint for fractures about the shoulder.................. 121 (vii) Viii InUSTRATIONS. FIGURE. PAGE. 37. Fracture of the shaft of the humerus...................................... 123 38. Dressing for fracture of the shaft of the humerus..................... 124 39. Diastasis, or separation of the lower epiphysis of the humerus... 126 40. Double fracture of the humerus............................................ 126 41. Deformity after fracture of the humerus.................................. 128 42. Fracture of the epitrochlea.................................................... 129 43. Fracture of the external condyle of the humerus....................... 129 44. Fracture of both condyles ofthe humerus...........,..................... 129 45. Fracture ofthe internal condyle ofthe humerus........................ 130 46. Dressing for fractures ofthe condyles ofthe humerus................ 131 47. Fracture ofthe olecranon and coronoid processes ofthe ulna..... 137 48. Dressing for fracture ofthe olecranon...................................... 138 49. Fracture ofthe shaft of the ulna.........1................................... 142 50. Fracture through upper extremity ofthe radius........................ 147 51. Shows action of rotating muscles of forearm........................... 148 52. Fracture through middle ofthe shaft of the radius.................... 148 53. Union of radius and ulna after fracture.................................. 149 54. Barton's fracture of the radius.............................................. 150 55. " Silver fork " appearance of the arm after Colles' fracture ofthe radius............................................................................ 151 56. Colles' fracture ofthe radius.................................................. 152 57. Splints and dressing for treatment in Colles' fracture of the radius. 155 58. Single splint for treating Colles' fracture of the radius............... 156 59. Fracture of both bones ofthe arm.......................................... 157 60.. Comminuted fracture of both bones of forearm......................... 158 61. Dressing for fracture ofthe bones ofthe forearm....................... 159 62. Fracture ofthe bones ofthe hand........................................... 162 63. Fracture of a phalanx of the finger......................................... 163 64. Fracture of the os innominatum............................................ 166 64. Section ofthe head and neck of femur..................................... 173 65. Fracture ofthe neck of the femur within the capsule................. 179 66. Consolidation after fracture of neck ofthe femur..................... 180 67. Ligamentous uniou after fracture of the neck ofthe femur......... 181 68. Excess of callus after extra-capsular fracture of the femur......... 1S2 69. Bony union after fracture of the neck of the femur................... 184 70. Fracture ofthe greater trochanter at its extremity..................... 185 71. Fracture ofthe cervix femoris and greater trochanter................ 185 72. Fracture ofthe trochanter major............................................. 186 73. " Wire breeches " applied...................................................... 188 74. Fractureof the shaft of the* femur......................................... 192 75. Straight splint in the treatment of fractures of the femur.......... 195 76. Extension obtained by means of adhesive strips........................ 197 77. Dressing for fractures of the femur......................................... 198 78. Union of fragments of femur with overlapping.......................... 199 79. Weight and pulley for making extension.................................. 199 80. Burges' fracture apparatus applied......................................... 200 81- Fracture of the upper third of the femur................................. 201 82. Fracture of the lower third of the femur.................................. 207 83. Fracture of the femur just above the condyles.......................... 208 Illustrations. ix FIGURE. pA0B, 84. Fracture of the internal condyle ofthe femur.......................... 212 85. Fracture of both condyles of the femur................................... 212 86. Wire appliance for treating fractures near the knee.................. 213 87. Fracture of the patella......................................................... 216 88. Ligamentous union after fracture of the patella....................... 218 89. Dressing for fracture of the patella........................................ 219 90. Fracture of both bones of the leg.............................,............. 222 91. Fracture of both bones ofthe leg at the same point.................. 223 92. Fracture of both bones ofthe leg near the ankle...................... 225 93. Handkerchief hitch just above the ankle, for making extension. 229 94. Gaiter appliance to the ankle, for making extension................ 229 95. Adhesive strip fastening to the leg, for making extension......... 230 96. Dressing for fracture of both bones of the leg......................... 230 97. Fracture box, for treating the leg after both bones are broken.... 231 98. Fracture of both bones of the leg, showing consolidation of fragments...................................................................... 232 99. Fracture of the tibia alone—.............................................. 237 100. Dressing for treating the leg after fracture of the tibia.............. 238 101. Double fracture ofthe fibula.............................................. 241 102. Potts' fracture of the fibula................................................ 242 103. Fracture ofthe fibula and dislocation ofthe ankle................. 243 104. Dressing for Potts' fracture of the fibula............................... 245 105. Dupuytren's dressing for Potts' fracture................................. 246 -----------♦ ♦ »----------- DISLOCATIONS. 106. Dislocation ofthe lower jaw................................................. 209 107. Appearance of the face produced by dislocation of the lower jaw. 292 108. Dislocation ofthe head ofthe humerus inwards (subcoracoid)... 317 109. New socket formed under the coracoid process........................ 321 110. Subglenoid dislocation of the humerus.................................... 326 111. Subspinous dislocation of the humerus.................................. 329 112. Dislocation of the elbow...................................................... 336 113. Dislocation of the elbow..................................................... 338 114. Dislocation ofthe head of the radius forwards........................ 342 115. Dislocation ofthe head of the radius backwards..................... 343 116. Dislocation of the carpus backwards..................................... 350 117. Dislocation of the carpus forwards........................................ 351 118. Dislocation of the first phalanx of the thumb forwards........... 355 119. Dislocation of the head of the femur upwards and backwards, upon the dorsum of the ilium........................................... 361 120. Manner of reducing dislocations ofthe femur by the manipulat- ing plan......................................................................... 373 x Illustrations. FIGURE. PAGE 121. Dislocation of the head of the femur downwards, into the thy- roid foramen.................................................................. 377 122. Dislocation of the femur forwards, upon the pubes.................. 381 123. Dislocation of the patella..................................................... 388 124. Dislocation of the tibia........................................................ 391 125. Lateral dislocation of the knee............................................. 394 126. Dislocation of the foot outwards........................................... 400 127. Dislocation of the foot backwards......................................... 403 PEEFAOE. The improvements and modifications which have recently taken place in the management of fractures and dislocations, and the fact that the ordinary text-books to be found in every physician's library contain too little on the nature and treat- ment of these lesions, and the special treatises too much, have induced me to venture upon the task of preparing a work specially adapted to the wants of the great mass of medical men. Accidents involving fractures and dislocations commonly fall into the hands of the nearest and most available practi- tioners, who may need practical suggestions in regard to the most approved methods of treating this class of injuries, especially as such accidents frequently involve great profes- sional responsibility. On account of the roller bandage being too often applied improperly, I have endeavored to enforce a due consideration of the dangers atteudant upon its careless application; and have urged the importance of employing as light dressings in each lesion as are compatible with efficiency. Lotions of various kinds which have generally been used in the treatment of fractures do not meet with my approval, for the reason that they induce vesications and render the patient uncomfortable in many ways. A bandage which is occasionally wetted will not maintain equable pressure, and may become the source of perilous constrictions. In treating fractures of the lower extremities, neither the double inclined plane nor the long straight splint, secures sat- isfactory results, therefore I have recommended the " natural (xi) xii Preface. method" of producing extension and counter-extension. The cleverly constructed specimens of mechanical art which have lately been invented to obviate shortening, may gratify the taste of those who have ample means to invest in novel- ties ; but the majority of medical men can not afford to pur- chase more apparatus than may be absolutely needed, conse- quently I have depicted and commended the simplest methods of treating fractured limbs. I have not advised the use of any appliance that could not be extemporized from materials to be found in every farm house. " Sets " of splints and ap- pliances serve to make a show in a physician's office, but only a few pieces in each are of any practical utility, even if fur- nished in assorted sizes. A moulded or carved splint, though made especially to fit a case under treatment, will soon become inapplicable from increase or subsidence of swelling. A splint carved into grooves and ridges with the design of con- forming to the natural outline of the arm, wrist, and hand, is calculated to deceive the unwary into the neglect of more simple means, which, if rightly applied, will answer better purposes. It is therefore advised that the surgeon construct from thin boards of soft wood, such splints of requisite width and length as each case may demand. I have designed most ofthe illustrations, and in no instance is a topic introduced for the purpose of exhibiting an old pic- ture; and no subject is distorted to meet the requirements of obsolete diagrams. In Part Second, well directed efforts to reduce dislocations by what has been called the " manipulating plan," are en- couraged as a substitute for the more dangerous method of overcoming displacements by the aid of pulleys and other mechanical means for multiplying force. Since the introduction of anaesthesia into surgical practice, there is less need of vio- lent measures to replace luxated bones. It is now known that obstacles to the easy return of a displaced bone, consist essen- tially in tense tissues which can generally be rendered lax by Preface. xiii changing the position of the dislocated limb. However, it is not to be understood, if a displaced bone can not be reduced by manual dexterity alone, that no other means are to be tried. But the manipulating plan in intelligent and persever- ing hands, has been so generally successful, that it would be rash to try harsher means until repeated and varied trials of the " physiological method " have failed. In preparing this work on Fractures and Dislocations, I have taken the liberty of drawing from every available source of information, and have not always given credit for material employed. This omission did not arise from a reckless dispo- sition to appropriate the ideas of others; but in an early attempt to give each author his due, I found that A had drawn from B, and B from C, and so on, and therefore I abandoned an undertaking which at best must have been imperfect, laborious, and unsatisfactory. In presenting this book to the profession, it is with no in- flated estimation of its merits; indeed I know it has glaring defects,—some of which may be placed to a lack of time for carefully correcting and amending what has been prepared amid countless interruptions, and during the busiest of pro- fessional life. "Whether it will accomplish what I have de- signed, time and readers must decide. It is offered as a guide to the multitude of practitioners scattered through the coun- try, who have comparatively limited facilities for becoming acquainted with the best methods of treating a class of inju- ries which often baffle the most experienced surgical talent. PABT I. FRACTURES. CHAPTER I. FRACTURES. General Observations upon their Nature and Treatment. The bones preserve the outline of the human figure, giving support and protection to the soft tissues; and serve the pur- pose of levers upon which muscular force is displayed. Hav- ing a large proportion of earthy matter in their composition, they are necessarily brittle, breaking under the influence of unusual forces, directly or indirectly applied. When a muscle, tendon, ligament, or other soft structure, is mechanically separated, the injured part is said to be torn, rup- tured, or lacerated; but the forcible separation of a bone into two or more pieces, is always called afradure. Bones are organized structures; when they are broken, the reparative processes can mend or consolidate the fragments, rendering a fractured arm or leg as strong as ever in the course of a few weeks. That the uniting forces may be as efficient as possible, the fragments of bone must be kept in apposition. The healing action firmly joins the pieces after they have been adjusted and retained in their places; and it is the office of the surgeon to place the broken parts in their right posi- tion, and to hold them there by the use of such appliances as the nature of each case demands. Fractures vary in extent and direction, and the forces act- ing upon the fragments produce a variety of deformities, there- fore it becomes important to draw distinctions between them, and to lay down some definite rules for their recognition and successful management. The principles of diagnosis and treat- ment have become so well established that the surgeon who fails to perform his duties according to the most approved rules, is held responsible for such defects and deficiencies as are justly chargeable to his negligence or ignorance; 2 (17) 18 Fractures. and the practitioner of medicine and surgery cannot undertake to treat a fracture without placing his professional reputation in jeopardy, and assuming the risks of vexatious and expen- sive litigation. Fractures are primarily divided into two classes, the simple and the compound. In a simple fracture the lesion is uncom- plicated with injuries of the soft tissues. A compound fracture has for its essential character a wound of the skin, with which the fracture communicates. There are two ways in which the wound may be produced at the time of the acci- , dent:— from without, by the direct force which fractures the bone ; or from within, by the end of one or both fragments being thrust through the soft parts, either by the continu- ance of the original force, or by the weight of the body. The latter mode is the more frequent; consequently compound fractures are more common in the leg than in any other part of the body. If caused by direct force the contusion will be considerable, and likely to be followed by inflammation, suppu- T| ration and sloughing; if simply incised or lacerated by the pro- trusion of a sharp fragment of bone, the wound may unite by first intention, converting the compound into a simple fracture. It may be remarked in this connection, that a fracture, simple at first, may be rendered compound by ulceration of the skin over a broken subcutaneous bone, as in oblique fracture of the tibia; and by the formation and bursting of an abscess at the seat of injury. The partial fracture exists only when a portion of the bone breaks, the fracture stopping before it extends completely through its substance, so as to leave the fractured portions still continuous in some part with the rest of the bone. This has been graphically called the "green-stick" fracture. Inthecom- plete fracture all continuity is destroyed, and the portions of bone are separated from one another : in the former kind the limb seems to be bent, while in the latter there is generally, though not always, more or less displacement of the fractured ends, giving the limb an angular, twisted and strongly marked deformity. The partial fracture is exceedingly rare, the com- plete very common. A fracture is said to be comminuted, when the bone is broken into many small pieces, some of which are often completely separated from the periosteum, losing all source of nourish- General Observations. 19 ment, and requiring to be removed either naturally or artifici- ally, before the other fragments can unite. A complicated fracture denotes the additional lesion of an im- portant blood-vessel or nerve, or the extension of the fracture into a neighboring joint. Fractures are not unfrequently attended with such serious complications that death is the re- sult. If a fracture extend into a joint, the high degree of in- flammation, and the interference of the reparative material, often bring about partial or complete anchylosis. A compound fracture is necessarily complicated; the flesh is lacerated or contused, renderirjg the injury very serious in its nature. A fracture complicated with much bruising and laceration of the soft parts, requires a long period to undergo reparation. The primary shock, and the subsequent suppuration, tell upon the patient's health ; and the pus and debris about the ends ofthe bones, prevent a speedy union of the fragments. The fragments of a simple, uncomplicated fracture ordina- rily become consolidated in five or six weeks, yet as many months may be consumed in the repair of a compound injury with perverse complications. The direction a fracture takes may be oblique or transverse, though the line of separation, in a strict sense of those terms, is rarely the one or the other. The manner in which the in- jury is received, has some influence over the direction of the fracture. Direct violence produces fractures more transverse than oblique; and an indirect force, as when a person in a fall, strikes upon the feet and receives a fracture of the leg, favors obliquity in the line of separation, especially if the fracture occurs to the shaft ofthe bone. Fractures near the extremities of long bones, and in the flat, and irregular shaped, as the scap- ulae and vertebrae, are apt to be more transverse than oblique. When the lines of separation radiate from a central point of the bone, at which the violence was received, they are regarded as stellate; and when the broken ends of bone are full of spiculae or serrations, which may interlock like opposing teeth, the frac- ture is dentate. The course ofthe fracture has a bearing on the reduction of the fragments, and their retention in apposition. Transverse fractures, especially if they be dentate, when once reduced, are not easily displaced; and these conditions often present obstacles to ready reduction. If the line of separation be oblique the 20 Fractures. reduction is not difficult, but'there is a disposition on the part of the fragments to slide past each other. As may naturally be supposed, all bones are not equally liable to fracture. Some are more exposed to injury than others, and some are increased or diminished in strength by their shape. It is plainly observable that the long bones are the most frequently fractured, while the short ones are com- paratively seldom broken, and always by direct violence. There are certain morbid conditions of the bones which ren- der them unusually fragile. Rickets, caries, necrosis, cancer, scrofula and syphilis, may so affect the bond^s that they are lia- ble to break from very slight causes. A dozen fractures, occur- ring at different times, and from trivial forces, have been treated in a boy under twelve years of age. Three of them were of the right humerus, and occurred in the act of throwing a stone. Esquirol possessed the skeleton of a woman, in which the traces of more than two hundred fractures, occurring at different periods, could be counted. The peculiar liability to fracture in the bones of certain individuals does not necessarily retard the uniting process. In some instances the recovery is unusually rapid. Stanley records one case, however, in which it was difficult to obtain a union. There is a tendency to fracture in old people, from the fact that their bones become chemically altered ; the earthy matter predominates over the animal, a condition which favors brittleness. In young people, the disproportion in the compo- nent parts is reversed; the animal matter predominates, so that the bones bend under the weight of the body, or under the action of the muscles. Children with bow-legs usually have a deficiency of lime in the skeleton. A disproportion between the strength of the bones and the power of the muscles also predisposes to fracture. Great mus- cular development, coupled with a rapidly acting nervous sys- tem, may prove too powerful for slender bones. The hume- rus and the femur have both been broken simply by muscular exertion. The olecranon, patella, and the os calcis are levers which, while enduring violent and sudden forces from the mus- cles acting upon them, are occasionally broken. Few bones are placed at such disadvantage for resisting muscular action. Tables drawn up to exhibit the comparative frequency of fractures in the different bones, vary somewhat. According to General Observations. 21 some authors the ribs are the most frequently fractured; the clavicle standing next in the order of frequency; the radius taking the third place; the humerus the fourth; the femur the fifth ; the fibula the sixth ; and the tibia the seventh. Both bones of the leg are broken at the same time more frequently than either singly. According to my own observation and experience the radius is the most frequently broken, the clav- icle next, and the ribs take the third place. When a bone breaks at the point where force is applied the fracture arises from direct violence ; a fracture of the radius or Jiumerus arising from a fall on the hand, is said to be by coun- ter-stroke (contre-coup), or indirect violence. A person falling from a height and striking upon the feet, does not sustain a fracture of the calcaneum or metatarsal bones, but the force is transmitted through the foot to the tibia, or even through it to the femur, and acts' indirectly to a degree that severs one of those long bones at a weak point. The radius commonly gives way, from indirect violence, near its lower extremity ; the humerus at the external condyle; the femur just below the trochanter, the tibia through its lower third. The fibula is often broken by a twisting force in the fall of the body to the ground after the tibia has yielded to the counter-stroke. It is reasonably supposed that muscular tension has something to do with fractures commonly considered as taking place from indirect violence, for a dead body may be let fall the same distance and it will receive no broken bones from the counter-stroke. The loose and passive condition of the bodies of drunkards seems to shield them from fractures while sus- taining fearful falls. A person in falling from a height, often seizes at some object to arrest his descent, or strikes some object on the way down, either of which impart a whirling motion to the trunk, so that in accounting for the injury upon the theory of counter- stroke, the compound motion should be estimated. The great degree of bruising of the soft parts, with ecchy- mosis, is sufficient in some situations to prevent the fracture from being discovered. This is often the case in crushing injuries of the hand or foot. Direct violence of a crushing nature, applied near the joints, may break the articular surfaces, causing effusions and swelling, which tend to obscure the real nature of the injury. CHAPTER II. SIGNS OF FRACTDRE. The symptoms of fracture are quite distinct and reliable. The patient hears a snap at the time of receiving the injury, and feels such a piercing pain, that the nature of the lesion is impressed upon the mind of the sufferer. Loss of power in the part implicated, and unnatural mobility at the point of injury, causing the limb to assume unusual twists and angular deformities, are peculiar to fracture. Crepitus, when it can be elicited, is the most decisive of all the signs of fracture. The snap, whether heard by the patient, or by persons who chance to be near, is a symptom of some value, though the sound may be produced by other causes, such as the rupture of tendons, ligaments, or the breaking of a stick or other for- eign substance at the time the injury4s received. It is almost impossible for a fracture to occur without a loud and distinct snap being produced, yet the sound is heard in only a small proportion of cases. Pain is not a reliable sign of fracture, for it is sometimes slight, being scarcely complained of unless motion be imparted to the fragments. However, in most instances, the pain is so acute and agonizing that it calls forth cries of distress, elicit- ing the deepest sympathy. In fractures that have existed several hours, the swelling having checked the preternatural mobility and masked the deformity, the pain which may be produced by motion, becomes a valuable diagnostic sign. If the finger be passed slowly and carefully over the whole length of the suspected bone, the absence of all pain on pressure proves its integrity, unless the parts have been subjected directly to external violence. On the contrary, the existence of pain, more or less severe, at a circumscribed spot, would afford strong presumptive evidence of fracture. (22) Signs of Fracture. 23 Loss of power in a limb is not necessarily a diagnostic sign of considerable importance. A patient with a fractured radius can often use the hand to the astonishment of by-standers who afterwards learn the true nature of the injury; a broken fibula does not always restrain a patient from walking; and a man with a fractured cervix femoris has been known to use the limb with a freedom truly puzzling. The impaction of the fragments and the interlocking of the serrations may account in part for these seeming anomalies or inconsistencies. It is certainly true that in most instances fractures inflict a notable hindrance, or an entire incapacity, of motion in the limb. The patient generally expresses his inability to use the fractured limb, and refuses to make even moderate effort, being intuitively conscious of the loss of power. The swelling attendant upon a fractured injury may take place immediately, or not be marked for several days. At the instant of fracture there is often, but not always, an effusion of blood around the fragments, and an extravasation into the surrounding tissues, constituting strictly an internal ecchymosis, which may uot betray itself unless the tissues are laid open. This effused or extravasated blood, especially in elderly patients, finds its way gradually to the integuments at quite a distance from the seat of injury, discoloring the limb to an extent which excites alarm. In fractures communicating with a joint, the blood mixes with the synovial fluid, and contributes not a little to the general tumefaction. The swelling following a fractured patella may be so great that, if the injury be not seen for two days after the accident, it is very difficult to determine the nature of the lesion. The same obscurity attends fractures into, or near all the joints, if the patient be not examined soon after the accident has occurred. Preternatural mobility is a characteristic sign of fracture. To develop this decisive diagnostic symptom one fragment must be held fixed while the other is moved in different directions; the limb is then observed to bend, the angle being at the seat of fracture, indicating, at once, a solution of con- tinuity in the bone. In the clavicle, the mere weight of the shoulder will produce the angle, and if the arm be grasped and moved up and down the mobility can be readily discov- ered. 24 Fractures. Motion can be easily produced in the shafts of the long bones, which have been fractured, but it is not so readily demonstrated when the solution of continuity is near joints. The portion of bone connected with the articulation, is so small or short, that it can not be easily fixed so the long frag- ment can be moved upon it. And then, the natural move- ments of the joint in such immediate proximity to the frac- ture, tend to obscure the mobility peculiar to the lesion. In fracture of the radius through its carpal extremity, very little mobility can be developed by manipulation of the parts. Displacement of the fragments is betrayed by the change in the form of the limb; often an experienced surgeon can at a glance divine the nature of the injury by the deformity. It would be unsafe to trust too much to first appearances; the deformity might be due to luxation or to a severe contusion. If a fractured limb present a bend or angle at a point where none should exist, the sign is valuable. One fragment resting in front or to one side of the other, constituting a salient projection which can not only be seen, but felt as the fingers are pressed along the bone, is quite decisive as to the nature of the injury ; deformity by rotation, as when the hand or foot is twisted around into an awkward position after frac- ture of the arm or leg, indicates what kind of an injury has been sustained. Shortening of a limb, which can generally be determined by measurements between prominent points in the skeleton, is a sign of great value in establishing a diagno- sis. If there be no. displacement, the spiculee of the fragments holding each other interlocked, no shortening will be percep- tible. Fractures of the olecranon, patella, and os calcis, are apt to be attended with a considerable degree of separation between the fragments. Muscular action is the cause of this displacement, and it always produces more or less deformity after fractures; it twists fragments of the fibula awav from each other ; and in fractures of the forearm, it drags the frag- ments of the radius and ulna into contact with one another, and if the pieces of bone be not kept in their proper relations, all the fragments may be so united as to prevent rotation. Crepitus is a grating sound, produced by rubbing one frag- ment of bone against another. It is the most positive of all the signs of fracture, though, unfortunately as a diagnostic Signs of Fracture. 25 symptom, it cannot always be elicited on account of the inter- locking of the ends of the fragments. If there be much separation between the fragments, as there usually is in fractures of the patella, crepitus can not, for obvious reasons, be elicited; and extensive overlapping is also opposed to the production of crepitation. A coagulum of blood, piece of muscle or other soft tissue interposed between the ends of broken bones may interfere mechanically to prevent crepitus; and many other conditions are opposed to the suc- cess of efforts designed to elicit crepitation. It often happens in fractures through the neck of the thigh bone, that free motion can be produced, yet no crepitus is elicited, one portion of bone being drawn up beyond the other. In these cases if the limb be extended, so as to bring the ends of the fragments in apposition, and the leg be rotated, a distinct crepitus can be obtained. In the majority of fractures the crepitus can be distinctly felt and heard ; therefore as a sign of fracture it is extremely valuable. To the patient and bystanders, who hear the crep- itation, the sound is particularly convincing. The surgeon enjoys a double satisfaction in the sound, for it not only gives decisive evidence of the nature of the injury, but proves that the fragments are in juxta-position, no muscle or other struc- ture intervening. The snapping of tendons, and the crackling of emphysema- tous tissues, resemble slight or indistinct osseous crepitus, yet the surgeon, manipulating the injury, feels rather than hears the crepitation, and judges or discriminates by that sense. Crepitus can be made most distinct soon after the reception of a fracture ; the changes which take place in the course of the inflammatory stages of the injury, and the healing pro- cess, thwart all efforts to elicit crepitation. Fractures are often dangerous injuries. The violence pro- ducing them may be of such a nature as to lacerate the soft tissues, and to inflict the most serious wounds. The sharp ends of the fragments sometimes sever or puncture large blood-vessels, and destroy the integrity of important nerves, subjecting the parts involved to the dangers of gangrene or extensive sloughs. Not unfrequently an injury involving a fracture, is of such a serious nature that amputation becomes imperative. Fractures extending into the joints always excite 26 Fractures. the gravest apprehensions; they may turn out well, yet there is no certainty of a perfect result. Partial or complete anchy- losis is a common sequence of fractures involving an articula- tion. Other injuries often simulate fractures, therefore the surgeon must discriminate between the symptoms of dislocations, sprains, fractures, and other lesions. A differential diagnosis cannot always be made out until the patient is placed under the influence of chloroform. The peculiarities of dislocation must be well understood, or the differences between the signs of the two injuries will not be apparent. It must be known that a fractured limb is characterised by unusual mobility, and that a dislocated one is unnaturally rigid ; that a fractured bone is easily reduced but it will not stay in place, and a dis- located one is difficult to reduce, but once returned to its nor- mal position, it will generally stay there. An examination and comparison of the most prominent processes, in fractures near the joints, may preclude error of diagnosis. In a severe bruise or strain the real condition of the injury can be deter- mined by a negative method of examination and reasoning. If it be satisfactorily demonstrated, in a doubtful case, that neither a fracture nor a dislocation exists, the logical conclu- sion is that the lesion is a sprain, bruise, or contusion. Children sometimes receive serious injuries that are exceed- ingly difficult to recognize. They are unable to tell how the hurts were received, or to give an intelligent explanation of the pain or other conditions of the parts implicated in the injury. Their fright, sobs, and agitation, thwart the best directed efforts to understand the nature of the accident; sometimes it is best to postpone the examination until the child has recovered from its nervous condition. Incomplete fracture, when it exists, and that is seldom, must necessarily be confined to the young. The bones of old sub- jects, from the amount of earthy matter in their composition, break like a dry stick. The bones of the arm are most liable to the partial or " green-stick" fracture. (Figure 1) The humerus, during childhood, has been found bent. It then offers considerable resistance to straightening or reduction. The child is averse to motion in the limb, and guards it against subsequent injury. An attempt at quick and forcible reduction may complete the fracture. Signs of Fracture. 27 Fissure of a bone is commonly an obscure injury to diag- Fio. 1. nose. In most instances of suspected fissure the evidence must be founded on what is little better than conjecture. The bone could not well be fis- sured without tearing the periosteum and the medullary membrane ; and the suffering would be long continued. The danger of these cases is illustrated by an example from Duverney. A man received a kick from a horse on the center of the left tibia. This was followed by severe pain and sloughing of the skin, which, however, readily healed, and the patient went about as cured. Three months later he was again confined to his bed by the accession of sudden, acute pain. After much ineffectual treatment by emollients, the bone was exposed, and a long deep fissure was found, the edges of which were raised twice, giving exit, on the second occasion, to pus. Subsequently the ^tici^'fracturln bone was trephined, and an abscess laid bare in the medullary cavity. Railway accidents produce fractures which, from their com- plications, and serious nature, deserve to be considered by themselves. The severer forms of injury, from the paralyz- ing character of the shock, and the number of parts impli- cated in the lesion, are apt to terminate fatally. An arm or leg, suffering from fracture by a railroad accident, is generally so badly bruised and mashed, that it may require amputation. In 1868 Dr. C. E. Witham, of Walton, Iowa, was called to take professional charge of a man who received a fracture of both bones of the forearm while shackling cars. In the course of twenty hours from the time of the accident, reac- tion having taken place in the entire body except the injured limb, which remained cold and pulseless, the docter in con- sultation with two other physicians, decided to amputate the arm. The injury was of such a crushing character that it was presumed the limb would slough, and greatly endanger the patient's life. The three medical men in council, had no misgivings in regard to the requirements of the case. There seemed to them an imperative necessity for amputation, and they accordingly removed the limb. The patient made a good recovery, and for the time appeared satisfied with the opera- 28 Fractures. tion ; but some rival physicians got posession of the amputa- ted limb, and injected the arteries ; the vessels proved to be untorn, at least they sustained an injection. The young man who had lost the arm was made to believe that his limb had been needlessly sacrificed, and, therefore, sued Dr. Witham and his associates, for damage to the extent of ten thousand dollars. A breakman on a freight train gets a leg or an arm broken by the moving cars, or receives a crushing injury by being thrown from his position. The shock may be so great that he will never react; or he may die from a multiplicity of in- juries, that do not manifest themselves at first. A question arises, in the contemplation of these terrible injuries, what is best to be done ? Ordinary rules applicable in surgical injuries, fail to meet the exigencies of the cases. A conservative course, which in ordinary accidents, succeeds so well, too often fails in these dangerous injuries. To attempt to save a limb that has suffered a compound, comminuted, and complicated fracture, may result in the sacrifice of life. Threshing machines, sorghum mills, and other modern agricultural implements, to say nothing of the powerfully moving machinery of our great manufactories, are constantly producing fractures and other injuries which tax the skill and ingenuity of the most experienced surgeons. * CHAPTER III. PROCESS OF UNION. -----. .» .----- The dearth of opportunities for examining broken bones during their various stages of repair, has prevented that thorough knowledge of the changes taking place from day to day during the healing process, which is so interesting and in- structive. Experiments upon animals have contributed something to a better understanding of the subject, yet vary- ing conditions have stood in the way of rigid comparisons. In man, a steady unvarying course of repair is not to be ex- pected in all cases. One person with fracture of the tibia may walk on the limb in five or six weeks from the accident: another person, with a similiar fracture, and every condition seemingly as favorable, may not walk for three months: in fact, no bony union may take place, the patient having to hobble about for the rest of life with a false-joint at the seat of fracture, the connection between the fragments being lig- amentous and not osseous. In the simplest forms of fracture, where the periosteum is not much damaged, and the soft tissues are not severely bruised, the healing process sets in earlier and terminates sooner, than in compound, complicated, and comminuted fractures. The effusion of considerable blood is an obstacle to early efforts at repair. If the periosteum be stripped from the fragments, and torn into shreds, the course of recovery will necessarily be prolonged. During the first few days the inflammatory action runs high, and the swelling and local disturbances create serious trouble. The swelling may commence as soon as the accident occurs, or come on anytime within a day or two. The violence of the inflammatory action may be reached on the second day, but there is no marked subsidence for five or six days. This (29) 30 Fractures. may be called the inflammatory stage of the difficulty. For the succeeding five days the swelling subsides, and .a great part of the effused blood—the debris of the injury—is removed; during the next five days there is an effusion of plastic material, of jelly-like consistence, which is to be elabo- rated into a firmer bond between the fragments. Fifteen days have now passed, and the union is a " rope of sand." If the parts be cut into and examined, the extravasated blood will be gone, an abundance of unorganized lymph will be seen between and about the fragments of bone, and the muscles and other soft tissues adjacent to the injury will seem to be glued together. The lymph is yellowish white, but the sur- rounding structures under the influence of the reparative action, have a pinkish hue, the reddish color coming from minute blood-vessels which are pushing their way into the newly forming material. Although the blended soft tissues around the bone assist in giving firmness to the parts, the fragments themselves move about as freely as when the frac- ture first occurred. Half of the time ordinarily consumed in the treatment is now passed, and the real work of repair is but just begun. During the next five days the plastic lymph becomes organ- ized into cells and fibrous bands. By the twentieth day the fragments are bound together by this newly formed connec- tive tissue, so that there is considerable firmness established between the ends of the fragments and the surrounding structures. The limb at this time will bend, but has not the mobility peculiar to a recent fracture. From the twentieth to the twenty-fifth day the osseous corpuscles are deposited in the meshes of the fibrous connec- tion. The new bony material is thrown out first and most rapidly from the periosteum and the medullary membrane, but is not placed with much regularity. At first there is an excess of corpuscles at one point, and a deficiency at another; but by the twenty-fifth day, in a young patient, under favor- able circumstances, the bony connection is sufficiently abun- dant and consolidated to sustain itself without artificial assist- ance. The osseous union is not yet complete ; in places there is too much of the fibrous, and not enough of the bony mate- rial ; and there is not that complete consolidation which proves to be unyielding. In fractures of the leg, the osseous union Process of Union. 31 is often so imperfect by the thirtieth day, that the uniting material may yield, allowing of shortening in cases inclined to overlap. I recently took off a dressing from a fractured femur that had been on thirty days. There seemed to be per- fect consolidation of the fragments, and careful measurement showed that the legs were of equal length. The patient, a lad of ten years, began to move about on crutches, and grad- ually to press the foot of the lame side to the ground. In two weeks after the fracture-dressings were removed, I again made a measurement, and found that the fractured limb was fully a half inch shorter than its fellow. As the measurements in both instances were made with scrupulous exactitude, the conclusion to be drawn was that the dressings were removed before the ossification was sufficiently complete or consolidated to resist the normal muscular tension. It is of the utmost importance that the surgeon understand, as nearly as possible, what is going on from day to day in the process of repair in a fractured bone. The differences of ac- tivity at the various ages of life, and the modifying influences arising from the kind of fracture, and from the region of body injured, to say nothing of general health, and minor considera- tions, render certainties out of the question, and leave a wide scope for conjecture and speculation. The most experienced surgeon can not, from manipulation or the appearances of the limb, determine positively when a fracture-dressing may be removed. If every part of the treat- ment has been satisfactory, and there be no known reason why the healing processes have not accomplished what they usually do in a given time, it may be presumed that a good union has been effected in four, five, or six weeks, as the particular case might seemingly require. If there be mobility, crepitus, or other signs of non-union at a time when a complete result ought to be expected, it would be certain that the fracture- dressing should be continued for a week or two, but there is no way to determine just how many more days the treatment ought to be continued, nor could it be positively determined whether a union would ever occur. After four, five, or six weeks have elapsed from the reception ofthe injury, and upon the removal of the dressing the limb is found to be firm at the point of fracture, the presumption is that union has taken 32 Fractures. place, and the surgeon would feel justified in laying aside the usual retentive supports. When the fragments do not accurately correspond, the uniting medium occupies externally the angle between them, and extends partly into and across the medullary canal. When they completely overlap, and even when there is an interval between them, provided it is not too great, the same rule pre- vails. The reparative material simply extends between them, bridging over the interval, and filling up all angles and irreg- ularities. It does not cover the free ends of the fragments, nor occupy the medullary canal. According to Dupuytren, the method of union in broken bones, is by a superabundance of reparative material at the seat of fracture, called " provisional callus." It may be likened to the mass of solder employed to join the ends of two pieces of leaden pipe, or to a " ferule " on a whip-stock. The re- parative material used to blend or weld the ends of the frag- ments, and not carried away by absorption at a period more or less remote, takes the name of permanent, " definitive," and uniting callus. Mr. Paget holds that the mode of union through the agency of a provisional callus, is peculiar to the process of reparation in animals whose broken bones are in constant motion, or not fixed by dressings. He teaches that the only bones which normally and constantly unite by this process, in man, are the ribs, the motions of which can not be fully restrained. Occa- sionally it is seen in the clavicle and humerus ; rarely in the tibia, fibula, and other bones. In children, whose motions it is not easy to restrain, the " ensheathing " callus is quite fre- quent ; according to Hamilton, almost constant. Dupuytren entertained the idea that the provisional callus was intended as a temporary support during the mobile stages of repair. It is now known that a " provisional" callus is not necessary in the union of broken bones; and only exists in cases where it is impossible to restrain motion in the frag- ments. The accompanying cut, (Fig. 2), from a specimen in my possession, shows that in the union of fractured ribs, where respiration keeps up constant motion of the fragments, there is not only a large amount of provisional callus, but bridges of bone reaching from one rib to another along the course of the intercostal muscles, are built up to give support, or to Process of Union. 33 steady, the moving fragments. I have another specimen from a leg, in which both bones were broken near the ankle, and a long, curved spur of new-made bone was sent backward from Flo. 2. Union of broken ribs, with "bridges " of bone in the course of the intercostal muscles. the tibia, at the seat of fracture, to the tendo Achillis, as if to gain support from that rather stable tendon. The excessive production of callus thrown out in the repair of fractures in the neighborhood of joints, especially of the hip-joint, is a strengthening buttress pushed out to give stability to moving parts. When a broken bone is not accompanied with much injury to the surrounding soft tissues, and there is no displacement; and when the fragments are steadily held in place, without motion or disturbance, there is no ring or ferule of reparative material employed in the union ; but the opposed broken sur- faces of the fragments unite without ridge or outside callus, by a process akin to that called " first intention " in wounds. It is still a question whether the intervention of cartilagin- ous material ever exists, or is necessary, in the last stages of repair in broken bones. In young subjects and in the inferior animals the presence of cartilaginous tissue has been observed, but as there are numerous instances in which its presence is not constant, the necessity for its existence is questionable. In adults the intervention of cartilage is exceedingly rare; and union without any perceptible callus is the rule, and not the exception, in well treated cases. The agency of granulations in the repair of compound frac- tures becomes almost a necessity. In the union of simple 3 34 Fractures. fractures, especially if inflammation be restrained within ordi- nary ranges,' no granulations are interposed. In the majority of cases the reparative material employed in the union of fractures, is similar to that employed for the repair of soft tissues by adhesion. This material is supplied from the vessels of the surrounding tissues, and by those of the bone and of the periosteum. The vessels of the medullary membrane also contribute a share in the work of furnishing supplies. If the fragments be kept at rest and in strict appo- sition, the reparative material is found chiefly, if not entirely, between them. When from irritation, motion, or want of apposition between the fragments, it extends outside the broken ends of the bone, it gets between the periosteum and the bone, and even into the adjacent tissues. The diagrams in Paget's Surgical Pathology, which represent the periosteum as having been separated from the bone to allow, as it were, room for the " ensheathing " callus, may faithfully represent the ideas of the author, but they do not represent the true healing state. The reparative material gets upon the outside or external surface of the periosteum, as well as between that membrane and the bone. The reparative material extends into the medullary cavity, but never between the medullary membrane and the bone. The shaping or modelling of the excess of reparative mate- rials after the union is complete, is a work of time. All rough and unnecessary projections are removed by absorption ; the sharp points left by the overlapping of ill-uniting fractures, whether deep or superficial, are first softened by the disap- pearance of their earthy matter, and subsequently removed, and the rough surfaces rounded off. The pressure and fric- tion of the muscles, are the chief agencies in the work of polishing and absorption. In fragments that overlap, a hard bony cap covers the ends of the fragments, and the compact walls resting against one another, (Fig. 3), and the cancellous tissue of both communi- cate, the new connecting material being more vascular and spongy than the walls of the old bone. Although the dressings can generally be removed with safety in from four to six weeks, ossification is rarely com- pleted before the ninth or tenth week after the injury. In in- fants the time of union is reduced to fifteen or eighteen days; Process of Union. 35 in old age two or three months are required to consolidate the fragments. If the fragments overlap or rest faultily with one another, the time of reparation is greatly retarded; in cases of double fracture, in which it is difficult or impossible to prevent riding, the work of repair is always tedious. Compound fractures require about three times as long a period to complete the union as the simple. Fractures from gun- shot wounds, on account of damage to soft parts, and the comminution of the bone, are exceedingly tedious in the pro- cess of cure. When there has been ac- tual loss of bone, as by the removal of splinters, or comminuted portions, the time occupied in the restoration is very much prolonged. A fracture extending into a joint is never followed by reunion of the articular cartilage. The bone unites, leaving an interval between the borders of the cartilage, which may or may not fill with fibrous tissue. Sometimes a ridge of osseous material projects into the space between the broken cartilage, which, by interfering with the functions of the joint, favors anchylosis. In frac- tures penetrating the articulations, the synovial membrane be- comes thickened by inflammation, the sheaths of passing ten- dons get blocked up with effused and organized plastic lymph, so that considerable stiffness, if not genuine anchylosis, is likely to follow. Passive motion after the bony fragments have united with osseous material, is the proper method of restoring the functions of the joint. Shows uniting medium wnere the fragments overlap. CHAPTER IV. NON-UNION OR FALSE JOINT AFTER FRACTURE. It is a fortunate circumstance in the history of broken bones, that the fragments rarely fail to unite through the medium of osseous material. The process of union may be delayed or completely arrested at any period of its progress. And as there is no precise time when consolidation is effected, a tardy union should not be looked upon as. evidence of a total lack of uniting capacity between the fragments. If there be no bony union in ten or twelve weeks after fracture, the surgeon begins to grow uneasy in regard to the result, and to cast about for the cause of the delay or inability. Certain fractures frequently fail to unite by osseous mate- rial. The neck of the femur, within the capsular ligament, seldom unites by bony union; the patella, from the fragments being held at a distance apart by the contraction of the quad- riceps muscle, often makes only a fibrous connection of its fragments; the olecranon and the coronoid processes of the ulna omit the osseous union for a similar reason; the condyles of the humerus occasionally fail to effect a bony consolidation with the shaft, when free motion is not restricted by a proper dressing. But these bones, having special causes for failure to unite, do not come so particularly under consideration in this place. When there is failure to unite in fractures which ordinarily consolidate in the usual time, the defect may be regarded as pseudarthrosis from extraordinary causes. In such cases a soft ligamentous substance remains between the ends of the fragments, and shows no disposition to become ossific. In rare instances no ligamentous substance is formed. The ends of the fragments become smooth and rounded, constituting a (36) False Joint after Fracture. 37 real false joint. The ends of the bones move freely against one another, being retained in their place by a kind of cap- sule, which is lined with synovial membrane. Ununited fractures are so exceedingly rare that some expe- rienced surgeons never met with a case. Lonsdale found but four or five cases out of four thousand fractures treated at Middlesex Hospital, London. Liston met with only one case in his own practice. Hamilton estimates that one case does not occur in five hundred fractures. According to Morris' tables, the humerus and the femur are bones most liable to non-union. This circumstance goes to show that motion has much to do with the failure to unite. When the tibia alone is broken, it rarely fails to obtain bony union,.yet after a frac- ture of both bones of the leg, false joint stands next in fre- quency to similar defects in the humerus and femur. The constitutional causes of non-union include all those con- ditions in which the powers of the system are much impaired. Old age, pregnancy, lactation, syphilis, scurvy, and especially the extreme debility of shattered inebriates, have been- ob- served as causes retarding osseous union. Patients having been subjected to courses of mercury, and other prolonged devital- izing treatment, suffer from retarded union after fractures, and sometimes wholly fail to obtain consolidation of their broken bones. Larrey frequently saw, in his extensive cam- paigns, cases of false-joint that he attributed to poor diet, and kindred causes. Dropsical subj ects suffer from pseudarthrosis, and very generally from retarded union. The local causes of ligamentous connections and false-joint, are numerous and varied. Disease of the bone, the presence of a foreign substance, separation of the fragments, and motion, are the most prominent. Obstruction to the circulation, whether from morbid conditions, or tight bandaging, always retard and may prevent bony union. Immovable dressings, especially if applied too tightly, obstruct the local circulation and delay the healing processes. A tight bandage, made uncomfortable by the use of anodyne, refrigerant, and stim- ulating' lotions, produces an anaemic condition of the limb that opposes rapid and satisfactory recoveries. Consolidation of the fracture is arrested by a faulty application ofthe bandage or dressings. I have seen an arm above the elbow bandaged so tightly that the hand and forearm were nearly strangulated. 38 Fractures. Such a radical interference with the nutrition of the limb must obstruct or wholly arrest the reparative action. The appearance of a fractured limb in which the work of repair has been suspended, is peculiarly striking. The wasted flesh, the scaly and dead condition of the cuticle, the puffy or flabby state of the member, are always observable, and indi- cate the greatly enfeebled nutritive action. Fatty degeneration in a limb partially paralyzed, though not previously mentioned by any author, is a cause of baffled reparation. In one case of this kind, I was unable to establish a bony union for five months. Even then the consolidation was effected with such imperfect material that the woman sustained a second fracture within a year. She died of gen- eral debility in a few months after the second accident, and at the time of her death there had been no progress in the work of repair. To repeat, movement of the fragments, whether due to the patients' restlessness, to some defect in the apparatus used, or to any other cause, is the obstacle which most directly inter- feres with union. In forty-four cases investigated by Norris, movement of the broken ends was clearly made out in twenty- two and strongly suspected in several others. Numerous measures have been devised for the cure of pseudarthrosis. If there be a constitutional vice, an attempt should be made to correct it, or so modify it that the recupera- tive powers of the system may be sufficient to heal the broken bones. The local means devised for the successful manage- ment of ununited fracture, are numerous and varied; but the object of all is the same, namely, to excite action in the parts around the ends of the fragments and to make them throw out material proper for their consolidation. Blisters, friction, rasping, removal of the fractured ends, setons, drilling of the bones, and other means have been tried, and with various de- grees of success. Blisters can accomplish but little, as the effect of the irritation does not reach deep enough ; rubbing of the sluggish fragments roughly together may arouse a new action which will result in union ; the opening of the fracture, and rasping the broken ends of the bone, has been recom- mended, though the results are not flattering; excision of the rounded and polished surfaces has been performed with suc- cess ; the seton applied by passing a long flat needle, armed False Joint after Fracture. 39 with a skein of silk, either between or close by the ends of the bone, and kept there till sufficient action is produced in the part to cause the adjacent textures to be excited to throw out the proper reparative material, has been highly recom- mended. Dressing the leg—in the event of the non-union being in one of the lower extremities—with a firm support of splints and bandages, and putting the patient on crutches to exercise in the open air, is an excellent method of improving the gen- eral health, and of arousing sufficient action in the limb to start or re-establish the healing process. Bearing some weight upon the leg produces friction between the fragments, and promotes vital activity. Exercise on crutches, with gentle use of the fractured leg, might remove or press out of position a piece of ligament, muscle or other soft tissue that had effected a lodgement between the fragments of bone. Drilling the bone near the fracture for the purpose of in- serting ivory pegs, around which a silver wire or hempen cord fastens the fragments in contact, has succeeded in establishing a union in a few instances; but the method has also failed. The .late Dr. Brainard, of Chicago, suspected that the drill- ing accomplished more good than the pegs and fastenings, therefore he tried perforating the sluggish fragments at their ends, with an awl or perforator. The instrument devised by him has a stock that admits of a change in the size of the Fig. 4. Brainard's perforator or drill. drills, though that is a complication not absolutely necessary. His directions for using the instrument are as follows: "In case of an oblique fracture, or one with overlapping, the skin is perforated with the instrument at such a point as to enable it to be carried through the ends of the fragments, to wound their surfaces, and to transfix whatever tissue may be placed between them. After having transfixed them in one direc- tion, it is withdrawn from the bone, but not from the skin, its direction changed, and another perforation made, and this operation is repeated as often as may be desired." Two or 40 Fractures. three perforations, according to Dr. Brainard, are enough to commence with ; more may be tried if the first fail to accom- plish the object designed. After the perforations have been made, the limb should be dressed as in a recent fracture, and kept at rest for several weeks before observations are made to determine whether consolidation has commenced or perfected a union. Of all the means devised and recommended for the treatment of ununited fractures, the plan of Dr. Brainard has been attended with the greatest degree of success. It is easy to put in practice, as any awl or drill which can be trusted to perforate bone, will answer the purpose. The point of an awl which makes few chips is preferable to others. Non-union is not so distressingly inconvenient as might be supposed. In the leg it is the worst; but even there a heavy leather apparatus, with side-irons, or a mechanical support of some kind, can be worn, which will enable the patient to walk tolerably well. In the arm, the functions of the member are generally preserved in a good degree, and the limb is not without strength and general usefulness. CHAPTER V. DEFECTIVE UNION. Some united fractures are subject to frequent and long-con- tinued pain, analogous to the neuralgia of cicatrices in soft parts; others are kept irritable by an exuberance of callus which piles up in ridges about the seat of injury. There are three species of deformity resulting from mal- union : Junction with permanent displacement, angular, rota- tory, or shortening; union of two contiguous bones, as of the radius and ulna ; and projection of one ofthe fragments. Angular deformity can sometimes be remedied by gradual compression. This may be applied with a common fracture apparatus, and by mechanical contrivances suited to the indi- vidual case. A splint may be placed opposite the concavity of the angle, and the bone drawn toward it; or it may be fixed to one fragment on the convex side, and perform the part of a lever to which the other is to be drawn by means of band- ages ; or, the projecting angle may be pressed between two opposing splints. The bandages must be kept tightened in order that the pressure may be maintained. The pressure may be begun as late as five or six weeks after the fracture is received, and be kept up for several weeks. Ordinary exten- sion, combined with pressure, aids in the straightening process. Re-fracture has been resorted to in cases of distorted union. This is to be done gradually with the hands and the knee, and not violently with a mallet or quick motion across the edge of a board or bedstead. There is some danger of breaking the bone in the wrong place, though the callus generally yields in preference to a new place. This tendency to break through the callus arises from the fact that in those cases requiring refracture, the union is apt to be irregular and otherwise faulty. Refracture is not to (41) 42 Fractures. be attempted in a consolidation over six months old. The new fracture is not attended with a deficiency of healing power; in many cases the reparative process in the effort at reunion, seems to have been accelerated. After the union of two contiguous bones, as of the radius and ulna, an attempt to effect a separation of parts not be- longing together, should be made in cases promising relief. A patient under chloroform does not suffer from the force the surgeon applies. An assistant, to steady the shoulder and elbow, gives the surgeon an opportunity to exert great pro- nating and supinating power upon the arm. A projecting point of bone at the seat of fracture, is gener- ally rectified in a great measure by the ordinary pressure of the soft tissues upon the part. In very objectionable instances. the'salient point of bone maybe cut down upon, and removed with the "saw or bone nippers. Chronic pains at the seat of fracture may be modified by the application of stimulating liniments, and by the use of flannel bandages. Enlarged capillaries and varicose veins, are also relieved by the bandaging. CHAPTER VI. GENERAL REMARKS IN REGARD TO THE TREATMENT OF FRACTURES. The treatment of fractures consists in reducing the broken ends of bone to direct apposition, and in keeping them in place until consolidation is effected. There are some cases in which there is no call for reduction, the relative position ofthe frag- ments being unchanged by the accident. In such instances the surgeon has only to maintain the parts involved in the in- jury, at rest, and to guard against displacement. These general statements render the subject apparently simple, for they make no allusion to the various complications which render this branch of surgery one of great responsibility. In the ordinary discharge of those professional duties which fall to the lot of the country practitioner of medicine and surgery, there are none so trying and difficult to perform suc- cessfully as those pertaining to the management of broken bones. The inexperienced physician may avoid performing what are ordinarily considered surgical operations, but if called to a fracture he does not feel like shirking the respon- sibilities of the case. A medical man would lose caste, and be considered timid, if he should decline to take charge of a fracture, though he knows that the public holds him pecuni- arily responsible for the result of the treatment. There is a wrong sentiment in every community in regard to the duties and responsibilities of a physician, called to take charge of fractures. The medical practitioner has a right to decline any case he pleases on the ground of inexperience on his part. "' It is not absolutely necessary that a fracture be "set" the very hour it is received. The patient can be made compara- tively comfortable until the services of an experienced sur- geon who is willing to assume the responsibilities of the case, (43) 44 Fractures. can be secured. The people should be made to understand that a fractured bone needs, for its skillful management, the highest order of surgical ability. A man maimed or lamed for life by a crooked or shortened limb, is often a striking ex- hibition of professional incompetency. The victim of a blun- deringly prescribed dose of medicine may go to the grave and be forever unseen, or fortunately recover, bearing no evidence of malpractice, but a bad piece of surgery follows the author of it like " a shadow," reminding him of inattention and in- discretion. It is not to be understood that a competent surgeon never has any unfortunate cases; very far from it. Even the most experienced are charged with malpractice, and sometimes justly. If a young practitioner expects to treat fractures, he should spare no pains to thoroughly inform himself upon all such injuries, and especially upon those that are oftenest followed by defects and deformities leading to malpractice suits. He should study the nature of rotation in the forearm, and the causes that lead to its arrest in the treatmeut of frac- tures of the radius and ulna; he will learn the necessity of being guarded in his prognosis when about to engage in the treatment of a fracture of a condyle; he must not be too cer- tain of a fortunate result in fractures of the shaft of the femur, though the nature of the injury be very plain; over- lapping and consequent shortening will have to be battled all through the healing process ; in a plain fracture of the tibia, he is not to be satisfied that the diagnosis is complete till the fibula, its whole length, has been carefully examined and pro- nounced intact; finally, he is to master that frequent in- jury, fracture of the fibula just above the malleolus, compli- cated with dislocation of the tibio-tarsal articulation. In the management of surgical cases the physician is held responsible for an average result. In other words, he must ex- hibit as much skill and attention as are ordinarily displayed by the profession at large. The term " ordinarily," as used in this connection, is susceptible of no precise or inflexible definition ; hence there must always be difficulty in applying its import or meaning in every case. In a rural district, where opportunities for treating and ob- serving surgical cases are necessarily limited, a less degree of skill must pass as ordinary, than in cities and large&towns General Remarks. 45 where exist greater facilities for observation and experimental knowledge. Besides, the country practitioner is not expected or required to have at hand for all emergencies, the most novel instruments and appliances; or to leave his business and spend time and money in seeking them,granting that he knows what is best or most approved. If the physician exercises ordinary skill, care and caution, and makes good use of materials within reach, or manages the case well, taking all circumstances into consideration, he is not pecuniarily liable for an unfortunate result. This is not written as an apology or excuse for igno- rance, blundering and inattention, which are never pardonable, but to place the question of pecuniary responsibility in the light in which it is held by the courts. If medical men wore to be held strictly accountable for the results of injuries and surgical operations, few practitioners would hazard their reputation and property in cases involving the dangers of alleged malpractice. Patients would call in vain for surgical aid at a time when professional services might be of vital importance. FIRST ATTENTIONS TO THE PATIENT. A person with a fracture of the upper extremity, can sup- port the injured member with the sound hand, and seek a surgeon himself, or go home, and have one summoned to his assistance. A patient will carry his own broken arm with more steadiness than any assistant. Walking producss less motion between the fragments, than riding. When a fracture occurs to the bones of the leg or to the femur, the patient is not able to walk. The pain attendant . upon being removed home from the place of accident, is often intolerable. The following is the language of that famous surgeon, Ambrose Pare, who, just as he was going on board a boat, had his left leg broken by the kick of a horse : " Having received the blow, and dreading lest the horse should repeat it, I made a step backward; but suddenly falling to the ground, the broken bones stuck out, piercing the flesh, the stocking, and the boot; from which I felt the most intolerable pain. Very soon I was carried to the boat, to be taken to the other side, that I might be dressed. But the jolting thus caused nearly killed me, since the broken ends of the bones tore the flesh, and those who bore me were unable to fix them. 46 Fractures. On landing I was carried to a house in a village, with even greater suffering than I had endured in the boat; for one car- ried my body, another my leg, and another my foot; and in walking along they did not keep in step. At length, how- ever, I was laid on a bed to take breath ; and here, while the dressings were in preparation, I found myself in perspiration all over; had I been plunged in water I should not have been more thoroughly wetted." The great surgeon, Percival Pott, had a similar experience to that of Pare. Falling from a horse in Southwark, in the suburbs of London, he broke his leg, and the jagged end of the bone pierced the skin. Esti- mating the suffering he would undergo if carried home in a carriage, he sent for men, and some poles suitable for support- ing his body. He purchased a door, and made the men nail the poles to it; once mounted upon this improvised litter, he rode home in comparative comfort, though his sufferings alto- gether were intense. A door or shutter taken from its hinges, constitutes a ready litter, upon which a patient with a broken leg can ride home without serious jolting. A carriage is difficult of ingress and egress; a wagon, with its bottom covered with straw or a bed, is a pretty good ambulance, and is oftener employed than any other means of transportation. The patient having been brought near the bed, the clothing should be carefully removed. While the broken leg is steadied, the seam of pants is ripped the whole length, so the garment can be removed without difficulty. The patient is now ready to take the bed, and to have the limb dressed. POSITION A FRACTURED LIMB SHOULD TAKE. A great deal of discussion has arisen among surgeons in regard to the position a limb should take in order to assist in the reduction ofthe fracture, and to facilitate the healing process. In fractures of the upper extremity, it is almost invariably the custom to keep the elbow at a right angle, the forearm being supported in a sling. There is but one exception to this rule, and that is in fracture of the olecranon. In this particular lesion the arm must be kept fully extended to relax the triceps, and to favor apposition of the fragments. General Remarks. 