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1
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(o^
PRACTICAL TREATISE
OS
FRACTURES AND DISLOCATIONS
BY
FRANK HASTINGS HAMILTON, A.M., M.D., LL.D.,
.; I'. Ii- j;l.l.I.KVl-t m'SflTAI., NEW V»>RK ; LONSl'iriNi; SlKltlvON TO IIDSI'IT.VI. IiiK Kl rTl'KM} ANU
. M'.il-l I-:^ : T> ST. ELlZ.VBKrii IIOSI'ITAI., RTC ; AI TIIMK of a TKI'ATISK on mii.ii akv sikgkkv
Avn irYr.lKNE, AM) OK A IKKATlsR UN 1 H E PKINCIPLKS AN1> fKAt Til T OK SIKCIFRY.
FIFTH EDITION,
H E V ISE D A y D I M P RO V E D.
ILLISTUATET) WITH
\
THREE HUiNDRED AND FORTY-FOUR WOODCUTS.
-' .-v \^' -. • ■ . .
, .-, y '' ■ . *
I .1
'LONDON:
SMITH, ELDER & CO., 15 WATERLOO PLACE.
1875.
[Cbpyrtffht Secured.]
PREFACE TO THE FIFTH EDITION.
The author may be permitted to express his gratification that this
work, to \5jhich he has given so large a portion of his active life, con-
tinues to meet with the approbation of his professional brethren, as
>hown in the demand for a fifth edition. In this alone he finds a
sufScient compensation for all his labor.
The present edition has been carefully revised ; many observations
of practical surgeons, both at home and abroad, have been added, and
the number of pages and of woodcut illustrations have been increased.
From the first it has been the intention of the author to declare, in
the most faithful and conscientious manner, precisely how much, with
the knowledge and appliances at our command, we were able to ac-
complish. This was absolutely necessary if we proj^osed to lay a
proper foundation upon which we might afterwards ho|)e to build suc-
cessfully. Indeed, it is apparent that, if we would make of surgery
an exact science, we must apply to its study the same exact rules
which are alone employed successfully in the study of other sciences.
Ever>- false or loose statement retards our progress, or renders our
stej)?? hesitating and unequal.
In reference especially to the Diagnosis and Treatment of Fractures
and Dislocations, the reader will find that in many respects the opin-
ions and practice of Surgeons have changed within the last fifteen or
twenty years, and there can be no doubt that most of the changes con-
stitute real improvements; but there remains, unfortunately, much to
be accomplished, so much, indeed, that no one who thoroughly under-
stands the facts, and feels an interest in this branch of our science,
will rest satisfied with what has been done, and hereafter cease to
labor.
Frank H. Hamilton.
Smw YoBK, September 10th, 1875.
PREFACE TO THE FIRST EDITION.
The English language does not at this moment contain a single com-
plete treatise on Fractures and Dislocations. The two small volumes
of Desault, and the one of Boyer, issued near the close of the last cen-
tury, and translated into English early in this, may perhaps properly
enough have been regarded as complete treatises at the time of their
publication, but they certainly cannot be so considered now. The
several chapters on "Diseases and Injuries of the Bones," contained in
the Leform Orales of Dupuytren, translated in 1846, and the Treatise
on Fractures in the Vicinity of the Joints^ and on Certain Forms of Acci-
deniai and Congenital Dislocations, by Robert Smith, are invaluable
monographs, but neither of them claims to be anything more than a
collection of occasional and miscellaneous papers. The writings of
Amesbury and of Lonsdale relate only to fractures. Even the justly
celebrated quarto of Sir Astley Cooper is no more than what its title
plainly declares it to be, A Treatise on Dislocations and on Fraiiurcs of
the Joints; but since the announcement of the present volume, a trans-
lation of Malgaigne's great and crowning work on Fractures and Dis-
locations has been commenced by Dr. Packard, of Philadelphia, and
the first volume has been placed in the hands of the American profes-
sion. Should the remaining volume be rendered into English, the gap
in our literature will be measurably filled.
Under these circumstances I might scarcely have thought it worth
while to continue my labors, already so near their completion, had it
not seemed to me that Malgaigne, whose researches have been truly
marvellous, had failed in some measure to give a just representation of
the oljservations and improvements which have been made from time
to time by my own countrymen.
The contributions of American surgeons to this department had to
be sought chiefly in medical journals, many of which have long been
discontinued, and most of which were inaccessible to the great French
writer. Even to an American, the labor of exhumation from archives
hitherto almost unexplored has not been small ; and it is probable that
VI PREFACE TO THE FIRST EDITION.
many valuable pai)ers have been overlooked; indeed it is impossible
that it should Ixi otherwise.
I am free to say, also, that I have l)een eneouraged by a hope that
my own jKirsonal experience, obtained during many years of j)ublie and
private service, might be of some value to my contemporaries.
Very little space has been devoted to what is now only historical,
except so far as was necessary to correct certain time-consecratcil errors,
or to confirm and illustrate the practice of the present day ; but by a
pretty full rejwrt of characteristic cxamj)les, selecte<l from more than
one thousand cases already published by myself, by coj)ions rcfcrcnci^s
to the exam{)les recorded by others, and by a wireful exclusion of what-
ever has not been confirmed by exj>erience or establisheil by dissection,
I have endeavored to make this treatise useful both to the student and
practical man, and a reliable exponent of the present state of our art
upon those subjects of which it treats.
In onler to render the description of the various forms of apparatus
employed in the treatment of fractures more intelligible, and to avoid
the necessity of lengthened explanations, a large number of illustra-
tions have l)eon introduced, more, jwrhaps, than might be thought
necessar}', especially as in several instances the apparel which is figured
18 not that which is recommended by the author. It is believiHl, how-
ever, that by a study of the princiiMil forms of approved <lrcssings the
rca<Ier will lie better preparetl for the exigencies of practice ; and that
by the simultaneoas presentation of those which are not approv<r<l, he
will l)e saved from a wasteful ex|)enditure of his time in th<' contriv-
ance of useless ap|>aratus. It is not in the discovery and multij»lica-
tion of mcchanicjil exi>edients that the surgeon of this day declares his
8U|KTiority, so much as in the skilful and judicious employment i»f
those which are aln?adv inventeil.
The author <lesires to actknowledge his in<IcbtiHlness to very many of
his professional brethrt»n, throughout the United States, for tln' prompt-
ness with which they have re>|N)nde<I frt»m time to time to \i\^ in(|uirir>,
and for the generosity with which they have opened their pathological
collections and placeil valuable s|><HMm(*ns at his dis|M>sal.
He wishes also to express his s{KM>ial obligations to l)r. J. K.
Lothrop, of this city, who has kimlly aidcnl him in ri'vising most ot'
the proof-^hcets as they have Ikvu issued from the pre>s.
Frank H. IlAMiF/r<»N.
Buffalo, N. Y., Decern Imt, 1S01».
CONTENTS.
PAKT I.
FRACTURES.
CHAPTER I.
PAGE
General Division of Fractures, 27
CHAPTER II.
General Etiology of Fractures, 29
CHAPTER III.
General Semeiolooy and Diagnosis, . .83
CHAPTER IV.
Repair of Broken Bones, 38
CHAPTER V.
General Treatment of Fractures, 44
CHAPTER VI.
Delated Union and Non-Union of Broken Bones, 63
CHAPTER VII.
Bending, Partial Fractures, and Fissures of the Long Bones, 74
2 I. Bending of the Long Bones, 74
J 2. Partial Fractures of the Long Bones, 78
{ 8. Fissures, 86
CHAPTER VIII.
Fractures of the Nose, 91
i 1. Ossa Nasi, 91
2 2. Fractures and Displacements of the Septum Narium, . . . .96
vm
CONTENTS.
CHAPTER ;X.
Fracturks or the Malar Bone, .
PAOK
99
CHAPTER X.
Fracturks of thk Upper Maxillary Bones, .
. 102
CHAPTER XI.
Fractureis or tue Zygomatic Arch, .
107
CHAPTER XII.
Fractures OK THE Lower Jaw, .
Ill
CHAPTER XIII.
FRACTUREH OK THE HyOID UOXE, .
37
CHAPTER XIV.
Fractures or THE Cartilages OF Til K Larynx, 141
i 1. Thyroid Cartilage, 141
J 2. Thyroid and Cricoid Cartilage?, 142
^ a. Cricoid Cartilage, 144
CHAPTER XV.
Fractures or THE Vertebr.e,
^1. Fractures of t lie Spinous ProcpfiSK*,
?} 2. Fraclurosi of tho Trans vorso Pn)coss,
J 3. Fractures <»f the Vi'rtfbral A rclh'-,
{4. Fractun»s of the Bodit's of th<' VtTtrlirsi*
1. Fractun* of tho Bodies <>f th** Lumbar Vertebra',
2. Fracturt'S t)f the Bodies of the Dorsal Vertebrae,
li. Fractures <)f the Bt>di<'s of tlh* tivi* lowi»r (Jervical Vertebrte,
4. Treatment of Fractures of the Bodiet* nf the Vertebrse,
J 6. Fractureii «»f the Axis,
{0 Fraoiurej* of the Atlas,
{ 7. Fractures^ (»f the lirst two CiTvicul Verteline (Atlas and Axi^i at
the >anie tinir, ...........
14»j
140
148
141)
ir>4
15(i
l."»8
1.">H
101
104
107
CHAPTEU XVI.
FmA(*n'RE8 or tub Stkkni m, .
lOU
CHAI'TKR XVII
FmAlTl KE> OK THE RlUS AM* Til Kilt (\\ I; M I.AGKs. .
J I. Fraeturi'H of thi» Ribs, . . . . .
2 2. Frueture* i»f lh»« (*artilagcs of the Rib*,
17r>
175
IhO
CONTENTS. IX
CHAPTER XVIII.
PAQK
Fracturxs oy the Clayiclb, 182
CHAPTER XIX.
Fracturks of tbe Scapula, 209
{ 1 . Fractures of the Body of the Scapula, 209
2 2. Fractures of the Neck of the Scapula, 214
{3. Fractures of the Acromion Process, 215
J 4. Fractures of the Coracoid Process, 219
CHAPTER XX.
Fractures of the Humerus, 221
{ 1. Fractures of the Head and Anatomical Neck, 228
J 2. Fractures through the Tubercles, 227
J 3. Longitudinal Fractures of the Head and Neck, or Splitting off of the
Greater Tubercle, 227
{ 4. Fractures through the Surgical Neck (including Separations at the
Upper Epiphysis), 229
Ij 5. Fractures of the Shaft below the Surgical Neck, and above the Base
of the Condyles, 246
3 6. Fractures at the Base of the Condyles (including Separations of the
Lower Epiphysis), 267
J 7. Fractures at the Base of the Condyles, complicated with Fracture
between the Condyles, extending into the Joint, .... 264
2 8. Fractures of the Internal Epicondyle, 268
} 9. Fractures of the External Epicondylo, 272
J 10. Fractures of the Internal Condyle, 272
J 11. Fractures of the External Condyle, 276
CHAPTER XXI.
Fractures of the Radius, 279
CHAPTER XXII.
Fractures of the Ulna, 811
J 1. Shaft of the Ulna, 311
I 2. Coronoid Process Of the Ulna, 316
} 3. Fractures of the Olecranon Process, 824
CHAPTER XXIII.
Fractures of the Radius and Ulna, 332
CHAPTER XXIV.
Fractures of the Carpal Bones, 848
CHAPTER XXV.
Fractures of the Metacarpal Bones, 844
CONTENTS.
CHAPTER XXVI.
rxon
FmACTURES OF THE FlNQERS, 847
CHAPTER XXVII.
Fracturea ov the Pelyis, and Traumatic Separations at its Sym-
physes, 850
J 1. Pubes, 3r>0
{ 2. Ischium, 354
2 8. Ilium, 355
2 4. Acetabulum, 359
2 5. Sacrum, 805
2 6. Coccyx, 307
CHAPTER XXVIII.
Fractures of the Femur, 307
2 1. Neck of the Femur, 808
(a.) Neck of the Femur within the Capsule, 309
(6.) Neck of the Femur without the Capsule, 393
(e.) Neck of the Femur partly within and partly without tho
Capsule, 401
2 2. Fractures through the Trochanter Major and Base of the Neck of the
Femur, .... 401
2 8. Fractures of the Epiphysis of the Trochanter Major, .... 40:>
2 4. Fractures of the Shaft of the Femur, 404
2 6. Fractures of the Condyles, 4'V>
(a.) Fracturesof the External Condyle, 455
(6.) Fractures of the Internal Condyle, 45<)
(e.) Fractures between the Condyles and across the Base, . 458
(//.) Separation of the Lower Epiphysis, 4(iO
CHAPTER XXIX.