47 In the lower extremities the attitude of partial flexion is that admitting of comfortable repose. Pott claimed that from the muscles arises the whole difficulty of reduction—the resistance depending upon the position of the limb, by putting them in a state of tension. To avoid this tension the limb should be so placed as to relax the muscles, that they may offer the least possible resistance. Such a position is that of semi- flexion. Desault took an opposite view. He contended that in semi- flexion there is difficulty in making the necessary extension on the broken bone; that in such a position there is an im- possibility of accurately comparing the two limbs; that it favors derangements of the fracture while the patient has a movement of the bowels. He also urged the impracticability of firmly fixing the leg in a flexed position ; and the- trouble of adopting this method when both limbs were broken; and, lastly, the results of experience were against it. Bichat as- serted that what was gained by relaxing one set of muscles, was lost by the tension of others. Dupuytren, in reviewing the subject, announced that while extreme flexion would stretch the extensors, and complete ex- tension made tense the flexors, partial flexion was a position of ease, which is the best condition for reduction. Malgaigne asserts that experiments made upon the dead subject could not settle the question of the most desirable attitude, for the cadaveric rigidity is quite different from vital contractions. " Muscular action can not be studied except where it exists; hence experiments must be made of necessity upon the living subject." He alleges that complete extension, like complete flexion, is a fatiguing and painful position when kept up a long time. Boyer says: " Sometimes the difficulty of the [reduction arises from the forced extension of the limb and the unequal stretching of the muscles ; it may be obviated by putting the limb in a state of semiflexion." A patient with a fractured leg which confines him to the horizontal position, can be attended with the least trouble if he be placed on a narrow bed, a mattress of cotton or hair being used instead of feathers. A number of pillows, to cushion and support aching and uneasy parts, can be put to good use. Bags, holding a peck or more, made of strong cloth 48 Fractures. or drilling, and filled with nice dry sand, are exceedingly use- ful to put under the knee, if semiflexion be adopted, or to bolster the limb at any point. Several of these sand-bag sup- ports may be needed to wedge up the trochanters, and to pre- vent the limb from becoming everted. The heel which grows restive under pressure, is generally put at ease between two small sand-bags. The weight of heavy bed clothes can be kept from the foot and limb, by means of hoops taken from a keg. Two half hoops can be fastened in the middle, and then twisted a little from one another at their free ends, so as to form a four-legged screen for the foot, knee, or other part of the limb. To prevent the trunk from sliding down the bed, a perineal band may be used. This can be fastened to the head of the bed, and be made to serve as counter-extension, to oppose ordinary extension, which is made downward from the knee, leg, or foot. A firm piece of buckskin forms the best perineal band. It is soft, unirritating, and strong. A belt of drilling or firm muslin, padded to prevent irritation at points of pres- sure, will answer the purpose. The elevation of the foot of the bed by placing blocks or bricks under the foot-posts, is a method of getting up coun- ter-extension, now considerably in use. The extending strips or apparatus for extension, being made fast to the foot-board, the inclination of the body toward the head of the bed, is a simple manner of accomplishing what otherwise would require a perineal band, and other disagreeable and complicated ma- chinery. This plan was devised by Dr. Van Ingen, of Sche- nectady, NT. Y. He called it the " Natural extension." To avoid unpleasant sensations from having the head too low, high pillows may be used. The elevation of the foot tends to prevent cedema and congestion of the limb. CHAPTER TIL REDUCTION OF DISPLACED FRAGMENTS. Before any efforts are made to reduce or adjust the dis- placed fragments, it is best to prepare and have at hand, splints, bandages, compresses, and such appliances as may be needed in the dressing. Every effort to pull and squeeze a fractured limb, is attended with intense pain ; and repetitions of purposeless manipulations may do harm to the parts in- volved in the injury. Everything being ready for the dressing, the reduction may be made, if any be required. In many instances there is no displacement, consequently no reduction is requisite. Inex- perienced practitioners give every limb, before they place it in a fracture apparatus, an energetic pulling-, and not a few vigorous twists, to reduce, perhaps, what does not need reduc- ing. It is folly to suppose that the extent, direction, and dis- placement of every fracture can be accurately determined by an examination. The depth of the fractured bone, and the swelling of the soft parts, may preclude a satisfactory diag- nosis. The usual signs of fracture having been observed, and comparisons made with the other limb, the existence of dis- placement can be pretty accurately determined. Shortening or overlapping of fragments can generally be overcome by extending and counter-extending forces applied by the hands of assistants. In obstinate cases of muscular contraction, chloroform may be used to overcome it, and to put the patient into that insensible condition which admits of free manipula- tion and examination of injured parts. As soon as sufficient extension has been made to overcome the resistance of the muscles, the ends of the broken bone are to be placed as nearly as possible in their natural relations. 4 (49) 50 Fractures. This is called adjusting, setting, or coaptating the broken bones; and is generally supposed to be a very skillful manoeuvre, though not half so difficult to perform, as to keep the bones in place when once adjusted. In fractures of subcutaneous bones it is generally easy to see when the extension is sufficient, and the coaptation per- fect. The sudden restoration of the natural outline of the limb is pretty good evidence of the mutual adaptation of the fragments. Measurements and comparisons with the opposite limb, afford valuable aid in determining the relations of the fragments: and are decisive when other evidences of reduc- tion fail. In the event of a serrated or impacted fracture, it is neces- sary to extend the limb beyond its natural length, and then, by. partial rotation, to coax the fragments into apposition. If soft parts intervene between the fragments, they are gen- erally released by extension and rotatory manoeuvres. As a general rule, the sooner reduction is effected after the accident, the better. Some surgeons recommend that the re- duction be delayed for three or four, or even ten or twelve days, or until inflammation has subsided. No reparative pro- cess of a substantial nature being yet commenced, the position of the fragments during that period does not interfere with the delayed reduction, nor affect the final result. However, immediate reduction has great advantages. It restores the patient to comparative comfort, and diminishes the dangers of spasmodic twitchings and other evils resulting from the mal- position of the parts. When reduction is delayed for several days after the acci- dent, the fragments become more or less fixed by effusions into the surrounding tissues; and the muscles, accustomed to a new position, offer considerable resistance to a change. If the surgeon is not called for three or four days after the reception of the injury, or until the inflammation is at its height, it may be advisable for the time, to use such remedies as tend to lessen the inflammatory action, and to put off the reduction until the parts are more manageable. The disturb- ance of an irritable injury, when much inflammation and ex- cessive ecchymosis exist, has provoked convulsions, uncontrol- lable twitchings, and even tetanus. On the other hand, ac- cording to Velpeau, neither inflammation, nor spasm, should Reduction of Displaced Fragments. 51 induce any delay; so far from that, immediate reduction is the quickest and surest method of alleviating them. Malgaigne declares that, on account of muscular contrac- tion and spasm, he has been frequently thwarted in his efforts at reduction, even with good assistants, and therefore has been obliged to resort to mechanical means to multiply force. As he says nothing about the relaxing effects of chloroform, it is probable that he did not use the agent. Under the influence of profound anaesthesia, few patients will be met whose mus- cular condition can resist well directed efforts at reduction. Several surgeons have been obliged to saw off the protrud- ing fragment in compound fracture, before a reduction could be effected. Cases treated in that manner have been reported as doing well, union taking place as readily as in ordinary compound fracture. Of course, there would be as much short- ening as there was length of bone removed, yet that would be moderate in most instances. CHAPTER VIII. APPARATUS FOR THE TREATMENT OF FRACTURES. Much ingenuity has been displayed in the invention and construction of apparatus for treating fractured bones. The apparatus for retention includes bandages, splints, junks, me- chanical contrivances for maintaining extension, immovable dressings, together with belts, adhesive plaster, woven wire, and various means to enable the surgeon to manage special cases. Bandages, or rollers, as they are sometimes called, can be made of several different materials. Those most commonly used are made of old sheets, or unbleached muslin. Flannel makes an excellent bandage. It is elastic, and does not slide, one fold over another, as freely as cotton fabrics. An arm-bandage should be at least two inches wide, and eight yards long; a leg-bandage, two and a half inches wide and ten yards long; and a rib-bandage, five inches wide and twelve yards long. There is no inflexible rule governing the dimensions of bandages, yet it is of considerable importance that the width and length of a bandage be properly adapted to the part to be treated. A bandage which is to extend from the hand to the elbow, or from the foot to the knee, need not be so long as indicated above. A bandage should be.cut off as soon as enough has been used ; no advantage is gained by making more turns than are necessary. All bandages should be rolled into a firm, even, and com- pact mass. This may be done perfectly well with the hands, or upon the knee, after the roll is started. An assistant may take the kinks and twists out of the strip as it is being rolled. A bandage which is used with plaster of Paris, to constitute an immovable dressing, ought to be made of coarse muslin, so as to retain the gypsum in its meshes. (52) Apparatus for Fractures. 53 As far as practicable, the bandage ought to be made of one continuous piece, or with few joinings; and the selvedges should always be torn off. In a word, the surfaces and edges of the bandage ought to be as smooth and even as they can be made; and there should be nothing which can press un- equally upon the limb, to constrict or irritate it in any way. In applying a roller it is desirable to secure the end of the bandage by the first turn or two, in order that the proper trac- • tion may be sustained without slipping. A turn is generally taken around the wrist or ankle for no other purpose but to fix the commencement of the bandage. Fig. 5. Method of making a " reverse " in a spiral reversed bandage. When a bandage is to rest in contact with the skin, it should be applied flatly to the surface—there should be no creases nor puckers. Where the part to be bandaged is of nearly uniform calibre, as, for example, the forearm a short distance above the wrist, the roller may be carried around the 54 Fractures. limb circularly, forming what is called a " spiral bandage." Each turn of the roller ought to overlap about a third of the preceding one, and no intervals or gaps be left between the turns. But the conical outlines of the human limbs do not readily admit of the simple application of the circular bandage. It becomes necessary, therefore, to apply the roller by making " reverses," (Fig. 5), or to adopt some other plan suited to the contour of the limb. It is not easy to describe in words the method of making " reverses," but the accompanying illus- tration shows how they are made. In a fracture dressing it often becomes necessary, in order to exert a considerable degree of pressure on a particular point, to place a wad of lint or folded cloth, called a compress, underneath the bandage. The pad or compress is to be of a size and shape to fit or suit the part pressed upon ; and some care must be exercised to confine the compress to the spot where the extra pressure is needed. When the arm is bandaged, the limb should be covered from the fingers upward to the elbow or shoulder; and the leg, when properly bandaged, is covered from the toes upward to the knee or hip. This will prevent the hand or foot from becoming swollen and cedematous. When a bandage is used to give support or to make pres- sure, great care should be taken that it is not so tight in any part as to cause constriction. Cases are on record in which the most disastrous results have been brought about by a ban- dage being drawn too tightly. Limbs have sloughed exten- sively, or become mortified, requiring immediate amputation, for no other reason than that the bandage which was intended to give even and gentle support, has been applied with so much pressure as to stop the circulation, and to establish gan- grene. It is the duty of the surgeon to dress a fractured limb for the first time as if he expected it to swell. This may save him the trouble of being called to loosen the bandage, and the patient a great amount of needless suffering. As a general rule, a bandage ought not to be applied under- neath a splint. The splint should be well padded with raw cotton, tow, or soft cloth, then wound with strips of muslin, and laid next the skin. Bandages. 55 Many-tailed Bandage.—This is made of strips long enough to go once and a half around the limb. These, to the num- ber of fifteen or twenty, may be laid, before application, in regular order, from above downward, one overlapping the other for about a third of its width. The strips may be kept in their places by a longitudinal band, stitched to their centre. When the bandage has been prepared, ' " the limb is laid upon it, or the strips, \ _•'!"'■ ■ —7- arranged upon a piece of pasteboard, are 7 slipped under the limb ; and then each Cj separate piece is made to encircle the " limb, beginning with the lowest, the ends S 1 v ---' being brought up, one on each side, and crossed in front. One end of the last piece Bandage of strips, or many- x tailed bandage. only needs pinning; the others are held by the overlapping. This has been called the bandage of Scultetus, and is convenient in compound fractures, as the lacerated tissues can be examined without disturbing the limb the ends of the bandage being laid off for the time, and then returned to their places. Another similar bandage is made by taking a piece of cloth long and broad enough to envelop the limb, and tearing it on each side into tails, leaving a few inches in the middle untorn, to support the tails or strips. The ends are brought around the limb, and lapped, as in the bandage of Scultetus. BANDAGES PREPARED WITH STARCH, ETC, What is called an " immovable apparatus," is generally made by saturating the bandages surrounding the limb with a liquid which, after it is dry, gives a great degree of solidity to the dressing. By means of this the patient is sometimes enabled to leave his bed in a few days after he has met with a fracture of the leg, or even of the thigh, and to go about on crutches during the time that union is taking place. The starch-bandage may be made as follows : The starch is mixed with water until it forms a thick paste. The surgeon, 56 Fractures. having at hand rollers, lint, strips of pasteboard, and the basin of paste, lays a piece of broad tape along the front surface of the space to be bandaged, (for a purpose to be presently ex- plained), and then begins the application of the dressing. A common roller, made of muslin or flannel, is run upon the broken part, whether foot, ankle, leg, or thigh, and an assist- ant, with a brush or swab, applies the starch-paste to the ban- dage as it goes on. Strips of pasteboard, leather, or other bracing material, are dipped in the paste, and then laid along the limb upon the first layer of bandage, to strengthen the dressing; over these splints another roller is applied, the as- sistant all the time using as much paste as may seem sufficient to stiffen and consolidate the dressing. Even the third roller may be employed in this way to give additional strength to the dressing. Extension and counter-extension should be kept up by some of the means already indicated, for thirty or forty hours, when the dressing becomes hard and immovable. If in the course of a few days, it be found that a subsidence of swelling has left the dressing loose, the piece of tape laid on the limb at first, may be used to lift the hardened case from the skin, so it can be ripped open the whole length. The same means may be used to free the constriction in the event of swelling. Suetin devised scissors, one blade having a probe point, to slit up the starch-bandage, and to cut a hole in it to correspond to the sore in a compound fracture. A grooved director and a bistoury will answer the purpose of the scissors. If the limb shrinks away to a considerable extent, the old apparatus should be removed, and a new one put on. An im- movable dressing is to extend to the knee in case of fracture of the leg; and to begin above the knee and extend to the body, in case of fracture of the femur—the knee-joint being left free in both instances. The ankle-joint maybe covered, the dress- ing beginning at the toes. Lint should be carefully packed between the ankle and the tendo-Achillis, on each side, that the dressing may not bear too heavily on the prominences of the joint. Gypsum Bandage.—A plaster of Paris bandage has the same general features as the starch-apparatus. A coarse roller of muslin is thoroughly dusted with the powdered gypsum, and Splints. 57 then applied to the limb. While the bandage is being put on, it should be moistened and freely dusted with the dry powder in order to strengthen or stiffen the application. It is well to wrap the limb in flannel or soft lint before applying the gyp- sum bandage. This precaution may save troublesome irrita- tion. Three rollers, well powdered while being applied, gen- erally make a stiff, immovable apparatus. The advantage of gypsum over starch is that it dries or " sets " immediately. On the contrary, it is heavier and not so easily cut away in the event of its being too tight or too loose. When plaster of Paris is used, extension should be kept up by assistants for a few minutes, or until the stiffening ingredient has become solid. The immovable apparatus is frequently employed in hospi- tals and public institutions, but it has not been extensively used in private practice. There seems to be no good reason why it is not more commonly adopted, as every house contains starch, and the other means needed to complete the dressing. SPLINTS. Splints are made of various substances, according to the caprice of the surgeon, or the nature of the materials at hand. Wooden splints are by far the most commonly used in coun- try practice; and, in the majority of instances, they are the best. From time to time splints of various materials have been introduced, so that a surgeon in a large city can make his choice among a number of appliances, and select that which he may fancy, or is best suited to his purpose. The country practitioner derives little instruction and con- solation, in case of emergency, from illustrations and teach- ings which deal only in " patent splints " and complicated con- trivances that can not at the time be obtained. With a few practical suggestions he can, if moderately ingenious, make from thin boards all the splints he may need, or, at least, con- struct a temporary appliance which will do till the village car- 58 Fractures. Fig. 7. penter can furnish him with a more suitable apparatus. A shingle, a piece of lath, a cigar box, sole-leather, binders' board, pieces of tin, and other materials adapted to the purpose, can be pressed into service. A surgeon of expedients is rarely baffled through want of appliances. Strips of bark, or even a trough of bark taken from a sapling, can often be used with great satisfaction in dressing a frac- tured arm or leg. Surgical instrument makers keep for sale lined splint material, which consists of thin board sawed into parallel strips, and held in place by a piece of pliable leather glued to one side. Splints cut of any desired length and width, from the lined material, can be used in two ways : to envelope an arm or thigh, as a concave splint, the leather actino- the part of a hinge between the strips ; and, with the wooden side toward the limb, to answer as flat splints for the forearm or leg. Splints of gutta-percha are easily moulded to the contour of the body. Cut into proper shape and size, they may be softened in hot water, and then made to fit the part to receive them Fig. 9. Splint material consisting of wooden strips glued to leather. Fig. 8. Moulded gutta-percha splints. Carved wooden splints. Splints. 59 What are ordinarily called " carved splints," several of which are represented in the accompanying diagram, are made from thin boards, and bent into desired shapes, the wood hav- ing first been rendered pliable by the action of steam. These appliances are cut and moulded into various lengths and shapes to fit the arms and legs, and fitted with hinges to span the joints. Appliances of this kind are put up in " sets," and sold about the country, by Welch, Day, and other manufac- turers of such wares. Although such curiously fashioned and highly polished pieces of surgical mechanism, make a display, it is plain that they constitute a Procrustean bed, to which patients of all sizes and shapes must conform. Woven wire has been cut, bent, and soldered into various forms for the support of fractured limbs. (Fig. 10.) The "Wire breeches," represented in the accompanying illustration, are a sample of the manner in which woven wire may be wrought to suit the purposes of the surgeon. This apparatus is one of Fig. 10. "Wire breeches." the best that can be employed to treat fractures of the neck of the femur. The screw in the foot piece permits of making extension, and the shape of the upper extremity of the machine is such that the tuber ischii can easily rest against it for coun- ter-extending support. The length of the limbs can be accu- rately compared while the patient is in the apparatus; and the wire extends so far above the hip-joint that the constant mo- tion between the fragments is prevented. The patient can sit up in the apparatus; and by having its upper extremity raised upon a temporary support, the alvine evacuations can be re- 60 Fractures. ceived in a bed-pan. The apparatus should be lined with thick flannel before the patient is put into it. All the edges of the wire-gauze have a heavy wire soldered into them, to give the machine a finish, and proper firmness. The " wire breeches " were first devised for the treatment of hip-disease. Concave and angular wire splints, of various patterns for the shoulder and other joints, have been in reputable use. They admit free ventilation, and are not particularly heavy. Adhesive Strips.—One of the greatest improvements in the treatment of fractures of the leg, where it is necessary to effect and maintain extension and counter-extension, has been the introduction into use of adhesive strips, to take the place of a gaiter or other contrivance fastened upon the ankle. Every practitioner who has had occasion to make fast to the foot and ankle with the means formerly in use, fully appre- ciates the difficulties growing out of attempts to produce ex- tension. Blisters, irritations and excoriations were the results of the gaiter and kindred appliances. Adhesive strips well applied, and carefully retained in place by the circular and oblique turns of other strips, keep their hold, and are borne with ease. The extending part of the dressing with adhesive strips, may be applied as follows: One long strip is cut, and Fig. 11. Adhesive strips applied. its two ends made to adhere to the sides of the leg and ankle, leaving a loop below the hollow of the foot. These ends will gradually slide down the limb unless they be bound in place by other strips, which are applied circularly about the leg and ankle, covering the two parts of the first piece at each turn. Finally, a strip or two may be applied diagonally to the others, to hold all firmly in place. A block of wood may be placed in the loop to prevent pres- sure upon the ankle when the extending force is applied. Splints. 61 The strips will firmly adhere for months unless some alco- holic lotion be allowed to come in contact with them. They rarely need removing during the whole period of treatment. A double inclined plane apparatus is one of the various con- trivances to keep up a natural extension and counter-exten- sion in fractures of the leg and thigh. It consists of two boards, hinged in the middle, and long enough to reach from the tuber ischii to the heel. There is a foot-board connected with the leg-piece; and this is sometimes made adjustable so it may be always placed in contact with the foot, whatever be the length of the limb. The double inclined plane is hinged at its upper extremity to a frame or board—the bed-piece—and is held flexed at any angle by notches in the lower end of the bottom board. (Fig. 12.) Side-boards maybe nailed or hinged to the halves of the double inclined plane bed or bottom Fig. 12. Double inclined plane fracture box. pieces, to form a fracture-box. Into this, cushions or sand- bags can be laid, and then the broken limb may be placed upon them, and secured by tapes and other supports. Double inclined plane apparatus, with various modifications, has been in use for centuries. The weight of the body and thigh sliding down the upper plane, produces counter-exten- sion, and the inclination of the leg down the lower plane— extension. Additional extending force is applied by means of the adjustable foot piece and screws. Two pieces of board, hinged with leather in the middle, having a cord to reach from one board to the other, to hold them flexed, constitute an easily constructed double inclined plane, which may answer every purpose of a more compli- cated apparatus. 62 Fractures. Fracture-beds are intricate and costly affairs, rarely con- structed for patients in private practice. They are not exten- sively used even in hospitals. A description of one will answer for all. That of Amesbury is perhaps as good as any ever constructed. It consists of a horizonal frame, supporting three pieces of wood, or planes, hinged together, and long enough, when connected, for an adult to lie stretched out upon. The upper plane receiving-the trunk, is raised at the bolster- end ; the middle one, intended for the thighs, is made of two pieces sliding -on one another so as to suit limbs of different lengths, and forms with the third piece a double inclined plane; this last, which supports the legs, has a foot-piece, used to confine the feet when it is necessary, and always serving to sustain the weight of the bed clothes. The upper of these planes is to be supplied with a thick mattress; the two others, with similar ones only half as thick. The middle one has an opening, with a ba- sin fitted to it to receive the faecal evacuations; and the pel- vis is fixed by means of a belt passing across the upper of the three planes. The hinges of the apparatus allow the differ- ent angles to be changed at will. Burge's apparatus, (Fig. 14.) consisting of a bed, and an arrangement to make extension and counter-extension in treating fractures of the femur, is a useful piece of surgical and mechanical mechanism, but it is too complicated and ex- pensive for ordinary use. The diagram presented to illustrate the appliance, shows that the machine could not be constructed for less than fifty dollars; and is made of so many different Splints. 63 materials that it would require a carpenter, blacksmith and upholsterer to construct the apparatus. Many intricate con- trivances of varied merit have been pressed upon the attention Fig. 14. Burge's fracture-bed. of the profession from time to time, but none have come into general use. If a surgeon were to possess all the different ap- pliances devised to treat fractures, he would need extensive store rooms in connection with his office, to give them shelter. CHAPTER IX. RE-DRESSINGS. After a fractured limb has been dressed, or " put up," to use a phrase of the London hospitals, it becomes a question when it should be re-dressed. According to some of the older authorities a definite time should be allowed to pass before the dressing is meddled with; and not a few timid followers of revered authority have permitted their patients to suffer need- less torture, inflicted by swelling and tight bandages, because the prescribed time for re-dressing had not arrived. Whenever a fractured limb undergoing treatment is painful, it is in danger, and should be undressed at once, that the cause of the distress may be ascertained and averted. If local pain and general uneasiness arise within twelve hours after the bandage or apparatus is applied, the limb should be re-dressed. An opiate or anodyne to allay the pain excited by the movements of the limb during the manipulations of dress- ing, may not be out of place, but repeated and heavy doses of any narcotic to allay the distress occasioned by the constric- tion of a tight bandage, may benumb the pain ; yet while the wails of the patient are thus silenced, the dreaded gangrene may be doing its fatal work. If the first dressing is well applied, and no swelling comes on to convert the retaining tapes and bandages into constrict- ing cords, the compresses, splints and bandages may be left in place for several days. I have frequently left the dressings a week or ten days without interference. Frequent renewals, without substantial reasons for them, are worse than useless. They hinder the healing process, give the fragments an oppor- tunity to play upon one another, and to overlap in cases where that condition is possible. (64) Re-dressings. 65 As soon as the swelling has subsided, and the shrinking of the limb permits the bandages to become loose, a renewal of the dressing should take place. It is probably best, in favor- able cases, to re-dress once a week while the retentive treat- ment lasts. The limb may be looked at oftener. A case that is convenient to watch may be seen every other day; if it be at a distance, and circumstances do not favor any more attention than is absolutely necessary, a revisit and redressing once in ten days may do just as well as daily inspections. There is generally intelligence enough among the patient's friends to be entrusted with the execution of certain instruc- tions pertaining to the case. If yellow blisters, or a livid color of the skin, show themselves between the folds of the bandage or anywhere beneath the dressings, the surgeon can be informed of the untoward condition. A too tight dressing can be loosened by cutting a few of the turns of the bandage partly or wholly in two; and, in the event of loosening, a few additional tapes can be tied around the dressing. In fractures of the thigh or leg, the surgeon should, every time he visits the patient, compare the two limbs in regard to length, direction of feet, and general aspect. This can be done before the dressing is removed. The patient, while his limbs are inspected, should be made to lie on his back, straight in bed. A slight twist of the pelvis makes a great difference in the apparent length of the legs. With the trunk and limbs straight, accurate measurements with a tape or inelastic cord should be made from the symphysis pubis to the inner mal- leolus of both ankles. The placing of the two heels together and observing whether one is below the other, is a good test of the relative length of the limbs. If there be evidence of shortening, the dressing should be taken off, and the defect or displacement remedied. Re-dressings for such a purpose are always proper, even at the risk of disturbing the healing pro- cess. There is always an urgent necessity, on the part of both surgeon and patient, to avoid deformity if possible. 5 CHAPTER X. MOVEMENTS ALLOWED A PATIENT. After a fracture of the arm has been dressed, and the limb is suspended in a sling hanging from the neck, the patient can take moderate exercise upon his feet. Motion at the point of fracture, for obvious reasons, is to be guarded against. In fact, the patient, to avoid pain, is very likely to carry a broken arm with much care. If the dressing become loose, the motion • between the fragments tends to establish false-joint. After fractures of the femur, and of both bones of the leg, the patient must keep quiet in bed during treatment, unless an immovable apparatus be applied. In a fracture of one of the bones of the leg, the condition is different. The unbroken bone prevents shortening, and acts as a stay or support to the one fractured. A patient with a broken tibia or fibula well dressed, can go about on crutches. In fractures of the femur, it is dangerous for the patient to go on crutches, even if the immovable apparatus be employed. If the fracture be of the cervix, or through the upper third of the bone, it is difficult for the bed-pan to be used without im- parting more or less motion to the fragments. A cord sus- pended from the ceiling, which can be grasped, enables the patient to raise himself with less motion than he can be raised by the efforts of assistants. If the patient is too feel.de to raise himself, an assistant can do it by placing a hand in each loin, and lifting upwards and drawing backwards at the same time. This prevents the body from sliding down in bed, or the pelvis from descending upon the broken thigh. The body may also be kept from sliding downwards, by using a perineal band, which is to be tied to the head of the bed. A box or block so placed that the sound foot may press against it, in efforts to raise the pelvis, may be of considerable service. (66) CHAPTER XI. MANAGEMENT OF COMPOUND FRACTURES. The directions given by Ambrose Pare, himself an eminent surgeon, to his surgical attendant, when he received a com- pound fracture of the leg, are quite explicit. " If the wound be too small, enlarge it with a razor, that you may the more easily replace the bones in their natural position ; and carefully explore the wound with the fingers, in order to remove such fragments and bits of bone as may be completely detached and press out the blood which has become effused about the wound." This suggestion, to clear the cav- ity of the wound from blood and splinters, is generally to be followed. Small fragments isolated from the periosteum, are likely to create as much trouble as other foreign bod- ies in the flesh. The wound once cleared of coagula, splinters, dirt, and other foreign substances,. and the fragments adjusted, the treatment is much the same as in simple fractures. The dressing should be so applied as not to permanent- ly cover and choke the wound, for it must have an opportu- nity for the free escape of pus and other fluids. When the immovable apparatus is employed, the wound, while the (67) Compound fracture. 68 Fractures. dressing is being put on, is covered in ; but, after the dressing has become consolidated, a hole or door is cut so as to expose the wound. The edges of the wound are not to be drawn together with sutures, but a piece of tin-foil, or a lead plaster, may be em- ployed to shield the lacerated parts. As previously stated, the many-tailed bandage is well suited for the treatment of such injuries, inasmuch as the wound can be often exposed without disturbing the limb. Care must be exercised that flies do not deposit their ova in the saturated folds of cloth about the wound. The immovable apparatus is not generally suitable for com- pound fractures. Unpleasant complications have too often arisen when it has been used. Malgaigne says of it: " Un- happily we have too much reason to fear pus will burrow be- tween the integuments and the muscles, and between the muscles and the bones, endangering the limb and even the life of the patient. I once had to treat an old soldier, a stout, sanguine man, who fell from a ladder, and sustained a com- pound fracture of the tibia at its lower part. The immovable apparatus was employed ; on the eighteenth day it had to be removed on account of the insupportable fetor. Four days later, pus flowed abundantly from the heel. On the twenty- ninth day, the increased discharge and the excessive fetor made a fresh removal necessary; the whole leg was pasty and flaccid ; a probe, introduced by the wound, passed up several inches between the two bones; the tibia was denuded at its external face; sinuses were formed in the limb above and below. Several surgeons regarded amputation as unavoidable. This, however, was postponed, and by great care, after three incisions had been made, and a long train of severe symptoms had been overcome, a satisfactory cure was effected by the end of six months." The application of carbolic acid in a dilute form, to the wound of a compound fracture, is valuable to remove the fetor; to prevent a profuse suppurative condition ; and to favor the formation of firm and healthy granulations. Topical Treatment. 69 TOPICAL AND CONSTITUTIONAL TREATMENT. It was once customary to apply cerates, poultices, and fo- mentations to fractured limbs. At a later period in the history of surgery, it was a common practice to soak the dressings in laudanum, brandy, lead-water, camphorated liquids, and various other lotions. At the present day, dilute tinctures of aconite, arnica, and wormwood, are thought to be valuable applications; rum and whisky have always en- joyed a popular reputation for allaying inflammation in almost every kind of injury. Some practitioners order the frequent application of water to fracture dressings, with the object of cooling the inflamed tissues beneath. The reasons adduced for employing cooling, stimulating, and anodyne lotions are not without plausibility, yet, in prac- tice, it is found that more harm than good follows any kind of topical medication. A common muslin bandage creases upon being wetted, often rendering the dressing harmful; then, if allowed to dry, as is frequently the case, it will be too loose. Blisters are more likely to occur under wet dressings; eruptions and discolorations, with itching and other unpleasant sensations, are among the troublesome effects produced by lotions. I invariably find that fractured legs do the best when treated with dry dressings. Much is said by those whose ex- perience ought to render them competent authority, about applying evaporating lotions to fracture injuries of the elbow, knee, and other large joints, yet the instances are few in which I could approve of such treatment. The extensive ecchymosis that occasionally attends upon a fracture of the leg, excites dire apprehension on the part of the patient, yet the extravasation of blood and discoloration rarely result in any harm. Neither leeches nor stimulating lotions will prevent the spread of the discoloration, or remove the effused blood and serum. If, upon the renewal of a dressing, it be found that large blisters exist, the bags of serum maybe punctured, care being exercised that the subsequent dressing does not press upon the parts lest suppuration and sloughing follow. The surgeon should frequently re-dress a limb in a blistered condition, 01 watch it carefully until parts thus effected are sound. 70 Fractures. Muscular twitching is occasionally a disagreeable complication which needs subduing. The application of chloroform to the limb may allay the difficulty; the internal use of an opiate has been, attended with relief, though some patients of great nervous excitability grow worse under its administration. Chlorodyne has a far more desirable effect upon spasmodic conditions. Distressing pain attendant upon the reception of a fracture, and the disturbance caused by the reducing process, ought to be assuaged by anodynes in doses gauged by the severity and continuance of the distress. Febrile symptoms may be allayed by the use of aconite, or kindred agents. The evacuation of the bowels by the influ- ence of an enema, or a mild purgative, frequently arrests feverish paroxysms. A hot skin may be cooled by the fre- quent use of the wet sponge. In case of " chills " and hectic, from exhaustive suppuration, iron, quinine, and the mineral acids may be employed to advantage. The diet should be light for the first few days after the in- jury, but in the course of a week or ten days, it may be sub- stantial and nourishing. Excoriations on the nates arising from unsuitable beds, and a prolonged recumbent position, may generally be prevented by the use of a soft piece of buckskin to parts threatened with such a disagreeable complication. Air and water-cushions are useful in protecting parts irritable and excoriated from prolonged pressure of the bed. CONVALESCENCE. There is generally too little attention given to patients after the fracture apparatus is removed. The limb, though the broken bone has united, remains stiff, swollen, weak and tender. Compression and inaction have established a condi- tion of atrophy; and the neighboring joints have lost their suppleness. A patient is very sensitive to this enfeebled state of the limb, and needs encouragement to make him exercise properly, and to employ those means Avhich tend to re-estab- lish the functions of the part. Extreme timidity prevents patients from giving their convalescing limbs a desirable Convalescence. 71 amount of action. There is an instinctive dread that the limb may be re-broken, or that it will not sustain the weight of the body. It is a discreet precaution to keep patients who have sus- tained a fracture of the thigh, or of both bones of the leg, in bed for a week or two after the consolidation is known to have been established. As has been previously stated, there is yet danger of a gradual yielding of the newly-formed callus 5 yet during this confinement to the bed, the limb may be moved at the joints, and rubbed with the hand or coarse towels. At length the patient may venture upon crutches, and then to take gentle exercise with the support of a cane; and, finally, he will walk without any assistance, though with a limp in the gait even when there is no shortening or other deformity. Sometimes a patient is so fearful of a fall or a second acci- dent, that he has to be coaxed and urged into sufficient exer- cise to invigorate the limb. Liniments and douches are of questionable utility so far as medication is concerned, but their indirect effects may prove exceedingly advantageous. The patient is recreated while applying a liniment; and the circulation of the limb is improved by the friction employed in the application. There is a popular notion that certain penetrating or oleaginous liniments will impart suppleness to stiffened joints and rigid tissues; this prejudice maybe turned to the advantage of the sufferer, for he will industriously employ any means that have ascribed to them the desired qualities. Patients are to be impressed with the importance of em- ploying considerable force in the flexion and extension of par- tially anchylosed joints; and of keeping up this action for weeks and even months in obstinate cases. Persevering efforts of this kind have accomplished wonderfully beneficial results. Flannel bandages should be kept applied for weeks and months to legs inclined to swell, especially if the veins be varicose. At length the bandages may be laid aside, and elastic stockings worn continuously to keep the limbs in good condition. Elderly persons make exceedingly slow recoveries; and if of irritable temperaments, are querulous and de- spondent. CHAPTER XII. DIASTASIS, OR SEPARATION OF THE EPIPHYSIS. Strictly speaking, there can be no fracture without breaking of osseous material, yet the forcible separation of the epiphy- sis from the shaft of the bone, through the cartilaginous con- nection, in young subjects, is a lesion analogous to fracture. It is an accident that can not always be distinguished from fracture ; and the treatment of the lesion should be the same as that directed for a broken bone. In the diagnosis of the case, clear and distinct crepitus will be wanting, but all the other signs of fracture may be present. All the long bones, from birth to fifteen years of age, are subject to this peculiar injury. Both extremities of the humerus, radius, femur, and tibia, have been separated from the shaft, through the cartilages interposed in growing bones, between these distinct ossific parts. The separation may take place during the careless delivery of a child. The obstetrician, unless he bears in mind the dangers of diastasis, may, in at- tempts to bring down an arm or leg, sever the cartilaginous connections of the humerus or femur. If such an accident should occur, it would be known by the flaccid, mobile condi- tion of the broken limb. Swelling and discoloration would soon exhibit themselves ; and, in handling the child, the in- stability of the member would be observable. The limb would fall powerless into unnatural attitudes. Once discovered, the injury should be treated like an o'rdinary fracture. I was once called to attend a lad of five or six years of age, who had separated the lower epiphysis (Fig. 16) of the humerus, by a fall upon the curbstone. The physician first summoned to take charge of the case, bandaged the arm so tightly that the soft parts, on the anterior aspect of the arm, sloughed. This was the state of the case wheu I wTas asked (72) Diastasis. 73 to take charge of it. The shaft of the humerus protruded through the opening made by the slough, converting the lesion into something like a compound fracture. The pro- truding bone was denuded of periosteum, and pus was dis- charged through two sinuses above the main opening. The Fig. 16. Separation of the lower epiphysis of the humerus. fortunate discovery of grauulations upon the end of the pro- truding bone, suggested the idea of extending the limb until the projecting bone would sink into its natural place and position. Accordingly, the hand was suspended to the bed- frame above, so that the weight of the body, by extension, kept the bone where it ought to be, in the bottom of the wound. The period of recovery was prolonged, and attended with profuse suppuration, yet in the end the result was quite satisfactory, considering the condition of the limb. CHAPTER XIII. FRACTURES OF THE CRANIUM. In the division of surgical subjects, fractures of the cranium, from the nature of the injuries and the peculiarity of their treatment, are always placed among wounds of the head. The gravity of such lesions depends essentially upon injuries and disturbances ofthe brain, therefore a consideration of the fracture alone would not reach the most important part of the subject. The treatment of fractures of the cranium is not based upon the ordinary rules pertaining to broken bones, but upon the brain-symptoms. Unaccompanied with cerebral complications, such fractures though almost always compound, are not to be interfered with. It is an established rule that simple fractures of the skull, even with depression, but with- out encephalic symptoms, are to be let alone. In the severer cases, the surgical interference chiefly consists in trephining, an operation performed in order to elevate or remove frag- ments of bone, and designed to relieve the brain-symptoms. Fractures of the cranium, then, will not receive attention in this connection. The bones of the face, though classed as belonging to the skull, may be broken without necessarily disturbing the brain ; and require the same general treatment as fractures in other parts of the body. FRACTURE OF THE ZYGOMATIC ARCH. A fracture of the zygomatic process of the temporal bone is an exceedingly rare accident, A direct blow, as a fall upon the side of the head, is the kind of violence most liable to break this bony arch. Although very prominent and slender, the process is protected by coverings of integument, fat, fascia. muscle, and other soft structures. (74) Fractures oe the Nasal Bones. 75 A simple fracture of the zygoma is an unimportant injury, but a force that breaks the process of bone, is generally suffi- cient to do other mischief. Concussion of the brain is the frequent attendant of such a lesion. A depression of the arch interferes with the temporal muscle. The swelling that follows the injury also impedes the functions of the parts implicated. Treatment.—In cases where the temporal muscle plays easily, and the depression of the arch is not distinct, no treat- ment is necessary, unless it be that employed in ordinary con- tusions. Duverney directs, in the event of depression of the arch, that the surgeon put his finger in the back part of the patient's mouth, against the inner surface of the cheek, and press the displaced fragments back into their natural line. An attempt to bring force against the inner surface of the zygomatic arch, by a finger in one's own mouth, shows that such a method of reduction is impracticable. Ferrier brought the pieces to their natural level, by cutting down upon the fracture, and elevating them with a spatula. In the only case I ever saw, the patient had been struck with a heavy chisel. A plain depression in the arch could be felt; and the sufferer could open and shut the mouth with difficulty. There was marked ecchymosis in the region hurt. The skin was broken, but there was no wound in the soft parts reaching to the bone. I -pushed the point of a strong tenaculum beneath the depressed bone, and with a lever-like motion, forced the displaced fragment into line. There was a perfect recovery in six or eight weeks, no perceptible deformity fol- lowing. The point of an instrument, like a carpenter's scratch- awl, might be employed as a lever to overcome the displace- ment. FRACTURE OF THE OSSA NASI. A not uufrequent injury is fracture of the nasal bones. It may be produced by the kick of a horse or mule, and by the forces of moving machinery. A circular saw might throw a block of wood with sufficient velocity to crush the bones of the nose. The handle of a windlass, while heavy weights are being raised, may slip out of the hand of a laborer, and so quickly take the reverse direction as to strike the workman across the bridge of the nose. 76 Fractures. Violence producing fracture of the nasal bones, rarely stops with that injury. The ascending processes of the superior maxillary are adjacent to the ossa nasi, the central lamella, and cells of the ethmoid are directly beneath, and the vomer and turbinated bones not far away. The nasal duct may be lacerated, and the Schneiderian membrane is sure to be torn. The symptoms of fracture which amount to reliability, are displacement. This may elude observation, on account of the great swelling which immediately follows the accident, unless the surgeon presses his fingers deep into the tumefied tissues, and thus discovers that the nasal bones, wholly or in part, are depressed below their natural position. The profuse hemor- rhage from the anterior nares, and other conditions generally attendant upon fracture of the nose, assist in the diagnosis, yet, without other evidence of fracture, the case would be likely to pass unrecognized. Ecchymosis and swelling, which extend to the eyelids, are the usual concomitants of contusions in the vicinity of the nose, and do not indicate the existence of a fracture. Even the introduction of a probe into the nos- trils determines nothing positively, unless it forces one frag- ment against another, producing crepitus. The nasal bones may be broken and displaced, yet the fragments may be so wedged against one another, and between other bones, that no crepitus can be elicited. When the fracture is much com- minuted, motion between the fragments can easily be given by holding the nose between the finger and thumb, and push- ing it laterally, or from side to side. If a grooved director be carried up the nostril beneath the fragments, and the finger be held upon the outside injury, alternate motion given by either instrument may disclose crepitus, and a pretty clear idea of the state of the parts. In the event of a wound exposing the bones, it would not be difficult to discover whether a fracture had been received or not. Treatment.—Diagnosis having been established, the sur- geon's next duty is plain, though not easily accomplished in every instance. A profuse and persistent hemorrhage is to be arrested before dangerous syncope comes on. The displaced fragments of bone ought to be reduced, if possible, for no de- formity is so noticeable as a flattened or distorted nose. A female catheter, grooved director, or other similar instrument, may prove a sufficiently firm lever when inserted in the nose. Fractures or the Nasal Bones. 77 to force the fragments back into place, but in some instances, a pen-handle, or piece of hickory wood whittled into the form of a pencil, may be required as a lever to elevate the bones from their depressed position. This elevator, first carried up one nostril, and then the other, to a point beneath the depres- sion, then, being poised on the forefinger which rests on the upper lip, is made, by a lever motion, to pry the fragments into their normal position. Once replaced, the bones will stay where they belong. Pledgets of lint stuffed into the nasal cavities to prevent the bones from falling out of place, can not accomplish any good purpose. Petit remarks : " These plugs are only of use to contain the medicaments; and those who have thought of putting plugs of lint with the idea of sup- porting the bones, for fear they should be displaced, have never made the reduction of a single fracture of the nose: experience would have taught them that it requires more force to depress these bones that have just been replaced, than was necessary to raise them up with the elevator." If the bones be much comminuted, the parts may be quite moveable and require some lateral support. This may be brought to bear by the use of small compresses, one placed on either side of the nose, and held there Avith strips of adhesive plaster. In many accidents, the fracture of the nasal bones is the least important part of the injury. There may be emphysema, the air from the nostrils finding its way from cell to cell, or tissue to tissue, till the parts about the e}7es and face are dan- gerously infiltrated; lachrymal fistula is another unpleasant complication ; and the crista galli of the ethmoid bone may be forced upwards or to one side, and do serious harm to the brain, or structures within the skull. A lateral deviation of the nasal appendage is not so objec- tionable a deformity as flattening or sinking down of the bridge, yet much care should be exercised from day to day, during the healing process, to prevent any lateral tendency. As soon as the swelling about the nose and eyelids subsides, any depression or lateral deviation can be readily detected; and if the injury be not more than two or three weeks old, the defect may be remedied. After consolidation of the frag- ments, no correcting operation should be adopted, so far aa the position of the bones is concerned. 78 Fractures. FRACTURE OF THE MALAR BONES. The bones of the face may be broken by direct violence; and, when broken, the displacement is generally by depres- sion. There will necessarily be a severe contusion, and not unfrequently a wound clear to the bone. No crepitation can be elicited, unless the comminuted fragments can be made to move against one another. The evidence of fracture is de- rived from displacement, and that is almost always by depres- sion. The swelling, which arises rapidly, masks the bony displacement, so that the true condition of the parts has to be ascertained by indentations made with the fingers. Although the malar bone is very prominent, and nearly subcutaneous, it is not easily broken, or forced out of place. In prize fights the projecting cheeks are especially exposed to blows, yet in the whole history of such " sports," not an instance of a broken malar has occurred. I have never been called to treat a fracture of this bone, but if I had an accident of the kind to manage, I should expect to treat it as I would a depressed zygoma. There is generally in connection with the fracture, a wound of the integument covering the bone, and through this an awl-like lever might be used to elevate the depressed fragments. FRACTURE OF THE SUPERIOR MAXILLARY BONES. Fragments by direct violence, are occasionally detached from the front portions of the superior maxillary bones. The nasal or ascending processes, as has already been indicated, may be broken by the same force that breaks the ossa nasi. In a case that came under my observation, a man, in a fall from the loft of his barn, struck upon the tire of a wagon, and sustained a fracture of one superior maxillary. The break beginning in the median line and extending back to the incisive and canine fossae, separated from the main bone a seg- ment of the alveolar arch containing four teeth. There had been a tooth—the first molar—extracted, which perhaps weak- ened the bone at that point, and allowed the fragment the more easily to be turned into the mouth. The soft palate was Fracture of the Upper Jaw. 79 not much.lacerated, therefore the piece of bone did not become completely detached from its connections. The upper lip was extensively bruised; and there were injuries to other parts of the body. I had no difficulty in pulling the segment of the alveolar arch back into its place, and retaining it there. None of the teeth were loosened from their places, though there must have been some interruption to their nervous and vascular supplies. The wound received no dressing except a wiring together of the two front or incisor teeth. The loss of a tooth beyond the other extremity of the fragment, prevented the application of another wire at that point. The recovery was perfect, no defect or deformity following the injury. Cases similar to the one described, are reported in several of our medical journals, and by Hamilton and Malgaigne in their Treatises. In the treatment of fractures of the superior max- illary, the rule is to save the detached parts if possible; and if the mucous membrane of a fragment be not entirely sep- arated from that connected with the main part of the mouth, the union of the piece in its original place, may generally be expected. The separation of splinters in the operation of ex- tracting teeth, is commonly final, there being no attempt to effect consolidation with the rest of the bone. In the management of a fracture of the upper jaw, includ- ing a segment of the alveolus, it is well to wire the teeth together at the extremities of the fragment, and then bind the inferior maxillary against it, with bandages around the head and under the chin. CHAPTER XIV. FRACTURE OF THE INFERIOR MAXILLARY. The lower jaw, from its situation, is exposed to injury; and parts of the bone, which are thinly covered, receive blows with full force. However, the inferior maxillary, in shape and mobility, is signally protected against fracture. A heavy blow directly in front, tells powerfully upon the symphysis, as the bone does not have an opportunity to slide or otherwise escape the full effect of the stroke; but a blow upon the side of the jaw is decomposed by the lateral sliding of the bone. Fig. 17. Fracture of inferior maxillary hone. The under-jaw is weakest at a point just in front of the insertion of the masseter muscles; at least, fracture takes place more frequently there than at any other place. Direct violence, as the kick of a horse, is the common cause of a broken inferior maxilla. Boyer maintains that the solution of continuity never occurs just at the symphysis. In two instances I have seen fracture in the median line. Plenty of similar cases have been reported. In adult age the (80) The Inferior Maxillary. 81 bone is very strong at the symphysis, yet the frequency of fracture at that point indicates that the strength of the bone may be overcome by a powerful blow centrally applied. The bone is rarely broken in two places. A crushing kind of force, as where the face is run over by a loaded wagon, may inflict a double fracture. The neck of the condyle is rathei slender, and, in a divided muscular action, in conjunction with a complication of forces acting in a fall, it may be broken. The coronoid process is so well protected by the zygoma and thick muscles, that a fracture of it must be exceed- ingly rare. The ramus may be separated from the body of the bone at the angle, or a little above. Fracture of the lower jaw may be simple, compound, com- minuted and complicated—the nature of the injury depending much upon the violence sustained. A segment of the alveolar arch, taking with it several teeth, is occasionally detached. In such cases, the gums and mucous membranes of the mouth are lacerated. Bonn gives an account of a fracture in combination with dislocation of the lower jaw. The same force in one direction did not occasion the double injury, but a series of forces acting at different times and in different directions, as when a man, in falling from a high building, strikes a scaffolding on his way down, and receives one kind of injury. Then as he reaches the ground covered with rubbish, sustains another kind of hurt or a multiplicity of injuries. It would be diffi- cult to account for certain complicated injuries, except on the theory of the action of a variety of forces. A jaw that has been weakened by ulceration around dis- eased fangs of teeth, may break under the force a dentist im- parts in the act of extracting a neighboring tooth. I once saw a jaw that had been broken while a dentist was extracting the lower teeth to prepare the mouth for an artificial set. The bone was carious at the point of fracture ; and had been thus rendered by an old fang that was completely hidden by the over-growing gum. Suspecting a diseased state of the bone, for the dentist assured me that he used only moderate force, I explored the fractured ends with a slender dental instru- ment, and discovered and dislodged the old fang. Suppura- tion kept up for three or four weeks, and then the fragments united as in an ordinary fracture of the jaw. 6 82 Fractures. Muscular action has been known to produce fracture of the neck of the condyle. Professor Joseph Pancoast once met such a case in the Jefferson College Clinic. An old man suf- fered the lesion while in a paroxysm of violent coughing. Mr. Holmes, of London, exhibited to the Pathological Society a specimen of a fractured portion of the neck of the lower jaw driven into the meatus auditorius externus. Vio- lence producing fracture of the inferior maxillary, may be sufficient to crush the bones of the face, and to injure the brain. In most of the instances coming under my observation, the direction of the fracture has been more transverse than ob- lique. This has not always been the experience of other ob- servers. Reports of a great variety of cases show that the course of the fracture in this bone may be similar to that iu the long bones. When fracture occurs in the body of the jaw, the symptoms are plain, and distinctly indicate the nature of the injury. There is mobility of the parts, crepitus, and irregularity in the line of the teeth ; the gums are torn and bleeding, the mouth is usually partly open, the saliva dribbles away, and the patient, in making known his wants and sufferings, utters words without allowing much motion of the mouth; One fragment rarely takes the same line as the other, but there is apt to be a rocking of the short piece, and a displacement above or below the long fragment, or overlapping as in frac- tures of the long bones. When fracture occurs in the ramus, or about the neck, or coronoid process of the bone, the displacement is either incon- siderable, or in such a situation as to be recognized with some difficulty. The pain at the point of injury, the mobility, and crepitus, are signs that might be expected, and when the latter can be heard or felt, it is not to be mistaken. Sometimes the bone is splintered at the time of the frac- ture, or a small portion becomes carious afterwards, causing exfoliation to take place before the part will unite. Abscesses forming in connection with these cases are often very tedious and difficult to cure. The tearing of the gum, a frequent complication in fracture of the lower jaw, is not to be considered fully in the light of a " compound " injury, for the laceration is within the mouth, The Inferior Maxillary. 83 bo that the healing process is not much prolonged by the wound in the soft tissues. The reduction of fractures of the inferior maxillary is not generally attended with serious obstacles. Manipulation of the broken parts is most conveniently conducted while the patient is sitting on a stool or low chair, and the operator is seated behind him. Then the surgeon with the patient's head leaning against his breast, can with his thumbs and fingers press the displaced fragments into line. Any loosened tooth had better be removed, lest it interfere with perfect apposition of the fragments, and the healing process. The surgeon, leaning over the patient, as indicated, has a good opportunity to feel any irregularities along the base of the bone, or want of harmony in the dental arches and planes. If the surgeon is unable to adjust the fragments by sitting behind the patient, he can have an assistant take his place to support and steady the head, while he, standing in front of the patient, has a better opportunity to manipulate the jaw. If a tooth-is merely loosened, and is not in danger of getting between the fragments, or of interfering with the healing pro- cess, an attempt may be made to save it. Having had some trouble with a loose tooth I tried to save in one instance, I am not so " conservative" in my notions in regard to saving teeth as were my early teachers. Treatment.—The common method of treating fracture of the inferior maxillary, is to fix the lower jaw firmly against the upper, either directly, or by placing two pieces of cork be- tween the teeth, and then applying a bandage tightly under the chin and over the top of the head. rUhe dressing is to be kept on for four or five weeks. During this time the patient must live on liquid food, or such as he can swallow without mastication. It is quite desirable that the nourishment should be rich and stimulating, therefore beef, mutton, and chicken broths, in which bread is soaked or softened, should constitute a part of the patient's diet. The variety of "splints" and dressings devised to treat fracture of the inferior maxillary, is greater than necessary. In hospitals where gutta percha and other splint-material is at hand, such substances seem very satisfactory for moulding 84 Fractures. purposes. However, it is my design not to give undue prom- inence to means and methods only practicable in public insti- tutions, or in large cities where almost any mechanical con- trivance can be obtained at short notice; but to make such suggestions and give such di- Fig. 18. A piece of pasteboard, split at each end toward the middle, to be folded to fit the chin. Fig. 19. Pasteboard folded ready to be applied to the chin. Fig. 20. rections as may enable a prac- titioner in a rural district to fix up his case satisfactorily* with materials at command. A piece of pasteboard about eight inches long, and four or five broad, may be taken and split up the middle from each end to within an inch of the centre. The material is then to be dipped in warm water, to make it soft and pliable, and folded, as indicated in the wood-cut. The splint thus moulded can be applied to the chin; and by a little manipu- lation, it may be made to adapt itself closely to the part, so it shall give equal and uniform support. It may be retained in place by a four-tailed ban- dage, or a roller carried in front of the chin, and around the base of the head below the ear, then across the top of the head obliquely, and under the chin and over the head again, as depicted in the wood-cut. At the points where the turns of the bandage cross each other, pins should be used to keep the dressing from slipping out of place. Gutta percha, cut like the pasteboard, and soaked in very hot water to make it pliable, may be used in the way just described. A firm piece of sole leather answers an excellent purpose. Tough bark is not without its desirable qualities in treating fracture Pasteboard applied to chin, and held in place by a bandage. The Inferior Maxillary. 85 of the inferior maxillary when other means can not be com- manded. The employment of silver wire as a ligature to fasten together contiguous teeth on each side of the fracture, is the most reliable and satisfactory means of holding the fragments adj usted. A strong silk or hempen cord will do in place of the silver wire. Even an iron wire may be used in case no silver wire is at hand. In one instance coming to my knowledge, a piece of tough iron wire was used to twist together adjoining teeth in fragments of the under jaw, and it held its place for three weeks. At the end of that time no further retentive means were needed. If silver wire be used, a large size, ordinarily employed for sutures, should be selected. There is generally space enough between the teeth, near the gum, for one end of the wire to pass readily. A piece from twelve to fifteen inches in length is long enough. After one end is carried through to the mid- dle of the ligature, it may be bent, and pushed back out of „ M the mouth between the two Fig. 21. . . teeth nearest the other frag- ment. Then, with the two ends of the wire in his hands, the surgeon can draw the pieces of bone together and hold them in apposition, by twisting the ends of the wire ligature around each other. After a secure fastening is made in this way, the free ends of wire may be cut with scissors, down to the twist. Finally, the rough end of the fastening may be bent with forceps, and thus kept from jagging the lip. Forceps may be employed with advantage in carrying the wire between the teeth. A silk or hempen thread may be passed between the teeth by the aid of a short needle. The wire may be carried twice around the necks of adjoining teeth, with the view of greater strength and security, but a single ligature is generally better than two. Silver wire passed around two teeth adjacent to fracture of jaw, and ready to be twisted. 86 Fractures. If the tooth next the fracture be loose, or missing, the liga- ture may be made to surround the next in the row. W here no teeth exist, the fragments may be perforated on each side of the fracture, and a silver wire ligature employed to fasten the pieces of bone together. I have had such excellent success in ligaturing the teeth, and the results have been so satisfactory, that I feel like be- stowing great praise upon this plan of joining the fragments in the treatment of fractures of the lower jaw. It permits free movements of the mouth, although mastication is not to be admitted. If the patient can not be trusted to keep the jaw pretty quiet after the teeth are wired together, it will be best to finish the dressing with the pasteboard cap for the chin, and the roller to keep it in place. Ivory aud metallic clamps to fit the chin, and others to be- stride the alveolar arch, have been employed with success. Perhaps there may be instances where it is impracticable to use the wire suture; and a chin or clamp dressing is the only means left which can be employed. However, the paste- board, gutta percha, or leather chin-piece, is never beyond reach. I have seen cases where all means, except the wire ligature around the teeth, have failed to keep the fragments in apposi- tion and at rest. Fractures through the ramus, neck of the condyle, or coro- noid process, can not, of course, be treated with the silver wire ligature. In such cases the chin dressing, with bandages, constitutes the only means that contribute to the support of the broken parts. Such fractures are beyond reach, and the fragments continue under the control of the masseter and pterygoid muscles. The coronoid process, as has been stated, is rarely broken.; and even when fractured, the temporal mus- cle, on account of the great extent of its insertion, does not generally displace the fragment. Delayed union and false-joint are occasional defects the sur- geon has to encounter in the management of fractures of the lower jaw. One of the alleged reasons for these defects is that the saliva may have free access to the broken surfaces, dissolving and washing away the reparative material; but a more acceptable explanation is that the inferior maxillary is to some extent, a floating bone, subject to motion at every act The Inferior Maxillary. 87 of speaking or swallowing. Want of steadiness in broken bones always delays union, or altogether prevents that result. In one of my cases, complete consolidation did not take place for over a year from the reception of the fracture. The mo- bility during the later period of the consolidating process, was very slight, and did not inconvenience the patient. The frac- ture was through the symphysis, and the accompanying inju- ries were so severe that there was little hope of a recovery for several weeks. Allusion has been made to the use of corks between the teeth. These when used are designed to keep the jaws apart so that food can be taken. The corks should be wedge-shaped, and channeled above and below for the reception of the teeth. There are objections to any material used in this way. Even the gutta percha wedges recommended by Hamilton impart an unpleasant flavor to the mouth as long as they are worn. In one instance, where the teeth were too closely set to allow of nutrient fluids to be easily sucked between them, I used leaden wedges, channeled for the teeth, and curved to correspond with the arches of the jaws. I was well pleased with the part they served. These interdental splints are not needed in cases treated by fastening the fragments together with silver wire inserted between the teeth. In the event of double fracture, a segment of one side of the jaw being detached, it may be difficult to use the wire far back in the mouth. However, if the front end of the de- tached piece of bone can be secured by suture to the long and more stable fragment, the result will generally be more satis- factory than when treated with chin splints and bandages. CHAPTER XV. FRACTURE OF THE HYOID BONE, ETC. The os hyoides is exposed not rarely to one kind of violence, viz., the grip of an antagonist. Other causes might be enu- merated, but the one mentioned breaks the hyoid bone more frequently than all others together. The shape of the bone is such that the thumb on one side of the throat and the fingers on the other, tend to force the two great cornua towards each other. The fracture may take place through the body of the bone, or, as is oftener the case, through one of the branches. While the head is bent forward, the hyoid bone is protected by the under jaw; with the head thrown back, the bone be- comes exposed to blows, and other kinds of violence. Ollivier reports that a woman, fifty-six years of age, made a false step and fell, her head being thrown forcibly backwards. She re- ceived, from muscular action, a fracture of the greater cornu of the hyoid; and heard a distinct crack at the upper part of the left side of the neck, at the moment she fell. Dr. P. G. Fore, of Cincinnati, had a case, which was sustained by a direct blow, received in falling down stairs, a projecting brick inflicting the injury. The signs of fracture of the hyoid are generally well marked. The snap is audible, and quite often heard by the patient; the pain, coming on immediately, is severe, and is quickly followed by notable external swelling ; discoloration, the result of ecchymosis, appears sooner or later; and the patient can not speak or swallow without occasioning distress. Crepitation can not always be elicited, owing in part to the displacement, and in part to the difficulty of manipulating the fragments. The finger carried back along the floor of the mouth to the root of the tongue, may discover the rough ends of the fragments. The treatment consists more in combatting (88) The Hyoid Bone. 89 inflammation, and enjoining a quiet, easy position, than in any kind of retentive dressing:. In the event of displacement, the finger of one hand is passed into the throat, and the other hand, externally, assists in adjusting the pieces. Once in place, the fragments are not generally drawn out of position, especially if the head be kept inclined forward, aud in a state of repose. The patient may have to be fed through a tube for a few days. The recovery is generally complete in four or five weeks. Dr. George Harley, in Holmes' System of Surgery, reports a case of frac- ture of the hyoid bone, which illustrates the peculiarity of the symptoms, and refers to abandage employed in the treatment. " On the 28th of March, 1856, a little girl, aged six years, while jumping, fell with her neck across the rail of an iron . bedstead, jhe was instantly seized with a fit of coughing, great dyspnoea, an inclination to vomit, and a copious flow of saliva. The saliva was partly tinged with blood. When brought to us, which was almost immediately after the receipt of the injury, there was distressing difficulty of breathing, the face was of a livid blackness, and there were all the other symptoms of impending death by apncea. On examining the neck, there was found a sharp body projecting beneath the skin. It was very angular and quite moveable. On close in- spection it was found to be the displaced ends of the fractured hyoid bone. One end of the body rode over the other. By a little manipulation the fracture was reduced, and all the symptoms of impending suffocation, together with the copious flow of saliva, etc., rapidly subsided. A bandage was placed around the neck to keep the ends of the bone in their place; and with the exception of a smart attack of fever, which lasted three days, the child made an uninterrupted recovery, and without any deformity, except a slight fullness caused by the callus ; but even this after a time disappeared." In the case just cited, the fragments nearly perforated the skin ; in some cases the sharp ends puncture the mucous mem- brane of the pharynx, pricking and irritating to an intolerable degree. Proper reduction consists in replacing the fragments so the ends shall be at a distance from sensitive parts. A handkerchief tied snugly around the neck would steady the muscles, and prevent, in some measure, the recurring inclina- tion to swallow. 90 Fractures. FRACTURE OF THE LARYNGEAL CARTILAGES. The cartilages of the larynx are sometimes broken, the re- sult of a blow or fall upon the front of the neck, or from a forcible squeeze of the throat. M. Ladoz has no doubt this fracture is produced exclusively by violence inflicted with the hands and nails. Plenck has seen a case in which the thyroid and cricoid cartilages were both broken by a fall against the edge of a bucket. Dr. Frank Hamilton reports a case arising from the kick of a horse. Injuries of this kind are extremely dangerous to life, in con- sequence of impediments to respiration, either immediately after the injury, from displacements, and effusion of blood ; or, subsequently, from emphysema, and cedematous infiltration. The neck has a swollen and distorted appearance, the voice is altered or entirely lost, and the act of swallowing is attended with difficulty. Cough supervenes, and the respiration becomes changed to a disagreeable whistling or crowing. The emphy- sema, by becoming general, is a serious complication, though the greatest danger is from rapidly approaching suffocation. An attempt should be made to overcome the occlusion of the glottis, by cutting down upon the larynx, and even iuto it, that the infiltrated and cedematous tissues may be relieved, and the fragments of cartilage pushed into place. A grooved director or small elevator, entered through a fractured or artificial opening, is a serviceable instrument to raise and to adjust fragments. The emphysema, if confined to regions around the injury, is nearly harmless, and may be let alone. Punctures to relieve the infiltrated areolar spaces, will do some harm and no good. The introduction of a laryn- geal tube, to breathe through, might be of service in cases where suffocation was imminent. Evaporating and anodyne lotions would be indicated to subdue or hold in check a high grade of inflammation. CHAPTER XVI. FRACTURE OF THE VERTEBRA. Severe injuries and displacements of the bones of the back, are generally complicated, fracture and dislocation being liable to occur at the same time. It seldom happens, from the me- chanism of the vertebral column, that a simple fracture or dislocation occurs as a distinct and uncomplicated lesion. In the cervical and lumbar regions, where motion is not restrained by the vertical articular surfaces, dislocation can occur without the absolute necessity of a fracture; but in the dorsal region, where the processes overlap, and are closely locked, simple dislocation seems impossible. In the management of injuries about the extremities, it is exceedingly important to draw nice distinctions between frac- tures and dislocations, that the proper treatment for each may be applied understandingly ; but in grave injuries of the back, the breaking of the tip end of a spinous or transverse process is not the serious part of the trouble. If dislocation exist, the displacement is to be overcome, but the gravity of the case depends upon the condition of the spinal cord. That delicate and important organ is liable to be compressed by the dis- placement of vertebrae; and the reduction of the bones is more to give relief to the cord than to get rid of a deformity. Fractures of the vertebral bones coming from direct vio- lence, arise mostly from blows; but they result from indirect violence, as when a man, in falling from a height, strikes upon the head or upon the nates. The parts hitting the earth may escape with bruises, yet the force is continued upward, and breaks some of the vertebral bones. The throat, chest and abdomen protect from direct violence the vertebral chain of bones in front, therefore the force must come from the rear, or from above while the body is bent (91) 92 Fractures. forwards. A miller's carman, standing in his wagon, was re- ceiving into it heavy sacks of corn, let down by ropes from the high story of a grocery; one of the sacks slipped, and in its descent, struck the neck and shoulders of the workman. The force fractured the spinal column at the fifth dorsal vertebra. A heavy force, striking the back, making it suddenly bend beyond its ordinary incurvation, is very likely to wedge off some of the processes. In the dorsal region the imbrication or overlapping is so considerable that not much flexibility ex- ists, but in the cervical and lumbar regions, there may be a ' good degree of incurvation without fracture. Effect of Fracture upon the Spinal Cord. — A fracture of the vertebral column at any point between the occiput and the third lumbar vertebra, where the cauda equina begins, generally inflicts injury upon the spinal cord ; and all the body below the fracture at once loses, more or less completely, both motive power and sensation. The great nerve center, being impinged upon, or compressed, loses its functions, and the parts depending upon it for nerve supplies, are paralyzed. The higher in the column the fracture occurs, the greater the part of the body affected—in other words, the graver the con- sequences. The fracture of a cervical vertebra makes the case extremely dangerous, owing to effects upon the spinal cord high up, where the respiratory nerves arise. The length of time a patient will sometimes live after a fracture of the vertebral column, with all the distressing afflic- tions of paralysis, is quite astonishing. Persons have lived thirty years under such unfortunate circumstances. Even with the fourth cervical vertebra broken, a patient has lived more than a year. Mr. Page reports the case of a Scotch gentleman, twenty-six years of age, the heir to extensive landed property, who, while running on the edge of a terrace, accidentally fell upon a hard road beneath, a height of ten or twelve feet, and injured his neck. From that moment every part of the body, with the exception of the head, was com- pletely paralyzed, the power of rotating the head being all that remained to him. When a man has the spinal cord crushed or torn, so low down that respiration is not materially affected, it is not the direct injury nor loss of function in parts below, that destroy Of the Vertebra. 93 life. If the circumstances be favorable the fracture will con- solidate and prevent motion dangerous to the cord if that re- main intact; the parts paralyzed may become atrophied, but that does not prevent vital continuance. However, there are formidable causes which, sooner or later, exhaust the strength of the patient. Bed-sores on the hips, coupled with disorders of the urinary organs, by combined influences, at length make life succumb. A remarkable feature of the sores is that they form and extend with unusual rapidity. In a few days, before nurse or friends suspect any difficulty of the kind, large sloughs have separated from the regions of the sacrum and hips. The patient, feeling no pain in the region, does not ask to be turned in bed, hence the prolonged pressure and irritation upon one spot, which result in disorganization of the tissues involved. Owing to the bladder being deprived of sensation, a condi- tion which frequently results in over-distension of that viscus, and which calls for the repeated use of catheters, derange- ments of the mucous lining of the urinary tracks begin, and continue with varying phases till the gravest effects are im- pressed upon the system already weakened or seriously im- paired from other causes. In simple fracture of the spinous, transverse, and articular processes, as pictured in surgical works, the lesion does not generally appear formidable, but when the bodies of the ver- tebrae and the walls of the spinal canal, are broken, the pro- longed and deplorable results tax the patience of friends and the ingenuity of the surgeon. Treatment.—A patient with suspected fracture of the ver- tebrae should be taken home in an easy horizontal position, on a door or shutter; and, after his clothes are cut from him, he should be laid on a mattress. The surgeon should see that extension and such manipulation be employed as shall favor the return of any displaced fragments to their places. A slight change of posture may be all that is needed to correct a marked deformity. Sand-bags should be prepared at once, and so employed as to sustain the attitude thought to be the most desirable. Common feather pillows answer a good purpose in bolstering up the head and shoulders, but the hips should be propped up 94 Fractures. with something more substantial. Sand-bags will be found useful in every case, though the service of air and water-pillows is needed for parts inclined to slough. A piece of buckskin next to the integument is better than lint or other fine tex- tures. In the event of sloughing, the use of carbolic acid to the raw surface is excellent. The agent corrects fetor, and hardens the tissues to which it is applied. It is still a question whether any operative measures are ever justifiable, undertaken to relieve compression of the cord. The trephine has been employed with success in a few in- stances, though there seems to be no definite indication for its use. There is no sign to distinguish between the compression made by a piece of bone and that arising from effusions into the vertebral canal. The diagnosis depends more upon infer- ence than substantial evidence, therefore the operation can never be performed under well grounded convictions. If a surgeon meets a case in which the indications point emphatically to an operation, he should not hesitate to execute what that exceptional case requires. To be always governed by general principles deduced from the majority rule, leaving no latitude for exceptions, which may always exist, would impose undue restrictions upon a progressive science. CHAPTER XVII. FRACTURE OF THE RIBS, ETC. The length of the ribs, their curved shape, together with their articulation to the sternum by means of elastic cartilages, contribute to their power of resisting forces, which otherwise would be continually causing fracture of these bones. Even as it is, with all their advantages for resisting fracture, such lesions are extremely common, forming about one-tenth of all fractures. The elasticity of the ribs varies greatly with age; the young rarely suffer from broken rib, while in elderly people, whose bones have become unyielding and brittle, the injury is ex- ceedingly frequent. The anterior extremities of the ribs being more elastic and less firmly fixed than their vertebral ends, fractures of these bones occur less often in front of the middle than behind that point. A rib may break at a point remote from the part struck, for it will first bend to a certain extent, and then yield at the point where the flexibility ceases. A given amount of compressing force applied to the front of the chest of a young person, makes a rib snap away back near its angle; the same force, applied to the same spot on the thorax of an old subject, breaks the bone in its middle or more anteriorly. A direct force against the side of the chest, breaks a rib and carries the ends of the fragments inwards, lacerating the pleurae and lungs. A force applied to the front of the chest, renders the rib more convex, or hoops it, so that when the fracture occurs the ends of the fragments will be directed towards the skin, and away from the viscera of the thorax. If a person be thrown forcibly against any projecting point, like the corner of the table, one rib is broken ; but the kick of a horse, or the crushing force of a carriage wheel, (95) 96 Fractures. generally breaks two or more of the costal bones. Several ribs are broken in severe injuries of the chest. The fracture of a rib may be incomplete, the bone being simply fissured. In such cases there would be no displace- ment, though there might be angular deformity in a percepti- ble degree. In complete fracture of the ribs the periosteum Fig. 22. may not be torn, giving no opportunity for displacement or deformity. The intercostal muscles assist in steadying the fragments and in preventing displacement; and the bones are firmly fixed both in front and behind; consequently there is seldom much shortening or other displacement. The ends of the fragments resting against each other, are moved sufficiently by active respiration to elicit crepitus. In the event of the thorax being caught between two op- posing forces, and in severe and complicated accidents, frac- tures may be produced on both sides of the chest; though in the majority of instances, only one side becomes involved. A rib may be broken in two or more places, yet the long bones of the extremities suffer comminuted fracture much more fre- quently. The first rib being short, and protected by the clav- icle, is seldom fractured ; the last two, or floating ribs, on ac- count of their natural mobility, scarcely offer resistance suffi- cient for a force to act on them; the ribs most frequently frac- tured are the upper false, and the lower true, these being the longest and the most exposed to injury. A simple fracture of one or more ribs, uncomplicated with lesions of the lungs and other important structures, is not a dangerous injury ; but when the pleurae and pulmonary organs, to say nothing of the heart and large blood vessels, are in- Of the Ribs. 97 volved in the accident, the most serious consequences are to be feared. An analysis of 136 cases admitted into Guy's Hos- pital, during five years ending in 1860, exemplifies the relative proportion of complicated and uncomplicated fractures of the ribs; 108 were uncomplicated, of which 8 only had secondary inflammation, proving fatal in two instances from previous old-standing disease ; 28 were complicated, 16 with emphyse- ma, of whom four had symptoms of pneumonia, though all recovered, and of the remaining twelve, 6 died at once from fatal collapse, and 6 recovered. Of the latter, 3 had haemop- tysis and emphysema, and 3 extensive injury and severe in- flammatory symptoms. The ordinary symptoms of fractured ribs are quite clear and definable. The patient declares he felt something break, or give way; he feels acute pain at the seat of injury; and complains of a severe stitch in the side or catching of breath during a deep inspiration ; the slightest attempt to cough disturbs the fracture, and gives rise to the sensation of grating ; movements of the ribs on the affected side, and even on the sound side, on account of the consonance of action, are guardedly suppressed, and respiration is carried on through the movements ofthe diaphragm; the arm on the injured side is held stead}7 and in such a position as to relax the mus- cles extending from that member to the thorax. Crepitation sometimes results from the motion of respiration, and can generally be produced by manipulating the chest. The hands placed on each side of the supposed seat of fracture, or on each side of the chest, and moved alternately, excite sufficient motion to elicit crepitus. When the fracture is situated very far back, it is more difficult to produce crepitation. The hand placed upon a point opposite the fracture, and made, by a sudden impulse, to impart motion by indirect force, sometimes causes a grating of the ends of the fragments. The ear placed against the seat of injury may detect crepitus, the patient being requested to cough while the auscultation is made. Crepitus, though an essential indication of fracture, is sometimes wanting, and its absence should not positively decide against the possible existence of such an injury. If there be spitting of blood, and escape of air into the cel- lular tissue, the evidence of fracture i3 quite convincing, even if no crepitus can be discovered. 7 98 Fractures. The prognosis is generally favorable, though of course it will be modified according to the primary and secondary com- plications. In old and elderly persons, especially if they be at the time subject to bronchitis, asthma, or other forms of chronic disease, a guarded prognosis should be given, even if the fracture be uncomplicated. Such individuals often suc- cumb, in the one instance, to shock from their low state of vitality; and in the other, to a kind of asphyxia from ina- bility to free the lungs of the accumulated mucous secretion. The pleura is very liable to become inflamed, either from the fractured ends rubbing against it, or from a direct wound caused by a spicula of bone lacerating it. The lungs them- selves are not unfrequently wounded, and, as a consequence, take on serious inflammation. The cavity of the chest, be- tween the pleurae, may get filled with purulent fluids, and col- lapse of the lung result. The escape of air from a wound of the lung, may fill the chest and compress the organ, and find its way through rents in the pleurae, to the cellular tissue ex- ternal to the chest, a fact that may be known by a peculiar crackling felt when the skin is pressed on. The emphysema is at first confined to the side of the chest, and is situated near to the fracture; but gradually, as the patient goes on inspir- ing, fresh supplies of air escape, until it occupies an immense extent of surface, sometimes spreading over the whole body, even down to the fingers and toes. A moderate amount of emphysema is not especially dangerous, but when it encroaches upon the space needed for the action, of the lung, and fills a great part of the superficial cellular tissue of the body, the respiration becomes impeded to a fearful extent, and the movements of the body, from the puffy swelling, uncomfort- ably restrained. The intercostal artery, running just within the lower edge of the rib, is in some danger of being punctured or lacerated by the sharp end of a broken and depressed bone. Complicated accidents of this kind are exceedingly rare, but quite within the range of possibilities. Treatment.—The local treatment consists in keeping the ribs in as perfect a state of rest as possible. The best plan to accomplish this object, is to apply long strips of adhesive plas- ter, extending from the spine to the sternum of the affected Of the Ribs. 99 side. Enough strips an inch and a half or two inches wide, must be used to cover a space several inches broad, the dis- tance covered depending upon the number of ribs broken. These stay in place better than a bandage, and do not interfere with the movements of the sound side of the chest. In those cases where the ends of the fragments sink in toward the pleura, and compression at two opposite points on the chest remote from the injury will pry the pieces of bone outwards, (a manoeuvre that is practicable in some instances,) a wide flannel bandage may be used; also compresses at the points where the desired leverage can be obtained. The use of pasteboard and other splint-material to stay the broken ribs and to impede the normal motions of the chest, can accomplish very little substantial good. Some restless patients refuse to have any dressing applied, declaring that they can not endure the confinement imposed upon the respiratory organs. In nearly all cases coming under my observation and treatment, the restrictions placed upon the movements of the ribs by the adhesive strips, have been described as grateful. The sense of relief, and security against irregularity of respiration, have been acknowledged by patients thus treated. Purulent collections in the cavity of the thorax, are to be removed by the use of the trocar, as in ordinary cases of em- physema. The escape of air into the cellular tissue can not always be prevented. Well adjusted compresses around the thoracic opening, and held in place with adhesive strips and a bandage, may arrest the further issue of air. In case the em- physema become wide-spread and troublesome, punctures may be made in the skin to let the air out. A compressed lung, from the collection of air in the cavity of the pleura, has been relieved by an incision made in the intercostal space some dis- tance above or below the fracture. To dull the acuteness of the pain, and to arrest the inclina- tion to cough, the patient should be kept under the influence of opiates for several days. Gelseminum, aconite, veratrum, and other vascular and respiratory sedatives may be adminis- tered to advantage. Antimony and bloodletting are altogether too depressing and devitalizing to be employed, though they still are held in favor among the advocates of the theory that inflammation is an exalted state of the vital powers. 100 Fractures. In four or five weeks from the reception of a fractured rib, the patient so far recovers that he can attend to his usual avo- cation, when all treatment may be suspended. Usually a large callus forms at the seat of fracture. This excess of reparative material is supposed to depend mostly upon the constant motion kept up by respiration. Fig. 23. Showing bridges of osseous reparative material deposited between broken ribs, in the course of the intercostal muscles. In some instances the callus extends obliquely along the course of the intercostal muscles, and joins several ribs together with these bridges. Want of bony union follows fractures of the ribs in a larger proportion of cases than in other bones. This defect is pre- sumed to arise from the impracticability of keeping the frag- ments in a state of repose. Fortunately the state of false- joint is not attended with serious inconveniences. .Necrosis of one or the other of the fragments has been known to follow fracture and to become a chronic trouble. At a proper time exsection may be performed to get rid of the dead bone. FRACTURE OF THE COSTAL CARTILAGES. The sterno-costal cartilages maybe broken by forces similar to those which fracture the ribs. In old age the cartilages become ossified wholly or in part, so that, by losing their or- dinary elasticity, they do not escape being fractured. The lesion is so rare that it was scarcely mentioned till modern times. Magendie having observed five cases in two years, wrote a thesis upon the subject; Malgaigne states that he has Of the Sternum. 101 seen only three cases ; and that at the Hotel Dieu, there was but one case in 2328 cases of fracture generally. He attributes this paucity to the probable omission of the lesion in the hos- pital returns. The cartilage of the eighth rib has been most frequently broken; then, those immediately above it. One fragment is liable to overlap the other, which renders the diagnosis easy, and the parts may become united in that position. Osseous material consolidates the fragments. No subsequent ill effects are reported. Though the callus is bony, the original carti- laginous condition of the broken parts remains unchanged. The prognosis, in cases uncomplicated with serious internal inj uries, is favorable. The diagnosis, unless one piece overlaps the other, is difficult. No true crepitus can be elicited, but the other symptoms are the same as in fracture of the rib. The treatment consists in applying adhesive strips, a foot or more in length, across the injured spot. The chest bandage is not required, though it may be used to modify the move- ments of the thorax in case pain is aggravated by the respira- tory movements. Malgaigne found the bandage useless, but succeeded in keeping the fragments in apposition by the use of a light inguinal truss, with a soft compress. In twenty days the union was perfect, no inequality or deformity remaining. FRACTURE OF THE STERNUM. Crushing injuries that break the ribs and the vertebrae, are liable to fracture the sternum. The bone, by its articulation with the clavicles and the cartilages of the true ribs, yields sufficiently to escape fracture from ordinary violence ; hence, uncomplicated fracture of the sternum is a rare accident. The elasticity of the costal cartilages and the ribs, which are like hoops, deadens the shock and decomposes the force of a blow. Separation of the manubrium from the gladiolus, is more fre- quent than true fracture through parts wholly osseous. In advanced age, when the original parts of the bone are com- pletely ossified, the point corresponding with the primary divi- sion between the upper two pieces, proves to be the weakest. At least, fracture generally takes place at that point. (Fig. 24.) The course of the fractured line is across the bone 102 Fractures. transversely; and one fragment may be driven in so as to be overlapped by the other. There may be perceptible displace- ment without one piece getting behind the other. The causes of the injury are generally direct violence, though persons striking on the back, and having the body bend suddenly in a fall, have sustained fracture of the sternum. Chaussier reports two cases arising from mus- cular action, during parturition. The females were in labor with a first child, and threw back their heads, curving the body backwards. A celebrated vaulter, whilst bending his body backwards in the feat of raising a heavy weight with his teeth, broke the sternum. The symptoms are: a sensation of breaking or cracking at the time of the accident, inter- ference with respiration, and sharp pain at the seat of injury. Crepitation may be produced Section of the ster- by manipulating the chest, or by movements fracture °w&ai of the body. The displacement, when any is present, is decisive in its character, but if the fibrous and fascial investments remain untorn, there may be no overlapping of the fragments. Swelling and effusions may obscure the usual diagnostic signs. Fracture of the sternum may be complicated with lacera- tion of the integuments, and severe injury of the thoracic viscera. The spongy nature of the internal structure of the bone, favors the formation of abscess. The pus, in such a case, would be more liable to collect or burrow in the medi- astinal space than in the cavities of the pleurae. Caries is not uncommon after fracture of the sternum; and the pus and debris may cause trouble unless they readily find their way to the surface. Longitudinal fracture of the sternum is excessively rare. A case is quoted by Malgaigne : A mason, aged 60, fell from a scaffold on some large stones, and received a longitudinal fracture of the sternum; the left portion overlapped the right. Reduction was effected by drawing the arm to the side, and carrying it backwards, then pressing firmly on the middle of the right sternal ribs, making alternate movements from before backwards, so as to disengage the fragments ; at Of the Sternum. 103 the same time gentle pressure was made on the left or riding portion, so as to keep it on its own level. After reduction, a compress was applied, and maintained by a firm bandage. The case was successful at the end of six weeks; no deformity resulted. Treatment.—The plan of treatment to be adopted in frac- ture of the sternum, is to prevent, as much as possible, motion taking place between the two portions of bone, whether they rest in apposition or not. If one fragment overrides the other, moderate efforts should be made to reduce them, which may be accomplished by manipulating the chest. But if re- duction is impracticable by such means, it is not advisable to use hooks or elevators to raise the depressed piece. It is found by experience that overlapping does not prevent con- solidation, or produce serious inconvenience, even if the pieces of bone unite, with one fragment depressed below the other. Adhesive strips, applied vertically and transversely, prevent motion, and retain the fragments in contact with one another. A flannel bandage in some instances where respiration is at- tended with pain, may be used to surround and moderately compress the chest. The fabric is more elastic than cotton or linen, and one fold or turn will not slide upon another. The horizontal position, and moderate doses of quieting medicine, soon put the patient in a state of ease. Coughing, laughing, or sneezing, are instinctively avoided by the patient, therefore protests against such acts are useless. Position sometimes affords considerable relief. A firm pil- low or a large bag of sand placed under the back, to curve the trunk in that direction, puts extension and counter-exten- sion upon the sternal fragments, favoring reduction, apposi- tion, and repose of the broken parts. CHAPTER XVIII. FRACTURE OF THE CLAVICLE. The clavicle is exposed to direct and to indirect violence; and the bone breaks from one influence about as frequently as it does from the other. Blows are always liable to be re- ceived, and the body is often thrown against unyielding sub- stances, hitting the clavicle with direct forces which result in fracture. Falls upon the hand, the elbow, and especially upon the shoulder, impart forces sufficient to produce fracture ; the radius, humerus, and scapula escape by conveying the shock or impulse along to the next bone in the order of articulation. The clavicle being slender and situated disadvantageously to take the violence communicated to it, breaks at its weakest or most severely tested point. The two extremities of the bone are stronger than its cen- tral part, and are connected to the sternum and scapula by means of protecting ligaments, which render the ends capable of offering much more resistance than the middle of the bone, which has no such support. When the fracture is occasioned by a blow, or by the body coming in contact with some hard substance, it is apt to be more serious in its nature and consequences, from the contu- sion and mischief done by the broken ends, than in fractures coming from indirect violence. The situation of the fracture in the majority of instances, is near the centre of the bone. When the fracture is not far from the extremities, the acci- dent occurs near the acromion more frequently than in the immediate vicinity of the sternum. The parts of the bone between the curves seem to possess the least powers of resist- ance. When the clavicle is broken near its middle, (Fig. 25), or between the middle and the sternum, the inner fragment is usually retained in its place by the ligaments, and counter- (104) Of the Clavicle. 105 balanced muscular action; and the outer fragment in some instances is drawn a little downwards, in others it is elevated above the inner. If the fracture be outside the middle of the Fig. 25. Fracture of clavicle near the middle of the bone, showing overlapping and angular deformity. bone, the broken ends of both fragments are generally drawn upwards. Dr. R. W. Smith, of Dublin, in his " Treatise on Fractures in the vicinity of Joints," gives a description of several specimens of fractured clavicle, in all of which the frac- ture described was within two inches of the acromial extrem- ity. According to his illustrations, the broken ends of both fragments were drawn upwards, except in one or two instan- ces where the fracture occurred between the coraco-clavicular ligaments. By the action of the trapezius muscle the frag- ments were elevated until they formed nearly a right angle with each other, and large masses of osseous material (excess of callus) were poured around the seat of injury, even con- necting the irregular bony mass with the coracoid process. The coraco-clavicular ligaments were either ruptured or lost in the excessive reparative material. Fracture of the clavicle occurs at all ages of life ; it is met in infancy and extreme old age, and at all periods between. Males are more exposed by their habits and occupations, to blows, falls, and fatal accidents, therefore they more frequently suffer fracture of the clavicle than females. The fracture may be simple, compound, comminuted, and complicated; it may be transverse, oblique, or intermediate, partaking of both varieties so far as direction is concerned. The prognosis, so far as prospects for a good use of the arm are to be considered, is favorable; but so far as deformity is concerned, exceedingly unfavorable. Few fractures of the clavicle unite without more or less displacement. In most in- stances there is shortening either from angular deformity or from overlapping. This common defect arises from various causes. In some instances the dressing is not suitable, or is 106 Fractures. not kept well applied; in others, the patient, not being much inconvenienced by the injury, fails to carry out the injunctions of his surgical attendant. It is needless to enumerate the causes of deformity. The weight of the arm dragging upon the shoulder and clavicle, tends to produce displacement, un- less the member be well supported. The symptoms of fracture of the clavicle are very evident in the majority of cases; the shoulder falls downwards and forwards, the level of the acromion being much lower on the injured than on the sound side. The shoulder and arm are nearer the chest, obliterating, apparently, the axillary space. One or the other of the fragments will be unusually prominent at the seat of fracture ; and the overlapping and displacement can be distinctly seen and felt. Crepitus can generally be produced by taking hold of the shoulder and moving it up and down, while it is held outwards. As soon as the arm is left unsupported it falls downwards and inwards, producing the characteristic deformities. The patient experiences great pain in these forced movements, and in his own attempts to move the limb. He is unable to bring the hand across the chest to the opposite shoulder. The mobility observed at the point of fracture, when the arm is moved, is quite decisive as to the nature of the injury. In most instances the evidence of fracture is so-clear that crepitus need not be sought. The appearance of the patient before the clothing is removed, is generally such that an experienced surgeon suspects at once the nature of the injury. An individual with a fractured clavicle, is careful to support the elbow of the injured side in the hand of the sound side. This is to take the weight of the limb from the parts involved in the fracture, and to keep the shoulder up in its natural position. The patient is generally conscious of the nature of the injury. He complains of numb- ness in the fingers, which may be produced by the pressure of one of the fragments on the axillary plexus of nerves. In some cases the pain is intense and sickening, while in others, very little distress is experienced. Treatment.—The numerous contrivances devised and em- ployed to treat fracture of the clavicle, indicate the difficulties in carrying out what is so plainly demanded. The shoulder is to be held upwards, outwards and backwards : to perform Of the Clavicle. 107 this simple feat, a dozen kinds of apparatus- are in practical use ; and all seem to bear evidence of ingenuity. If a patient would submit to the confinement of lying on the back in bed for three or four weeks, the head being fixed on a pillow, and both arms confined to the side of the body, no special apparatus need be used. Young ladies, whose dresses expose the neck, and in whom it is particularly desirable to preserve the symmetry of the clavi- cle, may put this plan in practice. Men and boj's will not submit to such restraints, therefore some method of treatment must be adopt- ed to render them comfortable dur- ing the healing process, and allow them out-door exercise. A moder- Unsightly deformity following a ~ , , •, badly treated fracture ofthe ate amount ot shortening and nod- ular deformity at the seat of frac- ture, is not often minded by them, provided the arm is at length strong and useful. The dressing of Dr. Fox, introduced in 1828, is much in use, and answers a very good purpose. It consists of a stout wedge-shaped pad, the thick end to be used upwards in the axilla- of the injured side, to serve as a fulcrum over which the arm performing the part of a lever is drawn outwards by other parts of the dressing. A sling, like a ripped coat sleeve, made of strong cloth, extends over the forearm and elbow, and has tapes at each end; a stuffed ring is slipped on the sound arm quite over the shoulder. To this the tapes of the sling are tied, to lift the shoulder upwards and outwards. That the pad in the arm-pit may not escape from its place, its upper end should have a couple of tapes, one to tie to the ring in front, and the other behind the chest. The accompanying drawings explain the dressing better than words. If the sur- geon, when he is first called to a case, can not wait for the dressing to be made, he can dress the arm with the handker- chief, and leave directions for the making of the wedge, ring, and sleeve-sling. The wedge may be made of strong cloth, and stuffed with cotton, tow, or hair. The upper or thick end should be packed densely with the stuffing, that it may fulfill 108 Fractures. Fig. 27. Front view of for fracture of the purpose for which it is designed. The ring may be stuffed ■ with cotton, wool, or hair. The sling needs no padding, yet it should be soft and yielding. Very good results have been obtained with the handkerchief dressing. It consists in placing a long roll of cloth in the arm-pit as a fulcrum, and using a common cotton handkerchief as a sling to support the elbow, and hold the forearm up towards the opposite shoulder. The ends of the handker- chief are to be tied around the neck. Dr. Lewis modified the dressing of Fox, using the pad and sling, with wide straps to cross the chest in front and be- hind. It is not superior to the Fox dressing. Some years since, Dr. Huntoon introduced to the notice of the profes- sion a dressing which he called his " Yoke- Splint," consisting of a yoke-shaped piece of wood, hollowed out on the under surface, so as to fit the neck and both shoulders. The ends extend some inches be- yond the shoulder; and to which are attached two stuffed straps to pass through each axilla. These straps can be buckled so tightly as to elevate the shoulders, and carry them outwards and backwards, a handkerchief or other appropriate ' Fox's dress'ing the clavicle. Fig. 23. Posterior view of " Fox's dressing " for fracture of the clavicle. Of the Clavicle. 109 sling supports the forearm and elbow in front of the chest. Such an apparatus will do for adults, but is unfit for children. Long strips of adhesive plaster, carefully applied, constitute a good dressing to hold the arm and shoulder immovable in young and restless patients. A firm compress is first placed in the arm-pit, then the roller-plaster is used like a bandage to lift the elbow upwards, to hold the shoulder backwards, and to fasten the forearm to the front of the chest. This adhesive plaster roller is easy to apply, and will not get out of place. If well put on, it will not have to be removed or renewed during the four weeks of healing. Many years ago it was customary to place a pad in the axilla, and then envelope the arm, shoulder and chest in a very long bandage. This is now discarded on account of its confining the chest, and of the difficulty of keeping it in place. About a year ago I adj usted a fractured clavicle with hand- kerchiefs. The patient was an old German, who received the injury by a fall on his shoulder in the street. Upon visiting him the second day I found the dressing had been thrown aside; and learned from the old man's son that his father had refused to have anything done in the way of treatment. The patient was thin of flesh, so that in the movements of the arm motion could be distinctly observed between the fragments. There was great angular deformity caused by the arm falling so low. No particular pain was complained of. The patient used his hand every day, though very carefully. I called once in a week or so to watch the progress of the healing process under no treatment. There was so much motion between the ends of the fragments, that I was afraid of non-union. At the end of three weeks from the date of the injury, a pretty firm callus had united the broken ends, though there was a salient projection of the fragments upwards. In five weeks the patient said he was well as ever, and claimed credit for success in his let-alone treatment. The point of the shoulder on the injured side stood an inch lower than the other, and the arm hung nearer the thorax than natural. As the patient and his friends were well satisfied with the result, I did not express my regrets at the deformity. CHAPTER XIX. FRACTURE OF THE SCAPULA, ETC. The shoulder-blade glides easily and freely in all directions, therefore it is well prepared to decompose forces or to yield sufficiently to escape fracture. Resting upon the convexity of the ribs and muscular cushions, the bone rarely suffers from lesions peculiar to more rigid and unyielding parts of the skeleton. The scapula is deeply covered with muscles, except at points which project quite prominently. The spine of the bone, the acromion and the coracoid processes, though subject to mus- cular action and external violence, escape fracture with almost as much certainty as .the blade itself. Fracture of the body ofthe scapula occurs in combination with other injuries when the trunk is severely crushed, as by the fall of a heavy weight upon it, or by the force of moving machinery. A fall back- ward upon some projecting point may produce fracture ofthe blade without the necessity of serious complications. The thin plate of bone below the spine may be broken, the fracture being transverse, oblique, irregular, or stellated. Motion and crepitus are the two most important symptoms. The numerous muscles arising all along its flat surfaces, and crossing the line of fracture, prevent much displacement. Sometimes motion of the arm and shoulder will cause crepitus, which may be felt by laying the hand flat on the dorsum of the bone while it is being so moved. In muscular and fat subjects, and where there is little displacement, the diagnosis is often attended with difficulty, but in others the signs are quite plain and obvious. To ascertain if the spine of the bone be fractured, it will be necessary to press it forcibly with both hands while the patient's arm is carried backwards and for- wards, to produce crepitus, and to disclose the line of separa- (HO) Of the Scapula. Ill tion. When the fracture extends through the body of the bone, including the spine, the course of the bony solution must be disclosed by movements imparted to the fragments, using the arm as a lever to incite the motions. Occasionally the body of the scapula is broken into several pieces. In such instances it is impossible to accurate- ly trace the outlines of the frag- ments, or to retain the fragments in place by any kind of a dressing. Treatment of Fractures through the Body of the Scapula. — The fragments having been reduced as completely as possible by manipula- tion, a broad bandage or strip of ad- hesive plaster should be applied around the arm, chest and shoulder, (including the scapula), so as to hold the broken bone steady in one posi- tion, and prevent motion between Fracture of the Made of the the fragments by a shifting condi- tion of the arm. The elbow should be supported in a sling. Slight deformities from overlapping of the fragments, rarely do any harm. As soon as consolida- tion takes place, the functions of the limb are regained by use. Rough overlapping and irregular callus may, for a time, im- pede the easy action of the muscles, yet these contingent de- fects will not be permanent. FRACTURE OF THE ACROMION PROCESS. The acromion process being the most prominent part of the shoulder, is liable to be broken across when a blow is received directly from above, in falls upon the shoulder, and also, per- haps, by upward pressure of the head of the humerus, in falls upon the elbow or hand. The most frequent accident to the acromion, of a fractured nature, is the separation of the epi- physis in young subjects. The accompanying cut illustrates pretty nearly the line of separation. In cases of real fracture, the process is broken nearer the root than the apex. The ex- 112 Fractures. treme tip may be broken off; and there may be genuine frac- ture in adults, at the epiphyseal line. The most frequent cause of fracture of the acromion pro- Fig.30. cess, is by the person falling side- ways against some hard resisting body, so as to strike the top of the shoulder as well as the side of it. Fracture from upward pres- sure of the humerus must be exceed- ingly rare. In cases reported, the cause was merely conjectured. The acromion, in the dry bone, appears weak and unsupported, but in its vital state, strengthened with muscles and fibrous bands, and sustained by ligamentous connections with the humerus and clavicle, to say nothing Fracture of the acromion process. 0f fts sharing in the gliding charac- ter of the scapula, it is capable of offering great resistance, and generally escapes fracture. The symptoms of fracture of the acromion are: dropping of the shoulder, and inability to raise the arm outwards, at a right angle with the trunk. The shoulder loses its salient prominence, its extremity being sunk. On passing the fingers along the spine of the scapula, towards the tip of the acro- mion, a sudden depression is felt at the seat of fracture, and mobility of the process itself can be perceived. On raising the arm so as to bring the fragments in apposition, all the ab- normal appearances are lost; and crepitus, which is absent as long as the arm hangs down, can now be obtained. " In a fat person," says Lonsdale, " or where there is much swelling present, the nature of the accident is not easy to discover, owing to the difficulty of feeling the extremity of the process, and of distinguishing the exact point at which the motion and crepitus are produced. I lately saw a case of this kind, where the patient did not apply for relief for two days after the accident; the whole shoulder was greatly swollen, and it was impossible to say whether any fracture existed, or in what situation it might be, if one were present. As soon as the swelling subsided, however, the acromion was found to be Of the Coracoid Process. 113 fractured, and to be depressed some way below the spine of the bone." Treatment of Fracture of the Acromion Process.—The principal indication is to support the elbow, so that the acro- mion may be raised by the head of the humerus: the hand- kerchief sling may be made to do this, care being taken to elevate the elbow, and to keep the arm straight across the front ofthe chest. The counterbalancing action ofthe trape- zius and deltoid muscles, prevents lateral displacement. A roller of adhesive plaster, to wind round the neck and under the elbow and arm, stays in place better than any sling or common roller dressing. The acromion, when fractured, does not always unite by bony uuion. The cause of this defect is supposed to depend upon a want of close contact of the broken ends. Probably that has more to do with the lack of osseous connection than any peculiarity in the situation of the process. To avoid non- union, is to make the head of the humerus hold the extremity of the acromion steadily upwards. If the broken surfaces can be brought in contact and held there, the consolidation will generally be complete and satisfactory. FRACTURE OF THE CORACOID PROCESS. The coracoid process is short and very strong; it is well protected, and shares in the instability of the scapula ;-■ indirect violence can have but little influence upon it, therefore when broken, the process must be separated by a blow or direct force of some kind. The process derives some support from the coraco-cla- vicular ligaments, and is sheltered in its position by the clavicle and the head of the humerus. When the coracoid process is broken, the nature of the injury is Fracture of the coracoid process. discovered by the displacement downwards and forwards. The separated process of bone is displaced by the action of-the three muscles that are attached 114 Fractures. to it; motion in the process may be observed when the arm is moved in various directions. Crepitus can not be discovered unless the arm is so held as to relax the muscles, allowing the broken surfaces of the fragments to come together. Manipu- lation may then produce the grating sound. In injuries about the shoulder, the diagnosis is often made out by carefully ob- serving the relative positions of the prominent points. The distance between the acromion and the coracoid processes, measured with the fingers and the eye, as compared with that found in the sound shoulder, is quite important in forming a conclusion, especially in distinguishing fracture of the cora- coid process from fracture of the neck of the scapula. Treatment.—A sling for the arm, whether it be a sleeve, a handkerchief, or the roller plaster, is the only dressing needed. This apparatus is designed to support the arm for the purpose of relaxing the biceps, coraco-brachialis, and pectoralis minor muscles. Bandages, compresses, etc., are not required. FRACTURE OF THE NECK OF THE SCAPULA. The accompanying diagram shows pretty clearly what is meant by fracture of the neck of the scapula; it exhibits the line of fracture somewhere near its occurrence, taking with the free and separated piece, the coracoid process and the glenoid cavity and rim, and leaving joined to the blade or body of the scapula, the spine of the bone and its terminal acromion process. If the dried bone be examined, it will be readily seen where this isthmus Future of the neck of the scapula, or narrowed place is. The con- striction makes the scapula appear weak at that part of the bone, but facts do not sustain this view in regard to fragility. There are very few, if any, speci- mens in the cabinets of Europe or America, showing that this fracture has occurred. Several surgeons competent to Neck of the Scapula. 115 recognize the injury have met with the fracture in the living subject. Duverney had an opportunity to examine one case in a woman who was killed on the spot from other injuries; he says, " On examining the left arm, I thought it was dislo- cated ; I made an incision through the integuments and muscles, and opened the capsule; the head of the humerus occupied the cavity, but I then discovered the fracture of the neck of the scapula." While a student of medicine, a young man came to the office of my preceptor, for treatment. The patient had, a few minutes before, fallen against a tree and pile of stones, while playing foot-ball. He supported the arm of the injured side with the hand of the sound side, as a person will who has a fracture of the clavicle or dislocation of the shoulder. After removing the clothing from the upper part of the body, I thought I recognized a dislocation of the right shoulder, and proceeded to reduce it in the usual way by manipulation. There was no difficulty in restoring the arm to its natural position, but it would not stay there; the head of the humerus would immediately, if not prevented, slide into the axillary space, leaving a hollow beneath the acromion. I tried to divine the cause of this perverse state of things, and conjec- tured that the head of the humerus did not slip back through the rent in the capsular ligament, but in some way folded the ligament in front of itself while returning to the joint. I was so certain of this condition that I considered the propriety of enlarging the rent with the point of a knife carried through the soft parts, down to the capsule. Fortunately I did not put the rash thought into execution, but began anew to consider the case. The arm was not rigid as it usually is when the shoulder is dislocated; but the limb had the mobility common to a fracture injury. Great pain attended the manipulations, and the tissues about the joint were soon swollen so as to render obscure some points that were at first quite prominent. However, I began to search for proofs of a fracture, and looked at a dried scapula and humerus, to help my diagnostic powers. The formation of the neck of the scapula suggested what might be the nature of the injury. I then turned to the patient, and hunted for the coracoid process. I found it held the same relative posi- tion to the head of the humerus that it normally did, but it 116 Fractures. was a long way too far from the acromion which remained immovable in its usual place. I then reduced the head of the humerus to its normal position beneath the acromion, and found that the coracoid process had followed the head of the humerus, taking its place on the inside of the joint, at a proper distance from the acromion. To verify the new diag- nostic conclusion, I moved the shoulder back and forwards, causing distinct crepitation ; and allowed the displacement to occur again, in order that I might carefully note the relative position of the coracoid process to the humerus and acromion. Every point in the diagnosis became so plain that there could be no mistaking any one of them. The neck of the scapula was broken, and no other injury existed. In the treatment I used a firm pad in the axilla, to keep the head of the humerus away from the chest, and held the elbow upwards with a sling. I also fastened the arm to the side of the chest, to obviate motion at the seat of injury. In four weeks the dressing was removed, and gentle motion allowed to the arm. The broken surfaces in this kind of fracture are small, therefore the apposition of fragments ought to be per- fect, and the motion as much restrained as possible. Fox's dressing for broken clavicles is a desirable appliance for treat- ing fracture of the cervix scapulae. CHAPTER XX. FRACTURE OF THE HUMERUS. Fig. 33. Anatomically the humerus is divided into the head, neck, tuberosities, shaft, and condyles; surgically, the bone is divided into the upper, middle, and lower thirds, and it has a surgical neck below the tuberosities. The anatomical neck is marked by a slight constriction between the round head and the tuberosities. The condyles make up the lower ex- tremities of the bone, including the ar- ticular surfaces, and the lateral projec- tions which can be felt so prominently beneath the skin. The thin crests which extend from the condyles upwards until they are lost in the shaft of the bone, are called condyloid ridges. The shaft of the humerus extends from the tuber- osities to the condyles. A deep groove between the tuberosities, is occupied by the tendon of the long head of the biceps. This brief description, together HSSS^uS.i?M?fSn^with the accompanying diagram, brings 4;io^wrdil',?ntem*cSS:to mind many ofthe peculiarities ofthe dyie.e,externa con ye. bone, and will save calling attention repeatedly to each part involved in fractures of the humerus. FRACTURE AT THE ANATOMICAL NECK. Pathological museums and autopsies furnish indisputable evidence of an occasional fracture through the upper extrem- ity of the humerus, at a point where the bone is strong and well protected from external injuries. The fracture alluded (117) 118 Fractures. to is within the capsular ligament, no muscles having any connection with the articular fragment. The lesion is generally produced by falls, the shoulder com- ing in direct and violent contact with the ground or some hard substance. In rare instances the evidence seems to be that great force conveyed upward from the hand and elbow, in falls upon those parts, has resulted in separating the head of the humerus from the remainder of the bone. In the event of impaction, a condition in which the end of one fragment is driven into the cancellated tissue of the other, the broken structures lend support to each other, and by their intimate relation favor osseous union of the fragments. If there be no impaction, the head of the humerus is a loose piece of bone entirely within the capsular ligament, cut off from nutritive supplies, and free to move in every direction, even turning over so as to present its articular surface to the broken end of the lower or long fragment. Cases are reported in which the detached head of the humerus has become united to the shaft of the bone in every conceivable attitude. In rare instances, no consolidation nor union of any kind has taken place between the fragments, but the head of the bone has continued in the joint as a foreign body. Bony union is effected in the majority of cases, yet with an excess of reparative material about the broken end of the lower fragment, and with such irregularities of surface that the function of the joint is impaired. The symptoms of fracture at the anatomical neck of the humerus are mostly those attendant upon fractures of other bones. Pain, swelling, and inability to raise the hand, are common signs ; the flattening of the shoulder, when present, may lead to the suspicion that a dislocation exists, therefore the distinctive features of the two injuries must be carefully compared. The displacement attendant upon fracture is easily overcome, yet the deformity is at once reproduced as soon as the limb is left to itself; a dislocated bone is not readily re- turned to place, but, having been restored to its normal posi- tion, it will stay there. After fracture of the anatomical neck of the humerus the arm is excessively mobile, and falls or hangs powerless by the side of the body; the depression beneath the acromion is not so great as in dislocation ; and in rare instances the detached Of the Tuberosities. 119 head of the humerus can be fixed with the fingers, so that crepitus can be elicited. In dislocation of the shoulder the arm is rigid, with the elbow standing off from the side. The treatment for fracture through the anatomical neck of the humerus, is about the same as in all the fractures that occur about the shoulder-joint. The axillary pad as a fulcrum, the arm as a lever, and slings to force the displaced parts into position and to keep them there, comprise a suitable dressing. To prevent motion, the arm should be bandaged to the side. The sling or handkerchief to support the elbow and arm should not force the humerus powerfully upwards. As the excessive reparative material sent out from the lower frag- ment is sure to impede the movements and impair the func- tions of the joint, the surgeon should announce in advance, to the patient, what may be expected in the way of a cure. Passive motion, begun about four weeks after the accident, may help to restore the usefulness of the joint. Fig. 34. FRACTURE OF THE TUBEROSITIES. Direct violence and muscular action are the only agencies that separate the tuberosities of the humerus from the body of the bone. Accidents of this kind are exceedingly rarte, and liable to be confounded with other in- juries about the joint. In dislocation ofthe head of the humerus, the three ^powerful muscles inserted into the greater tuberosity, may detach the lump of bone to which they are connected. In the dislocation outwards, the lesser tuberosity may be fractured in the same way, by the action of the subscapularis. A satisfactory diagnosis could not be made out in such injuries unless the bony tubercles can be moved independently of the remain- der of the bone. Pain, swelling, and aver- sion to movements of the arm, might cause the surgeon to suspect the existence of frac- ^dhfntedfouTZ™\- ture, but the suspicion would not be well der piece founded unless the fingers could feel the de- tached fragment, and make it grate against the surface from which it was detached. 120 Fractures. The indications in the treatment are to keep the arm and shoulder at rest for three or four weeks. A concave splint that fits the shoulder, may be used to cover the injured re- gion ; and a sling employed to fasten the arm to the front of the chest. FRACTURE OF THE SURGICAL NECK OF THE HUMERUS. The constricted portion of the shaft of the humerus, just below the tuberosities, is a common seat of fracture. The line of separation is above the insertion of the pectoralis major and latissimus dorsi muscles ; and is usually more transverse than oblique in direction. The amount of displacement is considerable, but varies in different cases. In characteristic examples the upper fragment is tilted upwards and outwards by the action of the muscles inserted into the greater tuber- Fig. 35. osity, the lower fragment is drawn inwards towards the axilla, by those inserted into the bicipital groove, while the various muscles ex- tending from the scapula to the humerus below the line of fracture, produce shortening. The symptoms are generally very evident and not liable to be mistaken for dislocation. When the arm is rotated, the head of the humerus remains motionless in the glenoid cavity. The mobility of the shaft or lower fragment is marked, and crepitus is distinct when extension is made, or the broken ends of bone are moved while in apposition. Frac- ture at the line of junction of the epiphysis, in young subjects, resembles true fracture through the surgical neck of the bone in old subjects. The only discoverable difference is a less marked crepitation in the cartilaginous separation. Fracture through the surgical neck of the humerus, in adults, is generally a half inch or more below the line where separation of the epiphysis occurs in the young. If the injury be not seen until the parts have become ex- cessively tender, and much swelling has supervened, fracture through the surgical neck will closely resemble dislocation of Fracture through the surgical neck of the humerus. Of -the Humerus. 121 the shoulder. However, in case of doubt and uncertainty, the patient may be put under the influence of chloroform, when the nature of the lesion can be determined. In case of frac- ture, the space beneath the acromion will be found filled with the head of the bone ; the humerus will not stay reduced, but slide towards the axillary space as soon as left to itself; and great mobility at the seat of injury will be observable. All of these signs present unequivocal evidence of the existence of fracture. From a consideration of the anatomy of the region, it would seem that a fracture through the surgical neck of the bone could not take place without marked displacement and deformity. In a small proportion of instances, however, there is no perceptible disjunction of the fragments, a state of apposition which is probably favored by the interlocking of serrations in the broken ends, and by the restraining influence of the tendon of the long head of the biceps. Malgaigne rarely met with displacement, though in this he differs widely from other experienced observers. Treatment.—It is not always easy to reduce the fragments to a state \7PiXes^ of perfect apposition, owing to the ^■lin%%nt^ln^t\?e°:^ shortness of the upper fragment, fractures of upper end of humerus. ^ ^ diverge &ct{on of the mug. cles attached to the two fragments. Extension and manipula- tion, aided when necessary by the relaxing effects of chloro- form, will generally restore the broken ends to their proper places. A roller bandage may be used to envelope the limb from the fingers to the shoulder, to restrain muscular twitch- ings and to prevent congestion and swelling, yet this is not absolutely necessary. The primary bandage, as this is some- times called, is going more and more out of use. A concave shoulder splint, made of leather, gutta percha, carved wood with a hinge, or woven wire bent and soldered to fit the parts, is quite essential for the outside of the limb. Two or three short board splints may be padded and laid on the inside of 122 Fractures. the arm reaching from the axilla to near the condyles. These; including the one that caps the shoulder, may be fastened in their places with tapes, or bandages. A firm compress is placed in the axilla, to prevent the upper extremity of the long fragment from inclining too much inwards, and a band- age fastens the elbow to the side of the body. The weight of the arm is to be left free to act as extending force. A handkerchief dropped from the neck is always convenient for the hand to rest in. No sling should be employed to support the elbow or weight of the arm. It must be borne in mind that ordinary dressings for frac- tures through the middle third of the shaft of the humerus, and which reach only about as high as the seat of the injury, are not efficacious in restraining motion between the frag- ments. Such dressings get no hold upon the upper fragment and the scapula, therefore they can not steady the parts and prevent mobility. There is some danger of false-joint, especially if motion at the line of separation be not thoroughly restrained. It is found that a fracture through the surgical neck of the hume- rus, does not become consolidated as soon as fractures lower down in the bone. The delay may be charged to the mobil- ity, for the more quiet the fragments the sooner is the healing process accomplished. FRACTURES OF THE SHAFT OF THE HUMERUS. All fractures occurring between the surgical neck of the humerus and the condyles of the bone, are commonly spoken of as fractures of the shaft of the os humeri. Such lesions are extremely easy to recognize, and are not usually difficult to treat. There is no joint near to mask the injury, nor com- panion bone, as in the fore-arm and leg, to obscure the diag- nosis, or to modify the treatment. Fractures of the shaft arise from direct and indirect forces ; a direct force usually comes in the shape of a blow, or a fall upon some hard substance ; the indirect acts upon a part of the bone remote from the point struck, as when a person falls with the arm extended from the body, the elbow being the part that receives the shock, but the shaft of the humerus, several inches from the point hit, may be the part to yield. Of the Humerus. 123 Fig. 37. Fracture of the shaft of the humerus between the inser Direct violence, besides breaking the bone, commonly inflicts more or less injury to the soft parts, which is manifest in the bruising, discoloration, and ecchymosis; the indirect force seldom produces much disturbance to the tissues in the vicinity of the fracture, though at the point receiving the shock, there maybe serious contusions. Muscu- lar action is often sufficient to fracture the humerus. I once treated a-lad's arm which was broken while in the act of throwing a stone. The patient heard the bone " snap like the break of a dry stick," and his arm fell powerless to his side. The fracture was near the junction of the lowTer with the middle third of the bone. Fractures from muscular action are not uncommon ; cases happening in different parts of the country are con- stantly being reported in the medical ££& dS^dES^" journals. It may be remarked that there is no particular point in the shaft of the humerus that gives way to muscular force, for reported cases show that fractures from such causes occur at any point ex- cept through the articulating extremities. The displacement following fracture of the shaft of the humerus, is not always appreciable, for the fractured surfaces may remain in contact, the serrations so interlocking as not to be easily moved from their apposition. In most instances, however, the contact is lost, and the muscles draw the frag- ments past one another. In some instances the angular de- formity is great when there is no shortening; and the defect produced by rotating one fragment upon the other, may cause a more marked and awkward defect than either of the distor- tions just mentioned. The distinctions between fractures above and fractures below the insertions of certain muscles, so far as the deformity is concerned, are of not much practical importance. The diag- nosis is extremely easy whether the line of separation is trans- verse or oblique, or the broken end of the lower fragment rests upon the inside or the outside of the other, in the over- lapping. 121 Fractures. Treatment. — The fragments having been adjusted, four small, straight, well-padded wooden splints should be applied, one on each side of the arm, extending several inches above and below the seat of fracture, and retained in place by means of tapes tied around all. Over the whole, including arm, splints, and tapes, a roller bandage ought to be applied as it gives support to the dressing that can not be obtained by straps and buckles, or a multiplicity of ties. A primary bandage, reaching from the fingers to the shoulder,before the splints are applied, is not necessary, although some sur- geons contend that this is valuable to prevent excessive swelling and muscular twitch- ings. The splints may be pad- ded with cotton, or wrapped with soft muslin. A sling dropped down from the neck is eonvenient for the fore-arm or hand to rest in. All me- chanical contrivances for keeping up extension and counter-extension, as Swinburne's apparatus, are open to such serious objections that they have fallen into disuse. The weight of the arm counteracts the retraction of the muscles. If there be slight overlapping in oblique fractures, no great trouble attends the defect. A shortened arm is not so objec- tionable as a shortened thigh. In compound fractures of the humerus, the arm may be kept dressed with three splints. Tapes may be used instead of a bandage to keep them in place. The patient should keep in bed for a week or two, until the violence of the inflamma- tion and the purulent discharge subside. Dressing for fracture of the shaft of the hu- merus. 3, and 4, are not seen, and refer to two splints on the other side of the arm. Of the Shaft of the Humerus. 125 FRACTURES OF THE SHAFT OF THE HUMERUS JUST ABOVE THE CONDYLES. Falls upon the hand or upon the elbow are not unfrequently attended with fracture of the humerus above the condyles, across the condyloid ridges. In young subjects, the separation of the lower epiphysis occurs in this region, and presents nearly all the characteristics of a true fracture. Figure 39 represents an injury of this kind rendered compound by a too tight dressing, which resulted in sloughing, and a protrusion of the broken end of the upper fragment. The epiphyseal Fig. 39. Separation of the lower epiphysis of the humerus, the injury rendered compound by a slough and protrusion of lower end of upper fragment. fragment retained its place in articular connection with the radius and ulna. The case was treated, after it came into my hands, by extension, to enable the protruding bone to sink into place. The boy's hand was tied high up to the bedpost, so that the weight of the body in pulling downward, exerted the proper force to accomplish the purpose. The humerus just above the condyles is very thin and pris- matic, expanding laterally at the expense of its thickness or rotundity. This irregular shape undoubtedly weakens the bone in that region. A fall upon the elbow in a bent position, seems to be the most frequent cause of fracture at all ages. The powerful action of the muscles passing from the upper arm to the fore-arm usually tends to shortening and riding of the fragments. In most cases the lower fragment is drawn backwards and upwards by the triceps, producing an appear- ance similar to that caused by dislocation of both bones of the fore-arm backwards. The distal extremity of the upper frag- 126 Fractures. Fig. 40. ment projects in front of the arm, making a prominence just above the elbow on its anterior aspect; the olecranon projects backwards, forming a hollow space in the arm just above it, which corresponds with the unnatural fullness in front. The general appearance of the deformity is that of dislocation ; and the restricted motion favors the same idea? though the immobility is not so marked as in dislocation. When doubt exists in regard to the nature of the injury, the distinction be- tween fracture and dislocation can be drawn as follows : an extending force in case of frac- ture, competent to overcome muscular con- traction, temporarily obliterates the deformity, but, as soon as the force is relaxed, the displace- ment reappears; in case of dislocation, it re- quires great force to restore the parts to posi- tion, and once in place they will stay there. When the brokeu surfaces are brought in contact by extension and manipulation, and slight motion is imparted to the fragments, dis- tinct crepitus is elicited. It will also be found, in the event of fracture, that the condyles, which can always be felt beneath the integu- ments, follow the radius and ulna in any motion imparted to the arm; and such movements are not in consonance with the lower end of the long fragment. In dislocation, the condyles continue as part of the humerus, and the olecranon is displaced backwards, forming a distinct prominence by itself, and the condyloid eminences are distinct from it. The distance from the acromion process to the internal condyle is less in the event of fracture than in dislocation. Double fracture of the humerus. Treatment.—The fracture being near the joint it is not easy to retain the fragments steadily in place. Reduction is to be effected, as already intimated, by grasping the arm with one hand, and the fore-arm with the other, making sufficient extension 'and counter-extension to overcome the muscular contraction. In this way the fragments may be brought into apposition. To keep them there the elbow should, with proper splints, and other dressings, be fixed at a right angle A jointed wooden splint may be used if at hand or readily Of the Shaft of the Humerus. 