Fractures of the Patella, 401
CHAPTER XXX.
Fractures op the Tihia, 472
CHAPTER XXXI.
Fractures of the Fibula, 477
CHAPTER XXXII.
Fractures of the Tihia and Fiiiula, 481
CHAPTER XXXIII.
Frai-tukks of the Tarsal Bonks, 502
CHAPTER XXXIV.
Practurks of the Metatarsal Bonk-*, 507
CONTENTS. XI
CHAPTER XXXV.
PAOK
Fractures of the Phalanqes of the Toes, 609
CHAPTER XXXVI.
Gunshot Fractures, 510
PAKT II.
DISLOCATIONS.
CHAPTER I.
General Considerations, 526
2 1. Division and Nomenclature, 525
2 2. Predisposing Causes, 526
§ 3. Direct or Exciting Causes, 627
1 4. Symptoms, 527
2 5. Pathology, 628
2 6. Prognosis, 630
2 7. Treatment, ... 530
CHAPTER II.
Dislocations of the Lower Jaw, 538
2 1. Double or Bilateral Dislocations, 638
2 2. Single or Unilateral Dislocations, 637
2 3. Conditions of the Jaw simulating Luxations, 638
CHAPTER IIL
Dislocations of the Spine, 640
5 1. Dislocations of the Lumbar Vertebra), 641
1 2. Dislocations of the Dorsal Vertebrae, 542
{ 3. Dislocations of the Six Lower Cervical Vertebras, .... 645
2 4. Dislocations of the Atlas, 651
2 6. Dislocations of the Head upon the Atlas, or Occipito-Atloidean Dis-
locations, 663
CHAPTER IV.
Dislocations of the Ribs, 553
J 1. Dij*locations of the Ribs from the Vertebraj, 563
2 2. Dislocations of the Ribs from the Sternum, 655
2 3. Dislocations of one Cartilage upon another, 556
XII
CONTENTS.
CHAPTER V.
PAOK
Dislocations OK THE Clavicle, b'u
J 1. Slerno-Clavicular, 557
(a.) DUlocations Forwards nt the Sternal End, .... 557
(h.) Dislocations of the St«Tnal End of the Clavicle Upwards, . 501
K.) Dislocations of the Sternal End of the Clavicle Backwards, . 'A)2
I 2. Acromio-Clavicular, 504
(n.) Dislocations of the Acromial End of the Chivicle Upwards, . 504
[h.) DislcK-ations of the Acromial End of the Chivido Downwards, 570
(c ) Dirtlocations of the Acromial End nf the Clavicle under the
Coracoid Process, 571
(rf.) Dislocations of the Clavicle at hoth ends simultaneously, . 572
CHAPTER VI.
Dislocations OK THE Shoulder (Scapulo-Uumeral), .... 57:i
i 1. Dislocations of the Shoulder Downwards (Suh«;lenuid), . . . 574
Dislocations, with Fracture of the Humerus near it.-* Upper End, . 001
J 2. Dislocations of the Humerus Forwards (Suhcoracoid and Subclavic-
ular). 002
J 3. Dislm-ations of the Humerus Biick wards (Subspinous), . (i09
^ 4. Partial Dislocations of the Humerus, 01 o
CHAPTEK VII.
Dihl«)Cations ov the Heai><)F the Kadics (IUmkro-Uadial),
{ 1. Dislocations of the Head of the Radius Forwards,
^ 2. DisUH'iitions of the llmd of the Rudiu^ Backward>, .
^ -i. Dislocations of the Head of the Radius Outwards, .
017
017
♦522
t;24
CHAPTER VIII.
Dl» LOCATION* «»>• THE UfPER EnI> OF THE UlNA BACKWARDS (HtMERO-
CHAPTER IX.
Dlf«LnrATloN> OF THE RaDU'M AND UlNA .FoR|:aRM AT THE ElHOW-JoINTJ
\ 1. Di»locationi« of tli(* ISadius and Ulna Backwiirds,
^ 2. Di^K'calionn of the Radius ami Ulna Outward^ (to the Kadial Side)
$ •(. Di!-Ii»(*ations of thi* Riidius and Ulna Inwards ^to the I'lnar Side-,
^ 4. Di.'^locations uf the Radius and Ulna Forwards,
02«'.
020
o:;0
on
i;i4
CHAPTER X.
DlML»rATH»NS OF THE \Vui«*I . KaDIO-CaKI'AL •,
H 1. Di^hu'iition* of tl]«* Carpul Biun*" Biu-kwnriN,
^ 2. Di«l<K-ati«in!« of thf Carpnl Bones Forward*,
045
OIS
051
CHAPTEK XI.
Dl»LorAlloNK OF THE LoWKU EnD oy rHE UlNA > InFKRIoR K \DIo- UlN AR I, ('•52
J 1. I>i*lorntions of ihi" hnwer End «»f \\u> riiia ItHckwiinls, . . »I52
\ 2. Di.-I«K'u(i<in« itt' tin* L«»wer End of th«> I'lnu Forwards, . . . 051
CONTENTS. Xlll
CHAPTER XII.
PAGE
Dislocations of thk Carpal Bones (among themsslvks), . 655
CHAPTER XIII.
Dislocations of the metacarpal Bones (at the Carpo-Metacarpal
Articulations), 657
CHAPTER XIV.
Dislocations of the First Phalanges of the Thumb and Fingers
(Metacarpo-Phalangeal) 660
i 1. Dislocations of the First Phalanx of the Thumb Backwards, . 660
2 2. Dislocations of the First Phalanx of the Thumb Forwards, 667
2 3. Dislocations of the First Phalanx of the Fingers, .... 668
CHAPTER XV.
Dislocations of the Second and Third Phalanges of the Thumb
AND Fingers (Phalangeal), 669
CHAPTER XVI.
Dislocations of the Thigh (Coxo-Femoral), 672
2 1. Dislocations Upwards and Backwards on the Dorsum Ilii, 674
2 2. Dislocations Upwards and Backwards into the Great Ischiatic
Notch, 701
2 3. Dislocations Downwards and Forwards into the Foramen Thy-
roideum, 709
2 4. Dislocations Upwards and Forwards upon the Pubes, . . 714
2 5. Anomalous Dislocations, or Dislocations which do not properly belong
to either of the four principal divisions before described, . 719
1. Dislocations directly Upwards, 719
2. Dislocations Downwards and Backwards upon the Posterior
Part of the Body of the Ischium, between its Tuberosity
and its Spine, 723
3. Dislocations Downwards and Backwards into the Lesser or
Lower Ischiatic Notch, 723
4. Dislocations directly Downwards, 724
5. Dislocations Forwards into the Perineum, .... 725
2 6. Ancient Dislocations of the Femur, 727
2 7. Partial Dislocations of the Femur, 781
2 8 Coxo-Femoral Dislocations, complicated with Fracture of the Femur, 732
2 9 Voluntary Dislocations of the Femur, 785
CHAPTER XVII.
Dislocations of the Patella, .
2 1. Dislocations of the Patella Outwards,
2 2. Dislocations of the Patella Inwards, .
2 3. Dislocations of the Patella upon its Axis,
2 4. Dislocations of the Patella Upwards,
737
737
740
740
744
XIV
CONTENTS.
CHAPTER XVIII.
Dislocations of the Hkad of the Tibia (Fkmoro-Tihial),
J 1. Dblocations of the Head of the Tibia Backwards,
J 2. Dislocations of the Hoad of the Tibia Forwards,
i 3. Dislocations of the Head of the Tibia Outwards,
^ 4. Di.slocations of the Head of the Tibia Inwards, .
I 5. Dislocations of the Head of the Tibia Backwards and Outwards,
J 0. Internal Derangement of the Knee-joint,
PA<iK
746
74r>
748
T.jl)
T.V2
7.V2
754
CHAPTER XIX.
DisLorATioxs OF the Lower End of the Tibia (Tibio-Tarsal),
^ 1. Dislocations of the Lower End of the Tibia Inwards,
1 2. Dislocations of the Lower End of the Tibia Outwards,
2 3. Dislocations of th(* Lower End of the Tibia Forwards,
J 4. Dislocations of the Lower End of the Tibia Backward?,
7»;i
7f)2
7t3G
CHAPTER XX.
Dislocations of the Upper End of the Fibula, .
J 1. Dislocations of the Upper End of the Fibula Forwards, .
J 2. Dislocations of the Upper End of the Fibula Backwards, .
I in
7r,7
7GS
CHAPTER XXI.
Dislocations of the Inferior Peronko-Tibial Articulation, .
70'.»
CHAPTER XXII.
Tarsal Luxations,
Ji 1. Dislocations of the Astragalus, .
^ 2. Astragalo-Calcaneo-Scaphoid Di^locatioll^,
{3. Dislocations of the Calcaneuin, .
^ 4. Mi<ldli* Tarsal Di^l<K'ations,
I 't. Dislocations of the Os CuboideSj
I i\. Dislocations of th(> <)t> Scaphttidcs,
§7. Dislticntions of the (\in(*iforni Bones,.
7r,lJ
7«;'»
1 1 1
77S
77'.>
77'.»
7S0
78<>
CHAPTER XXIII.
DiSLiM'ATloNS OF THE METATARSAL BoNKS, .
7V2
CHAPTEK XXIV.
DisL'MATIONS OF THE PHALANGES OF THE ToK>,
784
CUAPTKK XXV.
CoMi-firMi Dislocations or the L<»no Bunks, .
too
CONTENTS. XV
CHAPTER XXVI.
PAOB
Congenital Dislocations, 801
I 1. General Observations and History, 801
1 2. Etiology, 802
2 3. Congenital Dislocations of the Inferior Maxilla, .... 804
I 4. Congenital Dislocations of the Spine, 807
I fy. Congenital Dislocations of the Pelvic Bones, 808
I 6. Congenital Dislocations of the Sternum, 808
I 7. Congenital Dislocations of the Clavicle, 808
I 8. Congenital Dislocations of the Shoulder (Upper End of the Hume-
rus), 809
I 9. Congenital Dislocations of the Kadius and Ulna Backwards, . . 812
2 10. Congenital Dislocations of the Head of the Radius, .... 813
1 11. Congenital Dislocations of the Wrist, 814
2 12. Congenital Dislocations of the Fingers, 814
2 13. Congenital Dislocations of the Hip, 816
2 14. Congenital Dislocations of the Patella, 821
2 15. Congenital Dislocations of the Knee, 822
2 16. Congenital Dislocations of the Tarsal Bones, 824
2 17. Congenital Dislocations of the Toes, 824
LIST OF ILLUSTRA^|-@W?:-,
1 < <
FRACTURES. \ ^ -tt -
^' . »
' if
FIG. ■ ' . / PAOB
1. Transverse, serrated (denticulated), and oblique fracture. From author's
collection, 28
2. Perforating and lone^itudinal fracture, 28
3. Impacted extra-capsular fracture of neck of femur — vertical section, . 28
4. Fracture of the thigh of a turkey united with fragments widely sepa-
rated. From a specimen in the author's cabinet, 41
5. Fracture of the shaft of the femur; united with an oblique callus. From
a specimen in the author's cabinet, 41
6. Application of the "roller," by circular and reversed turns, ... 46
7. Many-tailed bandage, 46
8. Application of the many-tailed bandage, 47
9. Bandage of Scultetus, 47
10 Wood and leather splint, 51
11. Starch bandage applied for a broken thigh, 54
12. Seutin's pliers, 55
13. Opening of the apparatus with Seutin's pliers, 57
14. *' Apparatus immobile," applied over a compound fracture, ... 58
15. Von Brun's plaster-cutter, 61
16. Clavicle, united by ligamentous bands, 65
17. Hudson's splint for ununited fractures of femur, accompanied with short-
ening of the limb, 69
18. Phvsick's first case, after 28 vears, 69
19. Dieffenbach's drill for ununited fracture, 70
*J0. Brainard's perforator reduced one-half, 71
21. The author's bone-drill, 72
22. Gaillard's instrument for ununited fractures, 78
23 Fergusson's case of permanent bending without fracture, .... 77
24. Partial fracture without restoration of the bone to its natural form, . . 82
25. Partial fracture of the clavicle without spontaneous restoration. From
nature ; taken throe weeks after the accident, 82
26. Partial fracture after union is consummated, 84
27. Fracture of the lower jaw, Ill
28. Bean's maxillary articulator, 127
29. B^^n's apparatus for broken jaw, applied, 128
80. Plaster model of jaws, 181
81. Kingsley'B apparatus reversed, 181
82. Same applied to model 132
83. Gibson's bandage for a fractured jaw, 182
2
XVlll
LIST OF ILLUSTRATIONS.
FIO.
84. Dnrton's bandaf^e for a fractured jaw, ....
85 Finir-tailKl bandage or sling for the lower jaw, .
86. Tlio autbor'8 apparatus for a broken jaw, ....
87. Fracture of the spinous process,
88. Fracture of the vertebral arch,
80. Obliquo fracture of the body of a vertebra, .
40. Kfy's ciwe of fra^turo of the first lumbar vertebra, .
41. Wire b.'d,
42. ParkorV case of fracture of the odontoid process of the axis,
48. I)ev<»lopinent of sternum,
44. Fracturt* of the rib:*, with lateral union, ....
45. ("omplctc r>brKiue fracture of the claviclo, ....
46. Fracture of the clavicle outside of the trapezoid lis;ament,
47. Complete oblique fracture of the clavicle at the outer end of
two-thirds,
48. Comminuted fracture of the clavicle united,
49. V<*lpeau*8 dextrin bandage; no axillary pad,
60. Fijfure-of-8 bandaf^e, for a fractured clavicle, .
61. Moore*s apparatus for fractured clavicle. Back view,
62. MfMjre's apparatus for fracturi»d clavicle. Front view,
68. Sayrc's apparatus for fractured clavicle,
64. Sayrv'H apparatus for fractured clavicle,
66. iSayri'V apparatus for fractun-d clavicle,
66. Bartlett's apparatus for fractured clavicle,
67. F«>x'b apparatus for fractured clavicle,
68. Tho author's apparatus for fractured clavicle,
60. Fracture of angle of tho scapula,
60. Fracture^ of the btxiy and acromion proce>s of tho sea
CI. Comminuti'd fracture of the glenoid cavity,
62. FrHclur(> of the neck of the scapula, .
63. Si'apula with cpiphyM-s
64. FrHciuro of tin* roracoid process,
65 Friii'turi) at tho anatomical nock of the humeru!«,
66. INiprV .•^pi'cimen uf supposed fracture at the anatomical
and reversion of the head, ....
67. Sam«»,
68. Humerus with <>piphyHes
69. Upp<*r <'piphy^iH of humerus, ....
70. Kpiphy^ral hopurHiion,
71. Fniclure of surgical ne<'k of humerus,
72 Flan of HUthor't4 lone: leather arm splint, .
7:t. Loni; leather splint closed at top and in shape, .
74. .*^h«»rl -plint,
75. Lon<^iiul<-*rt apparatU"* for extennion, in fractures of th
70 MHrtin'* e\|cfiHii>n in fraclurf** of th<» humerus,.
77. Clark'fi extension in fractures of the humerus, .
78. Fracture of the humerus at the base of the condyles,
70. Si'pnration of lower epiphy.^e:*, ....
8<). Ueeve's cat^e uf separation of the lower epiphy^is of the hume
81. Ktoe'o arm and forearm splint, ....
82. Welch 't arm and f«)rearm splint,
8^). Bond's elbow splint,
pula.
neck of th
0 humeru:*
rus
the
innei
humerus,
LIST OP ILLUSTRATIONS.
XIX
no.
84.
85.
86.
87
88.
89
90.
91.
9±
93.
94.
%.
97.
98.
99.
UJO.
101.
102
103.
IW.
105.
106.
107.
IC"?*.
109.
110.
111.
112
11. ?
114.
llo.
110.
117.
118.
119.
1-20.
1-Jl.
121'.
1*23
124.
125.
12«5.
127.
128.
129.
130.
131.
132.
The author's elhow splint,
Fracture at the base of the condyles of the humerus, and between the con-
dyles,
Fracture of internal epicondyle of the humerus,
Fracture of external epicondyle,
Fracture of the internal condyle of the humerus,
Fracture of external condyle,
Mutter's specimen of fracture of the neck of the radius, ....
Fracture of head of radius, .
.Scott's apparatus for fractures of the forearm,
Fracture of the shaft of the radius,
Collcs's fracture — radius near its lower end,
Impacted fracture. Author's collection,
Comminuted fracture. Author's collection,
Bii^elow's case of comminuted fracture of the lower end of the radius, .
Nelaton's splint for fracture of the radius near iu* lower end,
Bond'ji splint for fracture of the lower end of the radius.
Hay's splint for fracture of the lower end of the rndius, . . . .
E. P. .Smith's splint for fracture of the lower end of the radius — front
view, . . ...........
Same as above — back view,
Shrady's splint for Colles's fracture,
Hftwit's splint,
Author's palmar splint ; right arm,
Author's dorsal splint,
Th«f author's dressing for a fracture of the radius near its lower end —
com|)Iete, ............
Radius, with epiphy.ses,
Fracture of the shaft of the ulna,
Fracture of the coronoid process of the ulna,
Ulna, with cpiphyse**,
Fracture of the olecranon process at its base,
olecranon process united by ligament,
Sir A:«tloy Cooper's method of dressing a fracture of the olecranon process,
The auth«)r'8 splint fur a fracture of the olecranon process, applied,
Fracture of the radium? and ulna in the middle third,
Fracture of the radius and ulna in the lower third,
Kadius and ulna united with displacement,
Palmar splint, ........
Gutta-percha splint for finger,
Development of os innominatum, ....
Clark's case of comminuted fracture of the pelvis, .
Development of femur, ......
Fracture of the neck of the femur, within the capsule,
Intracapsular fracture caused by a fall upon the trochanter, .
Impacted fracture of the neck of the femur, within the capsule,
Horizontal section of the neck of the femur, ....
Extracapsular fracture with inversion,
Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule
Impacted fracture within the capsule, ....
Section of the bead and neck of the sound femur of an adult,
Chronic rheumatic arthritis, in hip-joint,
PAGE
264
265
268
272
278
276
280
282
284
286
287
291
291
291
298
298
298
299
299
299
800
804
804
805
810
311
816
319
825
827
329
330
832
338
833
342
349
351
352
368
870
372
373
377
377
388
384
885
386
LIST OF ILLUSTBATIONS.
1. CrnKby's ipecinien of Tracture of neck of fumur within tho ckpnulo— iin-
:. Hhj'ii'b Kpociiucn uf fracture of tbu oi.'ck of the femur within thecupfule
— unU«l by ligiinipnt,
>. Author's HppHrntiiit fur fraeturci of the nuck of tha femur,
:. Ui^^>|ln'»mudifl<'lltion of IlBgedom'* thigh i|ilinU,
'. (tibMiti'a mudiflitl »plinli)ip1ictl,
I. Iiii|iiii;ti'<l vxtracHpauliir fraoturi^,
. Fruclure of the ni-vb uf the femur
. KitrHi'HpHuUr fravlun- uf the neck of tbi< fumur— ununil<yl, .
, EilrHcftpsulur tructurc uf the nock uf thii femur— with ciceya of
. Exlrm-'apaular fratturo of the nefk of the feniur-~unit<-d with ii
I. Milltrr'a i>]ilint fur i'ilr>ea)i:iu1ar frncturc-i
;. Mr. Ai-lon Kuy'srniip
'. Sir Axtlcy Cuu|icr'* iiiude of tresting fractunv of tbo trnchnntcr
I. Fraclure of tbu fi-tnur at tho bate of tbc cundytef, .
I. pby«i<:k'ilhigb''|itint
I. Liflun'x drLtsing uf fnicturcd femur with m tiirnight iplint,
. I hxiblu- inclined plniiu in Uiildleai-i Uo^pital, London, ■
1. Ami-»bury'i doubii'-irH'lini-d plane
i. Am-»hurjVFplinliipplii'd,
:. ]).>.v<Ti> thiKh spiiiit appiiirJ,
I. NiHhnii K. Hmith'K furpi'iiding apparntuii, or duiible-inelined phiii"
\ N..tl'<auuM<'-im'liiifHl plane,
'. N. R, Smith'* alil'-riurhplinl,
I, N R. SiiiltbV miu-riursplinl, applioil,
I. l'Hliii.-r'» iii.KliHi'utiiin uf tbc onti-rlor h|ilint
I. lIiidp'UH ^u,-]ii'ii.iuti Hi'paratnn,
i:;!. -
« ,lr»iKh
n ibigh Hp|>arHli
n and c.
.Liyod ill the Mhb:
ii'W, wilb f.>ia<'J •^\>-tt* IhiU aurr
I,,.— »p|iiir,it.i. nppli-d, fruut vinw. .
■i»—ii)>pMri.tu-' B).pli<-I, Md.' vi<-w,
m-.-m.»le nf applvihi; a.lb.^iv.- pla^l-r* l.> I
III. — iiL-le uf inukinn e Ifneiun by adheMve
nil— |H-riiuiil bniid ■'••.■ur.'d with a pailiixk,
iril"ii IturkV I'rHi'luroappiiratu*. .
iriKT'^ tbiifh rpliiit
•.'|.h lliirL-]i.irn.'-> tbi^h tptiii
[| ill rni.
of th.Mbii;h,
u huth thii;bi,
LIST OP ILLUSTRATIONS. XXI
FIG. PAOB
181. Dr. Gibbes's case, anterior view, 488
182. Extension during application of plaster of Paris, 441
183. Extension continued until the plaster is hard, 441
184. Fracture of femur just below trochanter minor, 442
185. Jenks'fl fracture-bed, 445
186. Daniels's fracture-bed — descriptive diagram, 446
187. The same — complete, 447
188. The same — in use, 447
189. Crosby's invalid-bed, closed, 448
190. Crosby's invalid-bed, open, 449
191. Standard for extension, 449
192. F<>ot-piec«, 460
193. Extension-band and foot-piece, 460
194. Extension-band and foot-piece folded, 460
195. Mode of applying adhesive plaster for extension, 452
196. Author's dressing for fracture of shaft of femur, complete, . . . 458
197. Author's splint for fracture of femur in a child, 454
198. Author's dressing for fracture of femur in a child — complete, . . 454
199. Crosby's specimen of fracture of the external condyle of the femur, . 455
200. Sir Astley 's Cooper's case of fracture of the external condyle of the femur, 456
201. Transverse fracture of the patella, 462
202. Comminuted fracture of the patella, 462
203. Transverse fracture of the patella — exhibiting the relations of the mus-
cles to the fracture, 462
204. Fragments of a broken patella separated by flexion of the knee, . . 462
205. Upper fragment of a broken patella drawn up very much by the action
of the quadriceps femoris, 468
206. The author's mode of dressing a fractured patella, 466
207. Wood's apparatus for a fractured patella, 467
208. Dorsey's patella splint, 468
2i»9. Sir Astley Cooper's method for broken patella by circular and parallel
tapes, 468
210. Sir Astley Cooper's method by a leather band and counter-strap, . . 469
211. L<m^dale's apparatus for fractured patella, 469
212. Beach's apparatus, 470
213. Beach's apparatus applied, 471
214. Mnlgaigne's hooks for fractured patella, 471
215. Burge's apparatus for fractured patella, 471
216. Laui^dale's apparatus for fractured patella, 472
217. Development of tibia, 478
218. Development of fibula, 477
219. Fracture of the fibula near its lower end, 478
220. Dupuytren's splint incorrectly applied, 480
221. Dupuytren's splint, as originally made and applied by himself, . . 480
222. Cornpjound and comminuted fracture of the leg, 488
223. Plaster of Paris dressing for fracture of leg, and suspension, . . . 491
224 Van Wagener's suspension apparatus, 492
225. Hutchinson 'a splint for extension in fractures of the leg, .... 498
226. Neili's apparatus for fractures of the leg requiring extension and counter-
extension, 494
227. Nei 1 1 's apparatus for compound fractures of the leg, .... 494
228. Gilbert's fracture-box, 495
xxu
LIST OP ILLUSTRATIONS.
no. PAGE
229. Crandall's apparatus for fractures of the leg requiring extension and
counter-ex tension — side view, 405
280. Same — posterior view of the entire apparatus, 41*6
281. Same — posterior view of the lower section, 496
282. Li.^iton's double-inclined plane, applied to the leg in a case of compound
fracture, 497
288. Bauer's wire splints for the leg, 408
284. Swinu; box for fractures of the log, 498
285. Salter's cradle for fractures of the leg, 499
28G. FrHCture-box for the leg, with movable sides, 499
287. Wire rack for fracture of the leg, (iOO
288. Malgaigne's apparatus for certain oblique fractures of the leg, . . 500
S89. Malgaigne's apparatus applied, 501
240. Apparatus for fracture of the tuberosity of the calcaneum, . . 507
241. Author's movable canvas for gunshot fractures of thigh, . . 514
242. Author's movable canvas for gunshot fractures of thigh, with extcn:iion,
on horses, 514
248. Ilodgen's apparatus for gunshot fractures of the thigh, .... 515
244. Same, 515
245. Gunshot fracture of thigh — front view, 521
246. Same— side view, 521
DISLOCATIONS.