127 attainable. A strip of tin, zinc, or other metal which can be bent to a right angle, may be employed when well padded, on the front aspect of the elbow, a firm compress being used be- tween the splint and the lower end of the upper fragment, to prevent the end of the bone from pressing forward. I have used a piece of bark, partly broken in the middle, also two pieces of lath, an end of each hinged together with a firm piece of leather. A strip of gutta percha softened in warm water and moulded to the parts while they are in good posi- tion, makes a nice splint for the front or back aspect of the arm. If a firm splint be used on the anterior part of the flexed limb, a piece of pasteboard may be employed on the back part. These splints, whatever be their material, are to be bound in place with tapes and bandages, and the arm sup- ported in a sling. At the end of three or four weeks, the dressing is to be removed, and the joint carefully subjected to passive motion, to obviate anchylosis. Delayed union, or no union at all, is quite common after fractures through any part of the shaft of the humerus. In fractures near the joints, it is extremely difficult to prevent all motion, therefore a fracture just above the condyles, is liable to failure of the healing process, or, at least, to a delay of the reparative action. Dr. Frank Hamilton does not think that mobility at the seat of fracture, is so often the cause of non- union as is generally supposed. In case of delayed union in fractures of the shaft of the humerus, he advises that the entire arm, from the hand to the shoulder, be dressed with a long splint, the arm being kept in a straight position, and allowed to hang down at full length. In one or two instances of delayed union, he succeeded in effecting a complete cure by the method just indicated. In one case he first overcame a partial anchylosis of the elbow, in order that the arm might be straightened ; and then used a gutta percha splint that reached from the top of the shoulder to the fingers. The pressure of the lower end of the upper fragment upon the brachial artery, or the median nerve, may operate unfavor- ably upon the nutrition and functions of the forearm and hand. Several cases of alleged malpractice have been tried in differ- ent parts ofthe country, which grew out of the enfeebled con- dition of the parts below the fracture. It is worthy of remark, that distinguished surgeon, while giving testimony in these 128 Fractures. Fig. 41. litigations, have differed widely in regard to the cause of paralysis in the fingers, sloughing, etc. Some have declared that the defects were owing to injuries done to the artery and nerve by the broken end of the bone—condi- tions which no surgeon could always avoid ; and others were of the opinion that tight bandaging, compresses, and a lack of adjust- ment of the fragments, were the causes of the difficulty. It is highly probable that in rare instances the trouble has been in the injur}7 in- flicted by the fragments, but in cases coming under my observation the defect has depended upon lack of proper reduction of the frag- ments, tight bandaging, and the injudicious use of splints and compresses. If the fracture be oblique, and the sharp edge of the upper fragment project forward, as it is always inclined to do, the brachial artery and median nerve are about sure to be pressed out of place and irritated. However, if the reduction is perfect, and the dressing retains the fragments in pla^e, the edges of the broken bone are cov- ered by one another. Even if the apposition be made perfect at the time of dressing, a fresh displacement may take place in a few hours. Fracture just above the condyles must not only be well dressed in the first instance, but it must be care- fully watched, and redressed as often as there is a suspicioa that everything is not going right. Deformity after frac- ture of humerus through its lower third. FRACTURES OF THE CONDYLES OF THE HUMERUS. The condyles of the humerus are often fractured. They are much exposed to direct violence, and may be broken by indi- rect forces. The simplest form of such injuries is a separation of the tip ofthe inner condyle (epilrochlea), for the lesion does not involve the articulation. It may be occasioned by muscu- lar action, though more commonly by direct falls upon the inner side of the elbow. The symptoms of this fracture are very evident, for the separated portion of bone can be easily Of the Condyles of the Humerus. 129 Fracture ofthe epitrochlea. moved, and crepitus is elicited by the motion. The swelling may alter the appearance of the articulation, yet a close ex- amination shows that the joint is unimpaired, and no marked Fig 42 displacement exists. The capsular ligament and ligamentous structures adhering to the fragment, keep it from leaving its position. The muscles arising from the epitrochlea may tilt the piece a little inwards, yet not sufficiently to require any special appliance to oppose the tendency. Very little treatment is required to secure a fortunate result. If the arm be carried in a sling for sup- port, and to maintain semiflexion ofthe limb, a good recovery will be made. The accident occurs mostly in children, in whom the epitrochlea is connected only by cartilaginous material, the tip of bone being an epiphysis. Cases are re- ported in which the accident has happened to adults, and in whom the detached fragment has been drawn downwards an inch or more by the powerful muscles arising from it. Fractures through the articular surfaces are of a more serious character. They may effect the inner or the outer condyle, extending from that part of the bone which meets the ulna or radius, and continue obliquely upwards and inwards, or upwards and outwards through the condyloid ridge, detaching a piece of bone some- what as represented in the accompanying diagrams. In instances more or less rare, the two condyles are split apart, the line of fracture dividing so as to terminate in both condyloid ridges. This would constitute a comminuted and complicated fracture, allowing the radius and ulna to be drawn up be- tween the fragments, the displacement being in part a dislocation. In such a case the distance between the two condyles would be too great, and the arm would have the appearance of a frac- ture of the humerus just above the joint, or a dislocation of the elbow. In fractures through the internal condyle, in- volving the articular surfaces, the line of separation extends from the middle of the trochlea, or concave articular surface which receives the ulna, through the fossse or depressions which receive the two upper processes of the ulna, and termi- Fig. Fracture of the external condyle of the humerus Fig. 44. Fracture of both condyles of the humerus. 130 Fractures. nates just above the epitrochlea. This fracture is generally caused by direct violence, the force of the blow in falls being received directly upon the condyle. It is an injury confined almost exclusively to childhood, and is not as com *jIG- 4,5, mon as fracture of the external condyle. 1 The displacement of the detached fragment is / 1 not great when the arm is semiflexed and in an /C 4 easy position. The separated condyle can not be /X-J^S drawn downwards, for the ulna prevents such a Fr^rTreofthe displacement; the muscles arising from it will not dy\Tol °°thl permit.of its being pushed or drawn upwards ; and humerus. ^ ligaments are opposed to other malpositions. However, the fragment can be moved when grasped with the fingers, and made to follow the ulna in flexing and extending the arm. These movements are almost certain to produce crepitation. The distance between the condyles is generally increased a little, and there is a peculiar deformity noticed which is partly produced by the swelling, and partly by a twist in the arm. When the limb is grasped above and below the elbow, greater lateral motion can be imparted to the joint than could be if no fracture existed. This is a valuable diagnostic manoeuvre in ascertaining a fracture of either condyle. These deflections do not determine which condyle is broken, but with a finger on each, while lateral movements are imparted to the joint, the point can be determined. Treatment.—Anchylosis, partial or complete, is the danger to be apprehended while treating fractures of either condyle. As has been stated, the displacement can not be great, there- fore hard splints, compresses, and tight bandages are not re- quired. However, few patients are satisfied unless the broken bone is " set," and the injured part dressed with splints and bandages. To satisfy this popular demand is quite desirable when it can be done without detriment to the case. In hos- pitals, where patients are under the control of rigid profes- sional directions, it may do to keep the arm resting on a pil- low, without any dressing or treatment, except topical reme- dies to keep down inflammation. In private practice such a course would be severely criticized; and unless the medical attendant had a firm hold on the patient's confidence, he would be in danger of being dismissed for pursuing such a Of the Condyles of the Humerus. 131 Fig. 46. course. Fortunately for those who have to conform to popu- lar prejudice, fractures of the condyles can be dressed with pliable splints and a bandage. A piece of pasteboard twelve inches long and six inches wide, should have two inci- sions made in each side to within an inch of each other, as indicated in the diagram: This may then be wetted, lapped and bent, so it will cover the flexed elbow, as seen in Figure 46. After the arm is manipulated, to overcome the displacement if there be any, and the limb is flexed to nearly a right angle, the pasteboard splint is applied, and a bandage reaching from the fingers to near the shoulder, is snugly made to envelope the limb. Great swelling usually at- tends fracture of the condyles, therefore some allowance should be made for that state if the arm be dressed before the swelling has reached its height. Once dressed in the way indicated, the arm may be carried in a long Quadrangular piece of pasteboard cut into ojinor let down from the neck. at. the sides to make it conform to the o bend of the elbow, and the same applied j^ o-utta percha Splint moulded to the arm. to the flexed arm answers a good purpose. Sole leather cut, wet, and moulded, as indicated for the pasteboard splint, is perhaps as good material as can be employed. Angular wooden and metal splints are not desirable, on account of their unyielding nature. I have used an angular woven wire splint with much satisfaction, though it has its objections. The arm should be redressed every two or three^ days, and oftener if great pain and swelling seem to demand it. At the end of two weeks the elbow should be subjected daily to gentle passive motion. In three weeks from the accident the dress- ing maybe wholly removed, and more forcible passive motion imparted several times a day. If the limb be left to itself the joint is almost certain to become anchylosed, therefore it will not do to trust so important a proceeding to the patient. 132 Fractures. The operation of forcibly flexing and extending the limb is attended with considerable pain ; and the patient in attempt- ing to follow directions is liable to be deceived as to the amount of motion imparted. Movements of the shoulder lead to the conclusion that the motion is in the elbow. When the arm is forcibly flexed or extended, it should be held to the maximum of those states for several minutes in order that the pressure imparted to the callus or excess of reparative material may stimulate absorption. Voluntary motion, on account of the stiffness of the muscles, is of little value. In forced motion the joint seems to lock, as a hinge into which a nail has accidently slipped, stopping the normal sweep of flexion. This impediment arises from the amount of uniting callus in the articulation, which inter- feres with the play of the hinge. Passive motion should be kept up for a year, if sufficient range of motion be not obtained before that time. The patient should be directed to voluntarily put his fingers to his cravat, chin, mouth, and forehead every day. He can thus determine whether he gains in the extent of motion. I have, in several instances, taken an arm that was quite immovable when the dressings were removed, and restored it to perfect action in the course of a few months. I may add that I have never failed to establish a satisfactory range of motion in the elbow in cases of threatened or impending anchylosis follow- ing fracture of a condyle. There is scarcely a fracture of any bone which is followed with so many unsatisfactory results as a broken condyle of the humerus. Litigations are numerous in which attempts are made to recover damages from the sur- geon who is unfortunate enough to be afflicted with unsatis- factory results. Some of our most experienced surgeons have refused to treat a broken condyle until the patient and the patient's friends are informed that the case would not be un- dertaken unless assurance be given that no litigation is to be commenced, or damages claimed in the event af anchylosis or other serious defect in the joint. Of the External Condyle. 133 FRACTURE OF THE EXTERNAL CONDYLE. The external condyle is broken more frequently than the internal, especially in adults. Children are extremely liable to fracture of either condyle, though the inner oftenest sutlers. The externa] condyle is frequently broken by direct violence, as by a blow or fall; yet it may become disjoined by indirect violence, the hand receiving the shock of a fall, the force being conveyed from the hand through the radius to the humerus. Although authors have hitherto neglected to speak of the fracture as occurring from indirect violence, I have met with several examples of the lesion, in which the evidence was that no violence had been received except upon the open hand thrown out to break the fall. In September, 1868, I stood watching the work of some paperers, when one of the work- men, John Fordice, who stood on the head of a barrel, lost his poise, reeled, and fell to the floor. He broke the force of the fall with his outstretched hand,-but received an injury of the elbow that gave an audible snap. Being present at the time of the accident, I had an opportunity to determine the nature of the lesion before swelling set in. The external con- dyle could be easily moved with the thumb and finger, and crepitus was distinctly produced by the motions imparted. The fragment was forced upwards, and the arm seemed de- flected to the radial side, as well as inclined to remain in a position of partial flexion. The elbow gained in lateral mo- bility, and appeared wider between the condyles. In a few minutes swelling came on and obscured some of the signs that were marked at first. The fragment then was not so easily moved on account of the effusions in and about the joint, and the crepitus was not so plain. If I had not seen the man strike on his hand while falling, or had not examined the case for an hour after the injury, I might have suspected that some of the swelling and discoloration which came on at the seat of injury, was caused by the elbow striking heavily against some hard substance, and that the fracture may have been caused by direct violence. Persons who sustain frac- tures by falls are often confused, and not positive whether the elbow hit something heavily, or the force was received on the palm of the hand. Dislocations of the head of the radius 134 Fractures. frequently occur from a fall received upon the hand. In one case reported by Hamilton, the dislocation occurred backwards in conjunction with fracture ofthe outer condyle. But in that case the patient was confident he struck the ground with the back of his elbow. It is not easy to conjecture how this double injury could arise from a single force applied all at once, to say nothing of the backward dislocation of the head of the radius. Treatment.—The displacement being slight in almost every instance, there is no reduction to be accomplished. The arm should be dressed in the semiflexed position, and the same shaped pasteboard splint employed, as was recommended for fracture of the internal condyle. The passive motion should be commenced by the fifteenth day, and kept up daily for a week or two longer before the dressing is laid aside. If the muscles and soft tissues be much stiffened, and there be evi- dence of impending anchylosis, the arm should be forcibly flexed and extended several times a day until the functions of the articulation are fully restored. The services of some friend or strong member of the family should be secured to regularly perform this important part of the treatment, for there exists the same danger of bony anchylosis as in the repair of the other condyle. The arm should also be exercised in the mo- tions of pronation and supination. In the process of repara- tion osseous material not only encroaches upon the fossae of the humerus, but makes connections with the head of the radius, preventing the normal rotation of the fore-arm. In rare instances the detached condyle fails to consolidate with the rest of the bone. Such a state does not impair the use of the limb to a degree that warrants the usual surgical interference devised to overcome false-joint or non-union. In the event of anchylosis there may be exceptional cases in which, while the patient is under profound anaesthesia, attempts to break up the osseous connections might be justi- fiable. In October, 1867, Thomas Anson, of Indiana, came to me with anchylosis of the elbow following fracture of the ex- ternal condyle. The arm was broken ten weeks previously, and had been treated in the usual way by the family physician. As near as I could learn, no particular directions had been given about passive motion to obviate anchylosis, but at the Of the External Condyle. 135 end of four weeks, when the dressings were removed, the arm was allowed to.remain in the same semiflexed position it had been made to assume during the treatment. I put the patient under the influence of chloroform, and broke the osseous bridges that joined the head ofthe radius to the consolidated external condyle. No great amount of inflammation followed the disjunction. Anodyne and evaporating lotions were kept on the joint for five or six days, and not much motion per- mitted, though no splints or dressings were used to overcome mobility. Finding that no severe inflammation was likely to arise, the joint was subjected to almost hourly exercises in flexion and extension. The patient went home on the tenth day after the operation, with directions to keep up the passive motion for weeks, and months if necessary. In a letter writ- ten six weeks after he left for home, he wrote that he could flex and extend his arm voluntarily, to a degree sufficient for all practical purposes. Anchylosis of long standing should not be treated in this way, for the limb is not useless though the elbow be stiff, and attempts to break up the articular adhesions and connections might result in no substantial advantage. It is only while anchylosis is recent that a forcible disruption is justifiable. A successful attempt to sunder the adventitious structures has been made six or eight months after the reception of the original injury, and other efforts have failed at the expiration of three months. Injuries of a crushing character inflicted upon the elbow, bruising the flesh and breaking the osseous structures of the articulation, are sometimes sufficiently grave to demand am- putation. However, unless the brachial artery and median nerve are known to be lacerated, it is commonly prudent to wait a few days to ascertain what may then be the indications. There is generally no pressing necessity for haste after such injuries, though every sign of vitality has departed from the extremity, and gangrene is apparent. If there be feeble pulsation at the wrist, and partial sensa- tion in the hand, there is a possibility, if not a probability, of saving the limb. At any rate, a primary amputation, as it is called, should not be performed unless the limb, after reaction has taken place in the rest of the body, remains cold and ca- daverous—pulseless and senseless. If sufficient vitality remain 136 Fractures. to warrant an attempt to save the arm, a few days will disclose the fact whether the limb must be sacrificed to save life, and amputation can then be performed with not much greater risk than would have been incurred just after the accident. In compound and comminuted fracture of the elbow, the finger may be used to explore the joint, to ascertain if any loose pieces of bone need removing. Small fragments com- pletely disengaged, or cut off from nutritious supplies, are about sure to act as foreign bodies in the joint; and may do as much mischief as pieces of wood, cloth, or common gravel in their position. All such pieces of isolated bone should be removed, and the limb placed on a pillow, in an easy attitude, for several days. The parts implicated in the injury should be kept wet with water, and lightly covered. The fcetor may be corrected to some extent by the use of dilute carbolic acid. As soon as it becomes known that the limb can be saved, though with no hope of motion in the joint, the arm should take the position of semiflexion, as the member when anchy- losed, is the most useful in that attitude. Many an arm, con- demned to amputation by surgical attendants, has been saved as a valuable limb, by the stubborn refusal of the patient to submit to what was professionally decreed. In one case, in which the joint was so opened that the finger could be passed through and feel the artery pulsating in front, Sir Astley Cooper proposed amputation, but the patient refused to sub- mit to it, and his arm was saved and became useful. CHAPTER XXI. FRACTURE OF THE ULNA. The ulna, the companion of the radius in the skeleton of the fore-arm, does not constitute an important part of the wrist joint, but enters more largely than its fellow into the articulation of the elbow. The bone terminates at its upper extremity, in a prominent process—the olecranon—which is a lever for the action of the triceps. This process, behind the Fig. 47. Shows fracture of the olecranon and coronoid processes. articulation, is thinly covered, and exposed to blows of suffi- cient severity to cause fracture. If the fore-arm be suddenly and forcibly extended, the olecranon, either by the action of the triceps or the violent contact of the humerus in extreme extension, is liable to be broken off from the rest ofthe bone. The summit or extreme tip of the process may be broken off in extremely rare cases, though the fracture usually separates the greater part of the olecranon. In falls directly upon the part, the greater portion of the process is likely to be broken off. The line of separation is commonly transverse ; and the displacement upwards in the direction of the triceps, renders the nature of the accident quite easy to understand. In some instances, where the ligamentous structures are untorn, and the arm has not been flexed, the displacement is scarcely per- ceptible. In most cases the process is retracted to so great an extent by the triceps, that every connecting medium must be torn through, the fragment being entirely under the control of the muscle. Flexing the arm puts the triceps on the (137) 138 Fractures. stretch, and necessarily widens the breach between the frag- ments. Displaced as the process usually is after fracture, it can be distinctly felt an inch or so above its ordinary location, and is easily movable from side to side. Power of voluntary extension is almost entirely lost after fracture of the olecra- non, and pain is aggravated by movements of the limb. Swelling quickly follows the injury, and tends to obscure the diagnosis if the patient be not examined for several hours after the accident. Crepitus can not be elicited unless the arm be extended, and the triceps pressed downwards, so that the broken surfaces may be brought in contact. In doubtful cases, when there is no apparent displacement, the finger placed upon the olecranon while the arm is flexed, will discover the line of separation which is always more or less marked by a lack of perfect apposition. If the arm be put into extreme flexion, the fragments are forced apart and a palpable depression is felt between them. Treatment.—It is plainly evident that fracture of the ole- cranon is to be treated with the arm in a state of extreme ex- Fig. 48. Splint and dressingfor fracture of the olecranon process. tension ; and a long splint reaching from near the shoulder to the hand, and bound to the front aspect of the limb, will keep the arm from being flexed. A roller bandage begun at the fingers should extend to the elbow ; then another started near the shoulder is made in its turns to envelope the arm down to and including the elbow. The first prevents undue congestion and swelling, and the other forces the triceps downwards so that the detached olecranon may come in contact with the rest of the bone. The long straight splint is now placed on the front of the arm and fastened there by the turns of an- other roller. This dressing holds the limb in a straight posi- tion, which is somewhat awkward, but it is the only way the Of the Ulna. 139 broken surfaces can be brought into apposition and held there securely. As there is danger of severe inflammation in the joint, anodyne and evaporating lotions should be applied to the elbow for several days. The dressing may be taken off and re-applied occasionally during the healing process, though the joint should not be fully flexed for five or six weeks, lest the fragments be forced apart. At the expiration of that time, the state of the parts involved in the injur}'' should be carefully observed, to ascertain whether the union of the frag- ments be osseous. If the consolidation be perfect, whatever of stiffness and anchylosis exist, should be overcome by passive motion. The arm should not be fully flexed at first, but there ought to be a gradual restoration of the functions of the joint. If the union be fibrous, which by some surgeons is thought to be the normal state after fracture of the olecranon, the connecting bands will be so short that the use of the limb is but slightly impaired. Extension can be performed even if the union be fibrous or ligamentous. In the event of false- joint, especially if the connecting bands be short, it is not best to attempt the establishment of bony union by any of the means usually employed for such purposes. The only objections raised against dressing the arm in the extended position is, that if anchylosis does take place, the limb is not in a good attitude for service. It is justly claimed that if the joint is to be permanently stiff, the semiflexed position is far preferable to a straight attitude. However, it is found in practice that the cases in which complete anchylosis results, are extremely uncommon. If the articulation be severely in- jured at the time the fracture occurs, so that anchylosis seems inevitable, it might be wise to dress the arm in a position which would be most useful, for if the elbow be anchylosed it would make little difference whether the olecranon was consolidated or not. It is recommended by Hamilton that moderate flexion and extension be performed every day, while the dressing is off, the finger pressing downwards upon the olecranon, to obviate anchylosis, but this increases greatly the risk of fibrous union, and opposes in a slight degree anchylosis which is very un- likely to occur. 140 Fractures. FRACTURE OF THE CORONOID PROCESS. Fracture of the coronoid process must be an extremely rare accident. The surgeons are few who have been positive that they have seen a case. Several cases have been reported, but full credence can not be placed in all of them. The accident is said to occur in connection with dislocation of the radius and ulna backwards, and sometimes perhaps without that complication. It has been stated by surgical writers that the action of the brachialis anticus would break the process ; their language being that the muscle is inserted into the process, when in fact it is inserted below or at the base of that promi- nence of bone, and has no direct action upon it. The occa- sion for distrust in some of the reported cases comes from the anatomical error into which writers have so frequently fallen. In a malpractice suit tried in the State of New York, one of the surgical experts in his testimony in regard to dis- location of the radius and ulna backwards, stated that the brachialis muscle was inserted into the apex of the coronoid process.' Mr. Liston, in his Operative Surgery, mentions the case of a boy who broke the coronoid process by the action of the brachialis muscle while hanging from a high Avail. Notwithstanding our great regard for such high authority, it will be convincing tj any one referring to the anatomy of the parts involved in the alleged injury and considering the action of the muscle upon the process while a boy was hang- ing by the arm, that no such lesion could take place. The boy's weight as he was suspended by the hand, would draw the coronoid process away from close contact with the hume- rus, and the brachialis anticus muscle, being inserted at the base of the process, also passing over it, would press upon its apex, the action tending to retain the bony prominence in place, and not to detach it, while the arm was in extreme ex- tension. The coronoid process -is not an epiphysis, with a cartilaginous connection with the shaft of the ulna durino- childhood; which is another circumstance opposed to the theory of fracture from muscular action, though it is declared by nearly all writers upon the subject, that children and not adults, are liable to the accident. Shaft of the Ulna. 141 It is not denied that direct violence, as the passage of a wheel over the part, may break off the coronoid process; and it is quite certain that in dislocations of the ulna backwards, the point of bone is occasionally severed from its connections with the main part of the bone. Treatment.—The dislocation having been reduced, for the fracture is presumed not to occur except in conjunction with that injury, the arm' should be kept in a state of partial flexion to prevent a recurrence of the luxation. The limb may be bandaged from the fingers to a point above the elbow, and a compress employed to retain the detached process in place. This dressing can be employed for four or five weeks, though the articulation is to be gently exercised daily to prevent an- chylosis. The difficulty of retaining so small a fragment steadily in position, and the scanty nutritive materials finding their way to the process after its violent separation from the shaft, would be liable to insure a ligamentous, and not a bony connection. If the detached process never obtained a firm connection with the shaft of the ulna, the osseous material poured out to consolidate the fragments, would constitute a barrier against repeated dislocations. The functions of the joint, under such circumstances, must be more or less im- paired, for the elbow is liable to chronic defects after even moderate injuries, ft is vastly more important to secure free motion to the joint, than to be striving for bony union, which would be utterly useless in the event of anchylosis. FRACTURE OF THE SHAFT OF THE ULNA. The shaft of the ulna, when fractured singly, is always broken by direct force. If the radius be previously broken, the ulna may be brought under the influence of the indirect force, and be fractured by it. When the hand is extended in falls to save the head and trunk from violence, the radius, from the mode of articulation in the fore-arm, receives the force of the blow and either breaks just above the wrist, or conveys the shock to the humerus; thus the ulna is preserved from heavy concussion. The ulna is subject, then, to direct violence, either in striking against some hard body, or in 142 Fractures. warding a blow aimed at the body. The arm is raised in pro- tecting the head, to an attitude which presents its ulna side toward the threatening violence. Also in falling backwards, the arm is thrown in advance of the trunk to shield it from injury, and receives a violent shock on its ulnar side. While descending stairs, a slip of the feet forwards throws the body backwards, and the ulnar sides of the arms come directly against the edge of a step. The situation of the fracture under such circumstances, de- pends of course upon the part of the bone struck. The lower half of the bone is smaller and weaker than the upper half, Fig. 49. Fracture of the ulna above the origin of the pronator quadratus, showing the action of that muscle upon the lower fragment. and should consequently be most frequently broken, all other conditions being equal. A force producing fracture of the shaft of the ulna, is very liable to convert the lesion into one of a compound nature. The symptoms of fracture are usually very prominent. The bone being thinly covered, the displacement is generally quite marked. However, in some instances, especially towards the upper extremity of the bone, the fragments may be interlocked, or held in place by the periosteum, so that no disjunction occurs. In fractures through the lower portion of the bone, the upper fragment remains nearly in the place occupied before the fracture, owing to the firm and wide articulation at the elbow, and the lower fragment is drawn towards the radius by the action of the pronator quadratus muscle. If the upper end of the lower fragment take any other position, it is driven Shaft of the Ulna. 143 there by the force that produced the fracture, and the muscular action was too feeble to restore it to the place it would take if uninfluenced by the paralyzing blow. When the broken ends are brought in contact, in the manipulations of the arm, cre- pitus is distinctly felt and heard. The power of rotation is impaired by fracture of the ulna, and in fact all the functions of the fore-arm are restrained by the swelling, pain, and loss of power attendant upon the lesion. In May, 1865, I was called to Mollie Shannon, a stout Irish girl, who fell backward from a stool while hanging out clothes. The fall brought her upon a flight of back stairs, and she slid to the bottom, lighting upon a brick pavement. I saw her in a few minutes after the injuries were received. She was complaining bitterly of her arm near the elbow, and refused to allow me to examine it as thoroughly as I desired, on account of the pain which the slightest manipulation seemed to produce. I therefore gave her chloroform until I could handle the limb, and ascertain the nature and extent of the injury. A contusion about five inches below the elbow on the ulnar aspect of the arm, led to a critical examination of the bone beneath. I found a fracture of the ulna at that point, though not much displacement existed. There was swelling about the elbow, which, with a huge development of the muscles, rendered the nature of any injury in that region perplexingly obscure. The rigidity of the joint, and the pe- culiar twist, amounting to marked distortion, which the limb assumed, favored the idea of dislocation of the head of the radius. To this conclusion I at length arrived, though not with that certainty which fully satisfies the mind. After put- ting the patient under profound anaesthesia I succeeded in re- ducing the dislocation, and then the arm became supple, and the fracture of the ulna permitted of the plainest crepitation, which could not be elicited until the luxation was reduced. To understand how both injuries were produced is not easy, unless the ulna was broken against the sharp angle of the post at the head of the stairs, and at the time she fell from the stool; the dislocation of the head of the radius upon the anterior aspect of the condyle, must have been done when she landed at the foot of the stairs, where the great weight of her body came upon the injured arm, which, she said, " doubled up under me." The case made a good recovery. 144 Fractures. Treatment.—It is not generally a difficult matter to reduce a simple fracture of the ulna. The broken ends, whether they project in one direction or another, or the upper fragment be in position and the lower dragged into the interosseous space, toward the radius, can commonly be manipulated into appo- sition without deviation from the natural course of the bone. The fragments once brought into line and properly adjusted, two padded board splints, wider than the arm, and reaching from the elbow to the fingers, are to be bound to the anterior and posterior aspects' of the arm, while the hand is held half way between pronation and supination. No roller should be applied except the one that holds the splints in place. Any circular compression is extremely liable to press one or both fragments into the interosseous space, where they may unite to the radius, destroying the functions of pronation and supi- nation. If the fracture be through the lower third of the bone, and the lower fragment is quite forcibly drawn toward the radius, two long, firm compresses should be laid between the radius and ulna, beneath the splints. These tend to wedge the bones apart. The width of the splints prevents anything but lateral compression. As the bandage, while it is being put on, passes across from one splint to the other, the upper and lower surfaces of the arm remain untouched, thus entirely obviating circular compression. After the arm is properly dressed, it may be carried in a sling. The redressings need not be frequent unless there arise a suspicion that all is not well. In the usual time, which is about four or five weeks, the dressings may be finally removed. False-joint after frac- ture of the shaft of the ulna is extremely rare. The callus is plainly felt for months, on account of the subcutaneous loca- tion of the bone. CHAPTER XXII. FRACTURE OF THE RADIUS, ETC. The upper third of the radius, from its being buried deeply in muscles, is seldom fractured; the middle third is not broken any more frequently than the ulna; but the lower third is fractured more often than any part of any other bone in the body. Fracture of the neck of the radius is admitted by every ex- perienced surgeon to be extremely rare. Dr. Markoe, of New York, thought he met with a case in which the signs pointed inevitably to a fracture through the neck of the radius,' but the autopsy showed that he had been mistaken. The injury proved to be a dislocation of the head of the radius forwards, and a fracture of the ulna near the elbow. The mobility of the parts and the crepitus which seemed to come from the radial side of the arm, led to the error of diagnosis. Mutter's cabinet in Philadelphia, contains a specimen of fracture through the neck of the radius, which I have examined. The history of the case is unknown. The fracture united with considerable deformity, which must have interfered consider- ably with the functions of the elbow. In the winter of 1855, Mr. Noyes, of Boston, was thrown from a sleigh in Lowell, and received a severe injury about the elbow. He went to a hotel, and requested that a surgeon be called to treat his arm. The landlord sent for Dr. Nathan Allen, his family physician. Upon his arrival, the doctor ex- amined the injury, and pronounced it a sprain. He applied a bandage to suppress the swelling, and ordered wormwood and rum as a topical application. Several professional visits were made Mr. Noyes while he was at the hotel, and assurances were given that in a few days the patient would be able to resume his business. After several weeks Mr. Noyes found 10 (145) 146 Fractures. that he could not bend the elbow except in a very moderate degree; he could not carry his fingers to the chin, even it the head was bent to meet them. Accordingly he went to the late Dr. John C. Warren, of Boston, for an opinion in regard to the nature of the injury and the prospects of a cure. Dr. W. asked " who had treated the arm;" and upon being told that it was Dr. Allen, he would not look at the case, as Dr. A. was a professional brother in the Massachusetts Medical Society. Mr. N. then went to Dr. Kimball, of Lowell, a sur- geon of some repute. Dr. K. examined the arm, and called his student's attention to what he called a fracture ofthe condyle. Mr. N. then went to Dr. Walter Burnham, of Lowell, also a surgeon of large experience, who pronounced the injury a fracture of the neck of the radius, which was ununited. Mr. N. now supposed that he had been maltreated by Dr. Allen, and sued him for damages. The case was tried at East Cam- bridge, in Middlesex County, in January, 1856, and resulted in a disagreement ofthe jury. ■ The testimony given in court was singularly conflicting, coming as it did from some of the most accomplished and experienced surgeons in the State. It was also a matter of surprise to Mr. Noyes that Dr. Kimball, who had directed his student to observe an old frac- ture of the condyle, should then under oath declare that the arm had never sustained a fracture. The real state of the limb, at the time of the trial was as follows: there was partial anchylosis at the elbow, flexion being greatly impeded, as has been stated ; pronation and supination restricted; and a grat- ing could be produced just below the elbow by passive efforts at rotation of the fore-arm. There was no evidence that the condyles of the humerus had ever been broken. The ulna seemed perfect in its processes and proportions, bearing no sign of fracture. The head of the radius was not dislocated. for it could be grasped with the thumb and finger, and plainly rotated, and it could be held still while the hand and lower extremity of the bone were rotated. These movements elicited a crepitating sound much like that heard in the motions of a false-joint. The evidence of fracture of the neck of the radius was reached by a logical necessity, on the application of a method of reasoning much resorted to in the diagnosis of dis- eases, viz., reasoning by way of exclusion. That there had been a fracture about the joint was quite plain, and as the humerus Of the Radius. 147 and ulna were excluded from the possibility of having been fractured, the upper extremity of the radius alone remained unexcluded, and every symptom in the case indicated fracture of the neck of the bone, whether the injury had previously been met or not by surgeons high in authority. In fractures of the head or neck of the radius, the arm should be flexed to relax the biceps which has its insertion just below the tubercle and tends to displace the upper extremity of the long fragment. The pasteboard splint recommended for fracture of the condyles of the humerus, would be excel- lent to steady and support the parts implicated in the injury. At the end of three or four weeks motion should be imparted to the joint to obviate anchylosis. In fractures of the radius which very rarely occur between the attachment of the biceps and the insertion of the pronator radii teres, the fragments are acted upon by muscles exerting their forces in different directions. The supinator brevis rolls Fig. 50. Fpacture of the radius between the insertions of the supinator brevis and pronator radiiteres. The fragments are separated by the action of these muscles. Fig. 51. Arm supinated to bring the lower fragment into apposition with the upper. the short, upper piece of bone outwards, and the antagonistic pronator pulls the lower piece inwards, somewhat as exhibited in Figure 50. Now, as the upper fragment is short and thickly covered with muscular tisstie, it can not be moved from the position given to it by the supinator brevis; but the 148 Fractures. lower fragment can be made to come in contact with the upper by the extreme supination of the fore-arm, as seen in Figure 51. To treat such a fracture successfully, the arm would have to be dressed in the attitude of extreme supination, and re- tained in that position until the consolidation of the fragments was sufficient to allow of rotation, and not endanger the breaking up of the callus. I have never treated but one case of the kind, wdiich was produced by a pistol bullet, and in that I followed the course just laid down. The recovery was not rapid, for the injury was rendered compound by the bullet wound. Two splints made of thin boards, two inches and a half wide, and reaching from the elbow to the ends of the fingers, were bound in place by a roller while the arm was supine. The back of the hand was allowed to rest in a sling, strict orders being given to keep the thumb directed away from the body. The position was irksome at first, but in a few days it was maintained without effort. Fracture through the middle third of the radius, below the insertion of the pronator radii teres, is generally caused by Fig. 52. Fracture of the middle third of the radius. The biceps (2) tends to pull the upper fragment in one direction, and the pronator quadratus (7) the lower fragment into the interosseous space. direct violence, and happens about as rarely as fracture through the middle third of the ulna. The diagnosis is unattended with difficulty. Rotation developes so much displacement that the ends of the fragments can be distinctly felt beneath the integuments. Crepitus can also be produced when the fragments are brought in contact and rubbed against one an- other. The inclination of the broken ends is to take a posi- tion in the interosseous space, approximating the ulna. The treatment is the same as for fractured ulna in the same Of the Radius. 149 region. Two straight splints, wider than the arm, to obviate circular compression, and padded to prevent excoriation of the skin, are to be ♦bandaged to the dorsal and front aspects of the fore-arm. A compress placed under each splint between the bones, so as to force the fragments away from the ulna, tends to prevent the reparative material from soldering one or both broken ends to the ulna, as represented in Figure 53. If one or both fragments become welded to the ulna, the condi- Fig. 53. Consolidation of fragments of radius with the ulna, preventing rotation of the fore-arm. tion is fatal to rotation. Oidinarily it is not necessary, in treating fractures near the middle of the radius, to use splints extending farther than from the elbow to the hand. These reach quite a distance above and below the line of fracture, so that no motion at the point of separation can take place if the splints be efficiently held with bandages. Figure 61 represents the splints padded and held in place with a couple of tapes preparatory to receiving the bandage. FRACTURE THROUGH THE LOWER THIRD OF THE RADIUS. There is no part of the skeleton so subject to fracture as the lower extremity of the radius. The lesion occurs from indirect violence. The hand in a fall is put forth to arrest the progress of the descent, and to save the head and the trunk from serious blows and concussions. These uses are the occa- sion of so many fractures of the radius near the wrist. The expanded articular extremity of the bone receives the carpus, leaving the ulna free from the shocks sent along from the hand to the fore-arm. The lower end of the radius, though quite large, has a thin shell of hard bone upon the outside, and an abundance of cancellated structure within. Several distinguished surgeons in this country and abroad,. have written upon the nature, appearances, and treatment of 150 Fractures. fractures occurring at the lower extremity of the radius, and a few of them have gotten their names associated with varie- ties of the injury. In 1814 Dr. Abraham Colles, of Dublin, published an article in the Edinburgh Medical and Surgical Journal, upon the peculiarities of a fracture commonly occur- ring about an inch from the carpal extremity of the radius ; and since that time all fractures of the lower portion of the radius, except such as involved the articular surface of the bone, have been called " Colles' fracture" In 1838, Dr. J. Rhea Barton, of Philadelphia, published an article in the Philadelphia Medical Examiner, on the subject of fractures of the carpal extremity of the radius. He called particular attention to such fractures as involved the articular surface of the bone, claiming that in many instances the line of separa- tion was not so far from the wrist-joint as described by Colles. Since the publication of the article American surgeons have Fig. 54. "Barton's fracture" of the lower extremity of the radius. The action of the supinator longus and pronator quadratus is exhibited in the position of the fragments. commonly called the injury, when the articulation is involved, " Barton's fracture." Both writers have described injuries pro- duced by the same causes, and presenting the same peculiari- ties. There is no difference between Colles' fracture and Bar- ton's fracture, unless it be that the latter name belongs to such lesions as present a break extending to the carpal articular surface. In the production of both fractures the hand is thrown out instinctively to break the force of a fall, and when the carpus meets the earth or the resistance of anything stable, the momentum of the body causes a fracture at the weakest part of the bone. The deformity following fracture of the radius near the wrist is observable, yet to an inexperienced person the nature of the difficulty is rather obscure. The swelling which rapidly Of the Radius. 151 supervenes, masks the irregularities of the broken surfaces, and otherwise conceals the symptoms of fracture. The ap- pearances of the parts may lead to the suspicion of radio- carpal luxation. If the hand and fore-arm of the patient be grasped and subjected to extending and counter-extending forces, the injured limb in case of fracture, will be made to assume its natural outlines and projections. In the event of radio-carpal dislocation, which is an exceedingly uncommon lesion, the deformities can not readily be overcome by such force; and wheu once in place the bones will stay there. The deformities attendant upon fracture are easily overcome, but they will immediately recur upon the relaxation of the re- ducing forces. The peculiar appearance of an arm suffering from fracture of the carpal extremity of the radius, has been compared to the outline of a silver fork. The accompanying diagram re- presents it pretty well. An elevation presents on the wrist, Fig. 55. " Silver fork " appearance of the hand and arm after Colles' fracture of the radius. extending to the back of the hand. This dorsal prominence is nearly apposite or a counterpart to a deep sulcus or depres- sion on the palmar aspect of the wrist. Higher on the front ofthe arm, above the sulcus, is a marked prominence. Besides these deformities, there is an abnormal projection of the lower extremity of the ulna, as if the carpus was dislocated laterally to the radial side. The muscles going to the thumb tend to pull the hand away from the ulna. In seeking positive evidence ofthe fracture under consider- ation, crepitus becomes important. This valuable sign can generally be elicited by grasping the hand and arm, and im- .parting various movements to the wrist. The finger pressed upon the radius immediately above the articulation, while the movements just spoken off are made, will discover the sharp or rough edges of the broken ends of the fragments, or such 152 Fractures. irregularities in the bone within an inch or two of the joint, as will be quite conclusive as to the nature of the injury, the direction of the line of fracture, and the size and shape of the lower fragment. The skeleton drawing in the accompanying diagram represents pretty accurately the line of separation Fig. 56. Fracture through the lower extremity of the radius, showing the tendency of the hand to slide away from the ulna. just above the radio-carpal articulation. The short fragment is larger in some instances and smaller in others. It is well to bear in mind, while considering the relative positions the fragments take, that the supinator longus is inserted into the lower fragment, dragging it and the carpus attached to it, away from the ulna, and the pronator quadratus drags the lower end of the upper fragment toward the ulna, making the arm just above the wrist rounder, or less flattened, than usual. Colles' fracture of the radius happens at all periods of life, from infancy to old age. Females not being so much exposed to the violent accidents of life as the other sex, suffer less from all kinds of fractures. In September, 1868, a gentleman and two ladies were thrown from a carriage, while riding on the Reading pike. The gentleman jumped before the carriage had fully upset, and landing heavily on one foot, received Pott's fracture of the fibula; the two ladies were hurled vio- lently to the earth, with hands extended to save more vital parts, and each sustained a fracture of the right radius near the wrist. If sex had any bearing on these injuries, it must have been confined to the conduct of each in an emergency, the man preferring the risks of a leap to the more passive course of being thrown upon his hands and head. The deformities following Colles' fracture present unmis- takable characteristics, whether treated well or ill, or not Of the Radius. 153 treated at all. Some years ago I examined the wrists of Mr. Coleman, an English gentleman, who on a voyage from Cal- cutta to New York, was thrown against some luggage by a violent lurch of the ship. He received the common fracture of the radius in both arms, and as there was no surgeon on the vessel, no treatment was instituted except the application of a wet cloth to keep down inflammation. Being injured off the Cape of Good Hope, it was several weeks before he arrived in port. It was then too late to have anything done to remedy the deformity. However, the wrists were fully as mobile and useful at the end of two months from the injury as they would have been if subjected to the usual treatment, and the deformities were not greater than in many cases which have passed through surgical hands. I was surprised to see no worse results in cases never treated. The examination of cabinet specimens reveals the fact that there is more or less impaction in many cases, the upper frag- ment being driven into the lower. In one specimen belonging to me, taken from the arm of a man who was killed by a fall, the lower fragment is split into three pieces, the line of frac- ture running through the carpal articular surface; and to every appearance the comminution was produced by the impacting and wedging forces of the upper fragment. The primary fracture was about an inch above the carpo-radial articulation; the splitting of the lower fragment must have been of a secondary nature, and was probably produced by the impetus of the body after the hand had struck the earth and received the earliest lesion. The symptoms of fracture of the radius near the wrist are, pain, swelling, greater or less inability to use the hand and arm, and all the deformities already described. Crepitus can not always be produced, though the cases are rare in which it can not be elicited by varied manipulation. In young subjects the results of well treated cases are quite satisfactory, but in elderly persons, some degree of anchylosis, and stiffness in the wrist and fingers, lasts for weeks, months, and even years. The sheaths of the tendons lose their slippery functions, and a troublesome sensitiveness chronically affects the hand and wrist. Treatment.—Many ingenious contrivances have been de- vised for successfully treating fractures through the lower 154 Fractures. third of the radius. In fact, some of our works on fractures contain so many plans, with lengthily expressed approvals and objections, that the inexperienced reader finds some difficulty in selecting the most feasible plan. It is thought best, there- fore, to describe a simple method of dressing the arm, which can be readily put in practice in the country, where a thin board, knife, and bandage can be obtained. The dorsal splint may be a piece of cigar box, two and a half inches wide and long enough to reach from near the elbow to the back of the hand. Before application it should be wound with strips of muslin or old cloth; the palmar splint may be whittled from the thin cover of a box, or from a shingle, or lath. Its shape may be something like the profile of the hand and arm, or like that represented by No. 1 in figure 57, which is broad near the lower end, and cut obliquely across, so that the upper or longest border corresponds with the thumb side of the hand. To this broad and obliquely cut extremity a compress large enough to fill the hollow of the hand, is bound. The com- press may be made of a strip of bandage, compactly rolled. This is to be fastened in place by the same strip which is used to envelope the splint. The obliquity of the compress when the splint is applied, forces the hand to the ulnar side, thereby producing a degree of extension upon the lower fragment. A compress is placed between the splint and the prominence of the arm on the palmar surface, and another small compress is placed on the prominence of the back of the wrist, under the dorsal splint. A piece of tape is tied around the splints near the hand, and another near the elbow, to retain the dressings thus far applied, in place. Extension is now made on the fingers to adjust the fragments ; and the lower tape is tightened to prevent the displacement from recurring. Over the whole dressing thus far applied a roller bandage is snugly, though not tightly wrapped. Figure 57 represents the two splints before they are applied, and the arm after it is fully dressed. The fingers and thumb are left exposed, and can be used enough to prevent anchylosis, or even much stiffness. This dressing is simple in its construction, easily worn, and prevents motion between the fragments. I have obtained better results with it than with more complicated and expen- sive apparatus. The width of the splints must always exceed the width of the arm in order that there shall be no circular Of the Radius. t 155 constriction. No enveloping bandage is to be used upon the arm before the splints are applied. No water or other topical application is to be employed, for the wetting of the bandage Fig. 57. No 1 is the palmar splint ready for use; and No. 2 the dorsal splint. The arm is represented as dressed in the treatment of " Colles' fracture'' of the radius. shrinks the cloth, and makes the dressing too tight. The limb should be seen the next day after the accident, and the band- age loosened if it seem to inflict pain or to arrest the circula- tion. It is better to re-dress the limb than to take any risk of mischief from strangulation. After the swelling has subsided, which will be in eight or ten days after the accident, the dressing may be left undisturbed for a week at a time. In four or five weeks, as a general rule, the consolidation will be complete, and the dressings may be laid aside. However, passive motion should be kept up for several weeks longer or until the functions of the fingers and wrist are re-established. Persons advanced in years are liable to neuralgic pains in the hand and at the seat of injury. This difficulty, if prolonged, and much troublesome, may be ameliorated by the use of stimulating and anodyne liniments. The excess of reparative material sometimes thrown out around the end of the upper fragment, constitutes a hard ridge at the seat of fracture, and seriously impedes the play of the tendons in that region. In time this excess of callus will be absorbed, leaving the parts nearly in their normal state. An impending evil after fracture of the radius near the wrist, is false joint, which generally occurs where the patient has used the fore-arm at too early a period, or where motion at the wrist has not been guarded against during the treat- ment. Two ordinary straight splints, though they extend be- yond the fingers, do not restrain motion at the seat of fracure 156 . Fractures. as well as the palmar splint, with its roller-like compress tor the hollow of the hand. The dorsal splint resting upon the back of the hand also serves to check that tilting motion, with the lower end of the ulna for a pivot, which is so promo- tive of non-union of the fragments. Fig. 58. The arm exhibits the deformity attendant upon fracture through the lower extremity of the radius. A single splint, like the one represented, will answer to dress the fracture. Some surgeons employ only one splint in the dressing for fracture through the lower extremity ofthe radius ; and claim to have obtained good results from such an appliance. I have secured satisfactory recoveries from the single splint, with a roller bound obliquely upon the wide end, to rest in the hollow of the hand, but I prefer using also a dorsal splint. If the dressing gets too loose, and the patient begins to use the hand before the consolidation is quite effected, the vital operations are perverted. Instead of continuing to furnish reparative supplies, they begin to remove the callus or uniting material, and make way for false-joint. In one case that came under my observation, the consolidation was nearly perfect on the twentieth day; there was plenty of callus, and every evi- dence of a complete repair. The patient now thought it was all useless to hamper his arm any longer, and assumed the re- sponsibility of throwing aside the dressing and using the arm. At once the operations of nature became opposed to consoli- dation, and in a few weeks removed the reparative material and established a false-joint where there might have been con- solidation by a week more of retentive treatment. Of the Radius. 157 A little girl was brought to me not long since with an arm that had been fractured through the lower extremity of the radius five weeks previously. The medical attendant had dressed the limb in the usual way, but the dressing had been loosened by the child's mother, and taken off altogether before the physician had given directions for such a course. The little girl had used her arm at play, keeping up motion at the seat of injury where there should be absolute rest. The con- sequence was that the fragments failed to unite, though the upper fragment furnished an abundance of reparative material. I regarded it as not too late for an attempt to re-establish the healing process, so I put on the dressing recommended for the treatment of this fracture, employing starch paste at each turn of the bandage. In fact, the roller was employed up and down the arm two or three times, and the paste freely applied, as the wrapping continued, to constitute an immov- able dressing. The rigid case thus constructed, was ordered to be worn six weeks at least. Consolidation followed, and a good result was obtained. FRACTURE OF BOTH BONES OF THE FORE-ARM. The radius and ulna are often broken at the same time. The injury is produced by direct violence. A blow, the pas- sage of a wheel over the arm, and moving machinery, are the Fig. 59. Fracture of the radius and ulna. The same muscles are shown as acting upon the fragments as when one bone is broken. common causes. The middle and lower extremities of the bones are broken more frequently than the upper thirds which are protected in a measure by the deep coverings of muscles. In regard to the frequency of such accidents, the analysis of 158 Fractures. tables shows that both bones of the fore-arm are oftener broken than the ulna singly. The diagnosis is usually simple; the pain, loss of power, the unnatural bend in the arm, the separate mobility of the upper and lower fragments, and the crepitus, constitute signs which are too plain to be mistaken. The displacement of the frag- ments may not be observable in some instances, for the broken ends do not always become disengaged, but in most cases the deformity is so great as to indicate at once the nature of the injury. When there is overlapping of the fragments there must, of necessity, be shortening of the arm. The peculiar distortion produced by bending the limb near the seat of frac- ture, can not be misapprehended. Crepitus can be elicited by grasping the arm above and below the fracture, and rotating the limb while it is brought to its normal length and position by extension. The tendency of the fragments is to sink into the inter- osseous space, where they will unite en masse unless well directed efforts are made to keep the ends of the two bones away from each other. In some instances one fragment will keep aloof from the others which incline to group. If the bones be broken conjointly and by direct violence, much damage may be done to the soft tissues, resulting in sloughs, Fig. 60. Comminuted fracture of both bones of the forearm. protrusion of the fragments, and the most dangerous compli- cations. Compound and comminuted fractures of both bones of the fore-arm have generally been considered a sufficient cause for immediate amputation, but such a course is not always necessary, as the following case will show. In October 1865, Mr. William Moffit, living on Longworth Street in this Of the Fore-arm. 159 city, had his arm drawn between the rollers of a leather split- ting machine. The crushing power to which the limb was subjected, broke the radius and ulna into fragments, each an inch or two in length, beginning near the wrist and extending to the elbow. The arm felt like a bag with pieces of broken ice in it. Some of the pieces of bone projected through the skin. Dr. E. N. Cushing, of Covington, Ky., was in my office at the time I was summoned to the case, and assisted in ar- ranging and adjusting the fragments, and in dressing the limb. It is needless to say that it was utterly impossible to bring every fragment into perfect apposition at both ends, but the fragments of the two bones were pressed into rows, and the natural contour ofthe limb was well restored and preserved. Splints and bandages were used to keep the pieces and parts steadily in place. No severe pressure was applied through fear of gangrene. In less than two months the arm was freed from its dressings, and put under passive motion. The limb lost only a small share of its functions, and therefore became quite useful. Pronation and supination were partly lost; and the elbow and wrist did not recover their full extent of motion. In treating fractures of both bones of the fore-arm, two splints reaching from the elbow to the wrist, and wide enough Fig. 61. to prevent circular constriction of the arm, are to be em- ployed upon the front and dorsal aspects of the limb. Tapes may be used to retain the dressing in place until the frag- ments are coaptated, and everything is ready for the roller bandage. As in all other fractures of the fore-arm, no primary bandage is to go on next the skin. The constricting influence of such a bandage would force the fragments into the inter- osseous space where they are liable to unite in a group. The retentive bandage should be applied lightly at first. 160 Fractures. Several cases are recorded in which the limb has had to be amputated, through the folly or carelessness of too tight dressings. There is time enough for snug compression after inflammation and swelling have subsided. Inexperienced surgeons often commit the error of strangling the local circu- lation by a tightly drawn retentive dressing. There is no other excuse for these repetitions in regard to the application of dressings to a broken arm, except in the fact that serious and fatal mistakes continue to be made by practitioners of medicine and surgery who have either not had an opportunity to read impressive lessons on the subject, or they are too heed- less to learn what is enjoined but once. CHAPTER XXIII. FRACTURE OF THE BONES OF THE HAND. The bones of the hand, including the carpus, metacarpus, and phalanges, are seldom broken. The carpus has no long bones, but a group of eight pieces, rounded and angular, which are held together by ligaments and other fibrous struc- tures, so Vhat even if one or more were broken or crushed, there would be no particular displacement or special signs of fracture. It would be more in accordance with a rational division of subjects if fractures of the carpus were arranged under the head of wounds or severe bruises. The carpal bones can not be broken unless by direct violence of a crush- ing character, as by the passage over the wrist, of a cart- wheel, or by being caught between the hunters of rail-cars. The treatment should consist in adjusting displaced parts as well as possible, and in using a bandage upon the hand, wrist, and fore-arm, to restrain motion. The topical use of anodynes and cooling lotions, would be indicated. In the management of a gunshot wound of the wrist, in which there must have been a crushing of one or more carpal bones, my patient ex- hibited signs of tetanus. Chloroform constantly applied to lint laid upon the wound, seemed to allay the nervous irrita- tion. FRACTURE OF THE METACARPAL BONES. Direct violence upon the back of the hand, and indirect force, as by blows upon the ends of the knuckles in pugilistic encounters, may produce fracture of one or more of the meta- carpal bones. I have treated cases that were produced by both causes. Two years ago, John Benson, of West Virginia, came to my office one morning with the right hand swollen 11 (161) 162 Fractures. and very painful. About sunrise that morning, he got into a fight with a negro deck hand on the Annie Laurie, lie says he struck at his assailant, and missing him, his knuckle hit a box of freight; something in his hand cracked like a pistol, and his hand became too painful to use. At the middle ot the metacarpal bone of the ring finger a tumefaction existed, and back and forward pressure produced motion between the fragments of the broken bone, and elicited crepitus. ^ In June last a boy came to my office from the printing de- partment of Stannage & Co., and complained bitterly of his hand, which had been injured in a printing press. Ifound three of the metacarpal bones broken, and the first phalanx Fig. 62. ^ Fracture of three of the metacarpal bones, and the first phalanx of the thumb. The hand was crushed in a printing press. of the thumb. I applied to the hand and arm the palmar splint used for fracture of the lower extremity of the radius, and retained it in place with a bandage. The injury proved to be very painful, and the inflammation ran high. The back of the hand was kept wet with the tincture of aconite. At the end of three weeks the dressings were removed, at which time the consolidation seemed to be complete. However, the stiffness of the metacarpo-phalangeal joints was so great that forcible passive motion had to be employed for weeks, before the functions were sufficiently restored to allow of his volun- tarily opening and shutting the hand. Slight displacement of the fragments toward the palm existed at the time I first saw the hand, and this deformity was not entirely overcome by the treatment. The boy was so stubborn and refractory that I could not carry out my plan of treatment fully. He objected to a moderately tight dressing, and would not submit to efficient passive motion. In treating fractures of the meta- carpal bones, the plan of causing the hand to grasp a large Of the Phalanges. 163 ball, and then binding a roller around the whole, as recom- mended by Sir Astley Cooper, is not so valuable as the palmar splint, with a roller compress bound to its end obliquely, to fill the hollow of the hand. This dressing leaves the fingers free, and prevents the ends of the fragments from sinking down toward the palm. If the metacarpal bone of the thumb be broken singly, the palmar splint having the roller com- press attached, is the best apparatus that can be employed to give the fragments support and prevent motion and displace- ment. FRACTURE OF THE PHALANGES. From the exposed situation of the bones of the fingers, fracture of one or more of the phalanges is an occasional in- jury demanding consideration. Direct, violence is by far the most common cause of the lesion, though a blow upon the end of a finger, as in attempts to stop or catch a ball, may produce fracture of the first or second phalanx. A simple fracture of the finger may be produced by the great velocity of the force applied. The phalanges have been broken by a smart blow of a cane, though no resistance was offered on the opposite side of the fingers. A phalanx is seldom broken in more than one place, and generally near the Fig. 63________ Fracture of a digital phalanx. middle. A crushing force not unfrequently produces a com- minution of the bone, including its articular extremities, and perforation of the integuments. The symptoms of simple fracture are crepitus and mobility ot the fragments ; sometimes the "shape of the finger will de- termine whether it is broken or not. If the flesh be mashed and the bone crushed, one of the joints of the finger is about sure to be involved; and the symptoms must depend very much upon the severity of the injury. Treatment.—Simple fracture of a finger is to be managed on the usual plans followed in treating the long bones. A 164 Fractures. narrow straight wooden splint is fastened beneath the finger, with a small compress against the point of fracture to support the ends of the broken bone, and to fill up the concavity which naturally exists between the joints. A strip of pasteboard laid upon the dorsal surface of the finger, offers moderate re- sistance to motion between the fragments, and serves to keep the bandage from constricting the integument. At the end of the third or fourth week, when the dressing is finally re- moved, well directed passive motion is needed to get rid of the stiffness which depends upon deposits of lymph in the sheaths of the tendons. Broken fingers left to themselves, without treatment, do not turn out well. They become angularly deformed, deflected laterally, or rotated on their axis, constituting permanent de- formities that are sources of much regret to the patient ever afterwards. I have been solicited to break a deviated finger, and attempt to straighten it. I have never seen a case that seemed to justify the measure, though such an operation would not always be unwarranted. Compound fractures of the fingers, with mashing of the soft parts, can sometimes be brought into proper shape by the use of sticking plaster. Such injuries, however, do not prop- erly come under the head of fractures, so far as adjustment and treatment are concerned, but must be managed according to the principles involved in the treatment of wounds. CHAPTER XXIV. FRACTURE OF THE PELVIC BONES. Crushing forces, as when a man is caught between heavy moving bodies, or strikes in the region of the hip at the ter- mination of a long fall, may produce fracture of some part of the pelvic circle. The symphysis pubis has been separated by the throes of labor, though such an accident must be ex- ceedingly uncommon. Several cases have been reported in which forcible separation of the two pubic bones occurred at the symphysis from injuries received while coupling cars, and in railway accidents generally. I was once called to see an old negro in Louisiana, who had been kicked by a mule in the region of the pubes. He was unable to urinate, and while introducing the catheter I discovered a sinking in of the body ofthe os pubis on the left side, at a point outside ofthe spine of the bone. The line of separation must have extended into the thyroid foramen though the ramus of the pubis did not appear to be broken. The fractured surface of the end of the outer fragment could be distinctly felt, but the other surface was too much depressed to be manipulated. No mobility ex- isted, and on account of the swelling no deformity was ob- served until in the attempt at catheterism the left wrist dis- covered an irregularity of the parts. The patient was not aware that a fracture had been received, but supposed his bladder was ruptured. The urine was not bloody, and there was no evidence that severe internal injury had been inflicted. The depressed bone could not be brought back into place; yet some months afterwards I heard that the patient suffered no inconvenience from his injuries. Fractures of the pelvic bones are not necessarily dangerous of themselves ; but the terrible forces which produce them are apt to inflict greater or less injury to important parts in their (165) 166 Fractures. immediate vicinity. Fragments of bone may perforate the rectum and bladder, or do such mischief to the viscera of the pelvis as may seriously interfere with the functions of those organs. The gravity of such injuries can not always be de- termined at the earlier examinations. The crest of the ilium, and the anterior superior spinous process may be broken off by moderate forces, as by a kick from another individual, but the massive strength of the deeper parts and their protective coverings and connections, serve to shield them from the damaging influence of all ordinary forces. In 1860, Andy Rice, in the employ of McHenry & Carson, fell through the hatches of four stories, and struck against hard substances in the cellar. He sustained a multiplicity of injuries, and fully recovered from all of them. At first he complained most of his left shoulder, which was dislocated. This I reduced without removing his coat or changing his position. Finding that he had several fractures I had him taken home. I there learned by examination that one femur was broken just below the lesser trocanter; that the under jaw was broken at the symphysis ; that three ribs were frac- tured ; and that the left os innominatum was broken into at least three pieces. It was difficult to determine just where all the lines of separation ex- tended. The great arc of the ilium could be easily moved by taking hold of it, and the the motions were attended with distinct crepitus. Its line of separation must have been nearly like the upper one repre- sented in the accompanying figure. The movement of this piece gave little pain ; but in attempts to diagnose the other fractures of the innominatum great distress was produced. The greatest degree of pain Fractures of the os innominatum. seemed to arise from motion imparted to the fragments of the femur. The pubic part of the bone was certainly broken through the ramus and body. This left the femur articulated Of the Sacrum. 