247. Clove-hitch,
248 Com}K>und pulleys and ring,
240. Doublo dislocation of the inferior maxilla, ....
250. Same,
251. A\reb'i» case of bilateral dislocation of the fifth cervical vertebra,
252. I>i^l^K•ation of the htcrnnl end t»f the flavioli* forwards, .
253. Sir Attley Ct>ojier's apparatus for dislofuled clavicle,
254 Di^lncalion of ht»'rnul end of clavicle upwards,
255. I>i^l<K'alion of the acromial end of the clavicle upwards, .
25(>. Dislocation of acromial end of clavicle upwards and outward;*,
257. Mayor'rt apparatus for dislocated clavicle, ....
258. Dislocation of the fhouldcr dow^ward^ into the axilla, .
269. Same. ...........
260. New tiocket in an ancient luxation of the shoulder ditwnwanls,
261. N. K Smith's method of reducini^ a di'>location of th«' shoulder,
262. La .MotheV methiKl of nnlucing a di^lo^ation of the should<*r — nuxlitiiHl
268. Sir Astley OH>pi»r'« method, with the heel in the axilla, .
264. Sir Astley Cooper^n m(>thod, with the knee in the axilla,
26*') Iron kn(»b em{>Ioy«'d by Skey instead of the heel, .
2t>6. Skey V methtal in didltK'Htions of the shoulder, .
267. Sir Astley Cooper's method by mean;* of pulleys,
268. Subct»racoid dihliK-ation of the humerus,
269. SuU-liivicular dii«l(»cation of the hiimeru.<», ....
270. SuU'oracoid di»locatii)n t»f the humerus,
5.12
r>n2
r>H5
5S6
551
558
5t;0
.Vi2
5419
575
57»l
5H:1
5hK
58y
590
591
591
592
604
604
605
LIST OP ILLUSTRATIONS. XXIU
FIB. PAOB
271. Subspinous dislocation of the humerus, 611
272. Displacement of the long head of the biceps, 616
273. Dislocation of the bead of the radius forwards — anatomical relations, . 618
274. Dislocation of the head of the radius forwards, 618
275. Dislocation of the bead of the radius backwards, 624
276. Dislocation of the upper end of the ulna backwards, .... 626
277. Dislocation of the radius and ulna backwards, 627
278. Sir A$>tley Cooper's method in dislocation of the radius and ulna back-
wards, 681
279. Maft frequent form of incomplete outward dislocation of the forearm, . 687
280. Most frequent form of incomplete inward dislocation of the forearm, . 642
281. Canton's case — dislocation of the radius and ulna forwards, . . . 644
282. Dislocation of the carpal bones backwards, 649
288. Same, 650
284. Dislocation of the carpal bones forwards — ^skeleton, .... 661
285. Dislocation of the carpal bones forwards, 662
286. Dislocation of the first phalanx of the thumb backwards, . 660
287. Clove-hitch, 662
288. Sir Astley Cooper's method of reducing dislocations of the thumb by the
pulleys, 668
289. Lev is 's instrument for reduction of the phalanges, 665
290. Same, 666
291. Indian <* puzzle "^-employed in the reduction of dislocations of small
joints, 666
292. Backward dislocation of the first phalanx of the index finger — reduction
by extension, 669
293. Dislocation of the second phalanx backwards, 670
294. Dislocation of the second phalanx forwards, 671
295. Dislocation of the femur upon the dorsum ilii, 676
296. Ilio-femoral ligament, 677
297. Dislocation of the femur upon the dorsum ilii, showing relations of ilio-
femoral ligament, 678
298. Dislocation of the fomur upon the dorsum ilii, 679
299. Everted dorsal dislocation, 680
300. Nathan Smith's method of reduction of a dislocation of the head of the
femur upon the dorsum ilii, by manipulation, 686
301. Relaxation of the ilio-femoral ligament, by flexion, .... 687
302. Hippocrates's mode of reducing dislocations of the hip by extension, 688
308. Reduction of a dislocation upon the dorsum ilii by pulleys, . . 689
304. Reduction of a dislocation upon the dorsum ilii by the Spanish wind-
lass, 690
305. Jarvis's adjuster — applied in dislocation of the hip, . . . . 691
306. Bioxham's dislocation tourniquet — applied for reduction of a dislocation
of the femur upon the pubes, 691
307. Bigelow's tripod for vertical extension, 700
808 Dislocation of the femur upwards and backwards into the great ischi-
atic notch, 702
809. Same, 702
310. Internal obturator in its natural position, 708
311. Internal obturator in its new position, 708
312. Dislocation upwards and backwards into the great ischiatic notch —
" below the tendon," when the patient is recumbent, .... 704
XXIV LIST OF ILLUSTRATIONS.
FIO. PAOK
818. Reduction of m dislocation into the great ischiatic notch, by pulleys, 707
814. Relations of the ilio-femoral ligament to thyroid dislocations, .710
815. Dislocation of the femur downwards and forwards into the foramen
thyroideum, 710
816. Reduction of thyroid dislocation by manipulation, . . .711
817. Sir Astley Cooper's mode of reducing recent luxations of the femur into
the foramen thyroideum, 718
818. Effect of flexion upon the ilio-femoral ligament in the thyroid disloca-
tion 714
819. Specimen of dislocation upon the pubes, in St. Thomas's Hospital, 715
820. Dislocation upon the pubes below the anterior inferior spine of the
ilium, 716
821. Dislocation upwards and forwards u|>on the pubes, . . .717
822. Reduction of dislocation upon the pubes by extension, .... 719
828. Anterior oblique dislocation, 721
824. Mechanism of anterior oblique dislocation, 721
825. Supraspinous dislocation, 722
826. Voluntary subluxation upon the dorsum ilii, 736
827. Same, 736
828. Dislocation of the patella outwards, 788
829. Dislocation of the patella inwards, 740
880. Dislocation of the head of the tibia backwards, 746
881. Incomplete dislocation of the head of the tibia forwards, . 748
832. Subluxation of the head of the tibia outwards, 751
838. Subluxation of the head of the tibia inwards, 752
884. Dislocation of the lower end of the tibia inwards, .... 757
835. Same, 758
886. RtHluction of a dislocation of the ankle by pulleys, .... 759
837. Dislocation of lower end of the tibia outwards, 761
838. Partial dislocation of the tibia forwards, with fractures of malleolus
internus and fibula — skeleton, 763
839. Partial dislocation of the tibia forwards, with fracture of the malleolus
internus and fibula, 763
840. Dislocation of the lower end of the tibia backwards, .... 766
841. Same, 766
842. Dislocation of the astragalus outwards — anatomical relations, 770
848. Simple dislocation of the astragalus outwards, 771
844. Com|iound dislocation of the astragalus inwards 771
PART I.
FRACTURES.
8
FRACTURES.
CHAPTEK I.
GENERAL DIVISION OF FRACTURES.
Fractures are divided into Complete and Incomplete, Simple,
Comminuted, Compound, and Complicated.
A Complete fracture is one in which the line of division completely
traverses the bone.
An Incomplete fracture is a partial separation of the bone : under
which name are included Bending, Partial fractures, Fissures and
pQDctured or Perforating fractures, the last of which is almost peculiar
to gunshot injuries.
A Simple fracture is one in which the bone is broken at only one
point. The term has no reference to the question of complications, but
io its technical meaning, as employed by both English and American
surgeons, it has reference only to the number of fragments into which
the bone is broken. It would be more correct, perhaps, to substitute
the word "single'' for "simple," as has been done by Malgaigne and
some other French writers, but I fear that to American surgeons the
substitution would be rather a source of confusion than otherwise.
A Comminuted fracture, called by Malgaigne " multiple," is a frac-
ture in which the bone is iMroken at more than one point, and in which,
consequently, the bone is divided into more than two fragments. It
is used also in a technical sense, and by no means implies minute
division or comminution of the fragments.
A Compound fracture is technically one in which there exists also
an external wound communicating with the bone at the point of frac-
ture. It may be either partial or complete, simple or comminuted, or
even complicated, while at the same time it is also compound.
Complicated fractures are such as present additional complications,
or complications for which no other specific term has been invented.
Thas, the fracture may be complicated with the lesion of an important
bloodvessel or nerve, or with great contusion or laceration of the soft
parte, with a dislocation, or with fractures of other bones, or even with
some constitutional fault.
Fractures are also divided into Transverse, Oblique, and Longitu-
dinal, according as the direction of the line of separation is at a right
OGNEBAL DIVISION OF FRACTUHES.
angle with the axis of the bone at the point of fracture, or as it deviates
more or less from this directina. But a fracture is called transverse
when it does not traverse the bone precisely
^"^ '■ at a right angle ; indeed, we usually apply
this term whenever the obliquity is only
moderate, or when, in the examination of
a limb, although we arc unable to detect
the precise line of the fracture, we ascer-
tain that, without being impacted or ser-
rated, the ends of the bones continue to
rest upon each other, or, being replaced,
do not spontaneously become displaced.
Longitudinal fractures occur generally
in connection with oblique or transverse
fractures; as when the lower end of the
femur is split vertically into the joint, and
the shaft of the bone is traversed horizon-
tally by a fracture which intercepts the ver-
tical or longitudinal fracture. A fracture
of a condyle, or of any projection from the
body of the bone, is caliett longitudinal if the
direction of the line of fracture is parallel,
or nearly so, to the axis of the shaft.
A Serrated fracture is one in which the
opposite surfaces denticulate, the eleva-
tions uiwn one fragment being reflected
by corresponding depressions upon the
other.
Impacted fractures arc those in which the fragments are driven into
FerfaniUaii (D>l l»B|ltiHllo>l
each other, the lamellnted structure of o
cancellous structure of tlie otlier.
i fragment penetrating the
GENERAL ETIOLOGY OF FRACTURES. 29
Writers also occasionally speak of fractures en rave, en bee de JliUe,
enbec de plume, spiroid, cuneate, etc. ; but we do not see the propriety
of multiplying the divisions and incumbering our nomenclature by
these fancied resemblances. For all useful purposes^ the divisions
above given are sufficient.
Epiphyseal separations we shall not hesitate to class with fractures,
aod to submit them to the same rules of nomenclature. These acci-
dents rarely occur after the twentieth year of life ; since after this
period, and in the case of some bones at a much earlier period, the
epiphyses are usually united to the diaphyses by bone.
CHAPTEK IL
GENERAL ETIOLOGY OF FRACTURES.
The causes of fracture may be considered as predisposing and ex-
dting.
Predisposing Causes. — Partial fractures, with bending of the bones,
are most frequent in infancy and childhood; but complete fractures
occur most often during manhood ; and if they are again less frequent
in old age, it is because the exciting causes are less operative, since the
fragility of the bones, as a general rule, increases with age. It will be
noticed, also, that somewhat in proportion as the bone is more brittle,
its fracture will be more nearly transverse, so that very old persons
have frequently what has been not inaptly termed the " pipe-stem frac-
ture;" but we must except from this rule fractures occurring in chil-
dren, which are also not unfrequently transverse, often denticulated or
splintered, and but rarely oblique. In all of the intermediate periods
of life, oblique fractures are by far the most common. Females are
less liable to fractures than males, except in old age, when the law
seems, in general, to be reversed. As to the season of the year, it has
been generally observed by surgical writers that fractures were more
frequent in winter than in summer, and an explanation has been
sought for in the greater rigidity of the muscles during the cold weather,
and the greater liability to falls upon the ice and frozen ground. Some
have aflBrmed that the bones themselves were more brittle; but, aside
from the improbability of this last explanation, it is a matter of ques-
tion whether fractures are actually more frequent in the winter than
in the summer. If, on the one hand, the rigidity of the muscles and
&Ils upon slippery walks are active causes in the production of frac-
tures in the one season, on the other hand, falls from buildings and ac-
cidents from a great variety of similar causes are equally active agents
in the other.
Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy,
mercurialization, and, in short, all diseases dependent upon cachexise,
more or less predispose to the occurrence of fractures. Inflammation
30 GENERAL ETIOLOGY OF FRACTURES.
of the periosteum, also, or of the bone itself, may predispose to fracture.
It is said, moreover, that the bones of persons who have lain a long
time in bed break easily.
Exciting Causes. — The exciting, determining, or immediate causes
of fractures are of two kinds : mechanical violence and muscular ac-
tion.
Of these two, mechanical or external violence is much the most fre-
Juentcause; and this violence may operate in two ways: by acting
irectly upon the bone at the point at which it se|)arate8, and then we
say the fracture is "direct,'' or from "direct violence;" or by acting
upon some point remote from the scat of fracture, and then we say the
fracture is "indirect," or from a "counter-stroke." When a person
falls from a height, alighting upon his feet, and the leg or thigh is
broken, the fnicture is indirect; so also if the bone is bn>ken by flexion
or torsion. Even direct pressure upon one side of a long bone in a
child may produce a partial fracture upon the opiK)site side, which is
properly an indirect fracture; or a direct blow upon the trochanter
major may occasion a counter-fracture through the neck of the femur.
Fractures from muscular action occur most often in the patella, cal-
caneum, humerus, femur, tibia, and olecranon process of the ulna.
These accidents may imply some condition of the bones themselves
which pre<li8|)ose them to fracture ; but I have seen one example of a
fracture of the shaft of the femur in a large and j)erfectly healthy man,
occasioned by a twist of the leg in rolling tenpins. I have also quite often
known the tibia and patella to break from natunil muscular action
in persons of uncommon vigor. Fractures sometimes occur in the vio-
lent contractions of the muscles during convulsions, and where no al)-
normal (condition of the bon(« could be assumed to exist. Parker, of
New York, relates a aise of fracture of the humerus in a negro preacher,
which occurretl in the act of gesticulation; also, a fracture of the clavi-
cle occasioned by striking a dog with a whip; in another case the hu-
menis was broken in attempting to throw a peach ; but the most singu-
lar case of all was a fracture of the humerus caused by an effort to
extract a twjth.*
I have mysi?lf seen the clavicle broken in the case of a man who was
reaching i>ack to lift the top of hLs carriage; and another in which the
humerus wjw broken in a contest to determine the power of the rotator
muM'les of the forearm.
I^»nte has sam lK)th femurs broken in epileptic convulsions, in a
chihl twelve years of age. The left femur was bn)ken April 10th,
1859, at the junction of the up|K»r with the middle thini, and the right
femur was broken at the same |K)int eight months at\er, and aixuit six
w«»ks later he died. The first fracture united with considerable l)ow-
ing and shortening. The second did not unite at all. He had l>een
subjei*t to epile|)sy since he was fifteen months old.^
Kemarkable examples of fragilitv of the bones have been from time
to time recorder]. Gibson relator tlie case of a young man who at the
> riirkrr, Xcw York Journ. M«i , July, 18r,2. ji. 05.
> Am. Med. Time* and Advertiser, July 21, 1860, p. 41.
GENERAL ETIOLOGY OP FRACTURES. 31
age of nineteen had suffered twenty-fonr fractures. Arnott speaks of
a girl who at the age of fourteen had suffered thirty-one fractures ; Es-
quirol had in his possession the skeleton of a woman in which were
found traces of more than two hundred fractures ; and we have had, at
the Charity Hospital, a man set. 53, who had suffered eleven fractures
and two dislocations, in whose case both the susceptibility to fractures
and to dislocations appeared to be hereditary.^ In most of these cases,
so far as is known, union occurred rapidly.
Nearly all of the cases of fractures occasioned by muscular contrac-
tion seen by me were transverse, or nearly so, and most of them have
been unattended with shortening, the ends of the bones not becoming
completely displaced from each other. The example of fracture of
the shaft of the femur before mentioned, as having been broken in roll-
ing tenpins, was, however, an exception. The limb was placed by the
surgeon in charge, upon a double inclined plane, upon the theory that
in this position no shortening was likely to occur. The bone shortened,
however, to the extent of an inch or more, and in this position it has
finally united.
Intra-uteriue fractures are not yet fully explained, but it is probable
that they, like extra-uterine fractures, may be ascribed sometimes to
external violence, and at other times to simple muscular contraction,
both perhaps acting upon bones already somewhat predisposed by a
peculiar constitutional cachexy.
November 18th, 1872, a child was broiight to me having a fracture
of the left clavicle, which had united with considerable deformity, the
point of fracture being at the junction of the middle and outer thirds.
The mother said that she fell upon her belly about two weeks before
the birth of the child, striking upon a tub; delivery occurred at the full
period, in the hands of an uneducated female accoucheur. Four weeks
later (when I was consulted) union was complete.
Lawrence Proudfoot, of New York, has related a case of compound
fracture in tUero occuring in the practice of Dr. Freeman, which was
apparently caused by external violence. Mrs. F., set. 38, always
having enjoyed good health, during the sixth month of gestation, while
attempting to pass through a very narrow passage, was severely pressed
upon the abdomen, and immediately experienced a severe pain in that
r^on, accompanied with nausea and &intness. The following day,
uterine ha?morrhage, with pain, commenced; and these symptoms con-
tinued at intervals, in a form more or less severe, up to the period of
her delivery, which occurred at full time, and was perfectly natural.
At birth, the right foot of the child, a female, was found to be much
distorted, and in a condition of valgus with equinus, the outer side of
the foot being laid against the side of the leg above the external malleo-
lus. The tibia, also, of the same limb, near its middle, seemed to have
been the seat of a compound fracture; the two ends of the bone having
united at an angle slightly salient anteriorly, and the skin presenting
over the point of fracture an old cicatrix. The sofl tissues adjacent
1 The Phjrsician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian,
HoQie Surgeon.
32 GENERAL ETIOLOGY OF FRACTURES.
were considerably thickened. Seventeen months after birth, when the
child was seen by Drs. Proudfoot, Van Buren, and Isaacs, the foot,
although much improved by the means employed by Dr. Freeman, was
still considerably deformed, in consequence of the contraction of the
tendo Achillis ; on cutting which, the limb was found to be of the same
length with the other.^
Dr. Aristide Rodrigue, of Hollidaysburg, Pa., has communicated a
case of fracture with dislocation, which he ascribes to a similar cause.
The woman, when about four months with child, fell on her left side,
striking upon a board, and hurting herself severely. At the full period
she was delivered of a well-grown male child. Its left humerus was
found to l)e dislocated into the axilla, and both the radius and ulna of
the same limb had been broken through their lower thinls, but were
now united by bony callus at an angle of about 45°, and slightly over-
lapped. In all other respects the child was perfect. It does not ap-
pear that anything was done to the fracture, and the attempt to reduce
the humerus was unsuccessful. Four years later Dr. R. saw the lad,
and found him strong and hearty, the dislocated humerus having grown
nearly at the same rate with the opposite, but the forearm remained
" short and deformed as at birth." The hand was of the same size as
the hand of the sound limb.^
Devergie has given an account of a woman, who, when seven months
with child, struck her abdomen against the corner of a table. Intense
pain followed, lasting some time. She went her full period, however,
and the child was then found to have a fracture of the left clavicle,
the fragments being overlap|)ed somewhat, and united in this position
by a firm and large callus.' A woman also six months gone met with
a similar accident, and at the full time she gave birth to a feeble
child, having in one leg a separation of the shaft of the tibia from its
lower epiphysis. The end of the shaft was necrosed, and projected
through a wound in the integument. This child died on the thirteenth
day.*
Schubert rejwrts the case of a female delivered before her term, of
twins, one of whom was l)orn with a fracture of the left thigh, which
had oecurreil in uiero; the fractured bone had pierceil the flesh, through
which it projected more than an inch, and it was carious. The mother
8tate<l that about six weeks before the accouchement, during a movement
of the f(rtus, she had heard a noise like that produce<l by breaking a
stick, and from that moment she had felt pricking pains in her belly.*
It is probable that in this instance the fracture was the result of a mus-
cular action, although it is possible that it was <Kvasioned by the thigh
having become entangled between the legs of the twin. Similar cases
have lK*en recorde<l by Ploucquet, Kopp, Devergie, Carus, Schubert,
Sachse, Moflat, and HnKlluirst.*'
» ProiuifiM.t, Now York Journ. Mod , Sopt. 1846, p. 190.
' R<Mlricin», Ai!H»r. Journ. Mini. Sci , Jan. 1854, p. 272.
• I>»vorj;io, R««v. McmI., 1826.
* MHl^ni^nt*, from Ari'hiv. (ien. do M^d., t xvi, p. 288.
* Amor. Journ. Med. Sci., May, 1828, p. 22;{ ; from Zcitsch. fOr Stantsarz. von
Honko, 7«* Krjj. Hoft., p. 811. IIolmcMV Surgery, vtd. iv, p. 826.
• Uolmet't Surgery, foI. if, 827, from Med.-Cbir. Trans., vol. zHii, 1860.
GENERAL ETIOLOGY OF FRACTURES. 33
In many other examples upon record* the explanation is plainly
enoogh to be sought for in the abnormal or rachitic condition of the
bones. Monte^ia saw, in a newly born infant, twelve united fractures.
Cbaussier, who has published a memoir upon this subject, mentions
two very extraordinary cases, in one of which the child presented
forty-three fractures, and in the other, one hundred and twelve.* I
myself was permitted to see, on the 29th of June, 1853, with Drs.
Hawley and White, of Buffalo, an infant only four days old, who was
bom at the full time, of a healthy mother, in whom nearly all of the
long bones were separated and movable at their epiphyses, the motion
being generally accompanied with a distinct crepitus. The bones were
also much enlarged in their circumference ; the bones of the forearm
and the femur were greatly curved; the fontanelles unusually open, and
the clavicles were entirely wanting. The child was of full size, but
looked feeble. It died in a condition of marasmus six months afler
birth ; at which time some degree of union had taken place at several
of the points of separation, the limbs having been supported constantly
with pasteboard splints and rollers.
Fractures occurring from violence inflicted upon the child by the
accoucheur, or from contractions of the neck of the womb while the
child is in trarmiUy are more common occurrences, and do not require
d separate consideration. I shall mention several in connection with
the various bones in which they have taken place ; among which, one
of the most interesting is that published by Jacob H. Vanderveer,
of Long Branch, N. J. The mother came to bed on the 18th of
January, 1847, after a labor of more than twelve hours. It was a foot
presentation ; the child weighed fourteen pounds, and was perfectly
healthy, but one of the thighs had suffered a complete fracture, occa-
sioned probably by the strong contractions of the cervix uteri. With
careful splinting and bandaging, the bone was finally, but not without
some difficulty, kept in position and made to unite, so that at the date
of the report one would not discover that the bone had been broken,
except by close inspection.'
CHAPTEK III.
GENERAL SEMEIOLOGY AND DIAGNOSIS.
Fractures are liable to be confounded with contusions, and with
various other local injuries, but most ofl^n with dislocations; and
especially when the fracture has taken place near one of the articu-
lations is the differential diagnosis sometimes rendered exceedingly
^ Lond. Med. Times and Gaz., April 7, 18G0. New Orleans Med. Journ , Not.
1860.
' ChauMier, Bullet, de la Faculty de Med. de Paris, 1813, p. 301.
■ Vanderveer, Amcr. Journ. Med. Sci., May, 1847, p. 878.
34 GENERAL SEMEIOLOGY AND DIAGNOSIS.
difficult. It is with particular reference, therefore, to the general points
of distinction between fractures and dislocations, that I now propose to
speak. The special signs or points of difference which belong to each
individual case will be considered in their proper places.
The most important general or common signs oi a fracture — and by
"common" signs I mean those which are common to most fractures —
are crepitus, mobility, and an inability on the part of the fragments
to maintain their positions when reduced ; indeed, in many cases, this
constantly recurring displacement is due to the fact that the surgeon
is unable to accomplish a complete reduction. While, on the other
hand, dislocations are almost as uniformly characterized by the al)scnce
of crepitus, by preternatural immobility, and by the fact that, when re-
duceil, the bones do not usually require support to retain them in place,
or indccil, we may say, by the fact that they are generally reducible.
I>et us study these phenomena a little more in detail.