167 to a large movable fragment of the innominatum, that was free from still another fragment which was firmly united to the sacrum. The costal segment was the most mobile, then the large piece that contained the acetabulum; the smaller fragment connected to the sacrum had no perceptible mobility, and the pubic fragment continued firm on account of its junc- tion at the symphysis. The catheter had to be used a few times, but there was no blood in the urine. The symptoms were so terribly severe for more than a week that there seemed little ground for hope. The pelvis now has its natural shape, excepting a slight abnormal twist in the left os innominatum, which does not cause lameness. The treatment of fracture of the pelvic bones consists in applying such bandages, straps, belts, or apparatus, as shall restrain all motion between the fragments. In the case of Andy Rice I used the " woven wire breeches," figure 10. This apparatus served several purposes: 1st, to keep up ex- tension and counter-extension for the fractured thigh ; 2d, to steady the pelvic fragments ; and 3d, it proved useful in hand- ling the patient during the six weeks of treatment. A wide belt of strong cloth or leather to buckle around the pelvic region, serves to steady a simple fracture of the ilium, ischium, or pubes. The patient is unable to walk, or to assume the erect posture, if anything more than a salient point is broken from the pelvic bones. The powerful muscles acting upon any considerable fragment, would disturb it too much for active exercise. Fracture extending into the acetabulum, seriously interferes with the hip-joint; and the diagnosis of such an injury must be exceedingly obscure. Cases have been dissected in which it had been demonstrated that a stellate fracture of the ace- tabulum was produced by a blow upon the trochanters of the femur, the force telling through the head of that bone. FRACTURE OF THE SACRUM. The sacrum, as a dry specimen, removed from its connec- tions with the other pelvic bones, is not difficult to break, but in its normal state, wedged between the ossa innominata, and covered with ligamentous and other firm tissues, the bone is 168 Fractures. in little danger of being broken. A kick or a powerful blow, such as may be received in a fall, might cause a fracture of the bone at any point, the line of separation running in any direction. The processes of the bone may be broken off, or a fracture may extend only as far as the central or spinal canal. In most instances, it is found that fractures of the sacrum ex- tend through the lower third of the bone, and mostly in a transverse course. If the lower fragment be carried in towards the rectum the functions of that tube might be seriously interfered with, A patient suspected of having a broken sacrum should be made to lie on the abdomen while an examination is going on, and an attempt made to overcome any considerable displacement. The finger carried into the rectum may be the only means of discovering the full extent of the mischief, and in correcting such deformity as lays within digital power. A lithotomist's scoop, or any instrument of proper proportions and strength, might be used in the rectum to press the deflected fragment back into place, care being used not to injure the soft parts. The patient should keep quiet in the horizontal position for a few weeks, to allow the healing process to consolidate the fragments. The bowels should be kept in a soluble state during the treatment, to prevent accumulations of gas and stercoracious matter near the seat of the injury. Hamilton recommends that the bowels be kept constipated in order that the accumulation of hardened material in the rectum may press back into line the displaced fragment, and act as a splint on the inner surface of the bone. The suggestion is quite in- genious, but the practical working of the plan is questionable. FRACTURE OF THE COCCYX. A fracture of the cornua of the coccyx, and a partial dis- location of the bone inwards, constitute an injury, which is caused by a direct blow, kick, or other violence telling upon the bony appendage. The lesion has been reported as occur- ring from parturient efforts. If such be the case the subjects must have been sufficiently advanced in life to have the bone consolidated to the sacrum. In young women the mobility of the coccyx allows the bone to yield to forces brought to bear upon it during the last stage of labor. Of the Coccyx. 169 I have never seen but one case of a broken coccyx; and this accident occurred to a man standing on the platform of a car as the train was suddenly put in motion by the engineer. The point or angle of the iron railing struck the passenger in the coccygeal region, and caused a sickening sensation from the severe shock to the nervous system. After receiving the injury the patient took a seat inside the coach, and although in severe pain, and complaining of a general uneasiness, he chatted with a fellow traveler, reaching home that night. Before morning he took a " chill;" and had his family physi- cian summoned. He no longer complained of distress in the region hurt, but asked to be relieved of a sense of constric- tion in the bowels, and nausea at the stomach. Morphia was administered in large and repeated doses. This relieved him of the acute distress, yet he declared that there was some ter- ribly deep seated disease about him that would terminate fatally. The bowels were evacuated by the influence of cathar- tics, and the bladder at length had to be relieved by catheter- ism. On the tenth day after the injury he died; and none of his medical and surgical attendants had suspected the true cause of death. An autopsy was held, at which I was present. The physician using the scalpel, remarked that he should first look for abscess of the liver, or for pus in or about that organ. Finding no cause for death in the viscera of the abdomen, and observing considerable redness in the pelvic colon, the peri- neum and anus were inspected. The discoloration in that region led to the suspicion that the difficulty had been some- where about the lower end of the spinal column. The body being turned over, the signs of decomposition in the region of the coccyx were strikingly apparent. A careful dissection showed that the coccygeal horns or processes were broken, and the bone somewhat displaced inwards. The entire coccyx except the detached cornua, was blackened, and bore the ap- pearance of having been dead for many days. An apparently trifling injury, which had not attracted the attention of several physicians in consultation, and which produced more general than local disturbance, terminated fatally. This case is not without parallel. Cloquet, Petit, and other surgical writers upon the subject of fracture and dislocation of the coccyx, speak of the dangers of caries, as if the bone, after serious lesions, was liable to mortification. Whether anything could 170 Fractures. be done to arrest the tendency to necrosis, if undertaken promptly, is not demonstrated. It is plainly the duty of the surgeon, when called to a case of fracture of the coccyx, to overcome any inward displacement by manipulation, using the finger in the rectum; and to keep the patient at rest by the use of opium suppositories and such other local means of a quieting or stimulating character, as would afford relief and promote a restorative action in a severe bruise or other wound in that region. It is not easy to diagnose fracture of the coccyx. Pain of a severe character might arise from shock or concussion, as, also, a general uneasiness, on account of the constitutional disturbance. With a finger in the rectum and the thumb on the coccyx, a great increase of mobility might be determined, as well as displacement; but crepitation, that distinctive sign of fracture, can not certainly be obtained, owing to the broken surfaces of bone being small, and the motion imparted not of a kind likely to cause rubbing of the broken parts against one another. It is not improbable that fracture ofthe coccyx has occasionally passed unobserved, or for a bruise in the region of the sacrum ; and a severe concussion in that part of the body followed by sharp pain in attempts to walk, and during defecation, has been regarded as a case of coccygeal fracture. The great mobility of the coccyx in young subjects might contribute to the deception. Fracture arising from the dis- placing force of the child's head in parturition, is quite differ- ent in character from that produced by a kick or fall upon some projecting substance. The shock is much less when produced by the forward movements of a child's head. When produced by accidental violence there may be a vast excess of force over that actually required to break the bone ; and this excess would naturally increase the dangers of the case. CHAPTER XXV. FRACTURE OF THE FEMUR. The length of the femur and the exposure of the bone to a variety of forces, contribute to its liability to fracture. The muscles surrounding the femur afford a certain amount of protection against external shocks, yet this shielding influence is more than counterbalanced by the strain the bone receives from their action. The different fractures to which the bone is subject, and the complicated appliances recommended for their treatment, constitute a series of topics well calculated to overwhelm the student who first directs his attention to this branch of surgical study. Unless the diagnosis of such injuries be clearly made out, and the treatment necessary to the accomplishment of good results be clearly understood, and efficiently carried out, the most lamentable consequences may be expected. An imperfect conception of the nature of the accident, or a " trust-to-luck " management ofthe injury, will surely lead to the chagrin and disgrace of the surgical attend- ant, and to the permanent crippling of the unfortunate patient. No medical practitioner should assume the responsibility of treating a fractured thigh, unless he comprehends what is absolutely necessary to insure at least an average recovery. A perfect result cannot be attained in all instances, for the cir- cumstances under which some cases have to be treated may thwart the best directed efforts of the surgeon. However, want of skill is the most common cause of bad recoveries. The neck of the femur is placed at an oblique angle to the shaft of the bone, and in old age it more nearly approaches a right angle. This peculiar conformation in advanced life, together with an increased amount of cancellated tissue on the inner structure, renders the bone weak at a point subjected to considerable lever power. (171) 172 Fractures. The trochanters are stout processes of bone, but the greater ofthe two being subjected to direct violence in falls, and the lesser to the action of powerful muscles, they may be discon- nected from the shaft, or forced into the central spongy struc- tures. The shaft of the femur is very long, offering forces a favor- able opportunity to break it in pieces. The muscles exert great influence upon a bone which offers the advantage of such extensive lever power. Indirect forces received by the foot, and transmitted upward to the great curve just above the middle of the shaft of the femur, very frequently produce fractures at that point. The condyles spread out into a broad base to give steadiness to the knee-joint, but they have so much spongy structure within, that they are not adapted to offer powerful resistance to direct forces. The resisting power of a bone must not be reckoned by its size, for the middle of the shaft, which is the smallest part ofthe bone, is probably the strongest. The causes which produce fractures of the thigh are numer- ous. When the direct force acts, it generally happens that the limb is crushed by some heavy weight falling upon it, or by a loaded wagon passing over it. When an indirect force acts, it is most frequently found that the person falls from a height, with the thigh in such a position that the bone snaps at a point remote from the part receiving the shock. An irregu- larity in the ground sometimes imparts a twist to the leg which may prove too great for the brittle neck of the femur. A person fancying he is treading upon level ground, takes a false step unawares, and the muscles not being employed to resist the impetus, or to counteract the accidental twist un- expectedly given to the limb, he receives a fracture ofthe neck of the thigh bone. FRACTURE OF THE NECK OF THE FEMUR. The neck ofthe thigh bone has been invested with unusual in- terest, both on account ofthe frequency of fracture occurring at that point,and the learned discussions that have taken place con- cerning the possibility and probability of bony union taking place here as in fractures through other parts of the bone. A quo- tation from Mr.Lonsdale expresses some of the reasons why frac- Of the Femur. 173 tures through the cervix femoris are so frequent: "It is an acci- dent that is met with chiefly in old people, and very seldom, indeed, in young. The structure of the bone in old people becomes altered, owing to the deficiency of the animal matter in it, causing the earthy to be in excess, which gives a brit- tleness to it, that does not exist in the bones of young people. This part ofthe bone is also naturally of a- loose, cancellated structure, and when deprived of its animal matter, will become weak and ill calculated to receive any severe shock, either from the weight of the body, or from a blow directly applied to the part. There are other causes also which tend to pro- duce fracture of this Dart of the bone. Fig. 64. Section ofthe head, neck, and upper extremity of the Shaft of the Femur, showing the inner cancellated texture, and natural shape of this part of the bone. The muscles surrounding the hip-joint in old people waste, causing this part to become flattened, and to have compara- tively little covering upon it; so that a fall upon the posterior part of the hip, which, in a younger person, in whom the muscles act as a cushion, might tell with little force directly on the trochanter, or neck of the bone, would in an old one, 171 Fractures. where this cushion is absent, be sufficient to produce fracture. In old people, also, the whole body loses its elasticity, all the movements are heavier, and more awkward and less secure, so that falls are likely to take place from trifling causes, with- out the power of resisting them; for though a younger per- son might break his fall by the use of his arms, or by the strength and activity of his body generally, an old person can not, but falls like a dead weight, and the shock, of course, becomes much greater than it otherwise would be. All these circumstances taken together cause this kind of fracture to be much more frequent in old than young people." Sex has something to do with the frequency of the fracture. In women the pelvis is wider, and the neck of the femur is longer, and it joins the shaft nearer a right angle than it does in men. Elderly females are apt to lose confidence in their pedestrian powers, which, so far as it goes, favors fracture; besides, their bones and bony supports are weaker or less de- veloped than in the other sex, being therefore less capable of offering resistance to forces acting upon the skeleton. Elderly persons, if they fall heavily upon the trochanter, may sustain fracture of the neck of the femur. This kind of violence has been called direct, though it is not more so than when a per- son, in falling, or in taking a false step, sends a force from the foot up to the neck of the bone. Indirect violence, then, must be considered the common cause of fracture through the cervix femoris. A fracture near the head of the bone, and wholly within the capsular ligament, is generally transverse, while the direc- tion of the fracture is likely to be oblique, if it be near the trochanters, making the line of separation partially within and partially without the cavity of the joint. It is quite essential to understand the place where the solu- tion of continuity exists, for in a fracture near the head of the bone ossific union need not be expected, but in a fracture extending outside the femoral attachment ofthe capsular lig- ament, bony union maybe reasonably expected, with a strong and useful limb. It will generally be found that fractures wholly within the capsular ligament, result in ligamentous unions; and that a break in the bone outside the ligament is about sure to end in osseous consolidation. In fractures partly within and partly without the ligament, as when the line of Of the Femur. 175 separation is oblique, or irregular in its course, crossing the attachment of the ligament to the bone, the union is most likely to be osseous, though it may be fibrous. Displacement has considerable to do with consolidation, though not so much as mobility. If the separation of the broken surfaces be so great that there is scarcely any contact, bony union is not to be expected ; and if in addition to dis- placement, there be constant rocking of one fragment upon the other, efforts at consolidation are thwarted. Much has been said about lack of reparative supplies afforded to the articular fragment, as if it were completely cut off" from vascular connections, except through the ligamen- tum teres. In some instances, especially if the synovial mem- brane be torn, as it is likely to be, the head of the bone is completely isolated except through the round ligament. This theory in regard to scanty nutritive supplies, is supported by the fact that large quantities of reparative bony material are deposited around the end of the lower fragment, constituting an excess of callus, while the scantiest amount is accumulated about the end of the short or upper fragment. The symptoms of a fracture within the capsule are, shortening of the limb, eversion of the foot, motion between the fractured portions of the bone, crepitus, great pain about the joint, and inability to move the limb, or to bear the weight of the body upon it. The shortening is not marked directly after the reception of the fracture, but it increases from day to day till it reaches an inch or more. The shortening may be overcome by making extension, and as soon as this force is relaxed, the limb draws up again. It requires considerable care, and regard for accu- racy, to ascertain whether one leg be longer than the other. A limb is often supposed to be shorter than the other, when the position of the patient's body produces the deception. Anybody can lie upon the back, and so twist the pelvis as to make one leg appear of a different length from the other. In the examination of a patient to ascertain the relative length of the limbs, the pelvis must be placed straight with regard to the transverse diameter of the body; for any obli- quity in this direction will give a corresponding obliquity to the lower extremities, and cause one to appear longer than the other. The pelvis being quite straight, the two knees ought to correspond, and the two heels also, if both limbs are 176 Fractures. of the same length. After observations have been taken, with the body carefully arranged as just indicated, measurements should be taken to determine exactly the amount of shorten- ing, if any exist. The patient being placed in bed, and care taken that the shoulders and pelvis are parallel to one another, and the legs in conformity to the straight attitude, a piece of tape or inelastic cord is made to take the distance from the anterior superior spinous process of the ilium to the patella or external malleolus; or, what is better, from the symphysis pubis to the internal malleolus of each ankle. Any well de- fined and unvarying point in the body is as good as those in- dicated ; the upper or lower extremity of the sternum, or the umbilicus, will answer as a point to commence the measure- ment. As the patella is rather moveable, it will be necessary to measure to the lower point of the bone when it is pulled upwards, in order to arrive at accuracy. Shortening alone is not a sure indication of fracture, for the limb may have been shrunken from childhood, or drawn up from dislocation, but in connection with other signs, this becomes valuable. In rare instances there may be fracture and no displacement, or shortening. Mr. Stanley relates the following case, which illustrates the point. " A man aged sixty, was knocked clown in the street; he complained of pain in the hip, but there was. neither shortening nor eversion of the limb, and its several motions could be executed with perfect freedom and power. A fracture was not suspected ; the patient, therefore, was merely confined to his bed. In the fifth week from the date of the accident he died from another cause. No trace of in- jury was found in the parts around the hip joint, but small effusions of blood, apparently not recent, were discovered be- neath the synovial and fibrous membrane, covering the neck of the femur, also beneath the synovial membrane coverino1 the ligamentum teres. The head and neck of the bone were sawed through their middle, and in each portion a dark line, evidently occasioned by the effusion of blood, was seen ex- tending through the bone at the base of the neck. A fracture was discovered extending along this line ; but the broken sur- faces were in contact, and the synovial and fibrous membrane covering the neck ofthe bone was uninjured." " In this case " Mr. Stanley very pertinently remarks, " if an attempt had been made to walk at the end of two or even three weeks Of the Femur. 177 from the accident, a separation of the fractured surfaces, and consequent shortening of the limb, would have been the result/' Either from the natural inclination of the foot to gravitate outwards, or from the action of the rotator muscles, the foot, after fracture of the cervix femoris, is almost always found to be in a state of eversion. In extremely rare instances, mostly where the force producing the fracture violently twists the foot inwards, the limb may continue in that position. It is highly probable that impaction has considerable to do with the position of the limb in cases varying essentially from the usual attitude assumed after fracture of the neck of the thigh bone. The fragments may be interlocked, or the lower one may be driven through the capsular ligament, and held in an inverted position until extension frees one or both pieces from the entangled state. If the limb be somewhat fixed in an everted or an inverted position, there exists a mechanical ob- stacle to rotation either in one direction or the other. When crepitation can be produced by motion imparted to the limb, it is conclusive of fracture; but in many instances this decisive and distinctive sign can not be produced. The round head of the bone and its free motion in the acetabulum require the least interlocking of the fractured surfaces to cause the lesser fragment to follow the natural movements of the larger. The articular fragment is so nearly concealed in the cotyloid cavity that it can not be seized and held fast while the other is made to grate against it. Crepitus can be elicited in nearly every instance of fracture of the neck of the femur, if the lower fragment be forcibly extended and carried through all the motions possible for the limb to take, yet a rash course, simply to produce crepitation, would not be justifiable. There are plenty of points to decide the question of fracture, even if crepitus be not sought. It is not a little singular that a patient with a broken thigh bone can walk directly after receiving the injury. As a gen- eral thing the patient falls immediately upon the reception of the fracture ; or, having received the fracture by the fall, he • is unable to rise ; yet there are notable instances in which patients have not only risen from the ground, but walked almost as if nothing serious had happened. These unusual powers after fracture, are difficult to be understood. Theo- 12 178 Fractures. rists have attempted to explain them on the supposition of a firm impaction, and on the ground that the fragments were interlocked. It has also been claimed that in such cases the untorn periosteum holds the pieces in exact apposition. Usually the loss of voluntary power is complete, and the limb falls into a state of eversion characteristic of the injury. Any one familiar with all the peculiarities of the limb after fracture of the cervix femoris, has observed the change of position assumed by the great trochanter. In the event of shortening, the bony prominence is drawn upwards, so that it occupies a site nearer the ilium ; eversion throws it back- wards; and impaction, when it exists, carries the process closer to the acetabulum, giving the limb a flattened appear- ance not seen in the sound thigh. Another notable feature of the trochanter is, that in rotating the limb the bony pro- tuberance does not describe the segment of so large a circle as it does in its natural state. Pain and Swelling.—There is rarely much pain in what is called intra-capsular fracture, unless the limb be moved or disturbed by manipulation. Gently extended and propped up on each side, the broken limb is affected with little or no distress. However, any efforts to voluntarily move the limb, or any attempts to discover the nature of the injury by rude handling, are attended with severe pain. The swelling may be moderate, especially if no violence be done to the parts in- volved, except mere fracture. In many cases the normal size of the limb renders manipu- lation at the seat of injury quite useless ; the diagnosis, there- fore, is based more upon measurements, eversion, and other signs already indicated, than upon the senseless kneading that inexperienced practitioners are apt to apply direptly to the parts about the hip joint suspected of fracture. If each diag- nostic symptom be carefully considered, enough signs will be discovered to decide almost any case, though some signs of fracture may not be prominent. Generally it requires only a superficial examination to determine the nature ofthe injury; • in rare cases the closest scrutiny is demanded to decide the matter. It is quite essential that the evidence of fracture be ascertained when it exists, in order that the treatment may be well directed. To confine a patient, hampered with frac ture dressings, to the horizontal position for weeks and Of the Cervix Femoris. 179 months, under the supposition that a fracture exists when really it does not, would be quite unpardonable. FRACTURE OF THE CERVIX FEMORIS WITHIN THE CAPSULE. In a recent fracture of the neck of the femur within the capsule, the tissues immediately involved are reddened, and there is an abundant effusion of lymph, and not much extrava- pIG 65 sation of blood. The capsu- lar ligament may preserve its integrity, and, also, the syno- vial membrane; these struc- tures, however,are quite likely to be lacerated, especially the delicate coverings ofthe bone at the seat of fracture. In the course of a few days the presence of reparative mate- rial is discoverable, and osse- ous particles at length find their way to the borders of the fractured surfaces; yet before any bony matter is ex- uded, plastic lymph, floating in an abundance of synovial fluid and gathered in shreds to the torn tissues, shows a disposition to connect the frag- ments with fibrous bands. In old cases, the capsular ligament becomes thickened, es- pecially at its upper part, which has to sustain the weight of the body in walking, the long fragment pressing up against it for support at every step. In cases where no impaction exists, and no real progress is made towards osseous consolidation, a variety of conditions are found within the capsule of the joint; in some cases the organized bands of plastic material form a pretty firm connection between the fragments, the patient being able to walk with some assistance from cane or crutch; in other instances the fibro-ligamentous bands are slender or too long to be of any service as connecting media between the fragments; finally, the fractured surfaces may Fracture of the cervix femoris within the capsule. 180 Fractures. Fig. 66. mutually yield to one another, the short fragment becoming excavated and polished, and the cervical portion of the long piece rounded into a conical knob to fit into the cup-like cav- ity presented to it. Such a false joint would be a troublesome affair, yet not necesarily prevent the person from enjoying somewhat restricted locomotion. Absorption occasionally alters the broken parts in-a wonderful manner. The short piece has been completely removed by the absorptive processes, and the upper end of the long fragment has been dissolved and removed, the absorption reaching into the greater tro- chanter, leaving nothing but the shaft of the bone which was steadied in place by the muscles inserted into it, and by the condensed tissue surrounding it. In the event of impaction, the cervical portion of the long fragment being driven into the cancellated structure ofthe head ofthe bone, the connec- tion is so intimate that the pieces mutually steady each other, and favor bon}r consolidation. A great deal of interest.attaches, at the present time, to the ques- tion whether bony union ever follows fracture of the cervix femoris, the line of separation being wholly within the capsule. It is pretty generally admitted among surgeons who have studied pathological specimens, that such a fracture, if impacted, may result in consolidation ; but if the break be simple, entirely within the capsule, and uncom- plicated with impaction, or tear- ing of the capsular ligament, the union is most likely to be liga- mentous and imperfect at that. Much ingenuity has been displayed in attempting to account for the lack of bony union ; the fact that motion between the fragments can not be arrested by any ordinary apparatus, has some bearing on the question; the abundance of synovia secreted under the influence of prolonged irritation, diluting and otherwise im- pairing the qualities of the reparative materials, is adverse to Consolidation following impaction Of the Cervix Femoris. 181 consolidation of the fracture ; but the chief obstacle to repair seems to reside in the almost complete isolation from vessels and nerves, to which the head of the bone and remnant of the neck are subjected by the fracture. The'ligamentum teres is a small band of dense white tissue, with scarcely a vascular sign in it. An adequate sup- ply of reparative material could not be expected to find its way through such attenu- ated channels. If the frag- ments could be maintained in perfect apposition for a few days it is possible that a direct union, similar to what is known as "first intention" in wounds of the soft tissues, might occasionally take place, which might in time ensure osseous consolidation. In some of those rare instances in which early union is known Ligamentous union following fracture of the to have takeil place after ill- neck of the femur within the capsule. , „ . . tracapsular fracture, without impaction, it is probable that the results followed perfect co- aptation, freedom from motion, and the quick restoration of the usual channels of supply. Where the line of separation is partly within and partly without the capsule, giving the otherwise isolated fragment an opportunity to get its supplies without drawing for them through the round ligament, the chances in favor of bony union are greatly increased. EXTRA-CAPSULAR FRACTURE OF THE CERVIX FEMORIS. In extra-capsular fractures, i. e., where the line of separation is entirely outside the apparatus of the joint, the upper frag- ment having a good supply of vessels entering it by the many foramina so conspicuous in that part of the bone, the union is likely to be osseous. Even if the line of fracture extend slightly beyond or within the capsule, it does not seem to in- 182 Fractures. terfere with consolidation in cases where the greater part of the fracture exists in the trochanter and that part ofthe neck immediately adjoining it. It is not uncommon, in falls upon the trochanter, for the fractured cervix to penetrate the can- cellated structure of that great process of bone, and even to act the part of a wedge and split it. Sometimes the two tro- chanters are rent asunder by this wedge force, more or less impaction taking place in every instance. Specimens are in existence which show the line of separation to be through the trochanter major, the upper part remaining with the neck of the femur, and the lower with the shaft of the bone. In a greater number of cases, however, the fracture is multiple or comminuted, the trochanter being broken into several frag- ments, and the cervix femoris de- tached from all of them. Although bony union is the rule, in extra-caps ular fractures, the healing process is slow, and the consolidation of the cervix to the trochanteric fragments is more tardy than it is in fractures lower down. A notable feature con- nected with consolidation of frac- tures near the hip-joint is the great exuberance of ossific deposits, which interfere with the motions of the limb, and tend to deceive any one examining the parts with the object of ascertaining the orig- inal state of the injury. Rough points in the reparative material render muscular movements painful; and may inflict permanent lameness upon the patient. These ledges of bone may become rounded off' in time, yet their complete obliteration need not be expected. The symptoms of extra-capsular fracture very closely re- semble those manifested by fracture within the capsule; there is shortening, eversion, inability to move the limb, and the other signs peculiar to fractures in general. If the great tro- chanter be involved in the fracture, the mobility of the frag- ments, and the attending crepitus, would be distinctive of extra-capsular lesion. In the extra-capsular variety the Exoess of callus after extracapsular fracture of the femur. Of the Cervix Femoris. 183 shortening of the limb is immediately to the extent of an inch or more, while in the tother variety the shortening rarely reaches its maximum for several days. The accidents which are most liable to be confounded with fractures of the neck of the femur, are dislocations of the head of the femur upon the pubes, severe contusions of the hip, paralysis, and absorption of the neck of the thigh bone from chronic arthritis. A fracture of the acetabular cavity, the bottom being driven into the pelvis, the head of the femur following, may present features leading to the suspicion that the cervix femoris is broken. However, a critical considera- tion of each symptom, and a careful analysis of each group of signs, will lead to a rational solution of almost every case. If the surgeon is not able to determine the exact course of the fracture in every case it is practically of very little impor- tance, for the treatment is substantially the same for all frac- tures in the vicinity of the joint. The real nature of obscure cases can only be determined after death. Very few suits, for alleged malpractice, have grown out of imperfect recoveries after fractures of the neck of the femur, for the reason that even the most experienced surgeons are averse to giving a positive opinion in regard to obscure injuries about the hip joint. In a recent case of severe injury in the vicinity of the hip joint, where great pain and swelling are in the way of a satisfactory examination, it is best to put the patient under the influence of chloroform, -when a more thorough explora- tion can be carried on. Some very interesting specimens of defective and deformed femurs are in existence, which have been selected and pre- served to show that bony union will take place after intra- capsular fracture. Sir Astley Cooper had gained the reputa- tion of having taught that ossific union could never take place if the line of fracture was wholly within the capsule. Certain other surgeons took a different view of the question, and hunted the museums and graveyards for thigh bones which tended to disprove the teachings accredited to Mr. Cooper. The specimens were sawed through and through in order to display the white line of ivory hardness that seemed to mark the consolidation of the fragments. Many of the specimens supposed to represent the line of union, were cast aside as spurious, and as representing the effects of chronic arthritis, 184 Fractures. or fracture partly outside the capsular ligament. The numer- ous specimens were narrowed down by professional criticism to a half dozen, more or less, of bones that furnish evidence of having been broken within the capsule, and afterwards consolidated. The late Prof. R. D. Musscy obtained a few pathological specimens of the thigh bones, which offered quite convincing proof of having been fractured within the capsule, and of osseous union following the injuries. These specimens were taken to Europe and exhibited to distinguished surgeons there for the purpose of eliciting opinions concerning the evidence of fracture and subsequent consolidation. It is a verity that " doctors disagree," and in regard to the morbid marks borne by the bones in question, there was not a unity of opinion. Of one specimen which had been regarded as clearly indicating the line of osseous union after fracture within the capsule, Mr. Cooper said there never had been any fracture in the case, or, if there had. the line of separation had run outside the capsular ligament. Mr. John Thompson, of Edinburgh, declared " upon his truth and honor " that a fracture had never existed in the specimen, but the changes in the shape and appearances of the bone were due to chronic inflammatory action and ab- sorption. Other pathologists abroad believed that the bone had been fractured. American surgeons who have examined the specimens generally agree in the opinion that intra-cap- sular fracture once existed in them. There is also a specimen of the same kind in the Wistar and Horner Museum of Phila- delphia, and one belonging to Prof. Willard Parker, of New York. Prof. H. H. Smith, of Philadelphia, thinks that Dr. Parker's specimen does not bear positive evidence of fracture ; or, if a line of separation did exist, it must have been partly extra-capsular. In a specimen of mine, exhibited by figure 69, the primary frac- Bony union after intra-eapsular fracture ;— with evidence of impaction. Of the Greater Trochanter. 185 ture was undoubtedly intra-eapsular, but impaction must have taken place, as indicated by the disturbance of the cancellated structure ofthe trochanters. As before stated, the impaction of the fragments favors consolidation in a variety of ways, therefore such specimens are not legitimate evidence in settling the question of osseous union after simple, uncomplicated in- tra-eapsular fracture. FRACTURES OF THE GREATER TROCHANTER. Fracture of the trochanter major, uncomplicated with frac- tures of the neck or shaft of the femur, is an extremely rare accident. Only a few cases have fallen under the notice of surgeons, and some of these were not discov- ered or verified until after death. The accom- panying diagram represents a simple fracture of the process, uncomplicated with more ex- tensive lesions of the bone. A splitting of the trochanter which is pro- duced by impaction in connection with fracture of the cervix femoris, is more properly consid- ered as a part of the injury to the neck of the bone. Heavy falls upon the hip may produce a chipping oft' of the the tip of the trochanter, to a greater or less depth; and age has not so much to do with the injury as it has with fractures of the cervix femoris. The break is not always characterized by displacement, for the fibrous struc- ture covering the process may con- tinue untorn, and hold the fragment in place. If the enveloping fibrous tissue be lacerated the fragment will be drawn some distance away from the rest of the bone, by the muscles inserted into it. In such a case the detached fragment could be felt in its mobile state, though it would be difficult to bring it in contact with the other fragment unless the limb, carried into Fracture of the ex- tremity of the greater trochanter Fig. 71. Comminuted fracture of the cervix femoris and ofthe trochanter major. 186 Fractures. extreme abduction, sufficiently favored apposition to allow of contact. Once brought into place the piece might be rubbed against the broken surface it originally left, and be made to produce crepitus. The exposed position of the great trochanter leads to the •conclusion that the process might be frequently broken, but experience does not sustain the inference. Probably, if the neck of the femur could better maintain its integrity under severe shocks, the trochanter would be the more frequently broken. As it is, the yielding of more fragile parts, saves the trochanter. In the event of fracture, separating the greater part of the process, the pain, swelling, and deformity might lead to the supposition that some more important lesion had been sus- tained, therefore a careful diagnosis should be entered into before a conclusion is drawn. A patient with a broken trochanter might not be fortunate enough to secure bony union, though chanter major. the detached fragment be kept at rest, and in a state of partial apposition. The horizontal attitude of the body, with the fragment drawn downwards by means of adhesive strips applied while the leg is abducted, is about all that can be done to secure a favorable result. TREATMENT OF FRACTURES OF THE NECK OF THE FEMUR. Substantially the same kind of treatment is indicated for all kinds of fractures about the neck of the femur, whether the line of separation be intra or extra-capsular, or partly within and partly without the capsule, including impaction and split- ting of the greater trochanter. The points to be overcome are shortening, eversion, and mobility. The object to be gained in intra-eapsular fracture is a short and firm ligamentous union, and if consolidation incidentally incline to take place, it should be favored by the treatment; in extra-capsular frac- ture osseous union may be reasonably expected, and proper dressings favor the desired result. However, the kind of patients liable to fracture of the neck of the femur is such, that confinement to the horizontal position, and the irritation Of the Neck of the Femur. 187 produced by dressings, are not borne without complaint and opposition. Some old people are so restive under the restraint of fracture dressings that they will assume the responsibility of throwing them all off. I well remember, in my professional beginnings, of having spent an hour or two in dressing an old man's thigh who had broken his cervix femoris by step- ping on his grandchild's playthings. I congratulated myself upon the success of having dressed the limb so skillfully. The next morning I called to see how my surgical case progressed, not doubting but all was right. My patient appeared at ease and composed. Upon asking him how the leg was doing, he said, " I could not endure your traps an hour, so I threw them aside, and put in practice my own plan, which you can inspect but not interfere with." The apparatus for producing exten- sion and counter-extension, with all additional straps, and trappings, were gone, and the patient had placed the tendo- Achillis of the fractured limb between the toes «of the sound foot; and thus he produced moderate extension, prevented eversion, and maintained the limb in a state of ease. He ab- solutely refused to have any dressings applied to the limb, and kept up his novel plan of treatment quite steadily for weeks. He at length got up with a useful limb, consolidation having taken place, though there was shortening to the extent of an inch or more, and much stiffness about the hip-joint, owing in part to an excess of callus, or " buttress of bone," thrown out near the trochanteric lines. Experience teaches that a great amount of extension should not be made even if the shortening be not entirely overcome ; first, because patients can not endure the forces applied; and, second, because the fragments are found not to rest in apposi- tion if subjected to much traction. The eversion can be easily overcome by the judicious use of sand bags or other easily pressing props. The long splint, so called, which reaches from the foot to near the armpit, or the long double splint, extending from the axilke down on each side of the body and along the outsides of the legs to a foot-piece, requiring perineal bands to secure counter-extension, is painful to wear, even insupportable in many instances. A wide belt of cloth buckled around the hips, with a notch near the anus to facilitate evacuations, serves a good purpose 188 Fractures. in steadying the broken cervix, especially if the patient be placed on a firm mattress, with the knee moderately flexed over a large sand bag. This arrangement can be made still more complete by strapping the lower part of the thigh or the ankle to the foot of the bed, raising the posts a little by put- ting bricks under them, to give the patient's body a slight in- clination toward the head of the bed. I have treated patients in this way quite comfortably for them and satisfactorily to myself. The " wire breeches " figure 10, fill the most indica- Fig. 73. The " wire breeches " applied. tions of any species of apparatus yet invented for the treat- ment of fractures through the cervix femoris. It should be well padded to obviate excoriations, and made so nearly to fit the body and limbs as to be comfortable. Extension is made from the foot-piece, and counter-extension against the tuberosi- ties of the ischium. The apparatus allows the patient to be bolstered up in bed, without imparting much motion to the fragments ; and it has an opening left between the leg pieces for evacuations of the bowels to pass. I have used the " wire breeches " in two or three cases, and secured the happiest results. Cases are reported as having been successfully treated by placing the limb over a double inclined plane made of pillows or junk. This is an easy attitude, and the plan is so simple that it maybe readily put in practice under almost any circum- stances. The inexperienced practitioner is apt to think, be- cause fracture of the neck of the femur is a serious lesion, that a complicated apparatus is demanded for its treatment. The Of the Neck of the Femur 189 quicker he dismisses such an idea the better it will be for him- self and patient. Death has ensued from the confinement of feeble and aged persons in a too rigid and " scientific appara- tus." If a patient does not bear the straight splint or any other, without becoming exhausted by the restraint and hori- zontal position, all dressings should be laid aside, and attention paid to comfort and general recuperation. No particular kind of dressing, then, can be carried out in all cases. The surgeon must consider the condition of his patient before applying the treatment, and modify it from time to time as circumstances seem to demand. A young person can generally endure such restraint as shall favor consolidation, and some old people bear up remarkably well under confining influences for weeks together. The diet should be nourishing and easily digested ; the bowels need not be disturbed by frequent evacuations ; and an anodyne may be taken to allay severe [tain. The question may arise among those who have few oppor- tunities to treat fractures of the cervix femoris, either within or without the capsule, or through the trochanters, why an effort need be made to distinguish one fracture from the other, since the same kind of treatment is recommended for all of them ? Practically it is not of vital importance to discrimi- nate between the different forms of lesion, and to trace the line of separation with the idea that nothing serviceable can be done till the course of the fracture has been established be- yond a doubt; yet it is an accomplishment worth possessing to be able to tell the patient that the case is one of intra-eap- sular fracture, and that such injuries generally unite with lig- amentous material, and that permanent lameness may be ex- pected ; or, that the fracture is one of the extra-capsular variety, and ossific union may reasonably be anticipated. In a mixed or doubtful case the best surgeons must acknowledge the imperfection ofthe art of diagnosis and the uncertainty of the result ofthe injury, even when scientifically treated. Im- paction is a condition favorable to bony union ; and impaction generally arises from a heavy fall on the trochanter, driving the cylindrical and perhaps sharpened cervix into the cancel- lated structures of the expanded part of the bone. It is to be borne in mind that an intra-eapsular fracture generally occurs in old subjects, from a trip of the foot on the carpet, or from some trivial cause, and commonly not from a 190 Fractures. fall on the trochanter; that the shortening, eversion, and other familiar signs attend extra-capsular fractures, and are therefore not differential or distinctive in character ; but in a simple fracture wholly within the capsule, the limb appears flabby, powerless, immovable, and as if paralyzed, with the whole expression altered. In extra-capsular fractures, whether impacted or not, bony union may be expected, though the excess of callus employed in the repair of the injury, is likely to impede motion, and to create considerable local deformity. In the event of shorten- ing after consolidation, the defect may be partly remedied by a higher heeled shoe. Exercise facilitates the removal of ir- regular and sharp projections, and helps to restore strength to the limb, and confidence in putting it to use. When called to take charge of a fractured hip, the surgeon should place himself right with the patient and friends by ex- plaining the nature of the injury, and the probabilities of a good or imperfect result. The prognosis should be carefully guarded, for old people frequently die from the irritation and restraint consequent upon fracture of the femur. Bed sores upon the sacrum and sloughs upon the heel render the patient's sufferings exceedingly irksome. Loops let down from the ceiling where the patient can grasp them with the hands, to assist in movements of the body, serve an excellent purpose. Little comforts are highly appreciated, and if brought about b}7 the surgeon's suggestions they add to his reputation for skill and attention. A piece of buckskin large enough to cover the excoriated hips of a bedridden patient, may save a great deal of distress, and contribute much to the healing of irritated and ulcerated parts. Dressed deer-skin, with the hair left on, is often exceedingly agreeable. The soft leather is much more comfortable to the irritated skin than any kind of cloth. FRACTURES OF THE SHAFT OF THE FEMUR. Fractures occurring below the lesser trochanter, and above the condyles, properly belong to the shaft of the bone. The line of separation is not confined to any particular locality, but is found in the upper, middle, and lower thirds. The point a little above the center of the bone is more liable to Of the Shaft of the Femur. 191 yield to indirect violence than any other. The greatest num- ber of cases coming under my observation presented a fracture a few inches below the trochanters. The bone has generally a little sharper curve in that region than pervades the entire shaft, which may be the reason that the accident occurs so often at that point. It has been a question whether the shaft of the femur is broken most frequently by indirect violence, as in falls, when the person strikes upon the feet, and has the force transmitted upwards to the thigh bone; or by direct violence, as a blow, or the passage of a wheel over the limb. The prevailing impression among surgical writers upon the subject, is that the direct application of force breaks more femurs than indirect agencies. Those who have had limited experience in the management of broken femurs are exceedingly prone to talk of oblique and transverse fractures of the bone, as if one or the other variety was certain to take place; and as if being particular in calling attention to the direction of the line of separation was an in- dication of wisdom concerning the subject. As has already been stated in another place, it is seldom that a fracture is wholly oblique, or wholly transverse, but an irregular and mixed condition prevails, the line of separation being oblique in some places and transverse in others. The broken surfaces in a fractured femur, present many serrations which may in- terlock and prevent overlapping, but the general course of the line of separation partakes of a predominant obliquity in the majority of cases. Unless the fracture be compound, one fragment being driven out through the flesh, the direction of the line of separation is not always easy to determine, for the depth of the soft tissues is too great to admit of such a dis- crimination. The prevailing opinion seems to be that it is exceedingly difficult to treat successfully an oblique fracture ; the presump- tion being that broken surfaces with much obliquity favor overlapping, and surfaces fractured transversely, if held in apposition, will prevent overriding and the attendant shorten- ing. However, it will be found of very little, importance practically whether the line of separation be transverse, ob- lique, or a compound of the two directions. If the limb be properly treated there will be little or no shortening ; and if managed improperly there will be shortening, though the line 192 Fractures. of separation be transverse. If the. accident occur from direct violence, the line of separation between the fragments is more transverse than oblique; and if the fracture arise from indirect violence the greater will be the obliquity. FRACTURES OF THE UPPER THIRD OF THE SHAFT, BELOW THE TROCHANTERS. Quite a common place for fracture of the femur to occur is at a point a few inches below the trochanter minor. It is a place where the muscular forces greatly influence the relative positions of the fragments, and oppose in some degree the in- fluence of the dressings. There is always considerable dis- placement whether the fracture be oblique or transverse. The lower fragment is drawn upwards, backwards, and a little in- wards, and the upper fragment is drawn forwards, and a little outwards, causing an overlapping of two or three inches, with the position of the fragments as represented in the accompany- ing diagram. The lower fragment sometimes acts upon the Fig. 74. Fracture through the ui;> rr thir.l o'the shaft of the femur, showing the tendency oi the fragments to overlap. upper, making it project forwards and outwards, contributing to produce angular distortion. Sir Astley Cooper and his fol- lowers have attributed this position of the upper fragment solely to the action ofthe psoas and iliacus muscles. u And," says Mr. Cooper, "to prevent this horrid distortion two cir- cumstances ought strictly to be observed; the one is, to ele- vate the knee very much over the double inclined plane ; and the other, to place the patient in a sitting position, supporting him by pillows during the process of union.*' The distortion, however, is in some measure due to the forces acting on the lower fragment, and to a certain degree upon the forces which produced the injury. The psoas, iliacus, and pectineus mus- Of the Femur. 193 cles tend to elevate the lower end of the upper fragment, but not to the extent claimed by Mr. Cooper. Muscular action being deprived of its normal influence upon the bone in consequence of the fracture, exerts forces upon the fragments of a rotatory character, so that the periphery of one piece does not correspond to that of the other piece. It is difficult to discover this defect, and to remedy it, although the limb will not be restored perfectly to usefulness if such a defect exist. The symptoms of fracture of the shaft of the femur below the trochanters are similar to those met in other fractures of the long bones. Pain, swelling, and deformity are prominent characteristics ; inability to move the limb or to bear weight upon it, is a necessary condition ; great mobility at the seat of injury may be expected, as well as crepitus when the broken surfaces are made to confront one another. The shortening is marked, amounting in some instances to several inches. Impaction is very rare, therefore the shortening is due to over- lapping and angular deformity. Eversion of the foot is gen- erally observable, as if the limb naturally inclined to roll out- ward, falling powerless and subject alone to gravity. In rare instances the lower fragment is found in front of the upper, a position into which it may have been forced by the power which produced the fracture. And when the upper fragment is thus behind the other, the psoas and iliacus do not tilt the lower end of the upper fragment forward, making a marked prominence on the anterior aspect of the thigh, except in cases where the breaking force threw the fragments into that posi- tion. In such instances there is no force in the muscles com- petent to radically alter the position of the fragments or to change their relative positions. Treatment.—There are two distinct attitudes in which the le<>- may be placed in the management of fractures below the trochanters: one is the straight position of the limb, and was always employed, so far as is known, until Percival Pott, a little more than a century ago, came out with his " physio- logical " notions in regard to the position the limb should be made to assume during the treatment of fractures of the thigh. Mr. Pott claimed that the muscles caused displacement of the fragments while in a state of tension, and therefore sug- 13 194 Fractures. gested that their contractile forces could be neutralized by posture alone ; and he proposed to flex all the parts involved in a fracture in order to secure apposition of fragments without the employment of force. For instance, if he wished to treat a patient with a fractured femur, he flexed the leg upon the thigh, and the thigh upon the abdomen, and kept the limb in that position for several weeks, using no splints, junks, or other mechanical contrivances to keep the fragments at rest, and to perform extension. This bold and seemingly rational plan created a revolution in the ideas of English surgeons; and among its able supporters was Sir Astley Cooper, who added mechanics to physiology. He placed the flexed limb upon a double inclined plane, by which the muscles were re- laxed, the weight of the leg on an inclined plane estab- lished extension, and the weight of the body and the upper part of the thigh, produced counter-extension. The elevation of the lower part of the thigh made the lower fragment cor- respond to the pitch the upper fragment generally assumed. Mr. Amesbury, a little later, modified the simple double in- clined plane of Cooper, by adding to it means for producing active extension and counter-extension. American surgeons have improved upon the splint of Amesbury, though all in- volve the physiological principle adopted by Pott, and the additional mechanical principle of Cooper. At length a reac- tion took place in the minds of European and American sur- geons ; and though the straight and the flexed plans of treat- ing fractures of the thigh are both in reputable use, the method of treatment with the long straight splint is followed in nearly all the hospitals at home and abroad. In the rural districts of this country the double inclined plane apparatus is in com- mon use. Whether the Pott and Cooper plans have certain captivating ideas in connection with them that readily per- suade the country practitioner; or the " sets " of fracture splints and appliances, all of which embrace a double inclined plane apparatus, with attractive illustrations to show the prac- tical workings of the splints, now hawTked about from town to town, contribute to the belief that all eminent surgeons em- ploy such in their practice, are subjects of interesting inquiry. That truly great and illustrious surgeon, the late Dr. Valentine Mott, never " reacted," or went back to the straight attitude for a fractured thigh. He once said to his class, in my hear- Of the Femur. 195 ing, that if he should ever be so unfortunate as to sustain a fracture of the femur, he should insist on having it treated upon the double inclined plane. The straight splint is a piece of board nearly an inch thick, and about four inches wide, pierced with two holes at its upper end, and notched two or three times at its lower end, and long enough to reach from the borders of the axilla to four inches below the foot. The splint should be well padded its whole length ; and the pad should be pierced Fig. 75. ||Hi'" „mlH""___________________....ilU'lll' illlllil'||i|l ill""!!1. The "straight splint" applied. The cushion to be used between the splint and the patient's limb, is represented by the upper object of the wood-cut. with holes corresponding to those in the splint, so that the ends of the perineal bands may slip through them easily, and be loosened or tightened as occasion may require. The peri- neal band may be a silk pocket handkerchief, a wide strip of buckskin, or any belt of strong and unirritating material. It is to be long enough to reach through the perineum between the genitals and the thigh, one end extending in front, along the groin, and the other behind the buttock, to the holes in the splint through which the two ends pass, to be tied in a bow-knot. In applying the apparatus, the surgeon, after ad- justing the fracture, takes the perineal band and applies it to the patient's perineum, bringing up one end in front of, and the other behind this part of the body. He then lays the splint along the outer side of the affected limb, against a long cushion to protect tender parts, and proceeds to fasten the foot to the notches in the lower end of the appliance. Before doing this, it is a good plan to bandage the foot and ankle 196 Fractures. with a flannel roller in the ordinary way, to protect them from the pressure of the splint, and to prevent them from swelling ; or, instead of this, the foot may be enveloped in a layer of cotton-wool. The surgeon should then take a muslin roller, and make a few turns round the foot and ankle in the form of a figure-of-8, so as to obtain a firm hold; after which he should carry the bandage in a regular way round the ankle and through the notches in the lower end of the splint, so as to fasten it securely to the foot. He should then get an assist- ant to make extension from the foot while he draws the peri- neal band tight, and ties it in a bow on the outer side of the splint. In order to keep the apparatus in position it is some- times necessary to apply a bandage over both the leg and splint from the foot upwards as far as the thigh, and also to put a few turns of a broad roller round the patient's chest. The thigh on each side of the seat of fracture may have a piece of splint material or pasteboard bound to it with tapes to make the broken parts feel more secure. This dressing, if well applied, and no serious complaints are made, may stay on for weeks, even till bony union has taken place. If at any time after its application, the dressing produce general uneasi- ness, it may be removed,, and the fault, should any be found, corrected. The patient gets up with more general stiffness of the joints after this straight dressing has been employed, than after a double inclined plane splint has been used. The straight splint is irksome at first, owing in part to the great restraint imposed upon so considerable a portion of the body. However, in a few days the patient gets over the feel- ing of being rigidly confined, and passes the remainder ofthe time without much complaint. A great deal may be done toward keeping the fragments in apposition, by simply attending to the position of the limb, without the application of any splint. If the patient has a good degree of self control, he may be laid on his back, and the limb can be kept straight by the use of several sand bags placed along the leg from the hip to the foot. Extension may conveniently be made by fastening the ends of long pieces of adhesive plaster to the sides of the leg, with the ends extending below the sole of the foot; the pieces should reach nearly to the knee, and over these other strips should be applied in a circular manner till the leg is enveloped Of the Femur. 197 as if in a bandage. The circular strips prevent any slipping or yielding when power is applied, and distribute the pressure falling upon the circumference of the limb. A short block of Fig. 76. Strios of adhesive plaster applied to the leg longitudinally, and held from slipping by the y rircular wrapping of other pieces of the same material. wood a little longer than the width of the ankle may be placed in the loop after the long loose ends are tied together, to pre- vent the downward strain from compressing the tissues on the sides of the joint. Around this block and the loop a cord may be fastened, which then extends over the foot of the bed, and sustains a weight. The extension thus produced need not be so great as to distress the patient. Moderate but con- stant traction upon the limb is all that may be desired. After the foot and leg have been arranged with the extend- ing apparatus, the thigh demands separate attention. The fragments should be adjusted while assistants are producing temporary extension and counter-extension with their hands ; and then four or five common wooden splints a foot long, and two inches wide, made of lath or thin boards, and evenly wrapped with cloth, are to be placed at a little distance from one another, parallel with the course of the femur, and reach- ing above aud below the line of fracture ; where they are to be firmly bound with tapes. Over all of these a roller or many tailed bandage is to be snugly applied. This part of the dressing prevents mobility between the fragments, and con- tributes to the comfort of the patient. The limb may be made still more comfortable by placing a sand bag under the knee to flex it a little. Extension may be made by fastening the limb to the foot of the bed by means of a cord reaching from the loop of adhesive strips to the lower bed rail, and then raising the foot of the bed upon a couple of bricks to give the patient's body an inclination toward the head of the bed. This is the easiest and most natural method of securing ex- 198 Fractures. tension and counter-extension without complicated apparatus. Any desired amount of extending and counter-extending power can be secured by this arrangement. If the foot of the Fig. 77. The splints upon the thigh prevent motion between the fragments ofthe femur ; the adhesive strips upon the leg and ankle make a comfortable fastening to the limb; the fastening is secured to the bed rail; and the foot of the bed is raised on blocks or bricks to incline the patient's body in the opposite direction. bed or lounge be raised high enough to have the patient's body incline effectively in the opposite direction or toward the head of the bed, great extending force may be brought to bear upon the limb. I have such confidence in this manner of treating a fractured thigh that I feel like urging its use upon my professional brethren. Very few perfect results can be secured by the use of the long straight splint; and the double inclined plane apparatus which goes with almost every " set" of splints or fracture appliances, does not give general satisfaction. About one-third of all cases of fracture of the shaft of the femur, as ordinarily treated by physicians and surgeons of every grade of skill turn out favorably, or without perceptible or appreciable deformity; another third of all cases treated exhibit so little shortening or other defects that in the course of time they fail to attract personal or professional attention; the remaining third are so seriously defective, either from shortening or other deformities, that the patient is temporarily or permanently compelled to walk lame, or forever made a cripple. The defect is generally shortening which comes from over- lapping of the fragments; and, in addition, there may be an- gular deformity, as seen in the following diagram. The shortening in the cases attracting attention, which constitutes Of the Femur. 199 Fia. 78. about one-third of all fractures of the shaft of the femur, amounts to three quarters of an inch. No shortening which is less than half an inch attracts atten- tion or proves a serious source of com- plaint ; but in rare instances the over- lapping reaches several inches. In several mal-practice suits in which I have been called to give testimony as an expert, I have found the shortening to be from one to three inches. In ad- dition to the shortening there has gen- erally been angular deformity, and ex- cess of callus which seriously interfered with the functions of the limb. In some of these malpractice cases the fault seemed to result from surgical incompe- tency ; and in others the defect may have arisen from untoward circumstan- ces beyond the control of the profes- sional attendant. Union of the fragments with shortening, and angular de- formity. Fig. 79. Extension by means of a weight and pulley; counter-extension is produced by a perineal band which may be fastened to the head of the bed. Weight and Pulley for Making Extension.—Another method of applying extension in the treatment of a broken femur, consists in employing weight to a cord which reaches from the loop of adhesive strips over the foot rail of the bed. The fastening to the limb may be made with a piece of belt 200 Fractures. leather secured to the thigh above the knee with lacings. This leather band may have loops fastened to each side of it, from which cords extend over the foot of the bed for the pur- pose of sustaining weight. It is well to have the knee gently flexed by means of a sand bag or cushion placed under the joint. Instead of producing counter-extension with a peri- neal belt, the foot of the bed may be raised on blocks, to give the patient's body an inclination in the direction of the head of the bed. This dressing is not complete without straight splints are bound to the thigh; and sand bags used to obviate rotation. Mr. Burge, of New York, has invented an apparatus for treating fracture of the femur, which is represented by the accompanying diagram. The machine has been successfully employed in some of the New York hospitals. It holds the Fig. 80. Burge's fracture apparatus applied. limb in the straight attitude, but allows the patient to take the sitting posture; and provides for the escape of alvine evacua- tions without disturbing the fragments of bone. Various in- tricate contrivances have been devised to treat fractures of the femur, but it is questionable whether they are superior to the more simple plans already described. The most of them are too costly for the ordinary practitioner who might not have an opportunity once in ten years to put one of them in prac- tice. To study the different parts entering into the Burge apparatus, for instance, would require more time than to dress a limb with more simple means. To a practitioner inexpe- rienced in the different machines invented to treat fractures Of the Femur. 201 Fig. 81. of the thigh, the diagrams representing such apparatus in works on surgery, offer more confusion than illustration. The fracture beds of Jenks, Daniels, Burge, and others, cost from fifty to a hundred dollars, therefore the surgeon of limited pecuniary means could ill afford to possess one or more of them. A fractured femur needs to be treated with retentive means for a period of six or eight weeks in the young and vigorous, and for ten or twelve weeks in patients advanced in years. A limb may appear firm, as if consolidation had taken place at the end of five weeks, yet it is not safe to lay aside the dressings and trust the patient on crutches lest shortening occur. As has been remarked in another place, the uniting material continues soft and yielding for many weeks after osseous consolidation between the fragments seems to have been effected. Many a surgeon of large experience in treating fractures has dis- charged his patient with one leg as long as the other, and has been astonished some weeks after to find that shortening had taken place. It may be remarked in this connec- tion, that there is no way to determine when the fragments are so far consolidated that shortening will not take place. Experience shows that the uniting medium generally be- comes unyielding at the expiration of ten or twelve weeks after the reception of the frac- ture. In young patients seven or eight weeks may be long enough to continue the retentive dressing. I have never had occasion to cen- sure myself for keeping a fractured thigh in its dressing too Jong; but several times I have regretted having laid the apparatus aside too soon. After the fracture has become consolidated there remains at the seat of injury an enlarge- ment which may annoy a nervous patient- This hypertrophy comes mostly from the ex- cess of reparative material employed in the At first the lack of perfect apposition of the fragments may present some sharp and jagged edges, which Consolidation after fracture through the upper third of the fe- mur, showing some permanent enlarge- ment at line of union and slight angular deformity. healing process. 202 Fractures. will irritate the soft tissues, and paralyze the muscles to some extent, but in time the rough points will be removed by ab- sorption, and the enlargement will be forgotten. A moderate degree of angular deformity will not prove a serious impediment to locomotion, therefore it should not be meddled with in old cases. Unless the defect be very great, any attempt to break the femur over again is not justifiable. In extreme angular deformities an awl or drill maybe used to perforate the bone at the point of union, until there is so little osseous material left that it can, with proper apparatus, be pressed into line, or re-broken, when the limb can be treated in the straight attitude until the fragments re-unite. It may be incidentally remarked, that the lameness dependent upon shortening, generally diminishes. The twisting of the pelvis and the vertebral column tend to conceal the defect. A higher heeled shoe worn on the lame side will improve the gait. FRACTURES OF THE MIDDLE THIRD OF THE FEMUR. The middle of the shaft of the femur is broken about as frequently as those parts of the bone near the extremities; and when a fracture exists near the centre of the bone, the manner of treatment does not differ essentially from that de- manded at points some distance from the middle line. The same forces which break the femur at points higher or lower in the bone, may produce a fracture of the middle third ; and the signs of the injury could not be substantially different from those in fractures through other parts of the bone. There would be inability to move the limb, eversion of the foot, shortening, angular deformity, and crepitus when the broken ends of the fragments were brought in contact. The mobility at the seat of the injury would be so marked that even the unprofessional observer could not fail to recognize the nature of the lesion. The line of separation between the fragments may be oblique, transverse, or intermediate between those directions, partaking in part of each. There is the same tendency for the fragments to overlap, producing shortening, as after fractures higher up or lower down the shaft of the femur. The same dressing will be required as for a fracture Of the Femur. 