Crepitus, oc^casioned by the chafing of the broken surfaces upon
each other, when actually present, is almost positive evidence of the
existence of a fracture. It is passible, however, to confound the chaf-
ing of engorged tendinous sheaths, or of inflamed joints upon which
fibrinous effusions have occurred, or of emphysema even, for the true
crepitus of a fracture; but to the experienced ear and well-practiced
touch these sensations are seldom a source of error. The one is rough,
crackling, or even clicking sometimes, while the other is more sub-
dued, and imparts a more uniform sensation to the hand, and but
rarely conveys an actual sound, unless the ear is directly applied or
the stethoscojK; is employed. It is only when the crepitus is trans-
mitted obscurely through a great mass of sofl tissues, or sufficient
time has elapsed for the ends of the fragments to become softene<I by
inflammation and partially covered with a plastic material, or when,
indeed, a dislocation is actually coincident with the fracture, that the
surgeon is lefl in doubt. Occasionally, also, the existence of caries or
of necTosis, in connection with a dislocation, might lead to the sup-
position of a fnic'ture; but the history of the case, aside from the
remaining common signs, and the s|>ecial symptoms hereafter to be
enumerated, would prevent any possibility of error. In a few ceases
the diagnosis may be facilitateil by the application of the ear or of the
stethoscope, its first recommended by Lisfranc*
It must not be forgotten, moreover, that a fracture at one point
may transmit the sensation of crepitus distinctly enough, but in such
a direction, owing to the relations of other bones to the one broken,
as to niisk»ad the surgeon, and induce him to locate the fracture in the
wrong l>one. iSeveral examples of this 8|)ecies of deception I shall
her«if\er have occasion to mention.
Valuable and imjmrtant as is crepitus in its relations to diffi.*rential
diagnosis, unfortunately it is not always present, and for reasons which
must l)e nlainly stated. First: we cannot, in a pretty large proportion
of ciu^e^, bring the bn)ken ends again into ap|)osition. Whatever mere
theorists may say to the contrary, and notwithstanding surgeons up to
> New England Med. Journ., 1824, p. 220.
OENBRAIi 8EMEIOLOGY AND DIA0N08IS. 35
this time have rarely ventured to allude to this subject, the fact is that
we do not usually " set" broken bones. We do not, even at the first,
bring them into complete apposition, unless it is as the exception. I
speak of bones once completely displaced by overlapping, and these
coostitote the majority of examples which come under the surgeon's
observation. Second : in transverse fractures of the patella, and in
fractures of the olecranon process of the ulna, of the acromion process
of the scapula, and in all similar detachments of processes and apophy-
ses, the action of the muscles, by displacing the fragments, may pre-
vent crepitus from being readily produced. Third : in a few cases,
soch as certain fractures of the neck of the femur, of the neck and
head of the humerus, in a Colles fracture, etc., the broken ends may be
impacted, or so driven into each other as to forbid the production of
motion and crepitus; or they may be simply denticulated, and the
consequences, so far as crepitus is concerned, will be the same.
Finally, in very many incomplete fractures, crepitus does not exist ;
and even when it is present, the sensation is feeble, or very much modi-
fied, sometimes giving only a faint and single click. Under the head
of crepitus we may properly include the sharp crack sometimes felt, or
even heard, by the patient at the moment of fracture.
Preternatural mobility, less valuable as a means of diagnosis than
crepitus, is, nevertheless, more constantly present, being never absent,
in some degree, in all complete, non-impacted, and non-denticulated
fractures ; but its presence does not, like crepitus, render the existence
of a fracture quite certain. Whenever the bony lesion takes place in
the vicinity of a joint, it may be difficult or impossible to determine
whether the mobility of the limb is due to motion in the joint or to
motion at the supposed seat of fracture. While, on the other hand,
the preternatural immobility so generally observed in dislocations may
^ve place to preternatural mobility, as when the ligaments and ten-
dons surrounding the joint are extensively torn, or the system itself is
laboring under the shock of the accident, or when from any other cause
there exists great general prostration.
As to the third common sign mentioned, namely, that in the case of
frairtures the bones do not generally support themselves, but demand
for this purpose the interposition of splints, bandages, and even of ex-
tending and counter-extending forces, its authority rests upon the same
evidence as does the assertion already made, that bones once separated
entirely, cannot generally be "set," that is, placed again end to end in
«ach a manner as to be made effectually to support each other. It
rests upon the evidence of my own personal experience; to which I am
permitted to add, also, the personal experience of Malgaigne, who, with
a frankness which does him great credit, and which, I am sorry to
?ay, has hitherto found few imitators, remarks : " Second. That over-
lapping is the most stubborn of all. Here I will add a disagreeable
truth, which classical authors have kept too much out of sight, namely,
that it is so stubborn that in an immense majority of cases the efforts
of art are unable to overcome it."^ And it must be observed further.
' Malgaigne, Traits des Fractures et des Luxations, Paris ed., t. i, p. 102.
36 GENERAL SEMEIOLOOY AND DIAGNOSIS.
that if we shall often find it possible to bring the broken surfaces suf-
ficiently into contact to develop crepitus, they may still be unable to
maintain themselves in this position, owing to the obliquity of the line
of fracture.
The other common signs of fracture may be briefly stated. Pain at
the seat of fracture; swelling; ecchymosis; deformity, produced by
either an angular, transverse, or rotatory displacement of the frag-
ments, and which is quite as often due to the direction and force of
the impulse which occasioned the fracture as to the action of the mus-
cles ; separation of the fragments, as in fractures of the patella and
olecranon process ; and inability to move the limb, a phenomenon due
in part to the breaking of the bony lever upon which the muscles
acted, and in part to the intense pain caused by any such attempts.
This latter symptom is, however, often entirely absent. It is not
generally present in impacted fractures, in serrated and partial frac-
tures, or in many other fractures in which the periosteum has not yet
completely given way.
Velpeau was the first, I think, to call attention to the fact that
patients with broken clavicles could very generally raise the arm above
the shoulder and even to the head, and I have repeatedly verified the
observation, notwithstanding the separation of the fragments has been
complete, and the overlapping considerable. In fractures of the neck
of the femur and of the tibia it is no uncommon thing for the patient
to walk some distance after the receipt of the injury.
As has been previously stated, fractures of long l)ones, caused by
muscular action, generally occur near the middle of the shaft, and they
are usually transverse. Direct fractures are also more nearly trans-
verse than indirect fractures, but less so than those caused by muscular
action; while those indirect fractures which are caused by a force
applieii in the direction of the axis of the lx>ne are, in general, ver}'
oblique. Hut what is of more importance in connection with diag-
nosis is, that in this latter class of cases the fracture usually takes place
near the point upon which the force of the blow is received. Thus, for
example, a fall ujwn the hand generally causes a fracture of the lower
end of the radius — a Colics fnicture — or if both bones break, it is
generally below the middle, and very seldom indeed in the up|>er third.
A fracture of the shaft, of the humerus near the condyles is a frequent
result of a fall upon the elbow. The classical fracture of the clavicle,
at the junction of the middle and outer thirds, is usually causeil by a
&II u|)on the shoulder. A fall upon the foot causes a fracture, in most
castas, near the lower end of the tibia, and the same is true, quite often,
of the lower end of the femur. Exceptions to the rule alwve stated
are most a)mmonly met with in advauc^ed life, when falls ujwn the
elbow occasion fractures at the surgiciil neck of the humerus, and falls
U|K)n the shoulder sometimes cause fnictures near the sternal end of
the clavicle. Similar accidents, in old people, also break the tibia
near its up|)er extremity, and the femur within its ca|)sule.
I cannot dismiss this subject without calling attention to the neces-
sity of exercising care and gentleness as well as skill in the examina-
tion of broken limbs.
GENEBAL SEMEIOLOOY AND DIAGNOSIS. 37
Xothing, in my opinion, betrays a lack of judgment as well as of
common humanity, on the part of the surgeon, so much as a rude and
reckless handling of a limb already pricked and goaded into spasms by
the sharp points of a broken bone. It is not enough to say that such
rough manipulation is generally unnecessary, it is positively mischiev-
ous, provoking the muscles to more violent contractions, increasing the
displacement which already exists, and sometimes producing a com-
plete separation of the impacted, denticulated, transverse, or partial
fractures, which can never afterwards be wholly remedied ; augment-
ing the pain and inflammation, and not unfrequently, I have no doubt,
determining the occurrence of suppuration, gangrene, and death.
In proceeding to establish the diagnosis in any case, the surgeon
should sit down quietly and patiently by the sufferer, so as to inspire
in him fix>m the first a confidence that he is not to be hurt, at least
unnecessarily. He ought then to inquire of him minutely as to all the
circumstances immediately relating to the accident, in order that he
may determine as nearly as possible its cause, which alone, to the ex-
perienced surgeon, often affords presumptive, if not conclusive, evidence
as to the nature and precise point of the injury. From this, he should
proceed to examine the disabled limb ; removing the clothes with the
utmost care by cutting them away rather than by j^ulling; and when
completely exposed, he should notice with his eye its position, its con-
tour, the points of abrasion, discoloration, or of swelling; and not until
he hss exhausted all these sources of information, ought the surgeon to
resort to the harsher means of touch and manipulation. Nor will his
sensations guide him to the point of fracture by any other method so
accurately as when, the patient being composed and his muscles at rest,
he moves his fingers lightly along the surface of the limb, pressing
here and there a little more firmly, according as a trifling indentation or
elevation may lead him to suspect this or that to be the point of fracture.
The limb, in case of a supposed fracture of a long bone, may now be
measured with a tape-line, and compared with the opposite limb, having
first marked with a soft pencil or with ink the several points from
which the measurements are to be made.
Finally, if any doubt remains, the limb must be firmly but steadily
held while the necessary manipulations are performed, for the imriMj^
of ascertaining the existence of mobility and of crepitus. Mobility U
most easily determined by giving to the limb a lateral motion, lAit, m
general, crepitus is most effectually developed by gentle rotati<XJ^ tf
the place of fi^cture is already pretty well declared by tlw* yr^k'jm
examinations, the surgeon should place one finger over tli-e t^iMf^^t^j^
pointy during this manipulation, by which means the crepitu* wijj fyi?
more certainly recognized.
I do not oflen find it necessary to resort to an«sth<?ti<3» f^tr O**- ^r-
pose of insuring quietude and annihilating pain in nmk%%h% iiMm ^-kh^^^
inatioas, since it is seldom that the patient need to Vie wmmA 4i*^^^/J ;
bat if the examination is not ftatisfactory, and the dbjipK^ >r tm^^n-
tant, I do not hesitate to render the patient corapki^y iAMi^Hi^*/^ ^f^A^
▼hJch the questions in doubt may be more thoroojfbJ/ m^^it^^itt^thrfi jtt>d
perimps definitely settled.
38 REPAIR OF BROKEN BONES.
The surgeon ought not to forget, however, that while the patient is
under the influence of an ansBSthetic, violent manipulations arc no less
liable to rupture bloodvessels, and to lacerate other tissues, than if em-
ployed when the patient is conscious. Surgeons have not seemed al-
ways to understand this, and the result has been that in too many in-
stances they have inflicted serious and irreparable injury ; in one instance
which came under my notice, the injury thus inflicted caused tetanus
and death.
It is scarcely necessary to say that the earlier the examination is en-
tered upon, the more readily will the diagnosis be made out; and if,
unfortunately, some time has already elapsed before the patient is seen
by the surgeon, and much swelling has taken place, the examination
is still not to be omitted, and .whatever doubts remain we must en-
deavor to remove by repeated examinations, made from day to day,
until the subsidence of the tumefaction has brought the surfaces of the
bone again within the reach of our observation.
CHAPTER IV.
REPAIR OF BROKEN BONES.
It is not my intention to enter very fully into a consideration of the
process of repair in fractures, preferring to leave this subject where it
more properly t)elongs, to the general treatises on surgical pathology.
I only proj>ose to state very briefly a few practical, and I trust I
may now say, pretty well-established facts, such as the manner or |)osi-
tion in which this reparative material, whenever it is employed, is ap-
plie<1 to the broken bones, the length of time which is usually required
for the completion of the process of repair, and the causes which may
impede or prevent bony union.
If I think it necessary to say anything more upon this subject, it
will be simply to announce my belief that the reparative material, con-
sisting originally of a plastic lymph, is poured out from the vessels of
the Haversian canals, the medullary tissue, the periosteum, and more
or less from all of the lacerated tissues which are immediately adjact^nt
to the seat of fracture; that after a period, longer or shorter, tin's lymph
becomes organized, and begins to receive from the same sources |>arti-
cles of bony matter, through which the consolidation is finally effected ;
that the transition from the original plastic material to bone is in adults
almost constantly through the inter{)osition of connective-tissue, rarely,
unless in the case of cliildren, through a cartilaginous tissue, and some-
times through both consentaneously or consecutively ; tliat, perha()s, in
a few fortunate examples bones unite directly or imnie<liatciy, without
the intervention of a reparative material ; and finally, that granulation-
tissue sometimes becomes transformed into bone, in certain cases of
compound fractures, or of fractures in which tlie process of inflamma-
tion exceeds certain limits.
REPAIR OF BROKEN BONES. 39
Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel,
Camper, and Haller, declared that "nature never accomplishes the im-
mediate union of a fracture save by the formation of two successive de-
posits of callus;" one of which is derived from the periosteum and from
the adjacent tissues, and from the medulla ; while the other, derived,
perhaps, from the broken extremities of the bone itself, is found at a
later period directly interposed between these surfaces. The material
or callus derived from the tissues outside of the bone, and which Galen
compared to a ferrule, but which Mr. Paget calls " ensheathing," to-
gether with the material derived from the medulla, compared often to
a plug, and by Mr. Paget named "interior" callus, are by Dupuytren
spoken of as the "provisional," or temporary callus, by which the frag-
ments are supported, and maintained in contact until the permanent
callus Ls formed. This temporary splint is completed or has arrived
at the condition of bone in a spongy form, at periods varying from
twenty to sixty days ; but it does not assume the character of compact
booe until a period varying from fifty days to six months has elapsed ;
after which it is gradually removed by absorption. The second pro-
cess, by which the ends of the bone are definitively or permanently
united, commences when the provisional callus has arrived at the stage
of spongy bones, and is not completed usually within less than eight,
ten, or twelve months, "when," says Dupuytren, " it acquires a solidity
greater than the original bone."
While it is certain that this eminent surgeon and most accurate ob-
server has described faithfully the various phenomena which usually
accompany the repair of bones in those animals which were the sub-
jects of his experiments, and that his conclusions have a certain degree
of application to the human species, it is equally certain that he erred
in assuming that in man simple fractures always unite by this double
process ; yet, such is the power of authority, these doctrines were ac-
cepted from the first without hesitation or debate, and for nearly half
a century they have occupied the minds of surgeons, to the almost
complete exclusion of every other theory. Mr. Stanley was among
the first to question the solidity of the doctrines of Dupuytren, but it
remained for Mr. Paget to fully expose their many fallacies ; nor has
Malgaigne, although not strictly a disciple of Paget, failed to detect
certain of these errors.
I should also do injustice to myself were I not to mention that at
the very moment when Mr. Paget was making his observations upon
the specimens in "the large collection of fractures in the museum of
the University College," 1 was myself employed in similar researches
both among cabinet specimens and in the hospitals of this country and
rf Europe; and that the conclusions to which I had arrived were
nearly identical with, although the inferences were far from being so
complete in their detail as those to which this distinguished pathologist
was himself brought.* I do not, however, wish to make Mr. Paget
responsible for any of the opinions upon this subject which I shall
» Piper on "Proviiional Callus," by Frank H. Hamilton. Buffalo Medical
Jaaraat, Feb. 1853.
40 REPAIR OF BROKEN BONES.
»
hereafter express, except so far as they may be fouDd to agree with his
own published views. ^
I think it may now be fairly stated that the repair of bones by the
double process described by Dupuytren is, in man, only an exception
to a very general rule ; and that fractures may unite by either one of
the following modes :
First. Immediately, or in the same manner that the softi tissues
sometimes unite, by the direct reunion of the broken surfaces, and
without the interpk)sition of any reparative material. This happens
probably sometimes in the spongy bones, and in the extremities or
spongy portions of the long bones, especially when one portion of bone
is driven into another and becomes impacted; as in certain fractures
of the neck of the humerus or of the femur.
Second. By interposition of a reparative material between the broken
ends ; as when the fragments remain in exact apposition, but immediate
union fails. This is especially apt to occur in superficial bones, such
as the tibia ; or upon those sides of the bone which are most superficial.
It is not an unusual circumstance to find the shaft of the tibia during
the process of union presenting no exterior callus upon its anterior and
inner surface, whilst the posterior and outer section of its circumfer-
ence is covered with an abundant dej>osit. In other cases, however,
of fractures of the shaft as well as of the epiphyses, the intermediate
callas secures a prompt union, but no ensheatning callus is ever formed.
Third. Bones broken and not separated, unite occasionally by the
process described by Dupuytren, namely, by the formation, first, of an
ensheathing callus, whilst at the same moment the cylindrical cavity
becomes closed by a sj>ongy plug, or its canal is merely interrupted by
a compact septum of bone; and second, by definitive callus de|K>sited
between the broken ends. It is probable that this happens generally
in children, and it is a common mode of union in the ribs, which
bones, during the whole progress of the union, are necessarily kept in
motion. My cabinet furnishes many illustrations of ensheathing callus
in ribs ; and also a few in fractures of the tibia and fibula.
Fourth. Under similar circumstances, where no displacement exists,
the fracture may unite by ensheathing and interior callus alone, no in-
termediate callus ever being formed l>etween the broken ends; in which
case it may be properly said that the bone itself has never united, and
the ensheathing callus, instead of being provisional, is permanent or
definitive. This was essentially the doctrine of Galen, Haller, and
Duhamel before Dupuytren ad<led his " fifth period," or the formation
of definitive callus ; and by these older surgeons it was held to be of
universal application, except jwrhaps in the case of children. To this
d<x;trine also Malgjiigne has returned ; at least to the question, " Is
thert* always a definitive callus, or complete union of the fnigments?"
he has made this laconic reply : " Galen admitted its occurrence, but
only in young subjects ; it iias been obtained in animals, where there
had been no displacement. I would willingly believe that such is
sometimes the case in human adults; but I must confess I have seen
' Lectures on Surgical Palhology, by James Paget, Phil, ed., 1864, Chapter XI.
EEPAIB OF BROKEN BONES. 41
only the iaslance above cited, which might just as well Iw used to
prove the compact oseiScatioo of the provisional callus." He accepts,
therefore, the <]octrine of Galen as having not merely an occasional
application, but as explaining the process of union in the large ma-
jority of cases; and in support of this extreme view he finds that the
exterior callus, which Diipuytreii called provisional or temporary, i8
actually permanent, unless removed by the absorption consequent upon
pre^ure.
To all of which we can only say that an examination of five or six
Epecimens in our own cabinet, after having carefully divided them with
a saw, has furnished only one illustration of union by ensheathing and
interior callus alone. In each of the other specimens the union was
completed by definitive or intermediate callus. We cannot, therefore,
avoid the cunclusion that Malgaigne has been deceived as to the rela-
tive frequency of these different modes of union, and that union with-
out intermediate callus is exceptional.
Fifth. "When bones are broken and overlap, they may unite by the
iuterpoeition of a callus between the op-
posing surfaces, that is, by an interme-
diate callus, but which will differ from
that described as the second method, in-
asmuch as the new material will be de-
posited upon the sides of the fragments
and not upon their extremities. The
limb being kept perfectly at rest, and all
other circumstances proving favorable,
this union may take place without any
excess or inwularity in the deposit.
The surfaces will unite firmly where they
are in actual contact; and smooth and
veil-formed bnttressea will fill up all the
spaces between the bones where they are
Dot in actual contact, sufficient generally
to give the requisite strength to this new
bond of anion. This modeof union will
be completed sometimes when the two
ends of the bones are separated laterally uniu">
an inch or more from each other. I have >pccLni(
42 REPAIR OF BROKEN BONES.
in my collection the bone of a turkey's thigh (Fig. 4) thus united by a
transverse bony shaft, although separated more than one inch; and
what is less common, I possess also a specimen of the adult human
thigh (Fig. 5), in which an oblique shaft of solid callus has, after many
months, and while no splints were employed, bound together firmly the
two opposite extremities of the broken bone.
Sixth. The fragments being overlapped more or less, and suffering
unusual disturbance, or the adjacent tissues having been much torn, or
much blood being effused, so that considerable inflammation is caused,
the amount of callus will exceed what is necessary for the complete
union of the bones; and this redundancy may be deposited around and
upon the broken ends of the bones, or anywhere in their immediate
vicinity, in layers, or in masses of irregular shape and size. Even the
bones which are not broken, but which are near, as in the case of the
fibula after a fracture of the tibia, may become inflamed, or their cov-
erings may inflame, and they may also contribute to the general mass
of bony callus.
Compound fractures, or rather, we ought to say, fractures accompa-
nied with granulations and suppuration, obey no uniform law of repair,
so far as the manner and position of the deposit are concerned ; but tliey
come together finally with more or less irregular distributions of ossified
matter, according to the varying circumstances of imperfect coaptation,
mobility, etc., in which they may chance to be pla(^. Occasionally
the amount of callus is less than occurs in simple fractures, and at other
times the excess is very great.
That was, no doubt, a beautiful thought, which ascribed the forma-
tion of provisional callus to an intelligent efficient cause, which in this
manner sought to support the fragments until a reunion of their divided
ends was accomplished. But the beauty of a conception supplies no
evidence of its truth ; and we have grave doubts whether Nature ever
allows any interference with her laws even in an exigency, unless by
the substitution of a miracle. Provisional callus is, in our opinion,
just as much the necessary result of natural laws, as is definitive. It
is formed because in that condition of the parts and of the general life
its formation was inevitable. Whether useful for the purposes of re-
pair or not, it will, under certain circumstances, exist. In the repair
of certain fractures, provisional callus, it is conceded, seldom occurs.
Thus it is with the cranium, the acromion, coracoid and olecranon pro-
cesses, the patella, and with all those portions of bones which are im-
mediately invested with a synovial capsule. Will it be affirmed that
in the examples just named this callus is not formed bemuse it is not
required ? To us it seems that nowhere could it prove more ast»ful,
since, with the single exception of the cranium, it is in these very cases
that the obstacles to a reunion are the most serious. In fractures of
the patella, olecranon, etc., the action of the muscles tends constantly
and powerfully to displace the fragments, and gladly would the sur-
geon avail himself of the assistance of a temjwrary callus, but it is
rarely pn^sent, at least in any useful degree. So also in fractures of
the neck of the femur within the cai>sule, and in other similar cases, we
cannot say that temi)orary callus would not be advantageous in fiicili-
BEPAIB OF BROKEN BONES. 43
tatiDg the retention of the fragments, yet the "intelligent efficient
agent'' neglects to famish it.
The only satisfactory reason which, as we think, can be assigned for
the absence of callus in these cases, is found in the doctrines we now
advocate; that is to say, it is usually absent because that amount of
excitement and irritation is usually absent which alone determines its
formation. In the case of the olecranon, patella, etc., the fragments
being separated from each other by muscular action, so that no painful
Einchings or chafings occur, and their rough surfaces or sharp points
eing rather drawn away from than protruded into the flesh, no suffi-
cient provocation exists for the production of inflammation and effusion.
Hence the failure of provisional callus; but wherever the fracture
occurs, and however moderate the action, definitive callus does not fail ;
still the broken surfaces of the patella and olecranon are softened, and
smoothed, and covered over with a new matter, which, if contact could
have been secured and preserved, would certainly have served to con-
solidate and repair the breach. The natural reparative process pro-
ceeds, but only the accidental process is omitted. This latter, however,
is seen again even here, when from other and unusual causes a sur-ex-
dtement is established.
Temporary callus is not fonned upon bones invested with synovial
membranes, because here, too — as in the neck of the femur — there are
not so many structures lacerated and irritated, and the supply of this
eflusion must be the less not only in proportion to the less intensity
of the inflammation, but also to the less amount of structures impli-
cated.
Possibly other and more satisfactory reasons may be assigned why
Ero visional callus is not formed usually when the neck of the femur is
roken within the capsule ; but we certainly can never admit the com-
mon, and, as here applied, the too palpably absurd explanation, that it
is not wanted. It is wanted, and in no case so much as in the one now
supposed.
Provisional callus has, therefore, no final purpose, but it is the un-
avoidable result of certain abnormal conditions. It still occurs every-
where when against and in the vicinity of the bone there is the requis-
ite lesion and action, and it will occur as certainly when there is no
fractare at all, but only a caries, a necrosis, or a simple bony or perios-
teal inflammation ; and whilst it is doubtless true that in fractures it
sometimes renders valuable aid to the surgeon, it is equally true that
it often proves a source of hindrance.
From these remarks I choose to except fractures occurring in chil-
dren, in relation to which the observations are not yet sufficiently
numerous to determine absolutely the laws of repair. If, however, I
were to venture an opinion based upon a few examinations, I should
say that in children we may accept with but little qualification the
doctrine of Dupuytren as already explained.
Dupuytren, in determining the limits of his " third " period, or of
that in which a provisional callus is formed of sufficient strength to
support the fragments, has given what has been usually quoted as the
natural period within which bones may be said to be united, that is^
44 GENERAL TREATMENT OF FRACTURES.
" from the twentieth or twenty-fifth day, to the thirtieth, fortieth, or
sixtieth/' But this dei)ends so much u|>on the age of the patient, his
general condition of health, the condition and position of the broken
ends, as well as upon the bone itself, and the point at which it is
broken, with many other circumstances, that it would be unsafe to es-
tablish any absolute laws in reference to this point.