203 just below the lesser trochanter; there will be the same danger of defects and deformities as in fractures at other points in the bone ; and it will require about the same length of time for the reparative forces to effect consolidation of the fragments. " These fractures," says Malgaigne, " when sim- ple and without displacement, unite in forty or fifty days ; sometimes they require two or three months, when the fragments overlap one another, being in contact only by their lateral surfaces. When the two ends can not be made to oppose one another, so as themselves to counteract the mus- cular contractions, it is impossible to preserve the normal length of the limb, whatever be the apparatus or method em- ployed. There has been too much discrepancy of opinion among surgeons in regard to this. Hippocrates gives the idea that the shortening can always be obviated; Celsus goes to the opposite extreme, declaring that a thigh once broken must ever remain shorter than its fellow. At a period by no means remote from our own, Desault claimed to cure all fractures without shortening, and his journal contains several such cases. In imitation of him many surgeons have varied, cor- rected, and improved apparatus for permanent extension, and have announced as complete successes from them. I must, however, state positively that I have never obtained anything of the kind, either with contrivances of my own, or with those of others, or even when I have invited the inventors of such apparatus to apply them in my wards. I have more than once examined persons said to be cured without any shorten- ing, but always discovered such shortening by actual measure- ment. Some have deceived themselves in regard to the merits of their treatment; they have happened to meet with fractures in which there could be no overlapping on account of an in- terlocking of the serrations, and imagined they had corrected a shortening which never existed. In short, when the frag- ments remain in contact, or when we can replace them and keep them so by means of their serrations, it is easy to cure a fracture of the femur without shortening; in the absence of these two conditions the thing is simply impossible. " Several distinguished surgeons ofthe present day, recogniz- ing this impossibility, have abandoned the idea of permanent extension. They allege moreover that an overlapping of even as much as an inch is of slight consequence, and involves no 204 Fractures. limping. I can not entertain this view. I have seen persons walk very well with one-third of an inch shortening, but with more than this they either limp, or must wear a thick soled shoe; or possibly their halt is masked by a lateral inclination of the spine. Hence we see how grave a fracture, with over- lapping, must always be, and what caution we should observe in giving a prognosis." Although the upper fragment rides usually upon the lower, and the tension of the muscles seems to favor the flexed or " physiological position " recommended by Pott, Cooper, and others, many of the most experienced surgeons of the present day, both in Europe and America, employ the long straight splint, instead of the double inclined plane, to treat fractures near the middle of the thigh. To the latter plan, Desault makes the following objections : " the difficulty of making extension and counter-extension while the limb is in a state of flexion—the impossibility of comparing, with precision, the injured thigh with that of the sound side, in order to judge of the regularity of the conformation—the uneasiness which this position continued for a long time occasions, although at first it may appear natural—the inconvenience and painful pressure of a part of the trunk upon the great trochanter of the injured side—the derangement to which the limb is ex- posed when the patient goes to stool—the difficulty of fixing the limb sufficiently to prevent movements of the femur—the evident impossibility of this method when the two thighs are fractured—lastly, experience so little favorable in France to this position." Such were the motives, says Lonsdale, which determined Desault to have recourse to it no more, after hav- ing tried it on two patients, one of whom had a considerable shortening, in spite of the most scrupulous attention. The objections to a flexed condition of the limb over a double inclined plane, as offered by Desault, are unworthy so eminent a surgeon. The experiment upon only two patients was too limited for a weighty argument; and then to say that experience was against the position, shows that prejudice ex- ercised an undue influence over his mind. It is unfortunate that no tables are drawn up to show under which plan of treatment the least amount of shortening occurs. I have had the best success with cases managed with a sand bag under the partially flexed knee, and extension applied Of the Femur. 205 from the leg by means of adhesive strips, the counter extend- ing force being derived from the descent produced by elevating the foot of the bed. A firm mattress is quite essential to the carrying out of several points in the treatment. In a soft feather bed it is quite impossible to bolster up the leg to obvi- ate eversion, and to determine how the dressing is accomplish- ing its various objects. On a mattress every indication can be fulfilled, and every defect watched and guarded against. I believe in securing every advantage that can be derived from position. Even while using the long straight splint, the limb may be made fast to the foot of the bed, and the body giveu an inclination toward the head of the bed by elevating the lower parts as already indicated. However, there is no necessity for complicating the means if the straight splint ac- complishes all that may be desired. Experience teaches that very few cases of fracture of the shaft of the femur can be trusted without some kind of extending and counter-extend- ing forces being employed clear through the course of treat- ment. The double inclined plane fracture appliance of Amesbury, and kindred contrivances, may possess principles which, if carried into execution by surgeons possessing mechanical skill, might secure the happiest recoveries ; but the complica- tions of the machines often confuse the professional attendant, and lead him to trust more to the apparatus than he would to a contrivance easier to be understood. I recently saw a patient under treatment for fracture near the middle of the femur ; and the double inclined plane splint of artistic con- struction was performing its part so badly that I asked the doctor what he designed to accomplish with the appliance ? He appeared unable to explain what the machine ought to perform, yet expressed confidence in the powers of the appa- ratus to avert deformity in the limb. If he had understood what the broken femur needed, he could have used almost any method to accomplish the object; but having no rational theory in regard to the wants of the case, he trusted blindly to the virtues of the appliance. The thigh-piece of the splint was so short that the body of the patient, bolstered up with pil- lows and other material, slid down against the apparatus, pro- ducing an angle and overlapping at the line of fracture, which would not have occurred if the limb had laid straight on a mat- 206 Fractures. tress, no dressing being employed. The splint was so defec- tive, or was so faultily applied, that the case was damaged by the treatment. In a soft bed, with the narrow double inclined plane splint toppling about, and the body pressing down against the fracture, there is little hope of a reputable cure. The double inclined plane under such circumstances is infin- itely inferior to the long straight splint of Desault. With the " physiological method " so imperfectly or wretchedly put into practice, it is no wonder a reaction in favor of the old-fashioned straight dressing took place. American surgeons have displayed much ingenuity in con- structing apparatus for treating fractures of the leg. Not less than half a dozen have gotten their names associated with splints. Dr. Wm. Gibson introduced an apparatus with a couple of long splints reaching from the axilla down on each side of the trunk and legs to a foot-piece, to which the feet of the patient were secured. This kept both legs parallel and the body straight with them; and prevented lateral twisting and swaying, and served as a kind of litter to raise the patient for defecation. The foot-piece could be moved up and down on the straight pieces, and held at any desired place by means of holes and pegs. The upper crutch-headed extremities rested in the axilke, and the movements of the foot-board downwards secured the necessary traction. Dr. Joseph Harts- horne used a similar apparatus, though only one splint reached the arm-pit, the other being placed on the inside of the broken leg, reaching to the perineum, with a crutch-like head to pre- vent excoriation. The foot-piece was moved by means of a wooden screw passing through a cross-piece. None of these more or less ingenious contrivances are so simple and effective as the adhesive plaster extending apparatus, with elevation of the foot of the bed for counter-extension. Besides, this method leaves the thigh free to be dressed with common re- tentive means. In fractures somewhere near the middle of the thigh, the immovable or starch dressing may be applied about the eighth day, and then the foot can be released from powerful traction. A compound injury is to be treated like a simple fracture, ex- cept the puncture in the flesh is to be left open to facilitate discharges. Of the Femur. 207 False-joint is an unfortunate termination, which may happen in any case of fracture of the long bones, and in the practice of any surgeon. No display of skill will absolutely obviate non-union, though a well applied retentive apparatus, after proper adjustment of the fragments, is believed to favor con- solidation. FRACTURE OF THE FEMUR JUST ABOVE THE CONDYLES. Fig. 82. Fractures of the femur above the condyles, in the lower third of the bone, are not rare; they are generally produced by direct causes, though indirect violences,as heavy falls upon the feet, may break the femur at any point. The direction of the line of separation is rarely transverse or fully oblique. Cases are reported in which the line of separation has been nearly transverse ; and others in which the obliquity was uniform all the way through, the broken surfaces exhibiting only minute serrations. The circumference of the bone increases from near the middle of the femur to the widest part of the condyles, and as the periphery increases the cancellated tissue augments, making so much spongy material in the lower extremity of the bone that the upper fragment may be driven into it, producing a state of impaction. In a simple fracture without penetration or impaction, the upper fragment usually occupies a position in front of the lower, producing shortening. There has been some speculation in regard to the influences which produce this position of the fragments. The action of the gastrocnemius upon the condyles, which project backwards, forming levers of considerable length, is the principal reason why the lower fragment is tilted so powerfully backwards. It is no uncommon occurrence for the lower end of the upper frag- ment to encroach upon the normal position of the patella, and even penetrate the synovial cavity beneath that bone, making United fracture of the femur through its lo w- erthird, withoverlap- ping and angular de- formity. 208 Fractures. a complicated injury quite serious in its nature. The upper fragment occasionally gets pushed out through the flesh, pro- ducing a compound fracture. In 1865 I was called to Peter Mecklin, a German'laborer, who fell from a high bank in a quarry. He struck, in his fall, upon a projecting rock, and then fell several feet further to a plane landing. His com- rades found him with the broken femur pushed through the soft structures on the inside of the knee. I saw the patient in about two hours after the injury, and observed the broken end of the upper fragment still protruding; the lower frag- ment was in place so deeply buried in flesh that its fractured end could scarcely be outlined by manipulation. After strip- ping the leg of pants and boot, an attempt was made, by means of assistants, to extend the limb sufficiently to allow the protruding bone to go back into place, but such efforts were in vain. I then sent for chloroform, and, when the anaesthetic arrived, I put the patient profoundly under its in- fluence, and exerted powerful traction upon the limb. This course proved successful ; the bone went back into place in apposition with the other fragment. Although the fracture was marked with considerable obliquity, the consoli- dation took place with not more than a half inch shortening. I saw one case of compound fracture of the shaft of the femur in its lower third, in which the resistance to a return of the fragment, balked the efforts of two quite accomplished sur- geons, in their efforts at reduction. The end of the fragment was finally sawed off, to allow it to go back through the rent made in the flesh. It is possible that such a proceeding might be justifiable in extremely rare cases, but it should be avoided if possible. Fig. 83. Fracture of the femur just above the oondyles, which shows the tendency of the lower fragment to encroach upon the popliteal space. The broken end of the lower fragment being tilted back- ward by the action of the gastrocnemius, its sharp edge may do harm to the vessels and nerves of the popliteal region. Paralysis of the foot, and aneurism of the artery, are said to Of the Femur. 209 have followed such an injury. Malgaigne in his criticisms upon what Boyer says of the backward movement of the lower fragment, declares that such a displacement is purely imaginary. Hamilton reports a case treated by a surgeon of Lockport, N. Y., in which parts of the foot sloughed after fracture of the femur just above the condyles; and there seemed to be great danger of death to the leg. All the dress- ings were thrown off, and efforts made to restore vitality to the leg. The limb recovered with shortening, and the loss of the toes and part of the foot. The surgeon at length sued the father of the patient for the recovery of his professional bill. The case was litigated on the ground that the dressings had been so tight as to impede the circulation and to invite gangrene. The surgeon got judgment in his favor on the tes- timony of several distinguished surgical witnesses who de- clared that the sloughing arose from injury done to the nerves by the lower fragment of the femur, and that no amount of skill and and attention could have averted the evil. In fractures so near a large joint the dangers are greater than when the femur is broken at a distance from its articula- tions. If the upper fragment is dragged down against the patella the injury may be followed by a high grade of inflam- mation, and anchylosis. The symptoms of fracture just above the condyles, are gen- erally marked; the pain, swelling, inability to move the limb or to bear weight on it, necessarily attend the accident. Cre- pitus may be produced if the broken surfaces can be rubbed against one another,butin the event of much overlapping the grating will be absent. In cases of many hours standing, the swellin £: obscures the characters which declare themselves so plainly just after the accident occurs. However, the angular deformity which is very great, or can be made so by manipu- lating the limb, is a convincing sign of fracture. The lateral mobility which does not belong to the knee, is another con- clusive diagnostic sign. Treatment.—It seems unnecessary, after what has already been said concerning the treatment of fractures of the shaft of the femur, to give anything more than general directions for the management of fractures just above the condyles. The reduction can sometimes be easiest effected by flexing the 14 210 Fractures. leg, and putting the arm just above the calf, for the purpose of making extension. A straight downward pull upon the heel and foot exerts traction upon the gastrocnemius, thereby tending to tilt the broken end of the lower fragment back- wards. If the fragments can not be adjusted without the in- fluence of an anaesthetic, there should be no hesitancy in its early employment. Cures effected with the aid of the long straight splint are not very satisfactory ; shortening to the extent of one or two inches being a common result, to say nothing of other glaring defects. The long straight splint, for the purposes of effect- ing extension and counter-extension, has many advocates, but it finds little favor with me in the treatment of such injuries; the double inclined plane apparatus does better, yet it has its objections. It is better to envelope the thigh with retentive splints, the pieces of lath or thin board being laid longitudi- nally with the limb, across the fractured line in the bone, where they are to be bound in place with tapes and bandages. Ex- tension can be made from the leg and ankle by means of ad- hesive strips, using the weight and pulley, or raising the foot of the bed on blocks after making the limb fast to it. To relax the muscles of the thigh and leg a large sand bag or cushion is to be placed under the knee to keep it permanently flexed. The limb may also be bolstered up and kept in a straight line by means of several sand bags placed along its sides at places where support is needed. Whatever be the dressing applied, it should be employed for six or eight weeks, and even longer in old subjects. After the extending and re- tentive appliances have been laid aside, no weight should be borne upon the limb until several weeks more have elapsed lest overlapping and angular deformity take place from yield- ing of the new formed callus or uniting medium. During this convalescing interval gentle motion should be kept up at the knee to obviate stiffness and anchylosis, and the limb may be rubbed with stimulating liniments to restore the normal activity of the muscles. Until consolidation takes place and while the retentive dressings are in use, measurements and comparisons of the two limbs should be often made. The general contour and condition of the leg should be observed at every visit, and any deviation or defect guarded against by re-adjustments of the appliances, or by changing the entire Of the Femur. 211 plan of treatment if deemed necessary. The state of the cir- culation in the foot, and the condition of the skin where dressings bear heavily, must not be neglected. A tight wrap- ping can generally be loosened by cutting part way through a few turns of the bandage; and a loose dressing may be made tighter by the application of a few additional strips employed as ties. The surgical attendant must bear in mind that the tendency of a broken thigh is to deformity, and that the per- verse inclination must be constantly and efficiently opposed, leaving nothing to "luck" or hazard. FRACTURE OF THE CONDYLES OF THE FEMUR. Fracture of one or both condyles is, fortunately, a rare acci- dent, for the injury is attended with dangers of a serious nature. The knee-joint is exceedingly intractable when sub- jected to the influence of disordered action. Effusions into the articular structures are attended with great distress and constitutional disturbance. The force which breaks a condyle of the femur may be direct, as when a heavy weight falls upon the knee; or it may be indirect, as when a person in falling strikes in such a way as to have the violence communicated to the side ofthe femur which did not receive the primary impression. The disen- gaged fragment may include the articular surface of the inner or outer condyle and four or five inches of the condyloid ridge, terminating in a point at its upper extremity. One condyle is broken about as often as the other, though the inner is less protected from direct violence. The muscular forces exerted upon a broken condyle are an- tagonized to a great extent; the two vasti pull upwards and the gastrocnemius downwards. The lateral and crucial liga- ments are opposed to much displacement, unless both condyles give way, allowing the central wedge-shaped shaft in its course downwards, to force them asunder. I have the specimen of a fractured internal condyle which was taken from the leg of Thomas R., a laborer, who lost his life by falling to the bottom of a well, which was being dug. In the descent the knee hit against the edge of a heavy tub attached to a windlass used in raising the earth which was 212 Fractures. Fracture of the inter- nal condyle of the femur. being excavated. The line of separation in the broken bone begins near the centre of the articular concavity at the lower end ofthe bone, and extends upwards and inwards about five inches, terminating in the condyloid ridge. The broken surfaces are rough with the usual spiculse, but bear no marked irregularities. The separated condyle was not displaced by the force which produced the fracture. The symptoms of a broken condyle are not marked and palpably distinctive, though the diagnosis can be determined by a careful man- ipulation of the parts. The pain, swelling, and inability to bear weight on the limb, are features that could not well be absent. The joint in its nor- mal state admits only of the hinge motion, backward and forward, but after fracture of either condyle the lateral motion which can be imparted to the joint clearly indicates the nature ofthe injury. The separation ofthe epiphyseal extremity of the bone in a young subject, might obscure the difficulty, as might a transverse fracture of the femur close above the con- dyles. Crepitus can be elicited in either kind of fracture, therefore the existence of that sign would not throw much light upon a doubtful case. However, when a condyle is sep- arated from the rest of the bone the disengaged fragment can be grasped, and moved independently of the rest of the femur, and the movement is attended with a crepitating sound that corresponds with the motion. The increased width of the joint is another sign of some value, and should not be neg- lected. If the fracture be caused by the pas- sage of a wheel over the joint, or by any vio- lence of a crushing character, the lower ex- tremity of the femur may be broken into sev- eral pieces, some of which may be so isolated from nourishing tissues that they will become foreign bodies, creating grave local and general disturbance. The suppuration attendant upon the discharge of such pieces of bone, exhausts the patient, and occasionally necessitates am- putation to save life. The case of a boy with a compound fracture, is reported in Braithwaite's Retrospect, Vol. XV., in which a good recovery was made, though a piece of the ex- Fig. 85. Fractures of both condyles of the fe- mur. Of the Femur. 213 ternal condyle worked its way out in the course of three or four months from the reception of the accident. Treatment.—The gravity of the lesion requires more pa- tience and skill to combat inflammation and to avoid the necessities of amputation than to adjust the fragments and to retaiu them quietly in place. Anodynes and cooling lotions must be topically used, and opiates administered internally. The employment of the long splint, which necessitates the straight attitude, is out of the question. If only one condyle is broken, and there is no displacement, the knee should be moderately flexed by being placed on a sand bag. If the foot is forcibly inclined to eversion, the tendency may be counter- acted by other bags arranged along the outside of the limb. In the event of a double fracture, both condyles being sep- arated from the shaft, there is considerable shortening to be overcome. This can not be accomplished by using the straight apparatus of Desault, or the double-inclined plane splint in common use. A moderate degree of flexion is one of great- est ease and repose; and should anchylosis take place the limb is the most serviceable in that position. The use of ad- hesive plaster repeatedly described, is the easiest method of ap- plying extending force, and the inclination of the body in the opposite direction, produced by elevating the foot of the bed, is the most comfortable manner of obtaining counter-exten- sion. If the knee be too wide, a leather or pasteboard splint should be bound around the limb, enveloping the joint and a few inches of the leg and thigh. Should the soft parts be much bruised, no stiff' dressing can be endured. As soon, Fig. 86. however, as the flesh wounds have sufficiently healed to re- ceive a slightly compressing support, it may be employed to advantage. Passive motion should be begun by the thirtieth day in a gentle manner at first, and kept up for months or until the 214 Fractures. functions of the joint are fully restored, or recovered as far as practicable. Passive motion is as essential during the period of convalescence after fracture of a femoral as in the final treatment of a humeral condyle, but the knee will not endure the rough usage that can be imposed on the elbow. In the earlier part of the treatment a tendency to deflection to the right or left is to be guarded against as well as shorten- ing. The leather or pasteboard splints if allowed to extend above and below the knee, and if kept snugly bound in place with a bandage or multiple ties, operate against lateral defor- mity, and the extending and counter-extending forces resist the overlapping. Eversion of the foot and limb is prevented by the use of sand bags. Moderate flexion of the knee re- laxes the muscles of the leg. The ordinary double inclined plane fracture box or appliance for the leg, constitutes a very serviceable dressing for treating a femur broken at the con- dyles. In a case of comminuted fracture of the lower ex- tremity of the femur, including a severance of both condyles, which recently came under the treatment of Drs. Potter and Clarke, of Hamilton, 0., the double inclined plane apparatus was used ; and the result could not be more satisfactory. By the courtesy of the surgical attendants I was invited to see the case under treatment, and was pleased with the skillful management of the means employed. CHAPTER XXVI. FRACTURE OF THE PATELLA. The patella is much exposed to direct violence, but the facility with which it slides in various directions, saves it from fracture. Indirect violence can not reach it; but museular action exerts a powerful influence upon it. The size and shape of the bone contribute to its immunity from fracture. The patella is a sessamoid growth in the tendon of the quadriceps extensor cruris muscle, and plays the part of a ful- crum and lever at the same time. In the former office it can not be crushed by muscular action ; but in the latter capacity it may be snapped, the fracture running through the bone transversely. A blow may break it longitudinally, or crack it into several pieces. The patella is broken by muscular force more frequently than any other bone in the body. When the knee is slightly bent the bone is supported upon the condyles of the femur on its transverse axis only, becoming wholly a lever, and losing its character of fulcrum. Its upper edge is then elevated and unsupported, as well as its lower, which is held rigidly in place by the ligamentum patellae. Under these circumstances the rectus femoris and its associate muscles, no longer act in a direction corresponding with the longitudinal axis of the bone, but nearly at right angles with it. In a violent effort to save the body from falling back- wards, the bone may snap transversely. In one instance I knew a boy to break one of his patellae while jumping a wide ditch. As he landed the body dropped down so as to bring the knee into extreme flexion, and he says the knee-pan snapped at that time. In that instance the conditions were not favorable to a fracture of the patella, for its position was such when the knee was excessively flexed, that its centre was unsupported, and the force acted in the direction of the ver- tical axis of the bone, and no leverage could be obtained upon (215) 216 Fractures. it. In order that the patella maybe placed in the most favor- able position for the muscular force to act upon it, the knee must be only moderately flexed; then the ligamentum patellae holds the bone poised on its centre, between the condyles of the femur, and the muscles act upon its upper edge. Extreme force is not brought upon the patella when it plays the part of a lever, except a person in walking, slips with one or both feet, and in an effort to resist a fall, or to recover an equipoise of the body, he attempts to straighten the knee which has be- come partially flexed. It is just at this time that the patella is placed under the most favorable conditions for the muscles to act upon it; and it is at this moment that the muscles act suddenly in the most powerful manner. While the knee is bending it is instantly checked in its course of flexion, and changed to a state of extension. If the patella be poised on its articular apex, its integrity is severely tested; but if the leg be nearly straight or extremely flexed, the force acts in a straight line with the bone, and the tendon above or below the bone is put to a dangerous test. The patella is ordinarily strong enough to resist any muscular force that can be brought to bear upon it, but, as has been stated, if it be caught in a poised position between the condyles when great and sudden power is exerted on the part of the muscles, the bone is put to a disadvantageous strain, and may snap, as a short stick is made to break across the knee by the power of the hands. A person in going down stairs may catch the heel or par- tially stumble, and in the effort to shun a fall receive a frac- tured patella. By far the most common cause Fig 87 • of a broken patella is direct violence; the kick of a horse, the hitting of the bone against some solid substance in a fall, the blow of an axe, hammer, or implement violently hurled by moving machinery, are all well known causes. T?hneS7arteliaractureof The symptoms of transverse fracture ofthe patella are prominent and unmistakable. The patient feels the sudden separation of the bone, and generally declares that he heard the snap attending it. He is unable to extend or advance the leg, and seems to be instinctively con- scious of the nature of the injury. The lower fragment remains in place,being held there by the ligamentum patellae; Of the Patella. 217 but the upper fragment is drawn upward sometimes to the extent of several inches—generally an inch or two. The upper fragment can be found as the hand is slid down the thigh near the knee, and the fingers find a yielding depres- sion between the fragments. Just above the lower fragment, the knee, when the leg is flexed, evidently has lost something which normally produces a fullness there. No crepitus need be expected unless the leg be extended and the quadriceps be pressed powerfully downwards, so as to allow the fragments to reach each other : if once brought in contact by the above means the broken surfaces may be made to grate against each other. Considerable swelling takes place from effusions of lymph and extravasation of blood. If the limb is not seen for sev- eral hours succeeding the accident, the swelling will mask some of the prominent symptoms, yet the fingers firmly pressed along the anterior aspect of the limb in the vicinity of the joint, will discover the upper fragment dragged up- ward, and the abnormal depression between the pieces. The furrow between the condyles will also be recognized if the fingers are pressed into that sulcus. In an oblique fracture of the patella the signs of the lesion will be as apparent as in a transverse separation. In multiple or stellate fracture the fragments may not be displaced, but all will be held in position by the tendinous surroundings. In such a case crepitation could be readily elicited, and move- ments of the limb would cause sufficient irregularity of the pieces to be discoverable with the aid of the fingers. Flexion of the limb would produce separation of some of the frag- ments, as the quadriceps must take one or more pieces of bone along with it as contraction ofthe muscles ensues. In a longitudinal fracture of the patella there may be lateral separation of the fragments, though the beveled and project- ing condyles on each side tend to keep them in place. The action of the vasti muscles, pulling in opposite directions, the force being from the centre towards the sides of the limb, may separate the fragments when the leg is flexed. One of the peculiarities of a fractured patella is that the fragments unite very frequently with fibrous material, and rarely consolidate with bony matter. The length of the fibrous bands depends upon the distance existing between the 218 Fractures. fragments during the healing process. It is not uncommon to find the fibrous connection nearly an inch in length. In the case of Mary Adams, of Covington, Ky., who broke the right patella transversely by a tumble on some out-door steps, I secured a very short ligamentous union, so that she walked well at first, but in less than a year the connecting band had stretched, torn, or yielded, so that there were two inches between the fragments when the leg was forcibly flexed. ^^^nsverse Dr. Coale presented to the Boston Society for patei"™ °f the Medical Improvement, a specimen of a frac- tured patella taken from a man sixty-five years old, the fracture having occurred ten years before. Dr. C. reports that the fragments at first 'were so closely united that no separation between them could be discovered; but subsequently they became disjoined at their outer edges one inch, and at their inner edges very much less. Treatment.—The sooner the limb is properly dressed, after fracture of the patella, the easier it will be to accomplish the chief object of the treatment. The muscles attached to the patella are so powerful that their contraction goes on from day to day until at the end of a week or two a space of two or three inches between the fragments exists, though the sep- aration of the pieces of bone may have been less than an inch at first. Immediately succeeding the fracture the two por- tions of bone can be easily brought into contact, whereas in the course of a few days the muscles have become so much contracted and accommodated, as it were, to their new posi- tion, that it is often quite impossible to elongate them suffi- ciently to bring the piece of bone connected with them down far enough to meet the lower portion : the consequence of which is, that direct apposition and consolidation are never obtained, but a kind of ligamentous or fibrous union is the result. It is generally believed among experienced surgeons that the great rareness of bony union in transverse fractures of the patella must be owing simply to the difficulty of keep- ing the fragments in sufficiently close apposition ; if contact of the broken surfaces could be produced and steadily main- tained for several weeks, bony union might be expected as in other fractures. Of the Patella. 219 A modification of the dressing employed by Mr. Cooper is represented in the accompanying diagram, and maybe applied as follows ; carry a circular bandage from the toes to the knee, binding two strips of uniting bandage which are laid on the sides of the leg, the upper ends being left free for tying above the upper fragment when it is bandaged down into place. Another roller is to be applied, beginning at the upper part Fig. 89. Circular bandages above and below the knee serve to hold firmly in place two sets of uniting tapes which are to be tied above and below the fragments of the patella. of the thigh and bandaging downward while an assistant with both hands near the knee pulls powerfully upon the quadriceps. The bandage secures and maintains the stretching and exten- sion applied by the assistant. Two strips of strong cloth are to be laid upon the sides of the thigh, and covered by the spiral bandage, as was done below the knee. The free ends of the uniting bandages are to be tied above and below the fragments, a compress being placed where the knots are to rest. If the uniting strips be tied snugly, they exert a pow- erful influence towards bringing the fragments in contact. To finish the dressing a compress may be laid on the patella, and held in place by a few turns of a third roller, which also covers in the space between the other bandages and secures equal pressure the whole length of the limb. A long splint may be bound to the posterior aspect of the leg to prevent the slightest degree of flexion at the knee. The rectus femoris is freed from tension by elevating the leg on cushions or other supports. The dressing just described operates very well wdien the bandages wholly prevent the ties from slipping, but practically it is found that they will not. To obviate that serious defect Dr. Sanborn, of Lowell, Mass., devised a modification of the old plan, using adhesive strips in place of the ties or uniting bandages. He. recommends a strip of ordinary adhesive plas- 220 Fractures. ter four feet long and two and a half inches wide to be applied to the anterior aspect of the limb from the upper portion of the thigh to the middle of the leg, leaving a free loop at the knee for purposes presently to be explained. The ends of the strip to within a few inches of the knee, are bound in place by a couple of rollers—m\e for the foot and leg, as in Cooper's dressing, and the other for the thigh. A hard roller compress is placed immediately above the upper fragment, and then a small stick, as a twister, is put through the loop, and revolved until great power is brought to bear upon the parts to which the adhesive strip is attached. This is an efficient and easily applied apparatus, and good results maybe obtained from its use. I have employed it in one instance, with the addition of a single inclined plane to elevate the foot, and secured a bony union of the fragments. If the fracture occurs from direct violence there will be danger of a high grade of inflammation and anchylosis. Cooling and anodyne lotions that will not interfere with the dressings, should be freely employed during the early part of the treatment. At the expiration of four or five weeks from the reception of the injury, passive motion is to be instituted, and kept up until the functions of the joint are restored. In a case of vertical or longitudinal fracture the knee-joint should be enveloped in strips of adhesive plaster to retain the fragments steadily in juxtaposition. The tendency is to lat- eral displacement of the fragments in a moderate degree, and the adhesive strips are used to counteract it. Osseous union is pretty certain to follow this treatment. Arthritis and an- chylosis are the most dangerous conditions to be guarded against. I have never met with a case of a recurrence of the lesion after fracture of the patella, but such accidents are reported. I am inclined to think that there was no bony union in such cases, and that the " recurrence " was merely a tearing of the fibrous connection. It is rare for a patient to recover entirely after having sus- tained fracture of the patella. In the event of fibrous union of the fragments the power of extending the leg is impaired; and bony union is generally followed by excesses of callus that impede the motions of the joint. A complete restora- tion of all the functions of the limb is a fortunate issue. CHAPTER XXVII. FRACTURES OF THE LEG. The bones of the leg are parallel in direction, but quite dif- ferent in size, shape, and function ; the tibia is large, and by its broad articulation with the femur and tarsus, is evidently designed to support the weight of the body; the fibula is small, and is destined not to sustain weight, but to give at- tachment to many muscles, and its lower end contributes to the formation of the ankle joint. The tibia has'broad articu- lar extremities and a triangular shaft; the fibula has moderate sized extremities, and a slender prismatic shaft. The two bones have quite different offices to perform, yet they are so intimately associated in their anatomical relations that both are more frequently broken by a single accident than either is fractured separately. A force sufficient to break the tibia is generally powerful enough to reach the fibula and to break it also. The tibia being thinly covered, is exposed to direct violence, and peculiarly liable to compound fracture; the fibula is pretty well buried in soft tissues, and when broken, its frag- ments rarely puncture the skin. The causes of fracture of the leg are either direct, as the passage of a wheel over the limb ; or indirect, as in landing heavily upon the feet, from a jump or fall. The relative fre- quency of these causes in the production of fracture has been variously estimated by different authors. Hamilton considers that four-fifths of them come from direct violence, while Mal- gaigne found that in sixty-seven fractures of the leg observed by him, thirty-six were produced by direct, and thirty-one by indirect violence. There are some parts of the tibia, as the head and lower extremity, that rarely yield from the influence of an indirect force; but when a person in a jump or fall (221) 222 Fractures. Fig. 90. comes to the ground on his feet, the force is likely to act ob- liquely upon the shaft of the bone, and snap it across. Direct forces may fracture any part of the bone, for all parts are ex- posed to the influence of kicks, blows, projectiles, falling bodies, and moving machinery. Both bones of the leg may be broken, as has just been stated, at the same time, or by the same accident; if the vio- lence be direct the fracture may be on the same line in the two bones ; if indirect, the tibia is liable to yield in its lower third, and the fibula somewhere above its middle. Peculiar circumstances may allow the indi- rect force to break the^ two bones in the same line; and others may occur which cause the direct force to break each at different points. When the indirect force acts, the fibula must almost always break after the fracture of the tibia has taken place, for the force continues on upwards and comes upon the fibula with the addi- tional weight of the body of the person which is no longer supported by the tibia, consequently the whole stress tells on the slender fibula above where the other bone gave way, producing a fracture in its upper third. A violent and sudden twist of the ankle, which is force indirectly applied, may cause fracture of both bones just above the joint, the line of separa- tion being nearly on the same level. It is rare to find the fibula broken below the point of frac- ture in the tibia, even though direct force has caused the in- jury. If the leg be broken by a wheel passing over it ob- liquely, the fibula being struck at a point lower down than the tibia is hit, the line of separation in the two bones must correspond with the points subjected to violence. The direction the fracture takes is much the same it is in the long bones generally : if the force be indirect, the oblique course prevails ; if direct, the transverse. In most instances the line of separation is irregular, but inclining to the oblique. The tibia is most liable to exhibit a predominance of obliquity Fracture of both bones of the leg; the fibula through its u p- per, and the tibia through its lower third. Of the Leg. 223 Fig. 91. in the line of its fractures; and the fibula shows a tendency to the transverse direction in the line of its separations. Displacements may take place as in fractures of other bones, and from similar causes; in transverse fractures the fragments may not become disengaged, at least there is less tendency to displacement; in oblique fractures, on the contrary, there is nearly always overlapping, sometimes to a considerable ex- tent, as when the fracture is caused by a fall on the feet from a height, for the force being more than sufficient to break the boues, continues to act, and so displaces them. Combined with this there is usually some rotatory displacement, due partly to the force received and partly to muscular action. The signs of fracture in the bones of the leg, are generally well marked, though not always comprehended in their utmost significance. In other words, it may be plain that a fracture exists, but it is not generally an easy matter to deter- mine whether one bone is broken or both, and what is the direction of the fracture, the extent of the injury in all its bearings and complications, and what obstacles are to be over- come in the treatment. The crepi- tus, mobility, and deformity are commonly detected upon the slight- est examination. The tibia is so near the skin that the smallest amount of displacement is readily detected by passing the fingers along the course of the bone; the fibula is more deeply covered, yet thorough manipulation can not fail to discover the place where the separation ex- ists. The surgeon, in examining a leg which has sustained a fracture, should not be content with the discovery of a break in one bone, but he should carefully scrutinize the other. It has been already stated that a fracture of both bones in a single accident, is more common than the fracture of one bone singly, therefore in a given case the probabilities are always in favor of both bones having been broken. In the treatment of fractures of the leg it is of the utmost importance to de- Fracture of both bones of the leg < nearly the same plane, the result direct violence. 224 Fractures. termine whether one bone is broken or two; if only one bone be broken there may be a rotatory or twisting kind of defor- mity, but there can be no serious degree of shortening; if both bones be broken, and the surgeon discover a fracture in one alone, and treat the injury according to his faulty diagnosis, the most serious consequences are sure to be the result. In considering the displacement that occurs in fractures of both bones of the leg, it may be easy to determine, for in- stance, that the upper fragment of the tibia takes a position in front of the lower fragment; but to decide upon the rela- tive positions of the fragments of the fibula may be attended with some difficulty. The force that displaces the fragments may be of two kinds,—it may come from muscular action pulling the lower fragment above the upper; or it maybe that which causes the fracture, driving one portion of bone from its contact with the other after the break has occurred. It is more probable that the same force would go on acting after it has fractured the bones, than it should cease directly. When the fragments are once displaced bjr the force producing the fracture, the muscles exert an action upon them, and may oppose reduction. Overlapping is one ofthe most important and constant fea- tures in fractures of both bones of the leg. To recount all of the muscles that either produce or maintain the retraction would be simply enumerating the entire list that make up the motive power of the leg. The line of action is towards the knee, the broken ends of the lower fragments being pulled upwards past the fractured surfaces of the upper fragments. The weight of the limb causes a part of the angular and rota- tory deformity, and the winding course of some of the mus- cles the rest of it. The direction of the force producing the fracture will always vary the line of the displacement; for, applied from the outside of the limb it will be disposed to displace the portions of bone inwards; and applied from the inside, it influences them in the opposite direction. The fibula, in fractures of both bones of the leg, has very little influence upon displacement; the fractured ends present so small a surface that'very little force destroys their apposi- tion, and if the bone be broken into more than two pieces the muscles destroy their parallelism, so that perfect coaptation of the fragments is exceedingly rare. Of the Leg. 225 Fig In fractures very high up, near or through the head of the tibia, where they may be when direct force inflicts the in- jury, the displacement is slight, unless the fracture be much comminuted ; for, in this situation the structure of the bone is cancellous, which causes it to break with a more irregular fracture, giving the surfaces a rough, uneven shape, by which the ends of the bone are locked Within one another, and re- quire a powerful force to displace them. Fracture through the head of the tibia, or through the lower extremity of it, is liable to be oblique or nearly vertical in its course, a circum- stance that always renders it doubtful whether the knee or ankle-joints are not complicated in the injury, rendering the nature of the lesion much more serious than a fracture of the shaft of the bone. Fracture of the internal malleolus and of the fibula a few inches above the joint, accompanied with partial or complete dislocation of the ankle, is an injury of a complicated nature, and is essentially the same as " Pott's fracture " of the fibula, with laceration of the deltoid ligament, and displacement of the tibia from the astragalus to a certain extent. Fractures through the extremities of the bones of the leg are not easily diag- nosed, especially if the patient be not ex- amined until swelling has rendered the case obscure. These accidents are always accompanied with more ecchymosis and swelling than fractures at a distance from the joints, owing to the nature of the force that produces the injury, and to the fact that the articular structures are more or less injured at the same time,,which causes the effusion to be greater than it otherwise would be. On July 6th, Dr. A. P. Freeman and myself were called to treat Mrs. Taylor, of West Covington, Ky., who had the evening before broken her left leg just above the ankle. There was considerable swelling1 and discoloration twelve hours after the accident occurred. The general contour ofthe leg showed that afrac- 15 Fracture of the tibia and fibu- la near the lower extremi- ties of those bones. 226 Fractures. ture existed near the ankle, but the line of separation in both bones could not be determined without careful manipulation. Crepitus decided the nature ofthe injury, though it could not be ascertained at first whether the grating sound came from the tibia or fibula, or both. The concavity on the outside of the leg led to the suspicion that the fibula was broken, and lateral motion, with the finger on the suspected point, made the existence of fracture certain. Antero-posterior motion developed crepitus between the fragments of the tibia; and the fingers pressed upon the bone just above the ankle dis- covered the line of separation. It was easier to comprehend the break in the fibula than it was the certainty of fracture and the line of separation in the tibia. The deviation from the ordinary shape of the limb, consisting of some angular defect, a visible twist or rotatory deformity in the lower part of the leg, made it apparent that both bones had been broken. The line of separation in the tibia was too nearly transverse, and there was too little displacement to admit of overlapping, therefore whatever of deformity existed was overcome by ex- tension made with the hands. Common thin board splints were wrapped with muslin, and applied to each side of the leg, and bound in place with encircling tapes and a roller, compresses being used to help secure the normal shape of the limb. In five weeks consolidation "was complete, and no shortening or rotatory deformity remained. No extending force was used after the reduction, for none was required. The interlocking of the fragments of the tibia would not ad- mit of overlapping. In fractures of both bones of the leg near the knee, the line of separation can be discovered between the fragments of the fibula, but the course of the fracture-line in the tibia is often quite difficult to make out. The tibial fragments are apt to remain interlocked, owing to their broad surfaces, and to the little power of the muscles over them. Crepitus may some- times be elicited, but it may not be easy to determine whether it is between the fragments of the tibia or fibula. If much displacement happens to be produced by the force which caused the fracture, or if the line of separation be oblique, the nature and extent of the injury are not difficult to understand. Fractures of the bones of the leg remote from the joints, are attended with signs quite unmistakable. Crepitus is Of the Leg. 227 easily produced, owing to the mobility that exists between the fractured portions. When the fracture exists in the tibia only, the same facility does not always exist, for the fibula then serves as a splint to a certain extent, and keeps the frac- tured ends of the tibia in opposition. Crepitus, for various reasons, can not always be produced even when both bones are broken somewhere near their mid- dle ; but the angular deformity which can be produced by bending the leg in any direction, sufficiently demonstrates the nature of the lesion. The inner and fore part of the tibia being quite superficial, a fracture of the shaft of the bone may at once be recognized by passing the finger along the anterior spine; for any irregu- larity along this surface will be easily discovered, and indicate the position of the fracture. The point of fracture in the fibula is not, as already stated, on the same level with that of the tibia, especially when the fracture is caused by indirect force ; for the fibula is found to yield at a point somewhere above the place the tibia breaks. The most frequent kind of displacement in the fibula is inward toward the tibia, causing a depression which may be felt when the finger is pressed along the outside of the bone; and the ends of the tibia can not be displaced to any great extent without the ends of the fibula moving with them. Overlapping of the fragments of the tibia can not take place without the same amount of dis- placement occurs in the fibula. TREATMENT OF FRACTURES OF BOTH BONES OF THE LEG. As already indicated, when detailing the course pursued in the treatment of Mrs. Taylor's leg, extension and counter- extension are not always required in the management of frac- tures of both bones of the leg. However, if there be shorten- ing, or an opportunity to overlap on the part of the frag- ments, as there almost always is when the fracture is through the shafts of the bones, those forces must be steadily and per- sistently maintained as long as a retentive apparatus is neces- sary, otherwise some degree of deformity will be inevitable. If there is a disposition to overlap, as there necessarily will be 228 Fractures. when the fracture is oblique, the difficulty in preventing this deformity is exceedingly great. The surgeon may effectually reduce the fragments to their proper places,, and carefully apply suitable means to retain them there, yet the tendency to overlap is so pressing that the pieces of bone will slip past each other, unless watched and guarded against with the utmost patience and skill. The facility with which the broken surfaces escape from one another, while the dressing is being applied, has been observed by every one familiar with such injuries. The force and dexterity required to effect, re- duction in the event of much overlapping, and in irritable patients whose muscles fly into a state of spasm as soon as the limb is touched, are far from trifling. The influence of chlo- roform is sometimes needed to accomplish a successful reduc- tion. In reducing fractures of the leg, an assistant should be placed so as to fix the knee firmly, while the foot is grasped, and steady and well directed extension is made downwards, care being taken to unlock or disengage the fragments by gen- tle rotatory motion. In manipulations of a broken leg it should be borne in mind that large arteries, veins and nerves, pass along near the rough and sharp edges of the fragments, and may be seriously injured by careless handling of the limb. It is the custom of some surgeons to allow a broken leg to remain several days under the influence of cooling and ano- dyne lotions, before an attempt is made at reduction. This course might do in a hospital where the patient has no choice of surgical attendants, but in private practice the most eminent practitioner is not sure of holding his case if he follow such a course. Policy, then, is against the practice, even if it have some points in its favor; but according to my experience there is no better time to adjust a fractured bone than as soon as it can be done conveniently. The muscles do not readily relax after they have been allowed to contract for several days ; besides, the patient does not rest well with the limb in a broken and unsupported state. There is a feeling of insecu- rity in an undressed fracture that is absolutely tormenting; every motion of the body imparts pain and invites a spasmodic action of muscles in the vicinity of the fracture. If it be im- possible to reduce a compound fracture on account of the mus- cular contraction and spasm, the influence of an anaesthetic will put the patient into such a state of relaxation that the Of the Leg. 229 Fig. 93. worst case can be managed successfully. If the wound in the integument be too small for the protruding fragment to return, it may be enlarged slightly to take off the tension. The ne- cessity for sawing off a piece of the bone in order to accom- plish easy and speedy reduction, can rarely or never exist. However, it would be necessary to resect a point of the bone if it could not be returned to its proper position, yet such a procedure is to be avoided if possible. I can not endorse the following from Prof. Hamilton : " Resecting thus the end of an oblique fragment does not generally affect in any degree the length of the limb, or interfere with a prompt and perfect cure, but on the contrary it often is advan- tageous in every point of view." The application of extending force in those instances where the overlapping de- mands it, taxes the ingenuity of those unac- customed to make a " hitch " upon the foot. Barton's handkerchief, as it is sometimes called, may be employed as a means of making extension. It can be applied as fol- lows: a handkerchief of good size being folded into a cravat, is so laid against the point of the heel that one-third of the hand- kerchief shall be on one side and two-thirds on the other; after which the longest end is to be carried round across the instep to the opposite side, where it takes a turn around the other extremity of the handker- chief, and is then carried under the sole of the foot to the other side of the ankle, where it takes a fold around the first turn. The two free ends reaching below the foot are to be used for making extension with what- ever apparatus the surgeon chooses to em- ploy. A gaiter has been one of the means of making fast to the ankle, when extension is needed; but if the fracture be near the ankle-joint, the folded handherchief is not endurable without great suffering and excoriation. The heel and structures about the ankle are proverbially intolerant of pressure, and the accident renders them more so. Hitch made upon the ankle and foot with a handkerchief folded like a cravat. Fig. 91. A gaiter-like appliance to make fast to the ankle. 230 Fractures. The adhesive strip fastening is the least objectionable of all kindred contrivances for making extension. The foot and ankle are to be covered in with narrow strips of adhesive plaster, then the vertical side strips of greater width are made to adhere partly to the skin and in part to the envelop- ing material, and, finally, over both a few en- circling strips are applied, which complete the first stage of the dressing. The surgeon can take his choice of these three forms of making fast to the foot and ankle, but I much prefer the " hitch " by adhesive strips. If the fracture be higher up, long pieces of adhesive plaster may be used and a firmer hold secured. A roller may be used to en- envelope the leg after the strips are applied if its compressing influence seems to be neces- sary, though I am not in favor of a bandage next the skin which may exert a constricting influence. The next step in the dressing consists in &reS.°f making applying the retentive apparatus, which may consist of two wooden side splints, well wrapped ; and over these the ends of a many tailed bandage may be lapped to hold them securely in place. Figure 96 shows the dress- ing in this second stage, with a few of the lower strips lapped across. Two or three encircling ties may be used to retain the splints in place until the full retentive influence of the many tailed bandage is brought to bear. A roller may be used in- stead of the bandage of strips. I prefer the roller in ordinary simple fractures; and the bandage of strips in compound injuries, for the latter is the easiest to be opened and closed when the wound is ex- Dressing for the leg, after both bones „_-• «, j are broken, in progress of applica- amineCL. tion. Adhesive strip fasten ing made to the foot and ankle, for the Fig. 96. Of the Leg. 231 The next step in the dressing is to give the leg the position it is going to occupy, and to apply the extending and counter- extending forces. The double inclined plane apparatus is used by some surgeons to give the limb the flexed position and to secure not only what force there is to be obtained by this attitude, but to apply by means of ties and screws as much in addition as may be demanded. Other surgeons pre- fer the straight position of the limb, using a fracture box, as it is called, or a contrivance made of boards to reach along the sides of the leg, a bottom piece, a foot piece which is nailed to the bottom and side pieces, and a movable foot piece to which the gaiter, handkerchief, or the side strips of the ad- hesive application, are tied. If the double inclined plane be used, counter-extension may be left to the weight of the thigh and body, and extension made by lashing the foot to the mov- able foot-piece of the apparatus, and then drawing it steadily downwards by turning the screws, or by other means em- ployed to accomplish the same object. To describe all the in- ventions and improvements of this kind introduced to the notice of the profession, would require more space than can be granted in a work of this kind. The accompanying cut represents an apparatus for making extension and counter- extension below the knee. The foot is fastened to the mov- able foot-piece by means of a gaiter; and the counter-extend- Fig. 97 1 Side of fracture box; 2, bottom of fracture box ; 3, movable foot-piece; 4, wooden screws ' to adjust foot-piece; 5, gaiter ; 6, belt of leather encircling the leg below the knee, for counter-extending force; 7, hooped rod to sustain the force. ing force is obtained by means of a piece of sole leather which is laced together after encircling the leg just below the knee. Some tapes extend from holes or loops in the upper edge of the leather band, to an iron rod, which is hooped, and has its two ends secured to the upper extremity of the box,—the hoop is made adjustable by means of a couple of wire loops driven into the upper ends of the sides of the box. The same 232 Fractures. Fig principle is applied to every apparatus of the kind, though many of these contrivances vary in general characteristics. It is not necessary to employ a complicated apparatus to treat successfully fractures of both bones of the leg. The ex- tending strips of adhesive plaster maybe attached to the foot of the bed, and then counter extension can be produced by elevating the foot posts of the bedstead, as already recom- mended in the treatment of fractures of the thigh. If this method be adopted a sand bag should be placed under the knee, and other bags may be laid against the outside of the limb to thwart the tendency to eversion. In some instances the leg should be supported between two junk bags in order to take the weight of the limb from the heel which is liable to slough under prolonged though moderate pressure. If the ends of the splints press heavily at their upper or lower ex- tremities, so as to threaten ulceration, cushions of cotton, hair, or wool should be placed under them. The limb must be watched very narrowly, to prevent any morbid action from doing serious mischief. Vesication is a common condition after fractures of the leg; and the bladders of serum that form.beneath the dressings, out of sight, may break and degenerate into ulcers and ugly sloughs. If the vesicles are very large and tense, they may be pricked to allow the serum to escape. These blis- ters commonly dry up in the course of a week or two, and leave no bad effects. In a fracture of both bones of the leg, es- pecially if the tibia be broken at one point, and the fibula at another, the tendency to overlap on the part of the fragments is con- siderable, therefore careful and persevering efforts must be made to obviate shortening. The accompanying diagram represents with consolidation of thTfrag- scrupulous exactness the bones of the leg bolh bonefofrtheUTeg, as found after having been under the treat. ment of a surgeon of more than ordinary skill and experience. The patient died of visceral disease in five months after receiving the fracture. The limb was three quarters of an inch too short, as may be judged by the Of the Leg. 233 overlapping of the fragments, and there was angular defor- mity, besides some arising from rotation. The upper fragment of the fibula split, and the wedge shaped broken edge of the lower fragment was forced between the splinters. The injury occurred from indirect violence, the patient in a fall striking upon one foot. The consolidation betweeu the fragments was found to be complete, but the rough points of the badly op- posed fragments were little affected by the polishing process which at length makes such irregularities comparatively smooth. Measurements during treatment should be frequently made to determine whether shortening is taking place. With the body straight, and the legs parallel, a tolerably correct com- parison can be made between the lengths of the two limbs. However, it is more satisfactory to measure from the umbilicus or symphysis pubis to the inner malleolus of each ankle. If the patient be a woman the measurement may be made from the patellae to the malleoli. When the two limbs are side by side, any deviation of the broken leg, as by rotation, is quickly detected. As a sight is taken up the limb to the body the great toe should be on a line that strikes the inner edge of the patella. The foot must be watched to see that the heel be not drawn upwards too much by the contracted condition of the sural muscles acting through the tendo-Achillis. When the obli- quity of the fracture favors that kind of contraction, as well as a slipping backwards of the foot and whatever of leg is below the break in the bone, the inclination or tendency must be arrested by the dressings and the proper use of sand bags. If a cushion or junk bag be carelessly placed just above the fracture the weight of the leg would tend to displace the foot backwards. In cases admitting of the leg resting upon its side, that position is favorable to ease and apposition. Some surgeons prefer to dress the leg with the view of having the limb gently flexed and laid upon its side. After fracture of one of the bones of the leg the limb may be placed in any attitude, for no extending apparatus interferes with free movements ; but when both bones are broken, and there be danger of overlap- ping, the limb can not be freed from the machine or apparatus that has to be employed to secure extension. 234 Fractures. In some instances it may do to lay aside the ordinary appli- ances, and to adopt the stiff dressing in their stead. The common starch dressing, when once dry, will obviate the ten- dency to shorten. However, the limb may shrink after it has been in the immovable dressing for a few days, affording op- portunity for lateral displacement and shortening. I never feel satisfied with a starch dressing when both bones are broken. In exceptional cases, where it becomes necessary for the patient to be moved by carriages and railroads before con- solidation of the broken bones has taken place, the immov- able or stiff dressing should most certainly be employed. Debilitated, dropsical, and broken down constitutions are exceedingly unfavorable to rapid bony union ; and in an occa- sional instance no consolidation will take place. In 1862 a raftsman on the river got his leg caught in some lumber and broke both bones in the lower third of the limb. He was taken to the house of Mr. Harrison, of Newport, Ky. I ac- cepted an invitation to take charge of the case, and treated it in the ordinary way. In the course of ten days the limb took on a flabby, dropsical appearance, and presented evidences of defective vitality. At the end of four weeks from the acci- dent, I perceived crepitus between the fragments, and the limb exhibited almost as much mobility at the seat of fracture as at first. The limb was redressed, and the patient who was Beriously impaired in health from the excessive use of liquor and exposure, was put upon a stimulating and nourishing diet, and three glasses of ale a day were allowed him. He soon began to improve in general appearance, and the leg which was redressed once a week, showed more firmness and vitality. At the end of-the eighth week the limb had stiffened at the point of fracture, very little deformity existing. I now put the leg in a starch dressing, and had the patient begin to take exercise on crutches. In four months from the reception of the injury, the patient walked to my office, using a cane to steady himself. There was no perceptible shortening, though the upper fragment of the tibia projected so it could be plainly felt. The consolidation seemed as perfect as in any case. During the early part of the treatment I was afraid of false joint, but the sequel showed that the case was to be looked upon as representing delayed or tardy reparative action. Of the Tibia. 235 FRACTURE OF THE TIBIA SINGLY. As has been previously stated, a force which breaks the tibia is generally sufficient to snap the fibula also. However, the tibia is sometimes broken singly, the fibula remaining in- tact. Direct violence, such as the kick of a horse, or a blow from some hard body, may be the cause. James Bucking- ham, in January, 1864, slipped while stepping from the street to the sidewalk at the corner of Sixth and Elm Streets, and hit his leg five or six inches below the knee against the sharp corner of the curb-stone. He distinctly heard something snap, and immediately experienced great pain in the limb. He was near home and attempted to wralk the distance, but the distress occasioned by an effort to use the leg compelled him to sit down. It was before daylight in the morning, and as nobody passed along to help him, he dragged himself home the distance of a square, on his hands and sound hip and leg. In an hour or so after the accident I found the tibia broken a few inches below the knee, and the fibula as sound as ever. The upper fragment projected a little, but there was no per- ceptible rotation of the leg below, or other deformity. In 1867, Fritz Gorman, a lad of eight years, was hit by a runaway horse, on Front Street, and received an injury of the leg. I was called to the case, and found a fracture of the tibia three inches above the ankle, with the anterior sharp edge of the upper fragment protruding through the skin. The fibula had escaped fracture. These cases are mentioned, not as pos- sessing any special interest; but to show what kind of forces may break the tibia alone. In the first case the patient said " the weather was so cold there must have been frost in his leg." There is a popular notion that the bones are more fragile when the weather is intensely cold. Probably this is an error founded on the fact that more fractures occur in frosty weather than at other seasons, the sufferers ascribing their misfortunes to osseous fragility and not to the slippery condition of every- thing frosted, where the real cause should be placed. It is possible that the highly contractile state of the muscles may, in cold weather, increase the frequency of broken limbs ; and if it be a fact that intoxicated persons whose muscular system is in a loose, flaccid condition, can receive heavy falls and 236 Fractures. enjoy an immunity from fractures, it becomes highly probable that a tense state of the soft tissues favors fracture. In fracture of the tibia the line of separation may be trans- verse, oblique, or irregular in its course. Being the result of direct violence in a majority of instances, the transverse vari- ety prevails, especially if the fracture be near the extremities of the bone. I was once called by Dr. Wm. Sherwood, of this city, to see a case in his practice, in which the fracture extended transversely through the tibia within two inches of the knee-joint,—the fibula was not fractured. There was little or no displacement, and consolidation took place in five or six weeks. Direct violence was the cause of the injury. Dr. Van Ingen, for a while in this city, exhibited to me a drawing which he had made to represent an oblique fracture through the upper part of the tibia, the line of separation ex- tending into the knee-joint. He says the case was treated by him successfully near Schenectady, N. Y. His diagram also showed a fracture of the inner condyle of the femur, which was a part of the same accident. It is possible he may have been mistaken in regard to the extent of the injury. I once took professional charge of a teamster who, in jump- ing from his wagon to the ground, received a longitudinal fracture of the lower extremity of the tibia. The line of separation began in the articular surface of the lower end of the bone, and terminated two inches above the joint, disen- gaging a wedge-shaped splinter of bone, including the inter- nal malleolus. The piece united without displacement or de- formity, but the function ofthe joint was restricted by partial anchylosis, lasting a year or more. The patient ultimately recovered the full use of the limb. In fractures of the tibia through the lower third of the bone, the foot, including the leg below the fracture, is liable to exhibit a twist, indicating more distortion than might be expected after a fracture of only one bone of the leg. The twist in the limb is permitted by the length and slender state of the fibula, and its lateral mode of articulation. The symptoms of fracture of the tibia alone, are quite dis- tinct and easy of recognition, if the solution of continuity be anywhere near the centre of the bone, for the inequality at the line of separation will be felt when the finger is pressed along the spine of the bone ; but if the break be near either Of the Tibia. 237 extremity, and the direction of the fracture line be transverse, without appreciable displacement, the diagnostic powers of ■ the surgeon may be put severely to the test. The perfect con- tact of the fragments often prevents crepitation, and the existence of the fracture has to be inferred from the nature of the force applied, the sharp, circumscribed and persistent pain increased by pressure or an at- tempt to walk, and the local en- gorgement. If mobility and crepi- tus can be detected when the frag- ments are pressed in opposite direc- tions the diagnosis of fracture is made out, but not of the tibia alone; for, the diagnosis is not complete until it is decided that the lesion is limited to the tibia, and that the fibula remains unbroken. When it Fracture of the tiWa; the fibula is known that a fracture of the leer remaining unbroken. # ° exists it is safe to consider both bones broken, until it is positively determined that the fibula is intact. The crepitus elicited may come from a fracture of one bone or both. To determine whether the fibula be broken the bone must be tested its entire length. The finger is to be pressed along its course slowly while the limb is carried back- wards and forwards and laterally to develop a point in which there is mobility or inequality. Treatment of Fractures of the Tibia.—In most in- stances a fracture of the tibia alone can be managed with ease and success. The coaptation of the fragments when there is displacement, is generally not a difficult matter. If the projection of the upper fragment forward be consider- able, it may require some tact to get it back into place. The influence of an anaesthetic maybe employed to overcome mus- cular rio-idity. The tendo-Achillis has been divided to over- come the spasm and contraction of the gastrocnemius and soleus, but such a course is rarely if ever necessary. I have never seen a case that demanded a section of the tendon to assist in reduction. 238 Fractures The twist or rotation which follows a fracture near the ankle is worse to overcome than the angular deformity following fractures of the tibia higher up. In an ordinary case the limb from the toes to the knee may be enveloped, not tightly, in a common muslin roller to mod- ify swelling, congestion, and muscular action ; two lath splints long enough to reach from the knee to the ankle may be laid on the sides of the leg, and bound there by another roller. If there be much tendency to the for- ward projection of either fragment a third splint may be laid upon the posterior aspect of the leg, and a compress upon the anterior surface of the limb near the fracture, and so placed as to bear upon the projecting piece of bone, though not at its very point. Side splints have been prepared with concavities to fit the form of the leg, and with holes near their lower ends to avoid pressure upon the Spto"thei>eeia?ter0frac^ malle°li- These carved and nicely construct- ive of the tibia. ed splints are applied with ease, and they an. swer an excellent purpose in most instances. Almost every surgeon has on hand more or less of such appliances for treat- ing fractures. He also keeps ready prepared a supply of rol- lers, raw cotton, adhesive plaster, and other material for emergencies. Some houses have so few comforts and imple- ments, that the surgeon is greatly troubled to find material from which to construct splints and bandages. And on re- markable occasions, when from a railroad accident, or from the fall of a building, a dozen fractures may need attention at once, ample preparation for the extraordinary occasion re- dounds to the credit and advantage of the surgical attendants. However, if a practitioner of medicine and surgery be called to treat a fracture, and he be not prepared with the usual ap- pliances, he should be competent to construct extemporane- ously such splints and bandages as the necessities of the case demand. Sheets may be torn into strips, sewed together, and wound into rollers ; splints can be whittled from lath or shin- gles, cigar boxes, and thin boards; pillows do for cushions and supports until bags of drv sand can be obtained. Of the Tibia. 239 After a fracture of the tibia has been dressed, the limb may be laid in a position favorable to ease and repose. The patient need not be confined to bed, but may lie upon a sofa or lounge. The limb may be flexed, extended, or laid on its side, just as the patient chooses. The fibula prevents short- ening, and the splints, bandages, compresses, and other parts of the dressing obviate mobility, rotation, and angular defor- mity. Lotions shrink the bandages, and favor vesication of the skin, therefore it is generally better to allow the dressings to continue dry. An opiate may be needed to subdue pain during the first few days. The bowels should be moved every twTo or three days, and the diet, after the first week, ought to be quite nourishing. The immovable dressing, of starch, or plaster of Paris, is suitable for treating fractures of the tibia. It may be well to keep the limb in an ordinary dressing for a week or ten days, or until the swelling subsides, and then it saves trouble to en- case the leg in a stiff dressing, and let the patient go about on crutches. Even with the ordinary dressing the patient can get about on crutches without pain, or danger of mobility at the seat of fracture. However, no 'weight should be borne on the limb for five or six weeks after the accident. Consolida- tion to the extent of preventing mobility may take place in four weeks, but the callus is not sufficiently hard in all its parts to obviate deformity under great pressure. There can be no harm in keeping light splints and a bandage applied to the leg for a week or two after the ordinary time for undress- ing a limb has passed. After fracture of the tibia extending into the knee-joint, the danger is anchylosis, therefore the limb should be slightly flexed, and placed on a pillow or between two sand bags so arranged as to support the knee and produce some lateral pressure. Lotions may be used for two weeks, then paste- board, leather, gutta percha, or other pliable splints. In four or five weeks from the accident, passive motion ought to be begun and kept up for months, or until the joint recovers its functions. In a longitudinal fracture of the lower end of the tibia* in- cluding the inner malleolus with the detached fragment, the foot and leg should be bandaged, and great vigilance exer- cised to prevent any lateral distortion at the ankle. If the 240 Fractures. foot incline too much outward or inward, the tendency may be overcome with a properly applied splint, compresses, band- ages and sand bags. 9 FRACTURES OF THE FIBULA. The fibula being a slender bone, may be broken at any point, especially by direct violence. A smart blow upon the outside ofthe leg has been known to snap the fibula into frag- ments. But the most common cause of fracture in this bone is a sudden and violent twist of the foot outwards, which dislocates the ankle and breaks the fibula a few inches above the outer malleolus. The accident often arises from getting the foot caught in a hole or cleft while walking. Sir Astley Cooper fractured his right fibula by falling, after his foot was entangled between two pieces of ice. Booth, in his leap to the stage of the theatre, after shooting President Lincoln, had his foot powerfully deflected by having the spur on his boot catch in a displayed flag, and thereby sustained a fracture of the fibula. The frequency of fracture of the fibula and dislocation of the ankle from forcible abduction of the foot, is notable. Every experienced surgeon, when called to an injury of the leg at a point near the foot, at once examines the fibula just above the external malleolus, as if he expected to find the bone broken at that point. In fact the lesion is too common to escape the observation of any practitioner of moderate ex- perience. The office of the fibula is not to take part in supporting the weight of the body, but to strengthen and complete the mechanism of the ankle-joint upon its outside. The bone also serves to give attachments to a large number of muscles, and lends support to the tibia. A kick, or smart blow of any kind, is enough to produce a fracture of the shaft anywhere between its two extremities. I have treated fracture of the fibula through the upper third of the bone which was caused by the rapid passage of an or- dinary buggy wheel; and in another instance the kick of a steer was the cause. In both instances the men were able to walk after the injuries were received, though great pain at- tended the taking of each step. Considerable tumefaction Of the Fibula. 241 Fig. 101. occurred at the seat of fracture; and, the upper fragment being driven inwards in both cases, I was able io detect the dis- placement by pressing the fingers along the course of the bone. The projecting end of the lower fragment stood out distinctly, and could be seen as a salient point, as well as felt. No particular mobility was discovered, but the foot could be rotated to a greater extent, or through a larger arc, than in the sound leg. Distinct crepitation was not elicited, for the broken surfaces could not be brought in apposition, though manipu- lation of the limb forced them in contact. The dressing in each case consisted of two padded side splints and a bandage. Both cases recovered without apparent deformity, or defect in the functions of the limbs. The specimen represented in the accompany- ing diagram shows a double fracture of the fibula above the middle of the bone, and the central fragment deflected, probably by mus- cular action, from its normal course. The ap- position is far from perfect, yet the reparative action formed an osseous connection between the fragments. The tibia shows no sign of ever having been broken. The double frac- ture may have been produced by the same kind of violence that would cause a single frac- ture. There was a slight deformity apparent in that part ofthe limb before a full dissection revealed the true state ofthe parts. The history of the case is not known. I have another specimen of the bones of the leg in which the tibia shows the marks of an old fracture three inches above its lower extremity, and the fibula a double fracture at about the junction of the middle and upper thirds, which shows a de- flection of the middle fragment much as is seen in the above diagram. Probably both the tibia and fibula were broken at the same time, and by indirect violence.. As previously stated, the most frequent fracture of the fibula is that caused by a twist of the ankle, which also ruptures the internal lateral or deltoid ligament,—a strong band that binds the inner malleo- lus down to the bones of the tarsus. The tibia being thus disengaged from its connection with the inner ankle, becomes 16 Fracture of the fib- ula through its upper half; show- ing deflection of the central frag- ment. 242 Fractures. partially dislocated. This complicated injury, from having been particularly described by Mr. Pott, is called " Pott's frac- ture." His words are as follows : " I have already said, and -, 1Q2 it will obviously appear to every one who has examined it, that the support of the body, and the due and proper use and execution of the office of the ankle, depend almost entirely on the perpendicular bearing of the tibia upon the astragalus, and on its firm con- nection with the fibula. If either of these be perverted or prevented, so that the former bone is forced from its just and perpendicular position on the astragalus ; or if it be separated by violence from its connection with the latter, the joint of the ankle will suffer a partial dis- location internally; which par- tial dislocation can not happen, without not only a considerable extension or perhaps lacera- tion of the bursal ligament of the joint, which is lax and weak, but a laceration of those strong tendinous bands, which connect the lower end of the tibia with the astragalus and os calcis, and which constitute in a great measure the ligamen- tous strength of the joint of the ankle. This is the case, when by leaping or jumping the fibula breaks in the weak part, within two or three inches of its lower extremity." Strictly in accordance with Pott's description, a simple frac- ture of the fibula through its lower third, whether by direct violence or other force, does not cover all the lesion he has described. In other words, " Pott's fracture " calls for lacera- tion of the internal lateral ligament, and partial luxation of the tibia, as well as a fracture of the fibula three inches above the lower extremity. I have seen the fibula fractured through its lower third, by direct violence; and the astragalus remained in place, and the deltoid ligament escaped untorn ; and I have also treated cases where the description of Pott was applicable Pott's fracture," or dislocation of the astragalus from the tibia, and fracture of the fibula above the ankle joint. Of the Fibula. 243 Fig. 104. so far as the broken fibula and tibial displacement are con- cerned, but the inner malleolus was fractured instead of there being a laceration of the ligament which is attached to that process of bone. And in one instance, that of a boy of six- teen who had a splay foot and lax ligaments, the fibula was broken by forcible eversion or rotation of the foot outwards, and the tibial part of the articulation remained intact, as well as the ligamentous structures about the ankle joint. Still further, the fibula has been broken by powerful adduction or inversion of the foot, the bone yielding to the pressure of the astragalus against the external malleolus. Malgaigne affirms that there is no displacement (luxation) nor laceration of lig- ament, external or internal, when the fracture is caused by ex- treme adduction ; that if any displacement be found it is secondary, being produced by the patient's attempt to walk. However, it must be admitted by every surgeon conversant with fractures, that in a large proportion of cases in which the fibula is broken a few inches above the external malleolus, the internal lateral ligament is rup- tured and the astragalus more or less displaced from its usual junction with the lower end of the tibia. Pott has described a complicated lesion that occurs in more than half of the injuries in which the fibula is broken near its lower extremity. Fracture of the fibula through its lower third may also be complicated with a dislocation of the tarsus backwards. A person in falling from a height may strike on an in- clined surface, or a hard substance that keeps the heel raised ; and the force caused by the descent continu- ing, dislocates the foot backwards, and breaks the fibula a few inches above the ankle by a lateral or twisting motion. In such an injury the lower fragment of the fibula follows the bones of the tarsus, and abandons all contact with the long fragment. This lesion is analogous to Pott's fracture, the foot being dis- located backwards, instead of outwards. The dislocation, in Fracture of the fibula above the ankle, and dislocation of the tarsus back- wards. 244 Fractures. both cases, is the leading feature of the injury. The foot, however, can be quickly replaced, while it requires several weeks' treatment to secure union between the fragments of the fibula. The symptoms of what is called " Pott's fracture " are quite marked ; yet the patient, as soon as the injury is received, often reaches down and twists the foot back into place, thereby overcoming those prominent signs which so clearly indicate the nature and extent of this complicated lesion. After the foot has been replaced the limb appears so natural in contour that the inexperienced practitioner may be led to suppose that no serious injury exists. I was once called to see Mr. Homan, printer, living then on Elizabeth Street, who had re- ceived a severe twist of the foot by having it caught in a crevice of the sidewalk. He suffered so much pain that he hired a passing hackman to carry him home. A physician of considerable surgical acquirements was called; but before he arrived the patient with his hand had overcome the distortion in his foot. The doctor examined the ankle, and pronounced the difficulty a sprain; he visited his patient every day for about a week, and ordered a lotion which was prescribed at his first visit, to be continued. Mr. Homan becoming dissatis- fied with the progress of the cure, discharged his medical at- tendant, and invited me to take professional charge of the case. According to my usual custom when called to an injury of the ankle, I carefully hunted for fracture of the fibula just above the ankle. There was much swelling about the joint; and it was apparent when the two limbs were compared, that the injured leg presented a little greater concavity on its out- side, above the ankle, than the other. The fingers in being pressed along the course of the fibula discovered at the point of preternatural concavity, a slight irregularity in the bone. Lateral rocking of the foot produced great pain, and caused crepitus. The forced rocking of the foot also developed mo- bility between the fragments, which the finger held upon the suspected point readily discovered. The foot could be rocked outward in a greater degree than is natural; and when once displaced in that direction it was inclined to stay in that position. In an ordinary case of Pott's fracture, the patient not having returned the foot to its normal position, the deformity will Of the Fibula. 245 appear like a dislocation of the foot outwards, though such an injury can not exist without fracture of the fibula. The pain and swelling are noteworthy signs, though not sufficiently distinctive in their character to establish a diagnosis. The fractured ends of the fibula will be driven or held in against the tibia, making a depression at the point of fracture. Per- sons having bad shaped feet, with a great concavity a little above the ankle, on the outside of the leg, and with the ex- ternal malleolus projecting outward, giving great width to the articulation, are prone to have such lax deltoid ligaments that the foot can hardly be kept in place even when no fracture exists. A weak ankle of that kind makes a bad recovery after " Pott's fracture ;" and the result is far from satisfactory even when good treatment is followed. \ Treatment of Fractures of the Fibula.—A fracture of the fibula, not connected with dislocation of the foot, may be Fig. 104. treated with a common lath splint laid along the outside of the leg, and a bandage to re- tain it in place. No shortening of the limb can occur, nor serious displacement of any kind, for the tibia is the chief bone in main- taining the stability of the leg. A patient with a fractured fibula above the lowTer third of the bone, can walk after the limb is dressed with a splint and bandage. However, it is always best not to use the leg except with the greatest care, and with the aid of a cane. The fragments need to be kept quietly in ap- position in order that the union may be osseous. Pott's fracture needs a skillfully applied dressing. After the reduction, which consists in twisting the foot into its natural shape, the leg may have applied to its inner and outer splints and compresses 8{^es a couple of lath splints, two inches or ready forties and ban- •>- x dages, to constitute a more wide, and long enough to extend from dressing tor "Pott's *"" ' o o fracture." near ^he knee to the sole of the foot. Under the lower end of the outside splint a firm compress is to be used to force or rock the foot inwards when the roller is made to perform its part of the work. The outside splint bridges 246 Fractures. over the depression which exists where the broken ends of the fibula are, and prevents the turns of the circular bandage from dropping into it; and the pressure brought to bear upon the very lowest point of the external malleolus tends to force the broken end of the lower fragment away from the tibia and into its proper position. After the dressing is applied the patient may walk on crutches, using the maimed limb with care. In four or five weeks, consolidation may be expected to take place. The limb need not be undressed often during the treat- ment, for the fracture generally does well if properly treated in the beginning. No leeches or fomentations can be of much service, and they may do serious harm. Great pain may attend the injury for the first few days, yet an elevated posi- tion of the leg, and an easily fitting appliance favor a state of comfort and repose. An opiate given twice a day while the inflammation continues, keeps the patient from complaining. Any large blisters charged with serum may be pricked, and excoriated parts kept from pressure. The dressing devised by Dupuytren, in his own language, " consists of a cushion, a splint, and two bandages. The cushion, made of cloth, and filled two-thirds with chaff, should be two feet and a half in length, by four or five inches in width, and three or four thick. . The splint, from eighteen to twenty inches in length, two inches and a half wide, and three or four lines thick, should be made of firm and slightly flexible wood. Lastly, the bandage should be four or five yards in length. The cushion, folded upon it- self in the form of a wedge, is applied to the inner side of the fractured limb, and laid upon the tibia, its base directed downwards, being applied upon the internal malleolus, not pass- ing below it; its apex being above and upon the internal condyle of the femur. The splint applied along this cushion should pass below it, from four to six inches, and'extend below the inner edge of the foot for three or four inches. These first pieces of the apparatus are fixed to the upper part of the leg, by a few turns of bandage directed from above downwards; in this state the splint, pro- Fig. 105. d2J ytren's folded cushion,splint and bandages for treat- ing Pott's fracture of the fibula. Of the Fibula, 247 longed like a kind of lever below the base of the cushion, leaves between it and the foot a space equal to the thickness of the cushion, that is to say, from three to four inches. This exremity of the splint will serve as a ' point d'appni,' to bring the foot from without inwards. For this purpose the end of a second bandage is fixed to it, and then directed suc- cessively from the splint over the upper surface of the foot, upon its outer side, under the sole of the foot, upon the splint; then from this upon the instep and under the heel, to return again to the spliut, and to be continued in the same manner until all the bandage is used; thus embracing in the same circles, which can be tightened at pleasure, the splint and the instep, and the splint and the heel alternately. The foot is brought into such a state of adduction that its external edge becomes inferior, the sole of the foot directed inwards, and its internal edge upwards." It will be seen by the diagram, and be understood by the description, that the dressing of Dupuytren will accomplish the object for which it is designed. The spliut is a lever, the pad a fulcrum, and the bandage through the power imparted to it, is the force to draw the foot inwards; and the action of the lower turns of the roller in drawing the lower end of the external malleolus inwards, necessarily tilts the broken end outwards, or awTay from the tibia, the space in the vicinity of the fracture being purposely left bare or uncompressed. So the broken ends, whether locked against one another or not, may be left unobstructed to return to their normal position. I prefer using two splints, for they stay in place better than one, and constitute an even and firm dressing for the leg and ankle joint; in Dupuytren's dressing his upper bandage con- stricts the leg near the knee, and tends to press the lower end of the long fragment into the interosseous space. In the dressing I have recommended, a compress is used below the external malleolus, large enough to keep the outside splint from bearing on the malleolus itself; and another compress on the inner ankle to keep the inside splint from pressing on the internal malleolus, and to allow the foot to be rocked in- wards without hitting the splint. There is no necessity for canting the foot too far inwards ; an excess of inversion is not desirable. 248 Fractures In cases where no displacement is perceptible I dress the ankle with pieces of pasteboard and a bandage, to strengthen the weakened parts, so the' patient may hobble about with the aid of a cane or crutch. I have seen very good recoveries made without any dressing. If a patient recover from Pott's fracture, with a weak ankle, he can derive some benefit from a shoe with side irons fas- tened to it, such as is worn to correct weak ankles from other Causes. Even a stiff boot or brogan lends some aid. In the case of Harry Edwards, who in a leap from the cars in motion near Brighton Station, broke both bones of one leg, and the fibula a little above the ankle joint in the other, I used two strips of adhesive plaster an inch wide and fourteen inches long, to treat the latter fracture. One end of each strip was applied to the outside of the foot and ankle ; and then the two strips were drawn under the heel and sole, and while the foot was twisted inwards, the other ends of the adhesive plaster were applied to the leg on its inner aspect. These strips prevented the foot from becoming everted ; and as the patient had to be confined to his bed for several weeks on ac- count of the fractures in the other leg, the broken fibula con- solidated long before the other leg was well. The adhesive strips accomplished every purpose sought in a more compli- cated dressing. CHAPTER XXVIII. FRACTURE OF THE BONES OF THE FOOT. The anatomical resemblance between the hand and foot, necessitates a similarity in the nature of the injuries peculiar to both. The tarsal bones are cuboid in shape, and contain a large proportion of spongy material; therefore they are sub- ject to fracture from direct violence alone. The nature of the force producing a fracture of one of these bones must be of a crushing character, consequently the injury done to the soft parts will constitute the leading feature of the lesion. The os calcis partakes, to a certain extent, of the character of a long bone. At any rate, its projection backwards forms the arm of a lever which is acted upon by the powerful muscles of the calf of the leg, and may be fractured by them. The carpus has no bone which, from its shape, is subject to great muscular power. The astragalus, situated so as to receive the entire articulation of the lower end of the tibia, is necessarily subjected to immense forces, and occasionally crumbles under their influence. These two bones, then, may be broken by indirect violence, but the cuboid, scaphoid and three cuneiform bones can only be broken by the fall of a heavy weight upon them or by the passage of a wheel over that part of the foot which they occupy. The fracture can hardly be simple under these circumstances, for the force must bruise the soft parts practically to the extent of rendering the fracture compound. The os calcis in a heavy person, who raises himself quickly upon the toes, is subjected to a powerful force, though the tendo Achillis is more likely to break than the bone. Either accident must be extremely rare, for few surgeons have ever met with a case. The projection of the os calcis posteriorly exposes the bone to direct violence. A miller of my acquaint- ance had his right os calcis broken by the end of a crowbar (249) 250 Fractures. which was violently hurled by the fall of a log from a wagon. He wore a low cut shoe, but it did not prevent the bar from inflicting upon the heel a telling blow. The astragalus is broken by a thrust of the tibia against it; as when a person jumps from a height and comes to the ground with the tibia placed vertically on the astragalus, the shock being sufficient to split or crush the bone. Mr. Lons- dale reports a case of the kind coming under his observation: " The patient was treated for a severe sprain, there being no reason to suspect fracture; the inflammation of the joint, however, was so great, and the man's constitution became so much affected, that the patient died on the twelfth day. The case was considered peculiar, from the severity of the symp- toms ; on opening the joint, however, after death, the astrag- alus was found to be split, in two or three directions, which fully accounted for the constitutional disturbance, and for the other serious defects produced by it." An isolated fragment ofthe astragalus could not well escape from the joint without such serious disorganization as to endanger the articulation, to say nothing of perils to life. In fractures of the os calcis, the strong plantar fascia pre- vents the disengaged fragment from being drawn far upwards by the gastrocnemius and soleus muscles, though surgical writers speak about the separated piece being drawn upwards several inches. In the case of Mr. Conklin, the miller, whose heel bone was broken by the iron bar, there was no marked separation of fragments, but the fullness in what is termed the hollow of the foot, was marked, and the heel seemed to be elongated. Manipulation discovered mobility and crepitus. The pain and swelling were considerable, though the patient claimed that the contusion produced by the missile, was the chief cause of the distress. The inability to walk was mani- fest as soon as an effort was made to take a step. The treatment adopted in that case may be applicable in all similar cases. While the foot was moderately extended it was encased in strips of adhesive plaster until every part was covered in; then two long strips were attached to the top of the instep by their lower ends, and then extended down on each side of the foot to the sole where they crossed each other and came up on each side of the heel and so on to the calf of the leg where they were made to adhere. These kept Of the Bones of the Foot. 251 the foot in a state of extension. The knee was flexed over pillows, and the limb was kept in a state of comparative repose for several weeks. The consolidation was complete, though the functions of the foot remained somewhat im- paired. The point of the heel appeared to be raised a half inch or so. The kind of apparatus commonly recommended is a slipper- like toe-piece nailed to a wooden sole or foot-board as a base for the application of mechanical forces; a pad is placed just above the heel, which has a long strap attached to it; this is first carried down through a ring in the wooden sole, through which it acts like the cord of a pulley, and then extends above the calf of the leg where it is confined by the circular turns of a bandage. The appliance is not equal in merit to the ad- hesive strip contrivance just described. Fractures of the other tarsal bones admit of no apparatus to overcome displacement, and to prevent mobility; but the injury is to be treated like other severe injuries of the foot, no special regard being paid to the fragmentary state of one or more of the bones. The inflammation and suppuration are to be managed on the general principles involved in the treat- ment of wounds. Amputation is required sooner or later in some of the worst cases, though a laying open of the foot and the removal of isolated and carious fragments may save life and a more or less useful foot. The metatarsal bones are less exposed and more exempt from fractures than the corresponding bones in the hand. The forces which break the metatarsal bones are the passage of a wheel, and the fall of heavy weights. Hermann Frieling, while removing a safe on Third Street, had his foot caught between the side of the safe and the door post, and received a fracture of the three outer metatarsal bones. He was carried home, and the boot was cut from his foot before I saw him. Swelling and discoloration marked the line where the sharp corner of the safe had pinched his foot. Crepitation was elicited by manipulation ; there was no displacement discover- able. I placed a compress on the sole against the seat of in- jury and bandaged the foot. In ten days he walked upon his heel, with the assistance of a cane; and entirely recovered, without deformity or defect, in five or six weeks from the re- ception of the injury. 252 Fractures. The fragments, after fracture of the metatarsal bones, are liable to project upwards, though the direction they take de- pends somewhat upon the force which produced the injury. If the healing process takes place with the ends of the frag- ments projecting upwards, the salient points are constant sources of irritation from the pressure of the boot or shoe; and if they sink downwards, so as to produce a prominence on the sole of the foot, the defect is still worse, for the points pressed upon in walking will be constantly tender. The pha- langes of the toes are seldom broken. The first phalanx of the great toe is fractured more frequently than the bones of all the other toes taken together. The fall of a heavy weight upon the great toe, or direct violence quickly applied, is gen- erally the cause of fracture of this digit. The other toes are so small and yielding that they commonly escape fracture though the great toe be caught and broken. The signs of fracture in the first phalanx of the great toe are sufficiently marked for ready recognition. The displace- ment is generally inconsiderable, but mobility and crepitus can be elicited. The treatment for fracture of the great toe consists in bind- ing a splint to its under surface, and keeping the foot at rest during the period of reparation. Lonsdale says that fractures of the great toe are attended with great irritation, which affects the absorbents all the way to the groin, causing ab- scesses to form in different parts of the limb, and producing great constitutional disturbance. Probably these complica- tions arise from the contusion which is apt to be severe when a toe is broken. Bruises of the great toe, if followed by deep suppuration, are attended with constitutional disturbances whether the phalanges be broken or not. PAKT II. DISLOCATIONS. DISLOCATIONS. CHAPTER I. GENERAL CONSIDERATIONS. -------------♦»♦------------ The term Dislocation, or luxation, is employed to signify the sudden and forcible separation of the articular surfaces of two or more bones. The displacement is commonly caused by accidental violence, and is generally attended with lacera- tion of the surrounding ligamentous and connective tissues. Dislocations are injuries of frequent occurrence, and, if allowed to remain unreduced, they constitute a serious and lasting class of deformities ; consequently the practitioner of medicine and surgery, who holds himself in readiness to assume the responsibilities of such lesions must give the sub- ject of luxations a vast amount of careful study, or he will inflict permanent lameness upon those so unfortunate as to call for his services. Almost all physicians are ambitious to attend to surgical cases on account of the eclat arising from a quickly performed operation ; but in order to accomplish sat- isfactorily all their laudable aspirations may crave, intense thought must be given to the mechanism and pathology of the joints. There is no such anomaly as a " natural bone setter," any more than there is a natural engineer or watch repairer. A man may have a love for the principles involved in nicely constructed machinery, and a desire to become a practical machinist,—a love and desire which constitute genius, but the possessor is not a finished artisan until he can practically apply the principles of the art or science—an at- tainment which is the result of prolonged study and persever- ing toil ; a young man may feel an intense longing to master a ship, and study navigation for that purpose, which is a pre- (255) 256 Dislocations. requisite to success, but he will never find the capitalist who will entrust a valuable cargo to his care until he has crossed the seas and learned the winds and the seasons, the currents and counter-currents of the ocean, and something of the varied influences known only to the practical navigator. Any claims for natural gifts in navigation would be treated with con- tempt. A few individuals have gotten the credit of being natural bone setters, but their merits, so far as they go, depend more upon tact than skill; and the prevailing credulity of the peo- ple has given them more reputation for ability than might reasonably be expected from their limited success. A family by the name of Whitworth, in England, and another by the name of Sweet, in Connecticut, have assumed to possess these wonderful inborn qualities. For tw^o or three generations, one or more of the male members of these families claimed to possess a secret power for reducing dislocated bones; and not a few persons of average intelligenee give credence to these preposterous assumptions. Any uneducated man with a large endowment of boldness and self assurance, claiming to be a natural bone setter, could by giving every distorted joint coming in his way, a severe pulling and twisting, accomplish some cures; the successes would be heralded far and near, and the failures would pass unmentioned and unre- membered, consequently he would soon gain considerable ex- perience in handling defective joints, and if he proved to be a good learner he would acquire considerable skill in his pre- tended art. Having received no lessons in anatomy and sur- gery, success even in a single case would be received in the popular mind as positive evidence of innate powrers. Love of the marvellous is so infatuating that every age will have to endure its quota of imposters. However, it is not to be denied that these charlatans have done some good indirectly. The fact that a dislocated bone could be reduced by manipu- lation, without the aid of pulleys and other instruments for multiplying force, led such discreet surgeons as Dr. Nathan Smith, to put the manipulating plan into successful practice* The Whitworths, Sweets, and others of their order, studi- ously keep to themselves their plan of operating, though ®See "Surgical Memoirs of Dr. Nathan Smith," by his son, Dr. Nathan K. Smith, of Baltimore. Dislocations. 257 competent observers declare that it is not essentially different from the plan now followed by-the most intelligent portion of the profession. Being aware of their general incompetency in surgical science, these " natural bone setters " preferred to keep secret the little knowledge they possessed, hoping to re- tain this meagre advantage over those who in every other respect were their superiors. Probably a similar feeling actu- ated the Chamberlains to keep as a secret in their family a knowledge of the obstetric forcep. Such detested selfishness, by a law as unvarying as that of gravitation, will taint the name of those who in any branch of the healing art, withhold knowledge which accident or genius has placed within their power. Anything in medicine or surgery which will benefit our fellow men ought to be the common property of mankind ; and he possesses a sordid spirit who from selfish motives will not promulgate a secret which will ameliorate the condition of the unfortunate. The dabbler in secrets is, by the common consent of all good men, branded indelibly with the disgrace that cleaves to the quack and the charlatan. The manipulating plan of reducing dislocations is now well understood by those having a knowledge of the anatomy of the joints, and of the muscles, ligaments, and other struc- tures involved in a luxation. The use of anaesthetics in overcoming the rigidity of dislo- cated limbs, has also contributed to overthrow the old method of replacing a displaced bone by mechanical violence. In the present advanced stage .of knowledge pertaining to disloca- tions there is little use for the pulleys, straps, hooks, and other appliances so indispensable a half century ago ; and it is to be hoped that knowledge will still further advance, so that these contrivances shall be looked upon more as objects of curiosity and implements of torture than as the appliances of an en- lightened profession; and that the cruelties practiced with them will be associated with those of the old Spanish Inquisitions. It seems a pity that somebody before Dr. Nathan Smith's time did not take a hint from the Whitworths or Sweets, and study out and put in practice a principle of reduction in dis- locations which was demonstrated by those charlatans to have an existence. Perhaps the spirit of the profession was too arrogant to receive suggestions from such a source. Unfor- tunately for the world, good ideas are often kept from seeing 258 Dislocations. the light on account of the illiberality of the influential classes. The joints are generally encased in capsular ligaments; at some point there may be a thickening and a strengthening of the ligamentous tissues, and this augmentation may receive the designation of a distinct band of fibers, yet these several ligaments, as the anterior, posterior, and internal and external lateral, generally go to make up one continuous structure which encloses the entire articulation. In nearly all instances of dislocation this ligamentous bag or capsule is torn by the force that displaces the bone; in" rare cases the ligament stretches sufficiently to allow the bone to remain partially dis- placed. The bone, after it has been forced through a rent in the capsule, is often dragged away from the opening, or so twisted by muscular contraction, that it is no longer in a fav- orable position to return through the laceration. This is par- ticularly the case with the shoulder .and hip joints. But if the limb be carried to the attitude it was forcibly made to as- sume when the head of the bone escaped from the socket, the part protruding through the capsule will be in a favorable po- sition to return. In attempts to reduce dislocations of the hip and shoulder the surgeon must seek to get the limb into that attitude ; and if he succeeds, very little force will be re- quired to complete the reduction. Direct violence rarely knocks a bone out of place; dislocations are generally pro- duced by forces acting upon the displaced bone as a lever, some portion of the articular structures performing the part of a fulcrum. Muscular force assists in producing dislocations, and the power continuing prevents the return of the bone to its normal position. However, the antagonistic muscles, if given an opportunity to act advantageously, assist in all ra- tional attempts at reduction. A proper appreciation of the construction of joints, and of the functions of muscles and other tissues surrounding them, has created a revolution in the art of reducing luxations. In the " Surgical Observa- tions " of Dr. J. Mason Warren, page 354, the revolution is acknowledged to the following extent: " The use of ether has made a very great change in the practice pursued in the treat- ment of dislocations of the hip, which can now be very fre- quently reduced by normal assistance only, thus enabling us, in many cases, to dispense entirely with pulleys ; and, by Dislocations. 259 successive movements of flexion, abduction, and rotation, to restore the head of the bone to its socket with remarkable facility."' This is an acknowledgment from high authority in regard to a joint which, when dislocated, once called for ex- tending apparatus of the most powerful kind. Dr. W. W. Reid, of Rochester, N. Y., who has written out an exceed- ingly clear plan for reducing dislocations of the femur by manipulation, says, in concluding his paper on the subject: " Dislocation of the hip on the dorsum ilii, an accident so serious to the patient, and so formidable to all surgeons, is re- duced with the greatest ease, in a few minutes, without much pain, without an assistant, without pulleys, without ' Jarvis' Adjuster,' or any other mechanical means, simply by flexing the leg upon the thigh, carrying the thigh over the soiind one, upward over the pelvis, as high as the umbilicus, and then by abducting and rotating it." Dr. Reid has succeeded in reduc- ing dislocations of the femur in several instances by the " natural plan," and therefore does not speak from a theoret- ical point of view alone. The plan has been carried into suc- cessful operation by a great number of surgeons, and always without failure when Dr. Reid's rules were followed. Jarvis' Adjuster, once so popular that the inventor could hardly fill orders as fast as they were given, has gone almost entirely out of use, and young surgeons rarely indulge in the expense of a set of pulleys. In my own practice I have found no case of recent dislocation that could not readily be reduced by manipulation, under chloroform. Our older works on dislo- cations, from Cooper to Hamilton, have a great display of il- lustrations to show how the pulleys should be applied in efforts to reduce luxations of the hip and shoulder, yet there is rarely, if ever, a necessity for following those directions. Perhaps the publishers of modern surgical works, whose illustrations belong mostly to the past, have been ambitious to make a numerical display of cuts, caring little whether they contrib- uted to perpetuate a fundamental error in practice or not. Dr. Reid, in his essay, read at the annual meeting of the Mon- roe County Medical Society, in May, 1850, says, "Having wit- nessed, on several occasions, the inquisitorial torture inflicted upon the unfortunate patients—their screeching—their piteous begging to be released—the slipping of bandages—the yield- ing and re-adjusting of fixtures—the delay—the duration of 260 Dislocations. the operation, sometimes two or three hours,—the exhaustion of the patient', and after all, in some instances, a failure, and the patient a cripple for life, a profound horror and prejudice against the use of pulleys seized me (Jarvis' Adjuster had not then been invented), and I could not avoid the conviction that a great power was unnecessary, and that it must be misap- plied. Preceptors, professors and authors were interrogated. The unanimous reply to all my queries wTas—' to overcome the contraction of the great muscles, which drew up and short- ened the limb, viz., the glutei, triceps femoris, the iliacus in- ternus and psoas magnus.' But do these same powerful mus- cles contract, and shorten the limb when there is fracture in the neck of the femur? Yes. And you tell me that one of the diagnostic symptoms between fracture and dislocation on the dorsum is, that in fracture the limb can be easily extended to its normal length, by the strength of one man, while in luxation it can not. Now why do these great muscles require so much more force to overcome them in one case than in the other ? To this I could get no satisfactory or even plausible reply." It will be seen that Dr. Reid looks upon the mechanical method of reducing dislocations of the hip as senseless in the extreme; and indicates a physiological plan which consists in giving the limb an attitude which relaxes the muscles, and places the bone in a position favorable to a return through the laceration in the capsule. To pull the limb straight down- wards, as is done by mechanical appliances, renders some of the muscles rigidly tense, and constricts the neck of the bone with the untorn portion of the capsular ligament. Every joint not being ball and socket, like the shoulder and hip, the same kind of manipulation will not succeed with them when dislocated, yet the principle of placing a bone in the exact attitude in which displacement was effected, is the position favorable to reduction. For instance, the first pha- lanx of the thumb is dislocated backwards by a force which throws it into extreme flexion, the bone being a lever to tear the capsular ligament, and the muscles a secondary force to draw it back after the usual points of resistance are overcome. The bone having been dislocated while in extreme flexion, re- turns to nearly its normal attitude as soon as the flexing force is removed, for the projecting articular rim has dropped into Dislocations. 261 a depression behind the head of the metacarpal bone. Now, to make extension straight forward would not effect reduction unless the force be great enough to rupture the yet untorn portion of the ligament which is rendered tense by the dis- placement of the phalanx. But if the thumb be carried into extreme flexion, where it was when luxation took place, the projecting rim is lifted from the depression spoken of, the un- torn portion of the ligament is relaxed, and everything is made ready for the reducing manoeuvre, which consists in the operator placing his thumb firmly behind the displaced pha- lanx where it is to perform the part of a fulcrum, while the dislocated thumb is used as a lever to pry the displaced bone into its normal position. In the upper extremity the bone nearest the trunk is re- garded by all authors as the one from which the distal bone is dislocated; for instance, the humerus is dislocated from the scapula, the radius and ulna from the humerus, and so on, but in the lower extremity the rule is not maintained by all; the femur is regarded as dislocated from the acetabulum, and the tibia from the femur, but several authors have changed the rule so far as the tibio-tarsal articulation is concerned. Cooper, Malgaigne, Hamilton, Gross, and others, regard dis- locations of the ankle as displacements of the tibia forwards, backwards, etc. On the contrary, many prominent French, English, and German surgeons, adhere to the rule as applied to other joints, and speak of dislocations of the foot when the luxation is at the ankle. There seems to be no valid reason for this exception to a rule that ought to be general; and it wTould have been credit- able in Hamilton, Gross, and other American surgical writers, if they had lent their great influence toward correcting this manifest error in the manner of considering the subject. Dislocations need to be considered in a variety of aspects ; they have been divided into congenital and traumatic as gen- eral classes ; and subdivided into the simple, compound, com- plicated, partial, complete, recent, ancient, primitive, and con- secutive. Congenital dislocation is a lesion intimately connected with malformations and defects of childhood, and does not legitimately belong to that great class of accidents ordinarily embraced under the head of luxations. Robert Smith, of 262 Dislocations. Dublin, reports a case of congenital dislocation of the jaw, in an idiot, and states that the upper jaw projected beyond the the lower, and the mouth could be freely opened and closed; the reverse order of signs is observed in accidental luxations of that bone. Certain dislocations of the shoulder seen in young subjects are occasionally not complete luxations, but partial displacements arising from paralysis or irregular muscular contractions. Dupuytren looked upon these defects of the shoulder-joint as the result of arrested development in the bones constituting the articulation, the socket being mostly at fault. Chelius and Cruveilhier ascribe them to the position of the foetus in the womb. Guerin considers them as the pro- duct of an active or primary retraction of the muscles, the remote cause of which is to be sought in the affection of some central part of the nervous system; and that they result from the same causes as club-foot, wry-neck, etc. I have seen a partial dislocation of the head of the radius, congenital in character, in a bright little girl having no other defects, ex- cepting that one. The entire elbow joint was considerably involved in the imperfect development which permitted the luxation. By the fifteenth year the arm so far recovered, without treatment, that the limb was as useful as the other, and no apparent deformity existed. Robert Smith reports several congenital dislocations of the wrist, in which there was defective development of the arm bones, and distortions of the carpus. His observations were founded upon dissections; and he criticises the speculations of Dupuytren and Cruveilhier in regard to cases of theirs which they regarded as the result of epiphyseal injury. A certain preternatural laxity of the soft tissues, brought about in some instances by nervous disorders and faulty nutrition is found in these cases of congenital luxations of the wrist, as well as of some of the other joints ; and a large share of which will improve by growth and age. Some of these cases are not true dislocations, but partial luxations arising from extreme flexion and extension. Congenital dislocations of the femur are occasionally met in defective organizations, or as Cruveilhier says, vices de confor- mation. He found in one case, in connection with club-feet and club-hands, a congenital luxation of both thigh bones ; the foetus died at birth, and was found to be without kidneys Dislocations. 263 and testes, and marked with other deficiences; the heads of the thigh bones were flattened, and the cotyloid cavities were shallow. Dr. J. M. Carnochan, who has given considerable attention to infantile deficiences, says that " Congenital defects occur- ring in the ilio-femoral articulation result from active morbid muscular retraction ; that morbid muscular retraction itself is to be traced to a morbid condition of the central ganglionic mass of the cord ; and this pathological condition is either located in the ganglionic mass, or conveyed thither by the in- cident-exciter nervous influence of the excito-motor apparatus of the medulla spinalis." This is not given with Prof. Car- nochan's usual perspicuity. The gait in congenital dislocation of .the thigh on both sides, is peculiar and unmistakable ; no other motion is like that which is occasioned by this lesion: it is a rolling motion ofthe trunk together with double lameness; and yet it is painless and rapid. In some instances the nervous defect is so great that the individual is compelled to move about in a go-cart, being unable to balance the body and move the limbs with any degree of certainty. Congenital dislocations of the knee are generally sub-luxa- tions resulting from abnormal muscular contractions; and, to be substantially benefited, require subcutaneous section of the ham-string tendons, and mechanical extension ofthe limbs. Partial dislocation of the ankle, as a congenital defect, is a species of " weak-ankle," the ligamentous and fibrous tissues being too lax or undeveloped to sustain the lateral strain ne- cessary to a firm joint. The foot seems to be affected with a variety of talipes, and flaps about with much uncertainty. A shoe with side irons extending up the leg, and fastened to the limb with a hoop and strap, affords some relief, and assists in a cure or substantial improvement. Congenital dislocations, from what has just been said of them, are to be looked upon as the result of arrested or per- verted development, and are not, except in rare instances, to be treated by a process of rapid reduction, like those luxations that occur suddenly from accident. Traumatic dislocations are the forcible separation of the ar- ticular surfaces of two or more bones, in which the loss of power is instantaneous, and the luxated part is excessively 264 Dislocations. rigid. The names of the varieties have already been given. A simple luxation is unaccompanied with serious complica- tions, though there is generally a rupture of the ligamentous structures. It may be caused by external violence, and mus- cular contraction. The humerus is often dislocated by the ac- tion of the muscles only. A convulsive condition has been known to produce dislocation of several of the joints. The term compound is applied to a dislocation, in connection with which the displaced bone is forced through the flesh and skin, or an opening is made in some other way, communicating with the cavity of the articulation. A complicated dislocation is one in which there is a more ex- tensive lesion than simple displacement or separation of ar- ticular surfaces : the term implies that the soft parts have been extensively lacerated, including nerves and bloodvessels; or that a fracture has been produced in connection with the dislocation. A partial luxation is one in which the articular surfaces are not wholly removed from one another, though the fuuction of motion in the joint is temporarily arrested by the displace- ment. In such dislocations the ligamentous surroundings are not necessarily torn, the fibrous structures being sufficiently elastic to admit of the disjunction. The injury is somewhat rare; probably such displacements are occasionally reduced without the medical attendant fully understanding whether the luxation was incomplete or not. In a complete dislocation the displaced bone is forced entirely clear, of the other so far as corresponding articular surfaces are concerned, and finds lodgment in a new position, gener- ally near the old situation, as when the head of the luxated femur rests against the border of the acetabulum. In a com- plete dislocation the capsular ligament is necessarily torn, and the head of the luxated bone escapes through the rent. A recent dislocation is one that has not existed many weeks; . in fact, a luxation of some joints is old at the end of a week, for it is not time alone that renders a dislocation old in a sur- gical sense. If such changes have taken place in the struc- tures about the joint as to render reduction unsafe or imprac- ticable, the dislocation is practically old though it have ex- isted only a few days. A dislocation, then, may be considered recent, if it can be reduced without danger of rupturing im- Dislocations. 265 portant nerves, blood-vessels, and other structures which have become changed in their conditions by inflammatory action, or rendered unfit to assume their normal relations. An old or ancient dislocation is one in which such changes have taken place in and about the joint as to render attempts at reduction unsafe and uncertain. It is not uncommon to meet with luxations which have escaped detection or passed unreduced for several weeks or even months; and the ques- tion arises whether an attempt to overcome the displacement is justifiable. The humerus has been replaced after being out six months and more, but to reduce a luxated elbow that had been out six weeks, would be to inflict an amount of injury that might result in death. Since the introduction of chloro- form into surgical practice, well directed attempts at reduction of ancient dislocations have not been attended with those serious injuries that were wont to occur, and the efforts have been rewarded with far more successful results. By the man- ipulating plan the displaced bone is not so liable to be frac- tured, nor is the danger of rupturing blood vessels so great, as when no anaesthetic was used, and pulleys and other in- struments for multiplying force were generally employed. A dislocated bone generally remains in the place it origin- ally took when luxation occurred; it may then be called a primitive dislocation, as distinguished from a luxation in which the displaced bone is made to abandon its original position and take up with another, which is called a consecutive disloca- tion. For instance, a man may have a dislocation of the shoulder, the head of the humerus being forced beneath the coracoid process; and in going home or in being removed from one place to another, the bone may get forced inside the process and be drawn up against the clavicle: the former would be a primitive, and the latter might be considered a consecutive dislocation. Joints which admit the most extensive range of motion, as the ball and socket,—the shoulder and the hip—are the most frequently dislocated ; the ginglymoid, as the knee and elbow —being more restricted in their motions, rarely get displaced. According to the tables of Malgaigne, the shoulder is dislo- cated oftenerthan all tne other joints in the body. The hip has a deeper socket, and is not so much exposed to displacing forces as the shoulder. The vertebras are so firmly bound in 266 Dislocations. place by ligaments, and prevented from displacement by com- plicated processes, that they seldom suffer luxation. There are few physicians of ten years' experience but have met with dislocation of the shoulder ; yet they may not have seen a luxation of any other joint. I once asked an old sur- geon of extensive experience to give me a list of the disloca- tions he had been called upon to treat; and this is his report: Dislocation of the inferior maxillary, 2 ; of the cervical verte- brae, 1; of the clavicle, 2 ; of the humerus, 11; of the radius, 3; of the thumb, 3 ; of the fingers, 2; of the femur, 2 ; of the patella, 2 ; of the tibio-tarsal articulation, complicated with fracture of the fibula, 5 ; of the toes, 3. It will be seen that in his practice the shoulder was found dislocated far more frequently than any other joint, though the number is less than all the other luxations counted together. He had never seen a dislocation of both bones of the arm at the elbow, although it is not an extremely uncommon accident; and had never met with a complete dislocation of the knee, though he said he had found the joint in a painful and rigid state which he diagnosed as displacement of the semilunar cartilages. Age has an influence upon the relative frequency of disloca- tions ; the very young and the very old are not liable to such accidents ; in middle life luxations most frequently occur. The elastic condition ofthe tissues in youth, serves to decom- pose forces tending to produce luxations, the pliant structures yielding sufficiently to avert the accident; in advanced age the bones become brittle, therefore they are more liable to be fractured than to be dislocated. Thus, if an individual sev- ( enty years old sustains a severe injury at the hip, a dislocation could scarcely be expected, yet a fracture of the neck of the femur would be highly probable. Elderly persons who suffer severe injuries ofthe shoulder, are most likely to sustain frac- tures of the clavicle, though dislocation of the humerus has been met in persons advanced in life. The causes of dislocation are sometimes quite insignificant, or apparently so. A girl of sixteen dislocated the shoulder in attempting to throw the loop of a string over a peg a little higher than she could reach ; another school girl dislocated the head of the radius while she and a companion were play- fully swinging arms ; the thumb has been luxated from seem- ingly trivial causes; the under jaw is frequently dislocated Dislocations. 267 while gaping; the patella may be displaced outwards when the patient had no reason to suspect even a mild form of in- jury. Muscular action in such instances seems to be adequate to produce luxation. If a bone has been dislocated once it is ever after liable to the same accident; at least, it is not un- common for some joints to suffer dislocation a number of times. External violence may operate directly and indirectly in pro- ducing luxations; thus, a severe blow upon the top of the shoulder may drive the head of the humerus downwards into the axilla ; but if the hip be dislocated by a force received on the knee, the action is indirect. There are not many joints that can be dislocated by direct violence; the shoulder is one, and I have known the patella to be knocked out of place by a blow. A combination of forces most frequently produces a dislocation. For instance, the .elbow is forced upwards until the humerus as a lever acts across the acromion as a fulcrum, to lacerate the capsular ligament; at this point in the progress of the injury the muscles jerk the head of the bone out of its normal relations with the joint. A drunken man whose mus- cles are in a state of relaxation, rarely sustains a dislocation though exposed to the action of forces that favor such inju- ries. In order to produce a luxation of the shoulder in a cadaver, the operator must first rupture the capsule of the joint by using the arm as a lever, then push the bone through the rent. Dead muscles will not complete the injury after the capsule has been lacerated and the bone is presented in a fav- orable attitude for displacement. When a bone is dislocated in life the limb is generally in such a position at the time of the accident that the antagonism of the muscles is for the moment destroyed,—one set being relaxed and another, whose action is in an opposite direction, put violently upon the stretch. Symptoms.—Timothy Holmes, in his System of Surgery, says : " A complete dislocation is, in typical cases, attended with such very distinct symptoms, that when these are fairly de- tailed upon paper the reader is tempted to say that the injury is unmistakable. Yet the great number of old unreduced dislocations which are still seen, even in patients who have been from the first under medical supervision, proves that, notwithstanding the elaborate care with which the symptoms 268 Dislocations. of dislocation in general, and of each special injury in partic- ular, have been described ever since the time of Astley Cooper, such mistakes can not always be avoided, even by well-in- formed and careful men ; and it is no doubt true that errors in diagnosis on this head will sometimes occur to the best surgeons, in consequence of extreme depth of the parts, of great effusion and swelling over them, or of complication with other injuries ; but with proper care such mistakes ought to be very seldom made even at the time of the accident, and attention to the subsequent progress of the case will alwa}rs enable the surgeon to correct his error while there is yet a fair prospect of easy reduction." I take pleasure in being able to offer such distinguished testimony in favor of opinions so near in conformity with my own. In the |inalpractice suit of " Larkin versus Jones," tried at Marion, Grant Co., Ind., in April, 1869, 1 declared to the court that it was no rare or un- common occurrence for physicians of average professional qualifications and experience, and of considerable surgical pretensions, to fail to discover dislocations, even when called early, and having opportunity to examine the case before swelling and other conditions tending to mask the real state of the injury, had come on. I cited cases of dislocation of the shoulder which had passed undetected through the hands of quite pretentious surgeons. This opinion was attacked as unsound, by Dr. Wm. Lomax, and other physicians of Grant County, who thought a dislocation of the shoulder would never be overlooked by a physician of ordinary skill and ability, though the injury be of two days' standing when first observed. All claimed to have had several cases of disloca- tion of the shoulder to treat, and denied ever having been in doubt in regard to the nature of the injury. '* The general symptoms of dislocation are, great pain sud- denly following the accident, loss of motion and rigidity in the articulation, change in the natural contour of the joint, shortening of the limb in most instances, loss of voluntary motion except to a limited extent and in certain directions, absence of crepitus, a disposition to remain in place after the luxated bone is reduced. Fractures have quite different symptoms; they are attended with pain and deformity, as are dislocations, but there is an increase of mobility, the existence of crepitus, the pain is not overcome by reduction, and the Dislocations. 269 displaced bone will not stay in place when adjusted. There are two distinct injuries, a fracture and a dislocation, of the shoulder, which closely resemble each other; a luxation of the humerus inwards appears much like a fracture of the neck of the scapula. The fracture allows of free passive mo- tion, and crepitus can generally be produced after reduction; and when adjusted and left to itself the displacement readily occurs. In dislocation the arm is rigid, and will not admit of passive motion, and reduction having been effected the dis- placed bone will remain in its natural position without assist- ance, no crepitus can be elicited, and the coracoid and acro- mion processes maintain the same distance between each other. Fractures of the neck of the femur are characterized by in- creased mobility and eversion of the foot; dislocation of the femur is attended with great rigidity and inversion of the foot. Injuries about the other joints exhibit certain signs which indicate whether a fracture or a dislocation exists ; and when luxated the natural axis of the bone is so changed that it no longer corresponds with its socket, there is intense pain where the head of the bone rests in its new situation, and the limb is greatly benumbed as well as rigid. If the symptoms be not sufficiently distinctive to remove all doubts in regard to the nature of the accident, the patient may be put under the influence of anaesthesia, and then care- fully examined. Pathological Anatomy.—In a recent dislocation it is found that the capsular ligament is torn, and m ^as been knoAvn to force the bone from its natural position. Young Avomen of lax ligaments, Avhose Avide hips, and approxi- mating knees, throAv the patella inside of a line drawn from the tubercle of the tibia, where the ligamentum patella is inserted, to the centre of the origin and action of the qua- driceps muscle, are most liable to this accident. It is obvious that the muscles A\Thich, in going to their insertion, are made to SAverve iuAvards to embrace the patella, Avould in their con- tractions tend to displace that bone outAvards. There are several varieties ofthe outward dis- placement ; the bone may be partially luxated or throAvn so far outAvards that the inner artic- ular half of the patella Avould rest upon the outer condyle ; and oAving to the obliquity of the surfaces in contact, the outer edge of the Di8\0eciiao^rdfypa' bone is made to project prominently. In a complete dislocation, the patella is throAvn wholly outside the most prominent point of the external con- dyle, and the inner edge of the displaced bone is made to project forward. The capsule of the joint is more or less (388) Of the Patella, 389 lacerated by the complete luxation. The inward dislocation, which is a rarer form of injury, is generally produced by direct violence, and not by muscular action. Blows received in falls, are the common cause. In the dislocation edgewa}^s the patella is turned on its axis, so that the articular surfaces of the patella face imvards, and the front surface outAvards, the outer edge of the bone being buried in the fossa betAveen the condyles. There is no difficulty in detecting the nature of these dis- placements ; the patella can be easily felt in its unnatural posi- tion, the bone being forced upon its edge or too far inwards, or outAvards. The knee after luxation of the patella is par- tially flexed and too firmly fixed to admit of voluntary motion. Any attempt to move the limb is attended Avith great pain. In the lateral dislocation the Avidth of the knee is increased; and the position usually occupied by the patella presents a depression to be both seen and felt. In April, 1860, I Avas called to see a boy on Fifth Street, opposite the Market House, who in falling down stairs hit his left knee against the corner of a box, and received a dislocation of the patella inwards. The mother avIio Avas near Avhen the accident occurred, carried the boy up stairs, and tried to make him stand and Avalk; but he complained that his knee Avas broken, and he could not use it. I found the leg considerably flexed, rigid, and excessively painful. After taking qff the patient's pants, I recognized the nature of the injury at once ; and proceeded Avithout delay to replace the bone. 1 encountered more resistance to a return of the bone than I had anticipated. At first I attempted to extend the limb to relax the quadriceps, but could not do it without eliciting the sharpest cries from the patient. I found the patella Avould not readily slip over the high edge of the inner condyle, so I sent for chloroform, and when the patient was Avell under its influence, I had no trouble in pulling the patella outwards into its place, the fingers being strong enough to lift it to a point where the action of the muscles Avould re- place the bone. Treatment. — The outAvard displacement may generally be overcome by slight movements of the joint, and firm pressure made against the outside of the bone ; but the displace- ment inwards, and the edgeways dislocation, are more diffi- cult to replace or return to position. In these forms of dis- 390 Dislocations. placement great force is required to effect reduction, and all movements are attended with extreme pain, therefore the quieting and relaxing effects of an anaesthetic should be brought into requisition. A case is reported by Dr. Gazzom, of Pittsburg, Pa., in which a man in a wrestling match Avas thrown, and was unable to rise on account of the patella hav- ing been dislocated upon its axis, the edge of the bone resting in the sulcus between the condyles. Varied and repeated at- tempts at reduction failed; the doctor, by the advice of an- other physician, divided subcutaneously the ligamentum patellae close to the tubercle of the tibia, and then made efforts at reduction but failed; bleeding to syncope Avas tried, yet the bone could not be adjusted; the next day the leg was flexed on the thigh, and the thigh on the pelvis, and then the leg suddenly straightened, according to the suggestion of Dr. Watson, who placed his patient in a chair, and then taking his foot upon the shoulder, flexed the knee a little by the for- ward inclination of the body, and then suddenly extended the leg, the hands being used to help execute the manoeuvre. This plan succeeded with Dr. Gazzom upon a fourth trial. Mr. Flower had a case in a lad avIio fell betAveen the seats of a theatre gallery, the patella being forced half Avay round and turned up edgeways, between the condyles of the femur and the head of the tibia. The limb AATas extended, and all attempts at reduction by bending the. knee, manipulating the patella, etc., Avere unavailing. Chloroform was then admin- istered, and the bone easily replaced. If the ligamentum patellae be ruptured or extremely relaxed the patella maybe displaced upwards. This could not be legitimately considered a dislocation, but a rupture of the ten- don. Such an injury should be treated in every respect as if it Avere a fracture of the patella. It is often difficult to keep a patella, which has once been dislocated, in place ; therefore when the bone is once reduced an elastic knee-cap should be worn, or an apparatus with ring or disc on the side the dislocation has occurred. Side irons extending a feAV inches above and beloAV the knee ioint 1 in the middle, and having a semi-circular iron band at e- 1 end to surround the posterior half of the leg and thio-h . i straps to buckle over the front part, may be worn to streua-th'm the joint and to prevent re-luxation. CHAPTER XIII. DISLOCATION OF THE TIBIA. The tibia may be dislocated forwards, backwards, and to either side, though it is seldom displaced in any direction. The articular surfaces at the knee-joint being large, and the connecting ligaments exceedingly strong, luxation can not be produced without great displacing power be brought to bear. The lateral dislocations are frequently partial, but the for- ward and backward luxations are generally complete, the tibia being also rotated in some degree upon its axis. In the backward dislocation the head ot the tibia forms a projection in the ham, and a deep depression exists in front of the knee, beloAV the protuberant condyles of the femur. The lower end of the patella follows the tibia, and thus becomes placed horizontally, with its anterior sur- face looking downwards and its upper margin forwards. The limb may be straight or forcibly extended. The mus- cles about the knee are nearly all put upon the stretch, and the vessels and nerves of the popliteal space are com- pressed. If the tibia be thrown entirely behind the articular surfaces of the con- dyles, the crucial ligaments will be torn, and other tissues about the joint stretched or lacerated. The backward luxation is generally produced by direct violence applied to the upper and front Bart of the tibia when the knee is beut. F (391) Dislocation of the tibia backwards, 892 Dislocations. Treatment.—When the patient is under chloroform there is no great difficulty in reducing the bone by manipulation. If ordinary manipulation fail, an assistant may hold the thigh upon the arm of a sofa, foot-board of a bed, or any projecting ridge, while the surgeon extends the leg if it be flexed, or flexes it if in a state of extension, at the same time pulling the leg into position. It is rarely necessary to make use of pulleys or other appliances for exerting poAverful extending and counter-extending forces. The hands of another assistant to push the tibia forAvard and the femur backward, might aid in the Avork of reduction. Dr. Rose, in the Provincial Medical Journal, reports being present Avhen a woman had the tibia dislocated backwards by a fall occasioned by a carriage being driven furiously against a ladder on Avhich she Avas standing. The kuee Avas rigidly held in a state of fixed extension. The patient being relaxed from the shock of the injury, the doctor had no difficulty in pressing the displaced bones into position ; and in the course of a few weeks, under the influence of local antiphlogistic treatment, the woman made a successful recovery. The forward dislocation of the tibia is a rare accident, and presents features quite the reverse of the backward displace- ment : the tibia and patella project forwards, and the condyles of the femur produce a SAvelling in the ham. The popliteal artery and nerves are compressed to the extent of endanger!no- gangrene; the ligaments about the joint are lacerated; and the limb is more or less shortened and extended. The pro- jection of the leg bones in front and the femur behind, clearly indicate the nature of the displacement. The causes of this injury in cases reported, have been the stepping into a ditch while carrying a heavy Aveight; the fall- ing of a heavy spar on a man's back, tho knee being forced to give way under the weight and shock; and direct blows. Malgaigne is of the opinion that neither the forward nor the backward dislocation of the tibio-femoral articulation is com- plete, though it would be difficult to account for the shortening in the cases reported, if the luxations were only partial October 10th, 1860,1 was called by Dr. Adams, of Covington Ky., to see a negro boy who received an injury of the knee by falling into a coal barge anchored in the Licking river The boy m falling backwards struck the edge of a projecting Of the Tibia. 393 board, which hit just above the calf of his right leg The upper part of the leg was driven forwards, and the condyles of the femur Avere prominent in the popliteal space. The for- ward dislocation of the tibia Avas unmistakable; and its re- duction Avas effected by manipulation, while the loAver part of the thigh projected over a chair. The leg Avas found in a forcibly extended position. The boy received other injuries of a serious nature, but ultimately recovered perfectly from all. His left ulna Avas broken by direct violence through its upper third, and it Avas thought that the eighth rib Avas broken near its angle. Dr. Sanborn, of Lowell, Mass., reports through the Boston Medical and Surgical Journal, for 1856, a case of dislocation of the tibia forwards which Avas produced by moving machin- ery in one of the factories of the city, the man being caught in a belt and carried round a shaft, the leg hitting the timber above at each revolution. At first sight the limb seemed to be broken in many places ; it Avas shortened by several inches and shapeless ; a closer examination proved that no fracture existed, but a complete dislocation of the tibia fonvards, the condyles of the femur being driven doAvn beneath the gastroc- nemius muscle ; and the tibia rose up in front, forming a marked projection. An assistant held the pelvis, and the sur- geon grasped the ankle and drew the leg doAvnwards to its proper length; and the bones then slipped into place. The patient made a satisfactory recovery. The treatment of the forward dislocation is to be managed on precisely the same principles as the backward luxation; the patient is to be put under the relaxing and stupefying effects of chloroform, and then the surgeon extends the leg and pushes the displaced bones into their natural relations. If he is unable to accomplish reduction alone, he can engage the strength of assistants to good advantage. In those cases of forward and backAvard dislocations Avhich obstinately oppose reduction, it is not improbable that the lateral ligaments, Avhen they escape untorn, offer the chief resistance. To over- come these obstacles the leg would have to be forcibly flexed or extended to relax the tense tissues. If the leg was found in a partially flexed condition, it Avould have to be flexed still more; if in a state of extension, it should be extended even 394 Dislocations. beyond the straight attitude, before the displaced bone would slide into place. The outward and inward dislocations of the head of the tibia, as has already been stated, are, on account of the Avidth of the knee-joint, only partial. A violent twist of the leg, coupled with the displacing force the leg often sustains in a fall of the body, and the effects of moving machinery, are accounted as the common causes of lateral dislocations of the tibia. The signs of the displacement are too strongly marked to pass undetected. There is no shortening, but the limb is rigid, slightly flexed, with the foot inverted or everted as circumstances may direct. The prom- inent projections laterally ofthe femur to one side, and the tibia and fibula to the other, exhibit the true state of the injury. The width of the joint is greatly increased, and the limb will almost ahvays present a twisted appear- ance, there being some rotation of the tibia upon its axis. The accident can not occur without considerable lacera- tion of ligaments, and straining of muscles. Treatment.—Lateral dislocations of the knee are reduced with greater facil- ity than any other luxation of impor- tance in the body. An assistant holds Lateral dislocation of the ubia. the thigh fixed, and the surgeon makes extension and pushes the head of the tibia in the direction favoring a return of the bones to their natural positions. After reduction is accomplished, the joint must be kept per- fectly motionless for two or three Aveeks, and the ordinary remedies employed for preventing or subduing inflammation. Passive motion, which Avould be serviceable in preventing an- chylosis, might also interfere'with the healing of the lacerated ligaments; therefore it should be employed with due regard to the state of all the parts implicated. Displacements of the Semilunar Cartilages.—Chronic in- flammation of the knee-joint, caused by a strain, or other in- jury, is sometimes folloAved by thickening of the semilunar Of the Tibia. 395 cartilages, and by elongation of the ligaments which connect them Avith the tibia; and it may create other difficulties with the internal working of the joint, so that the cartilages may become displaced by some trivial effort in the use of the foot. For the time the patient falls, or is unable to Avalk until the limb is gently flexed and twisted, Avhenthe defect is OATercome, and the leg resumes all its functions without evidence of serious impairment. This injury has passed among surgical writers and teachers as a sub-luxation of the semilunar carti- lages, though little is positively knoAvn in regard to the path- ology of the difficulty. It is possible that the cartilages do become slightly displaced, so that some part of their structure gets pinched between the condyles of the femur and the head of the tibia. Surgeons have declared that they have found the cartilages projecting outAvards at some part of the articu- lation. In a few instances Avhat was supposed to be a displace- ment ofthe semilunar cartilages, has turned out to be loose or false cartilages in the joint. M. Gimelle has related a case of this kind, the mistake being corrected by Larrey avIio cut into the joint and removed the foreign body. In some patients, either from lax ligaments, or a predispo- sition to joint affections, the knee is constantly tender and un- stable. A slight twist imparted to the joint in walking, or even Avhile turning in bed, is folloAved by sickening pain, and acute arthritis. The difficulty may be regarded in most in- stances as a morbid sensibility of the joint structures Avhich will pass off in the course of time, even if nothing be done ; but it Avould be judicious to put such patients on tonic and re- storative treatment to remove any constitutional dyscrasia, and to bathe, and galvanize the kuee. If in any case there existed evidence of displacement, whether of cartilage or bone, the limb should be extended, flexed, and rotated, until the parts displaced resumed their proper positions and functions. I have seemingly relieved a difficulty of this kind by flexing the knee to its utmost, then suddenly straightening the limb, re- peating the operation Avith the addition of a slight rotatory movement. " Natural bone-setters" have occasionally gained great advantages by imparting to a disordered joint certain movements of this kind. Whether anything like reduction is effected or not, some degree of synovitis will attend the injury, Avhich needs to be 396 Dislocations. subdued by proper management. As all such difficulties of the joint are liable to be repeated sooner or later, an elastic knee-cap should be worn for months or even years. Compound dislocation of the knee is one of the most danger- ous accidents that occur to a limb. Besides the injury to the soft parts, which must be considerable, large articular surfaces are exposed to the influences ofthe air, and subjected to those changes Avhich begin in shock and end in suppuration. The popliteal artery, veins and nerves, are stretched, or torn, so that complications ofthe most dangerous character can scarcely be escaped. In most instances it would not be advisable to attempt to save the limb ; though, if the subject of the acci- dent be vigorous, and the vessels and nerves apparently not much injured, an attempt to save the limb would be justifiable. HoAvever, the entreaties of the patient or those of his friends, who can not comprehend the extreme dangers of a compound dislocation of the knee, should not, in a severe case, deter the surgeon from expressing his vieAvs. in decisive terms, nor swerve him from his plain path of duty. Many a timid, vacillating, or too easily influenced surgeon has, when too late, regretted having trusted to the recuperative powers of nature in severe injuries of the knee-joint. Amputation, or even resection,seems a harsh and uncompromising measure to adopt in case of compound dislocation of the tibio-femoral articulation, yet the more experience a surgeon has the less he is disposed to trust to any conservative course in the man- agement of compound lesions of the knee. CHAPTER XIY. DISLOCATION OF THE TIBIO-FIBULAR ARTICULATIONS. Separation of the tibio-fibular connections must be ex- tremely rare, for two principal reasons: 1st, no considerable force can be so directed as to tell effectively towards separating these bones; and 2ndly, the interosseous ligament, together with the ligamentous fastenings betAveen the tibia and fibula near the extremities of these bones, render their disjunction exceedingly difficult. If all the ligaments connecting these two bones be preternatuixilly relaxed some displacement of the fibula Avould be admissible, Avithout, however, presenting a dislocation in the ordinary acceptation of the term. Dislo- cation of either end of the fibula may attend a fracture of the tibia; but as a distinct lesion, unaccompanied with frac- ture, the fibula is seldom disengaged from its articular rela- tions with the tibia at either of its extremities. The upper end of the fibula is reported to have been displaced fonvards and backAvards. In the forward dislocation, three or four examples of which have been collected, there was doubt Avhether muscular action or direct violence produced the displacement, though it is probable that the latter cause was the true one, inasmuch as little muscular force can be exerted in the forward direction upon the upper extremity of that bone. In the extreme flexed state of the limb, as in a squatting attitude, the thigh presses the upper end of the fibula forwards, and the muscles arising from the anterior aspect ofthe upper half ofthe bone, also tend to displace it forwards. With these forces at work, and a direct bloAV coming at the same time, the head of the fibula mio-ht be thrown in front of its normal position. (397) 398 Dislocations. The signs of this displacement are tolerably plain. The head of the fibula is not in its natural position, but its pres- ence is discoverable near the ligamentum patellae; the biceps flexor cruris, Avhich is inserted into the head of the bone, is put upon the stretch; and the natural contour of the leg just beloAV the knee, is lost. Treatment.—Dislocation ofthe head of the fibula forward, is reduced by extending the leg and rotating the foot out- Avards, the surgeon at the same time pressing the bone back into its natural position. Rest for a couple of weeks will allow the torn ligaments time to heal. Dislocation of the upper end of the fibula backwards'is a rarer accident than the forAvard displacement. Direct violence is the chief cause, though the action of the external ham- string muscle might assist in the luxation. Malgaigne has reported a case or tAvo in which muscular action and direct force seemed to have produced the displacement. The head of the fibula Avas thrown behind its usual position, and could there be distinctly felt beneath the skin. The reduction is accomplished by flexing the leg to relax the biceps, and then the bone may be pushed into its normal place. Unless the leg is kept flexed at the knee for two or three weeks there is danger that the luxation may be reproduced. A compress bound against the posterior aspect of the bone, will assist in keeping the head of the fibula in its natural position. Dislocation of the loAver end of the fibula from its tibial connection has been reported. The displacing force of a passing Avheel, might throAV the loAver end of the fibula back toward the tendo-Achillis; and a similar force acting upon the bone Avhile the leg was resting upon its anterior aspect might possibly effect a forward displacement. Either variety of luxation Avould be difficult to overcome. While the foot was rocked inwards the surgeon should make an effort to push or pull the bone into place. Once restored to its natural position there would be no particular danger of a reproduc- tion of the lesion. CHAPTER XV. DISLOCATION OF THE ANKLE-JOINT. Following the nomenclature heretofore adopted, luxations at the ankle Avill not be regarded as dislocations of the lower end of the tibia. In all other dislocations the distal part of the limb is assumed to be displaced, though it may not be strictly correct in all instances. The foot may be held fixed, and a displacing force throAV the tibia forward on the astraga- lus, the tibia being the bone displaced: the same thing may happen to other joints. For example, the arm maybe caught and held immovably, while a force twists the body until the scapula is displaced from the head of the humerus. This cir- cumstance does not do away Avith the fact that the injury, so far as surgical recognition is concerned, is a dislocation of the humerus. Those Avho contend for exceptions to ordinay rules, as applied to dislocations, gain nothing, and contribute their support to Avhat can be correct only a part of the time. In- deed, in not a few instances neither form of language could be strictly correct, for the displacement is mutual, i. e., a double force produces the dislocation,—one drives the tibia forwards, for example, and the other propels the astragalus backAvards in the same accident. It is absurd, then, to destroy the harmony of nomenclature by adherence to an exception which presents no compensating adATantages. Dislocations ofthe foot at the ankle-joint take place in four directions ; and, mentioned in the order of frequency, they stand as folloAVS : outAvards, inwards, backwards, and fonvards. In the outward dislocation, the injury is commonly compli- cated with a fracture of the fibula a feAV inches above the malleolus. The foot is strongly everted, the outer edge of the sole being elevated, and the inner resting on the ground. A (399) 400 Dislocations. depression exists at the seat of fracture, and the internal malleolus projects prominently. The injury is produced by a violent twist or wrench of the foot outAvards, as in stepping on the outer edge of the foot the sole comes doAvn upon a roll- ing stone or a projection of frozen earth. It is often caused by a fall, the weight of the body being received on the outer half of the sole, giving the lesr a cant imvards. This injury has already been de- scribed in the chapter on frac- tures of the fibula; one part of the accident rarely occurs except in combination with the other. In extremely rare instances, the fibula may be broken just above the ankle- joint, Avithout dislocation of the astragalus; and occasion- ally the foot may be luxated, partially or completely, Avith- out the fibula being broken. However, the double form of injury is to be expected in the majority of cases. Besides the fracture of the fibula, either the internal malleolus is broken, or the internal lateral ligament (deltoid) is torn. If the loAver end of the tibia be broken, as well as the fibula, and the foot throAvn outwards Avith these two inferior fragments, the injury is not legitimately a dislocation, but a fracture of both bones of the leg. Boyer relates a singular case in which the dislo- cation of the foot Avas not attended Avith fracture of the fibula, but with displacement of that bone at its upper extremity. It is possible for the foot to be throAvn outwards, the fibula not suffering fracture but separation from the tibia at the peroneo-tibial articulation. Such accidents have occurred un- less there has been some mistake on the part of those Avho reported them. The ordinary form ofthe accident is sometimes adjusted by the patient before the surgeon has an opportunity to examine the parts implicated in the accident. Finding his foot in an Dislocation of the foot outwards. Of the Ankle-Joint. 401 awkward state of deformity, the patient reaches down and tAvists it back into place ; and then after being carried home, he has his ankle bathed in liniments, believing the injury only a sprain, and does not send for a surgeon until he finds that the difficulty is more serious and tedious than at first antici- pated. Called several days after the accident and the return of the foot to nearly its natural position, the surgeon must not be misled by the patient's opinion of the case; but should seek the depression in the course of the fibula an inch or two above the ankle, and rotate the foot to elicit crepitation. Though the parts be SAvollen, a careful examination will reveal the nature of the injury. If asked the question, the patient Avill remember having, Avith his OAvn hands, twisted the dis- torted foot into position. In the event of dislocation, without fracture of the fibula, the reduction is too difficult for the patient to accomplish, and the surgeon will then find the parts involved in the injury just as the accident left them. Treatment.—The outAvard dislocation of the ankle, as has already been intimated, is not difficult to overcome. In most cases the surgeon, after flexing the leg on the thigh to relax the gastrocnemius, can Avith his hands press the foot into its natural position. It may facilitate the operation by gently rocking the foot while moderate extending force is applied. After reduction is accomplished, two side splints are to be used, with a compress between the loAArer end of the outside splint and the external malleolus, or the outside of the foot just beloAV the malleolus, as recommended in the treatment of " Pott's fracture " of the fibula. In some instances, where the internal lateral ligament is torn across, as it generally is, the ankle Avill remain weak, with a tendency for the foot to turn out too much, especially Avhen a step is made upon an uneven surface. Hamilton reports two cases in his work on Fractures and Dislocations, in which the reduction could not be effected on account of some obstacle in the articulation, which may have arisen from fracture of the lower extremity of the tibia, the small fragment being in the Avay of reduction. He also re- ports having amputated the limb for compound dislocation of the foot outAvards ; and a dissection exhibited a fracture of the outer part of the articular surface of the tibia, the wedge- 26 402 Dislocations. shaped fragment occupying a position in the joint adverse to reduction. When the top of the astragalus has slipped away from the articulating surface of the tibia, and lodged in the channel betAveen that bone and the outAvardly displaced external mal- leolus, the reduction can not be exceedingly difficult to effect; and if the displacement could not be overcome by ordinary means, the inference Avould be that a piece of the outer side of the tibia had been chipped off, and dropped down between the astragalus and the main fragment of the tibia, either maintaining the upright attitude or turning over upon its side and becoming an obstacle in the capacity of a wedge. The dislocation of the ankle imvards is a rare accident, and must occur from a forcible rocking of the foot upon its axis in a direction calculated to split off the internal malleolus, and to stretch and tear the external lateral ligaments of the joint. In this injury the foot is thrust inwards, so that the outer edge of the sole meets the ground, and the inner edge is raised, making the bottom of the foot present toward the opposite foot. The lower end of the fibula, or the external malleolus, projects very prominently ; the AAridth of the joint is increased ; and the internal malleolus is displaced and moves with the as- tragalus. In a case that recently came under my obser\ration, the internal malleolus was broken, and the fibula was fractured three inches above its lower extremity. If I had not seen the deformity before it Avas overcome, I should have been disposed to believe that the luxation had been originally outAvards, and that in the efforts at reduction, the foot had been rotated too far inwards. The accident happened by a fall from a building, the foot striking among some rubbish. It is not improbable that the displacement was primarily outAvards, breaking the fibula above the ankle, and the internal malleolus, by the strain on the deltoid ligament; and that by a further descent of the body the foot received an inward cant Avhich threAV it in that direction beyond its usual limit. Treatment.—The im\rard dislocation of the ankle is always reduced with ease. If the patient has not turned the foot into place Avith his own hands, the surgeon has only to seize the foot and make extension, at the same time rotating it out- wards. No powerful forces are required to replace the luxated bones, or to adjust the displaced fragments. The healing pro- Of the Ankle-JointI 403 Fio. 127. cess will occupy four or five Aveeks, and during this time the two leg splints should be worn, Avith a compress betAveen the inside of the foot, beloAV the malleolus, and the lower end of the splint. Any rotation or distortion of the foot is to be corrected during the time the dressing is worn, by the judicious use of adhesiA-e strips, A\Thich in their application are to begin at the base of the great toe and cross the hollow of the foot obliquely, along the course of the peroneus longus muscle, and thence over the external malleolus and up the leg on its anterior aspect. The position of the foot can be regulated by the proper employment of strips of adhesive plaster, even if no splints be applied, though the use of splints keeps the ankle from turning laterally in either direction. If the fragment embracing the internal malleolus unites to the rest of the bone by osseous consolidation, the cure Avill generally be satisfac- tory ; but if it make only a ligamentous connection the ankle must always remain weak. Dislocation of the foot backwards may take place in a leap from a car- riage in motion, or from a fall in which the heel catches or the toes meet something solid, the impetus of the body carrying the leg for- wards. The displacement is gener- ally accompanied with a fracture of the fibula just above the ankle, the loAver fragment, constituting the ex- ternal malleolus, remaining in con- tact Avith the astragalus. The tibia takes a position in front of the as- tragalus, on the navicular and cunei- form bones. The symptoms of this accident are a shortening of the anterior part of the foot and a lengthening of the heel. The toes are pointed doAvmvards, and the extremity of the tibia forms a projection in front of the ankle. The tendo-Achillis is arched, and the tendons on the top of the foot are tense and sharply defined. Treatment.—This variety of dislocation is commonly re- duced without much difficulty, though considerable extending Dislocation of the foot backwards: 404 Dislocations. force is required before the bones of the leg and foot can be pulled and pushed into their proper positions. The flexing of the leg on the thigh relaxes the gastrocnemius muscle, therefore an assistant should put his arm under the lower ex- tremity of the thigh, to make counter-extension, while the surgeon makes extension with one hand on the patient's heel and the other on his toes. The dressing and after-treatment should be much like that recommended for treating the lateral dislocations of the ankle. Due regard must be exercised for the fracture of the fibula. In some cases it may be found difficult to maintain the parts in place after reduction is accomplished. HoAvever, if the foot is kept flexed on the leg, and the heel made to support the weight of the limb, the tendency to displacement is mostly overcome. In cases Avhere the heel will endure pressure, and the anterior part of the leg near the ankle, some additional re- tentive means may be employed. If the foot and leg be placed in a box, Avith the heel suspended on a strip of buckskin, an- other strip of the same material may be made to press on the front of the leg by passing the ends through tAvo holes bored in the sides of the box beloAV the level of the limb, and then tied'over the top of the box. Great Avatchfulness is needed to prevent a slough of the heel, for such a complication is fre- quent, and its effects tedious and distressing. Dislocation of the foot forwards is the rarest form of dis- placement occurring at the ankle-joint. The injury arises mostly from falls, the foot meeting the ground Avith the toes elevated, and there remaining fixed Avhile the descent of the body carries the leg bones doAvn behind the summit of the as- tragalus. One of the best described cases is that of Mr. R. W. Smith, in the Dublin Quarterly Journal of Medical Science, for May, 1852. The subject of the accident was a sailor, Avho, while assisting to raise a very heavy cask on board ship, hav- ing at the same time one leg much flexed on the foot, and the thigh on the leg, was struck by the falling of a cask just above the knee, forcing the distal end of the tibia backAvards from off the astragalus on the upper and posterior surface of the calcaneum. The symptoms of this accident were, a lengthen- ing of the dorsum of the foot to the extent of one inch, and a shortening of the leg to the extent of half an inch, the two malleoli being so much nearer the ground. The projection of Of the Ankle-Joint. 405 the heel had disappeared, and the tibia formed a remarkable projection in front and to the inner side ofthe tendo-Achillis. The fibula Avas uninjured; but the extremity of the inner malleolus received a fracture. The only accident with Avhich this could be confounded is a fracture of the tibia immediately above the ankle-joint; but the situation of the malleoli Avould be decisive of the nature of the injury. " In the feAV cases of this accident Avhich have been published," says Mr. Carsten Holthouse, " reduction Avas not effected, and the patients remained very lame ; but there seems to be no reason why cases of this description, if seen early and properly recognized, should not be reduced in a similar manner to the lateral dislocations, and treated in all respects similarly." A dislocation of the foot forwards could not take place without extensive laceration of nearly all the ligamentous structures about the joint; and the tendons passing behind the two malleoli are put greatly upon the stretch, and may drop from their sheaths into the mortise-like excavation usually occupied by the astragalus. Treatment.—The forward luxation of the foot can not be overcome Avithout well-directed and vigorous efforts on the part of the surgeon and assistants. The aid of chloroform in relaxing the muscles is invaluable ; and the ^patient should be made to take the agent until he is profoundly under its influence. The injured limb should then be flexed at the knee, and held by an assistant; the foot is to be extended by the hands of another assistant; and the surgeon pulls the leg fonvards and pushes the foot backwards. If several efforts of this kind prove unsuccessful, the most unyielding tendons may be divided subcutaneously, to facilitate the reduction. .> Once in place, great care must be exercised to prevent a recurrence of displacement. The weight of the limb must not rest on the heel, but on the leg above the ankle. The limb should be kept at rest for several weeks, or until it is presumed that the torn ligaments have united. CHAPTER XYI. DISLOCATION OF THE BONES OF THE FOOT. Says Mr. Robert Wm. Smith, in his Treatise on Fractures, etc., " The mechanism by which the bones of the foot are secured against the effects of external violence, is so complete and powerful, that we seldom have opportunities of Avitness- ing luxations of the bones of the tarsus from one another, or their displacement from the metatarsal range." The os calcis has been dislocated from its relations with the astragalus, and in the same injury the scaphoid bone has been disconnected from its astragaloid relations, these bones Avith the rest of the foot going backAvards, causing the head of the astragalus to take a position upon the instep, where it forms a tumor, projecting almost through the skin. The foot is shortened in front of the leg, and the heel is elongated. An example of this injury is reported by Macdonnell, in the Dublin Journal. On the 6th of August, 1838, Mr. Carmichael was riding at a brisk trot when his horse suddenly fell. To prevent being pitched fonvards, he threw himself back in the saddle, and strongly extended his legs to meet the ground. The shock of this descent was accordingly received upon the anterior extremities of the metatarsal bones, especially the metatarsal bone of the great toe ofthe right foot, Avhich alone came to the ground. The folloAving Avere the symptoms: " The toes were turned outwards, the inner edge of the foot forming an angle of about 30° with its uatural direction • the sole was slightly turned outAvards, and the outer edo-e slightly elevated. The concavity of the tendo-Achillis posteriorly was manifestly increased, and the heel lengthened. On grasp- ing the soft parts between the tendo-Achillis and tibia Ave found the distance between these parts much greater than in the other foot. The absence of the hard projection which (406) Of the Bones of the Foot. 407 would have been formed by the upper articulating surface of the astragalus, had it passed backwards Avith the other tarsal boues, Avas evident. The malleoli Avere perfectly defined. Below and before the inner there was a hard prominence, over which the skin Avas tense, formed by the inner surface of the astragalus brought into relief by the dislocation, and the slight eversion of the sole of the foot. Much the most striking part of the deformity consisted iu a promineuce on the dorsum of the foot. Immediately in front of the tibia it presented a flat surface broad euough to receive the finger, and from Avhich there Avas an abrupt descent upon the anterior part ofthe tar- sus. Over this projection, caused by the head of the astraga- lus, the integuments Ave re so tense that it Avas evident a very small additional force Avould have driven it through the skin. Lastly, on taking the distance from the point of the internal malleolus to the extremity of the great toe Avith a tape- measure, I found it to be nearly exactly an inch less than the distance between the same points in the left foot. We could detect no fracture. The foot could be flexed and extended, but it occasioned great pain." To understand this dislocation better, it must be considered that the astragalus retains its normal connections with the tibia and external malleolus, and becomes disconnected from the calcaneum and scaphoid bones, they passing backAvards. The reduction of such a dislocation is to be effected by the strength of the surgeon's hands, the patient being anesthe- tized, and his leg flexed and managed bv an assistant, Avho pulls the tibia, fibula, and astragalus backAvards, and the sur- geon, Avith one hand on the patient's heel and the other on his instep, epcerts extension and a fonvard movement of the foot. Some tAAUsting and rotation of the foot facilitate the return of the displaced bones to their normal relations. Dislocation of the calcaneum and the other bones of the foot forwards, the astragalus alone being left in connection with the bones of the leg, is an exceedingly uncommon acci- dent. Malgaigne finds but one example, and that is reported by M. Parise. The injury happened to a quarryman avIio, while at work, Avith his left foot resting on a block of stone, and his right on the ground, Avas throAvn forcibly fonvards by the falling of a mass of stone; the thigh being at the same time strongly flexed on the trunk, the leg on the thigh, and 408 Dislocations. the foot on the leg. The following symptoms were observed : the foot was flexed; the projection of the heel had disap- peared ; and the bones of the leg with the astragalus in its normal relation Avith them, were found behind the calcaneum, or were resting upon its posterior extremity. As no crepitus was discoverable it Avas presumed that the injury was a dislo- cation ; but the pain and the swelling were so great, that a complete examination could not be made, and reduction Avas not attempted. Nine months aftenvards the condition of the limb Avas as folloAvs : the foot was flexed at a right angle with the leg, its point inclined imvards, and its inner border slightly depressed ; it Avas elongated in front of the bones of the leg, and the projection of the heel Avas completely effaced. At the level of, and a little below the malleoli, posteriorly, was a bony projection, Avhich pushed backAvards the tendo- Achillis beyond the heel. Above this projection there Avas another less marked, formed by the posterior and inferior margin of the tibia; the malleoli Avere not separated from each other, nor did they present any traces of fracture. The extensor tendons of the toes Avere stretched over the instep, and beneath these on the outer side was a projection, which appeared to be the head of the astragalus, and immediately in front of this a depression. Flexion and extension of the ankle-joint existed to a limited extent. It is possible that this displacement could not be OA*ercome, but if chloroform had been administered, it is quite probable that a surgeon to pull the foot backwards, and an assistant to pull the leg forwards, might have accomplished reduction. Flexion of the leg and extension of the foot, would favor a return of the bones to their accustomed places. # Dislocation of the foot sideways at the calcaneo-astragaloid joint, is apt to be incomplete and compound ; the astragalus rests on a portion of the os caleis, and is not throAvn upon its side, as it Avould be if the dislocation were complete. Forced adduction and abduction are the principal causes of these lateral dislocations of the calcaneum. In the outward dislocation the foot is abducted, the outer border of the sole being raised, and the inner resting on the ground. The external malleolus is buried in the fossa caused by the eversion of the foot, and the inner malleolus and the head ofthe astragalus project unnaturally inwards. In thiv- Of the Bones of the Foot. 409 teen examples of this variety of dislocation collected by Broca, nine were compound, and in six the fibula was broken. The inward dislocation at the calcaneo-astragaloid joint, presents deformities similar to the varus form of club-foot; the foot is inverted, and its inner border raised. The head of the astragalus and the external malleolus project beyond the outer border of the foot, and a deep depression exists beloAV. On the inside of the foot an elongated projection, formed by the inner border of the calcaneum, completely masks the in- ternal malleolus. The scaphoid bone can be felt nearer to the os calcis than natural, and thus the inner border of the foot is shortened and rendered somewhat concave, while the outer is lengthened aud made unnaturally convex. The widest difference seems to exist in the difficulties en- countered by the several surgeons AATho have reported cases of dislocation of the bones of the tarsus. Probably the kind and degree of displacement are not ahvays the same ; and it is possible that all cases were not managed Avith the same amount of intelligence and perseverance. In not a few in- stances the ligaments of the tarsus, and the tendons passing from the leg to their insertions in the foot, act as mechanical impediments to the return of the displaced bones; in ex- tremely rare cases, they may become insuperable obstacles to reduction. In those cases in which it is apparent that the tendons offer the principal resistance to reduction, it is advis- able to divide subcutaneously the tendo-Achillis, and perhaps the tibialis anticus and posticus. In some dislocations about the foot and ankle it is ex- tremely difficult to determine the exact nature of the injury, one lesion so much resembles another. There are deformities attendant upon fractures in the immediate vicinity of the ankle, that appear like those following luxations of the bones of the tarsus, therefore the surgeon should exercise his powers of discrimination if he Avould escape making a faulty diag- nosis. Those injuries Avhich are compound, do not present so many difficulties in the way of a correct solution of the mys- tery. It Avould not ordinarily be easy to diagnose a rotation of the astragalus, in Avhich the upper or trochlear surface pre- sented imvards, and its outer surface upwards ; but if the ac- cident leave an opening to the bone the insertion of the finger might determine exactly the nature of the displacement. 410 Dislocations. According to the results of cases collected by M. Broca, it is much safer to let a dislocated tarsal bone, which can not be reduced, remain in its abnormal position than to attempt to remove it; and amputation, which has so many times been adopted at once after some of the tarsal dislocations, should not be considered as long as there existed a possibility of es- caping gangrene, and other serious complications. In acci- dents of a crushing character, breaking and displacing the bones, and compounding the injury by lacerating the soft tis- sues, no special rules can be given which would be generally applicable, yet in the management of such injuries, the accom- plished surgeon who is accustomed to act in emergencies, and is gOA'erned by the general principles of his science, knows as well what the necessities of each particular case demand, as if he had just studied a Avritten direction for the treatment of such a case. The astragalus, when it is displaced, may become so com- pletely isolated from nutritive connections, as to be in danger of necrosis. Under such circumstances, it would be better to extract the bone at once, than to leave it Avhere by prolonged irritation it might jeopardize the limb, or even the life of the patient. Mr. Burnett, in the London Medical Gazette, for 1837, de- scribes the case of a gentleman who, in taking a leap Avhile fox-hunting, dislocated the scaphoid bone from its connections with the cuneiform bones. A Avound three inches in length was made in the instep through whicli the scaphoid and part of the astragalus protruded. By making steady pressure on the bone for fifteen minutes it was reduced. The wound healed, and the patient recoA7ered the free use of the foot. Piedagnel Avas unable to reduce a displaced scaphoid that came under his observation; and the bone being broken longi- tudinally, and the accident compound, he amputated the foot. In the case of Walker, reported in The Medical Examiner, for 1851, the scaphoid Avas forced fonvards and upAvards, as a stone is forced from an arch. By bending the foot downwards, the surgeon was enabled to press the projecting and displaced bone back into its normal position. Malgaigne has not seen a case of dislocation of the cuboid bone, nor has he confidence in the reports of those avIio claim to have met with the accident. The assertion of Piedagnel Of the Bones of the Foot. 411 that the bone may be displaced in three directions, is probably based upon speculation, as other surgeons, since his time, have enjoyed great opportunities for observing such displacements, if they Avere of eA-en rare occurrence, aud no Avell authenti- cated accident of the kind has been reported. There seems to be nothing in the shape of the bone, or in its connections, to prevent displacement; and that is probably Avhy it has been stated that the bone may be dislocated doAvmvards, imvards and upAvards. The internal cuneiform bone may be luxated from its sca- phoid connection in an upAvard and imvard direction, as if in- fluenced by the action of the tibialis anticus muscle; aud its anterior extremity may also be forced from its metatarsal rela- tions, though in conformity Avith the nomenclature adopted in this Avork, such a displacement must be considered as a luxa- tion of the metatarsal bones. All three cuneiform bones have been luxated upAvards, the deformity being marked, and the diagnosis easy, on account of the bones being thinly covered on the dorsum of the foot. The reduction, when the internal cuneiform is displaced singly, or the three together, is not difficult. The foot is seized in such a Avay that the hands bend the anterior part of the foot doAvmvards, and the thumbs press the bone or bones back into place. DISLOCATION OF THE METATARSAL BONES. Robert Wm. Smith, of Dublin, makes the following appro- priate remarks: " When we reflect upon the admirable mechanism of the foot; Avhen we consider the beautiful con- struction of its arches, the peculiar forms of the tarsal bones, the extent of their articulating surfaces, aud their mode of adaptation to each other; when we also take into account the number aud strength of the ligaments which bind them together, the arrangement of the muscles, tendons, and tendi- nous expansions in the plantar region, and the very slight de- gree of motion which is p-ermitted to the bones ;—when we reflect upon all these conditions, we fiud, that in the mechan- ism of this solid, but at the same time, highly elastic fabric, nature has adopted every provision calculated to ensure strength, and immunity from external violence. 412 Dislocations. "Notwithstanding, hoAvever, these numerous and varied sources of security, the bones of the foot occasionally suffer displacement, when subjected to the influence of great exter- nal force." Sir Astley Cooper observes: " The metatarsal bones I have never known luxated; their union Avith each other, and irreg- ular connection with the tarsus, prevent it; and if it ever hap- pens, it must be a A^ery rare occurrence." Mr. Robert Smith, whose words have just been quoted, twice had an opportunity of ascertaining by post mortem ex- amination, that the metatarsus and internal cuneiform bone, were dislocated upwards and backwards, the luxations having remained unreduced many years. The appearance of the foot in both instances indicated pretty clearly the nature of the accident. The heel preserved its natural relations to the bones of the leg; but the foot in front of the ankle-joint Avas shortened an inch or more; the inner edge of the foot Avas elevated, and the outer depressed ; the sole of the foot exhibits a rounded appearance, and the dorsum a transverse promi- nence, situated about an inch below and in front of the ankle- joint. Upon examining the skeleton of the foot, the meta- tarsal bones, and the internal cuneiform, were found dislo- cated upAvards and backwards upon the tarsus. The accident which effected the displacement Avas a fall from a horse. In the second example the history of the case was not ascer- tained. The patient died of malignant disease of the abdomen at the Richmond Hospital; and as he did not walk lame, no inquiry Avas made concerning the condition of the foot which appeared simply fore-shortened in front of the ankle-joint. The appearance of the foot in every particular, was like that of the other just described. Dissection showed that the second, third, fourth and fifth metatarsal bones, and the internal cuneiform'bone, Avere dislocated upwards and backAvards upon the tarsus. Anchylosis had taken place between the tarsus and metatarsus, and osseous buttresses had been thrown out to assist in the consolidation. Mr. Smith thinks the disloca- tion is liable to occur " when a p'erson, in falling or leaping from a considerable height, alights upon the anterior part of the foot. Under these circumstances, the limb is submitted to the operation of two forces operating in opposite directions • one, the aveight of the body and impulse of the fall, tending Of the Bones of the Foot. 413 to depress the tarsal bones; the other, the resistance of the ground, tending to displace the metatarsus upwards ; the ar- ticulating surfaces thus glide past each other, aud the anterior part of the foot is then draAvn backwards, and the aspects of its surfaces altered by muscular action." In the injuries just described it Avill be observed that the first metatarsal bone—the one to which the great toe belongs— was not dislocated, strictly speaking, but, as it went upAvards and backwards it folloAved the rest of the metatarsal row, and the internal cuneiform bone, to which it maintained its normal connections. Mr. Smith thinks that the two cases of dislocation of the metatarsus upon the tarsus related by Sanson, as having hap- pened in the practice of Dupuytren, may have been strictly such, but he inclines to the opinion that the internal cuneiform bone preserved its connections Avith the first metatarsal bone ; and if that condition Avas overlooked, he regards it as not the slightest disparagement to the judgment of that great surgeon. The tAvo cases dissected by Smith Avere found unreduced; and it is not knoAvn whether attempts at reduction were ever made. Dupuytren found it impossible to reduce the bones to place in the two cases coming under his treatment. In a case of dislocation of the metatarsus under the tarsus, reported in the Dublin Quarterly Journal of Medicine, 1854, as falling to the practice of Mr. Tuffhell, in the Dublin City Hospital, reduction was not accomplished, though the most poAverful and persevering efforts Avere made. The accident happened to a trooper AAdiosehorse fell upon the soldier's right leg and foot, crushing them against the ground. In six months after the accident the patient was able to walk upon the heel and outside of the foot, but could not bear any weight upon the sole on account of the burning, lancinating pain excited by the endeavor. Dr. Hershey, of Williamsville, N. Y., in 1856, reported to the Boston Medical and Surgical Journal, a dislocation of the first, second, and third metatarsal bones upon the tarsus. The accident occurred to a young man Avho was suddenly dis- mounted from a horse. The reduction Avas accomplished as follows: an.assistant made counter-extension upon the-heel, and the surgeon grasped the anterior extremity of the foot with both hands, made extension, bent the toes doAvnwards, 414 Dislocations. and with his thumbs pressed the projecting bones back to their natural position. . A lateral dislocation of the metatarsal bones outwards-ks re- ported by Dr. Gross to have occurred in the practice of Drs. Green and Swift, of Easton, Pa. The accident happened to an elderly gentleman who, in falling down a flight of stairs, sustained the injury. The metatarsal bones were all forced laterally outwards to the extent of a half inch or more; and the foot is reported to have been shortened and twisted. The reduction was accomplished by extension, and pressure in directions calculated to return the displaced bones to their natural positions. DISLOCATION OF THE PHALANGES OF THE TOES. The great toe is dislocated at the metatarso-phalangeal ar- ticulation much more frequently than the other toes. Of twenty-two cases, confined to the first roAV of phalanges, re- ported by Malgaigne, the great toe suffered luxation in nine- teen instances; and in the three other cases, all the toes Avere dislocated at once. The displacements are generalh', if not always, upwards, the phalanges being forced upon the meta- tarsal bones. Partial displacements of the toes are common ; and com- pound luxations are more frequent than in displacements at other joints. There seems to be a certain analogy betAveen the dislocation of the first phalanx of the great toe, and that of the corresponding phalaux of the thumb ; and a similar difficulty is experienced in the reduction. As both joints are organized on the same general plan, it would be strange if the like causes did not produce like effects, the same kind of resistance being offered in both articulations. In the only case of dislocation of the great toe at its metatarso-phalano-eal articulation, that has come under my treatment, I met Avith no serious obstacles to a ready reduction. Extension Avas made upon the toe by an assistant, and with my hands around the sides of the foot to exert counter-extension, pressure Avith the thumbs against the projecting and displaced phalanx effected reduction. In the event of failure after employing all ordinary means, it would be justifiable to divide the oppos- Of the Bones of the Foot. 415 ing barriers, whether they be ligaments, or tendons, or both, though such a course should be avoided if possible. Dislocation of the second toav of phalanges, is an accident of extremely rare occurrence. Reduction, by means of exten- sion and pressure, has not been difficult in the feAV cases re- ported. The terminal bones of the toes have been luxated ; and the accident, as Avith other dislocations of the toes, generally arises from falls received in horseback exercise. A crushing force so directed as to double the toes under the foot, is the one which commonly produces displacement of one or more of the phalanges. The pain attendant upon the displacement is severe ; and the deformity denotes the character of the in- jury. Reduction may be accomplished by the ordinary man- ipulation required to reduce displaced digital extremities. INDEX. PART 1. FRACTURES, PAGE Acromion process, fracture of the...................................................... Ill Adhesive strips, for making extension................................................... 60 Apparatus for treating fractures........................................................ 52 Appliances, defects of, in fractures of the femur.................................... 205 adhesive strip, as a fastening to the leg.......................................... 230 handkerchief, as a fastening to the leg......................................... 229 gaiter, as a fastening to the ankle................................................. 229 Astragalus, fracture ofthe............................................;............249 Attitude of limb in treating fractures of the femur............................... 193 Bandages....................................................... 52 Brainard's perforator, for treating false-joint........................................ 39 Burges' fracture-bed................................................................. g^ Burges' fracture apparatus for treating fractures of the femur. ............... 200 Calcaneum, fracture ofthe.............................................................. 250 Callus, soft and yielding after apparent consolidation............................ 31 provisional............................................................................... 32 yielding nature of, after fractures of the femur.....*......................... 201 Capsule of hip-joint.......................................................................... 179 Carpus, fractures of the.................................................................... 161 Cartilages, costal, fracture of the........................................................ 100 laryngeal, fractureof the............................................................ 90 Cervix femoris, fractures of the.......................................................... 172 scapulae, fracture of the.............................................................. 114 Clavicle, fracture of the.................................................................... 104 Coccyx, fractureof the.................................................................... 168 Condyles of the humerus, fractures of the............................................ 128 of the femur, fractures of the...................................................... 211 Convalescence.................................................................................. 70 Costal cartilages, fracture ofthe........................................................ 100 Coracoid process, fracture of the......................................................... 113 Cranium, fractures ofthe.................................................................. 74 Crepitus as a sign of fracture........................................................... 24 Dangerous complications in fracture injuries.......................................... 25 Defective union after fractures............................................................ 41 Diastasis, or separation of epiphysis of the humerus.............................. 125 or separation of epiphyses in general............................. ............... 72 Differential signs of fracture and dislocation........................................ 26 Direct and indirect forces as causes of fracture.................................... 21 Pirection ofthe line of separation, as oblique, transverse, etc.................. 19 27 418 index. PAGE. 255 Dislocations, (see Part Second)........................................................... ' Division and subdivision of the subject of fractures.............................. _. . .... 52 Dressings.................................................................................. Dupuytren's splint and fracture dressing.............................................. ^ Epiphysis, separation of......................•.............................................. Epiphysis of the humerus, separation of the......................................... Exercise allowed a patient treated for fracture...................................... 66 Extension, adhesive strips in making........................................ ........ 60 Fracture, general observations upon nature and treatment of.................. 17 division and subdivision of subjects of, as simple, compound, partial, complete, comminuted and complicated....................................... 18 direction of the line of separation in, as oblique, transverse, etc........ 19 comparative frequency of, in different bones.................................. 20 causes of, as direct and indirect violence........................................ 21 signs of, as pain, mobility, crepitus, etc......................................... 22 incomplete or "green-stick"...................................................... 26 with dangerous complications....................................................... 25 rendered serious by railway accidents, etc....................................... 27 apparatus............................................*...................................... °- beds......................................................................................... 62 process of union and method of repair in....................................... 29 non-union after........................................................................ 36 defective union after.................................................................. 41 responsibility in the treatment of................................................ 44 management of compound........................................................... 67 ofthe cranium........................................................................... 74 of the zygomatic arch................................................................. 74 of the nasal bones...................................................................... 75 ofthe malar bones................................................................... 78 of the superior maxillary............................................................ 78 of the inferior maxillary............................................................. 80 of the hyoid bone........................................................................ 88 of the laryngeal cartilages........................................................... 90 of the vertebrae......................................................................... 91 of the ribs................................................................................ 95 of the costal cartilages................................................................ 100 of the sternum........................................................................... 101 of the clavicle........................................................................... 104 ofthe scapula.......................................................................... HO of the acromion process............................................................... HI of the coracoid process.........................u..................\ ................. H3 of the neck of the scapula........................................................... 114 of the humerus........................................................................... H7 of the anatomical neck of the humerus......................................... 117 of the tuberosities of the humerus............................................ H9 of the surgical neck of the humerus.............................................. 120 of the shaft of the humerus.......................................... 192 of the humerus, just above the condyles....................................... 125 of the condyles of the humerus............................................... 12§ of the internal condyle.................................................. # 12g of the external condyle............................................................... 133 INDEX. 419 PAGE. Fracture, of the ulna (olecranon process)................................... 23Y of the coronoid process ofthe ulna................................. 14a of the shaft of the ulna.......................................... 142 of the radius......................... , ., .......................................................... 145 of the shaft of the radius......................................... 14a of the radius, (Colles')............................................... # 150 of the radius, (Barton's)................................................... 150 of the carpus, metacarpus and hand.......................................... 161 of the phalanges........................................................ ig, of the pelvic bone9, as ilium> ischium and pubes.............................. 165 of the sacrum.............,...............................................##> ^ 10<7 ofthe coccyx......................................................................... Igg of the femur..................................................................... 171 of the neck of the femur............................................................. 172 ofthe cervix femoris within the capsule (intra-eapsular).................. 179 of the neck of the femur outside the capsule (extra-capsular)............ 180 of the trochanter major............................................................... 185 of the shaft of the femur............................................. ............... 190 of the shaft of the femur just below the trochanters........................ 192 of the shaft of the femur just above the condyles............................ 207 of the condyles of the femur........................................................ 211 of the patella............................................................................ 213 of both bones of the leg............................................................... 221 of the tibia, singly.................................................................... 235 of the fibula............................................................................ 240 of the fibula, Pott's..................................................................... 242 of the bones of the foot............................................................... 249 ofthe astragalus...................................................................... 249 of the os calcis.................................................. ........................ 250 of the metatarsal bones .............................................................. 251 of phalanges of the toes............................................................. 252 Femur, fracture of the...................................................................... 171 fractureof neck of the............................................................. 172 fracture of the shaft of the.......................................................... 202 fracture of the condyles of the..................................................... 211 Fibula, fractures of the..................................................................... 240 Pott's fracture of the.................................................................. 242 and tibia, fracture of the........................................................... 221 Gaiter, fastening upon the ankle....................................................... 229 General observations upon the nature and treatment of fractures............ 17 General treatment of fractures........................................................... 43 Gibson's apparatusfor treating fractures of the thigh............................. 206 Gypsum dressing.....• ...................................................................... 56 Hand, fractures of the....................................................................... 1(>1 Hamilton, in regard to mobility at seat of fracture................................ 127 Humerus, separation of its lower epiphysis.......................................... 73 fracture of the..................~..........•..............................-............ Hf fracture of the anatomical neck of the.......................................... 117 fracture of the tuberosities of the................................................ 119 fracture of the surgical neck ofthe............................................... 120 fracture ofthe shaft ofthe.............. ........................................... 122 420 INDEX. PAGE. Huntoon's yoke-splint for treating fracture of the clavicle..................... 108 Hyoid bone, fracture ofthe........................................................... Ilium, fracture of the......................................................................" * Incomplete, or "green stick" fracture................................................ Immovable fracture dressing...............«................»................... Impaction in fractures of the neck of the femur.................................... Innominatum, fracture of the............................................................ Ischium, fracture of the................................................................... 78 Jaw, fractures of upper.................................................................... Jaw, fractures of lower..................................................................... Laryngeal cartilages, fracture of the................................................... 90 Levis' dressing for fracture of the clavicle........................................... 108 Ligamentous union after fracture of the neck ofthe femur..................... 181 Ligament, capsular, of the hip-joint.................................................... I?9 Ligamentous union after fracture of the patella................................... 218 Malar bone, fracture of the.....................................•.......................... 78 Malgaigne and others on shortening after fracture of the femur.............. 203 Management of fractures......,........................................................... 43 Many-tailed bandage..................................................................... 55 Maxillary, superior, fractureof the........................ ............................ 78 inferior, fractureof the.............................................................. 80 Metatarsus, fractureof the................................................................ 251 Mobility as a sign of fracture............................................................. 22 " Natural method " of producing extension............................................ 48 of applying extension in treating fractures of the femur.................. 198 Nasal bones, fracture ofthe............................................................... 75 Neck of scapula, fracture of the......................................................... 114 Neck of femur, fracture of the........................................................... 172 Olecranon process of ulna, fracture of the.......................................... 137 Osseous fragility.............................................................................. 20 Paget, ensheathing callus of............................................................... 34 Partial fracture (incomplete)........................................................... 26 Patella, fractureof the.................................................................... 215 Pelvic bones, fracture ofthe..........................,................................... 165 Phalanges of the hand, fracture of the................................................ 163 of the foot, fracture of the........................................................... 252 Pott's fracture of the fibula............................................................... 242 Pubes, fracture ofthe........................................................................ 165 Radius, fracture of the...................................................................... 145 fracture of the neck of the.......................................................... 145 fr'acture of the shaft of the.......................................................... 148 Colles' fractureof the................................................................ 150 Barton's fracture ofthe.......................................................... _ 150 Reduction of fractures................................................................... 49 Re-dressings of fractures.............................................................. 64 Responsibility in the treatment of fractures................................... 44 Ribs, fracture of the................................................................... 9g Sacrum, fracture of the................................................................ ,»» Sand bags in the treatment of fractures of the leg.......................... 4™ Scapula, fracture ofthe...................................................m........... j^q Shoulder blade, fracture of the.................................................. H0 INDEX. 421 PAGE. Signs of fracture.......................................... ##ti............................. 22 differential, of fractures and dislocations....................................... 26 Silver wire to fasten together fragments of lower jaw........................... 85 Smith, of Dublin, on fracture of the clavicle........................................ 105 Spinal cord, injuries of the............................................................. 92 Splint, long straight, for treating fractures of the thigh......................... 195 Dupuytren's ..................................^......... ^ 246 Starch bandage, treatment of a case with............................................ 234 Sternum, fracture of the...............................„................................... 101 Swinburne's method of making extension............................................ 124 Tarsal bones, fractures of the................................................. ........... 249 Tibia, fracture of, singly........„ ....................................................... 235 Thigh bone, fracture of the................................................................ 171 Treatment of fractures.............................__................................... 43 Trochanter, fracture of the..............................................................*. 185 Ulna, fracture of the olecranon process of the....................................... 137. fracture of the coronoid process of the.............„........................... 140 fracture of the shaft of the................._...................................... 142 Union of fractured bones................................................................. 29 by "first intention."....................................................,.............. 33 defective................................................................................... 41 ligamentous, after fracture ofthe neck of the femur....................... 181 ligamentous after fracture of the patella........................................ 218 Weight and pulley for extension...........„..„........................................ 199 "Wire breeches".............................................................................. 59 in the treatment of fracture of the neck of the femur...................... 188 Zygomatic arch, fracture of the...............~......................................... 74 PART II. DISLOCATIONS. Ancient dislocations, dangers in attempts at reduction of........................ 271 Ancient dislocation of the hip-joint..................................................... 384 Ankle, dislocation of the................................................................... 399 Axillary vessels, dangers of rupture of, in attempts to reduce ancient dis- locations of the shoulder........................................................... 273 Beach on the reduction of dislocations of the hip by manipulation.......... 372 Blackman on the reduction of ancient dislocations of the shoulder........... 272 Carpal bones, dislocation of the......................................................... 352 Carpus, dislocation ofthe.................................................................. Cartilages of the knee, displacements of the......................................... 394 Causes of dislocations-..................................................................... 281 Clavicle, dislocation of the................................................................ 30° Dislocation, general consideration of the subject................................... 255 an injury of frequent occurrence.................................................. 255 division of the subject of............................................................. 261 congenital................................................................................ 261 422 Index. PAGE. .................. 263 Dislocation?, traumatic................................................... „_. Partial..................................................................".".!".".".".".""..' 265 ancient..................................................................... „*. dangers in attempts at reduction of................................... '" ... „ ............................ 266 relative frequency ot..................................... „ ................................... ^o< symptoms of...................•........................ 26g alleged malpractice following............................................. recurring, of the shoulder................................................... •■ ~ ......................... 281 causes ot............................................................ general treatment of............................................................. 5 , ........................ 288 compound............................................................ of the inferior maxillary............................................................. 297 of the vertebrae....................................................................... ofthe ribs................................................................................ 303 of the clavicle............................................................................ 305 of the scapula.......................................................................... 31U ofthe humerus......................................................................... 3^4 of the shoulder.......................................................................... 3*4 of the humerus, with fracture....................................................... 332 of the elbow...................................................................... ...... 335 of the head of the radius forwards................................................ 341 of the head of the radius backwards............................................. 343 of the ulna backwards................................................................. 346 of the radius from the ulna......................................................... 347 of the wrist............................................................................ 349 of the carpal bones................................................................... 352 of the metacarpal bones ............................................................ 353 of the phalanges of the fingers..................................................... 355 of the thumb............................................................................. 355 of the fingers............................................................................. 357 of the femur............................................................................. 359 of the hip................................................................................. 359 of the hip, anomalous................................................................. 383 of the hip, ancient..................................................................... 384 of the hip, congenital.................................................................. 385 of the hip, partial............................................................. ......... 385 of the hip, and fracture............................................................... 386 of the patella............................................................................ 388 of the tibia................................................................................ 391 of the knee................................................................................ 391 of the knee, compound................,..........,.................................... 396 of the tibio-fibular articulations.................................................... 397 of the fibula.............................................................................. 398 of the ankle........................................................................... 39