In ver}' early infancy, union is accomplished in half the time re-
quired in adult life, and it is generally thought to he still more retarded
in advanced a^, but Malgaigne has not found this latter observation
confirmed by his own exi>erience. Various constitutional causes, as
\\c shall hereafter explain more fully, retard bony union. Motion,
also, sometimes delays consolidation : fragments which are overlapped
do not unite as speedily as those which arc placed end to end, and
other complications interfere in a similar manner, such as lesions of
nervtis, of bloodvessels, comminution of the bone, the interposition
between the ends of the fragments of a blood-clot, a |)ortion of mus-
cular, tendinous, or other tissue, etc. In general the bones of the
lower extremities, inde|)endently of their size, unite more slowly than
the bones of the uj)i)er extremities.
Epiphyses, when separated, unite by the same process as fractures of
the bone. It is affirmed, however, that, when certain epiphyses unite
with much displacement, the shafts from which they have been sepa-
rate<l cease to grow, and the limbs Iwcome atrophied.
For a more complete consideration of the causes which retard the
union of lK)nt«, I l)eg to refer the reader to the chapter on " Delayed
Union, and Xon-Union of Bones."
CHAPTER V.
GENERAL TREATMENT OF FRACTURES.
All that ha** l)een sjii<l in relation to the propriety of han<lling a
bn)ken limb gtmtly, when the surgeon is examining the |H)sition and
character of the fnicture, is equally applicid)le to the lifting and trans-
|H)rting of the patient to his l)ed, to the removal of the clothing, and
to the general management of the limb Iwfore it is dresscMl. Rude or
awkwanl manipulations, by which netKll(»ss |>jiin is inflicted, are not
simply act* of wanton cruelty, but they are sources, and I think I
may say fn^juent sonnies, of inflammation, suppunUion, and gangrene.
Here, as in all the sul)se<]uent handlings, everything should be done
slowly, thoughtfully, and systematically. Yet it is difficult to state
the pre<'ise manner in which the surgeon ought to proctHnl. Much
will de|)cnd u|xm the circumstances of the ea-H?, something u|>on one's
natural tad, and U|x>n the amount of ex|KTience, but mori', I think,
u{K,n natunU kimlness of heart, and social education. The man of re-
GENERAL TREATMENT OF FRACTURES. 45
fioement and sensibility will know instinctively how to proceed, and
needs no instruction. They who lack these qualities can never learn,
and it would be quite useless to undertake to teach them. I sincerely
wish such men as these latter would find some more suitable employ-
ment than the practice of a humane art.
Nearly all fractures present three principal indications of treatment,
namely : to restore the fragments to place as completely as possible ; to
maintain them in place; and to prevent or to control inflammation,
6|)asms, and other accidents.
It ought to be r^arded as a rule, liable only to rare exceptions, that
broken bones should be restored to place, or to the position in which
we hope to maintain them, as soon as possible after the occurrence of
the accident. If the patient is seen within the first few hours, or be-
fore much swelling has taken place, we scarcely know the circumstances
which would warrant an omission to adjust the fragments either end
to end or side by side, as the one or the other might be found to be
practicable. We have before sufficiently explained the general impos-
sibility of again restoring to place, end to end, and fibre to fibre, frag-
ments which have been made to override. We are therefore in no
danger of being understood to say that bones should in all cases be
immediately "set," in the popular sense of this term. They ought to
be "set," no doubt, if this can be accomplished through the application
of a prudent amount of force ; but if they cannot be thus placed end
to end, they may at least be laid in such a manner side by side as to
restore, in some measure, the natural axis of the limb, and prevent the
points of the bone from pressing unnecessarily into the flesh.
Experience has, indeed, furnished us with four or five very good
reasons why broken bones should be reduced as soon as possible.
When the injury is recent, the muscles offer less resistance ; their re-
sistance being increased after a time not only by the reaction which
ensues upon the shock, but also by actual adhesion between their
fibres ; eff*usions distend both the muscles and the skin, and compel
the limb to shorten ; the constant goading of the flesh by the sharp
points of the broken bones increases the muscular contractions ; the
patient will submit readily to manipulation and extension at first, but
after the lapse of a few days it is very seldom that he will permit the
limb to be in any manner disturbed, even if he is assured that his
refusal entails upon him a great deformity. If it is true that no callus
or bony structure is deposited earlier than the seventh or tenth day,
it is also true that the renewed attempt to adjust the bones at this
period, by chafing and tearing again the tissues, reduces the fracture,
in some degree, to the same condition in which it was at first, and,
consequently, the time which has elapsed, or, at least, a portion of it,
m^ be regarded as lost.
We cannot, therefore, understand the argument by which Bromfield,
South, and a few other surgeons have {>ersuaded themselves, that reduc-
tion should never be attempted before the third or fourth day ; nor,
indeed, do we fully appreciate the refinement which Malgaigne has
given to this question, in itself so simple. To affirm that we ought not
to reduce the bones to their original positions during the period of
G^NEBAL TBEATHEHT OF FBACTUSE8.
intense inflammation, or of great swelling, or while the muscles are
acting Hpasmodicttlly, is only to affirm that we may not do what ia
Applintinn of I he
impossible; and the attempt to do
wliicli, therefore, can only oe mis-
cliievous; but to authorize their
restoration to a better position,
by such manipulation, extension,
and lateral support as tliey may
comfortably bear, is warrantable
under any circumstances. The
practice is not only defensible,
but imperative, and we do not
tliink any really sound and prac-
tical surgeon ever intendwl to
teach the contrary, Wc say rfiii,
if bonce can be easily reduced, or
the ])ositiou of tlie fragments improved at any moment, or umlcr any
circumstani-es, it ought to l)e done ; and if wc full in accomplishing all
that wc wish to do in the first instance, wc must renuiin incessantly
watchful to Kcize the earlit.'^t opportunity which presents, to complete
the adjustment. Ko doubt our efforts will prove fruitless very much
in pro|K>rtion to the amount of swelling, inflamniution, or mnsculur
HiHism which exists, and also in proportion to the time which has
eluiised ; but this will not excuse us for omitting to do all which the
circumstances [icrmit.
It ha" been the practice of most suiwions, for a long ix'riod, to cover
the broken limb with sonic form of a bandage or roller iMifore applying
the lateral splints.
Of these itriniary dressings there arc two princi|»n] varietitw: first,
the " roller' or Mmpic luimlagc, applied to the limb in circular and
rvversed turnn ; and, second, the " many-tailed Itandage," consisting of
n pii-<-c of muslin, or other cloth, torn down from each side into a
suitable numi*er of Htri|M, leaving the centre, which is to be applied to
the IhicIc of the limb, entire.
A modification of this latter bamlage consists of a number of separate
Btri|M, so laid upon one another, comineDcing from above, as tliot cadi
QENEBAL TREATMENT OF FRACTURES,
47
Blrip shall overlap the other by one^third or one-half of its breadth.
This is called the oaodage of Seultetus, and it possesses one advantage
over the many-tailed handle just described, especially in the case of
compoand fractures, in the facility with which each separate piece
may be removed and another eubstituted. Some surgeons prefer to
fonn the bandage of separate strips, and having overlaid them in the
manner directed, to unite them again into one by running a thread
through the whole mass along the centre.
Whichever of these several varieties of strips are employed, the
mode of applying them is the same. They are folded alternately
aronnd the limb, being made to overlap and cross upon each other in
front, and only the last strip or two is fastened with a pin.
AniUnUon of the ininr-talled bandige.
BiDdigaorSciilUtiu,
The object proposed in the use of the roller or of the many-tailed
bandage is twofold: first, to compress and Hupport the muscles, by
which their tendency to contraction is in some measure controlled ; and
eecoad, to protect the limb against the direct pressure of the side
Bplints.
A moment's consideration will convince us that the first of these
objects is in most oases fully attained by the lateral splints themselves,
and by the bandages by which they are retained in place ; and that the
Kcond cau be as well accomplished by a sinde fold of cloth, or by the
compresses, which ought generally, even when the roller is used, to
nnderlie the Bpliots. Nevertheless, we should hardly feel authorized
48 GENERAL TREATMENT OF FRACTURES.
to reject these primary dressings solely because the splints and com-
presses furnish a convenient substitute, especially since we are com-
pelled to admit that they are occasionally useful, unless objections of a
more serious nature could be brought against them. Unfortunately
this latter supposition is actually true. By ligating the limb com-
pletely, leaving no point of the tegumentary surface to which the
pressure is not applied, they too often occasion congestion, inflamma-
tion, and gangrene. It is not until lately that the attention of surgeons
has been sufficiently called to this subject; but the reicords of surger>'
are to-day filled with these terrible accidents, formerly attributed to
the original injury or to the splints themselves, but now understood to
lx» plainly traceable to the too common employment of the primary
bandage. The roller is by far the most dangerous dressing of the two,
since it does not yield to the swelling so readily as the bandage of
strips, and it is more objectionable also on account of the inconvenience
of applying and removing it; but even the bandage of strips may be so
confined as to produce the same consecjuences, as I have myself seen in
more than one instance. It is also all the more dangerous in the hands
of the inexperienc!e<l surgeon, l>ecanse he feels a confidence that it will
not cause ligation.
H\(vpt in Hire cases and for especial reasons, which we shall attempt
to indicate in their appropriate places, we «innot recommend the em-
ployment of any kind of bandages next to the skin.
In order to fulfil thesei'ond indication, namely, to maintain the frag-
ments in place, we employ usually what are called short, side, or cc>a|>-
tation splints, and long or extending splints, or the weight and pulley.
Side-splints may be constructed from various materials, acconling
to the size and circumstances of the limb, or act*ording to the conve-
nience of the surgeon ; and as the surgeon cannot Ik? exjKH»ted to have
always on hand, at the bedside of the patient, such splints as he might
prefer to use, it is well for him to unaerstand how to avail liimself of
such materials as mav be within his reach, in onler that he may make
the m(»st of his sometimes im|)erfect resources.
Lead, sheet-iron, z'mvy and other metals have been occasionally em-
ployed, but esjKH'ially tin and copper, which possess all of the re<juisitc
firnnu*ss an<l malleability to allow them to be hammereil, and thus
moulded to the liml). In general, however, they are nnniHH^sjirily
heavy, and demand too much lal)or to l)e wTought into shap<». I have
s<»metimes emi)loyed tin splints perforateil with large fenestra* to dimin-
ish their weignt and increase* their flexibility, and found them to answer
an excellent pur|>ose. The light i>erforated zinc splints, intn>«luce<l
into the U. S. Armv bv th«» Sanitarv Commission, throuirji the avrencv
of Dr. K. Harris of New York, were found excecdinjjlv useful.
Iron-wire splints, made from wire-cloth or coarse giuize, were first
publicly mentione<l, so far as I <-an l(*arn, in a communication to the
MemphU Mvdicnl lirrordrr, made by Dr. J. C. Nott, of Mobile; but
they have been brought more particularly into notict?, and their ci>n-
Htniction perfe<'te<l, by I>mis Bauer.* These splints are moulde<l u|>on
* Nott and Bauer, Buf. Me<l. Journ., vol. xH, April, 1857.
GENERAL TREATMENT OP FRACTURES. 49
"gypsum or wooden casts," of different sizes, and surrounded with a
stoat iron wire frame, in order to give them the requisite degree of
firmness, and to preserve their forms ; after which they are tinned by
galvanism, and varnished, to prevent them from becoming rusted.
When applied, Dr. Bauer recommends that they shall be filled with
loose cotton, and that they shall be held in place by rollers. It is
claimed for these splints that they are light, flexible, permeable to air
and* to the perspiration, and that they permit the application of cool-
ing lotions without impairing their firmness ; the last of which is a
quality of questionable value, since lotions applied to permanent dress-
ings of any kind are only warm fomentations, and do not, therefore,
in this respect serve the purpose for which they are intended. They
render the skin tender, and disposed to vesicate, and they, also, give
rise to a sensation of scalding, which is sometimes almost intolerable.
The water soaks into the bed, and in many other ways renders the
patients uncomfortable. Lotions are only applicable where the dress-
ings are open, loose, and temix)rary.
The same objections hold, also, to this as to all other forms of
moulded metallic, or carved wooden splints, namely, that they seldom
exactly fit the limb, even when the supply of assorted sizes is complete,
and that they are not sufficiently flexible to adapt themselves to any-
thing but the slightest irregularity of surface. They are not, however,
without merit, and they deserve at least a qualified commendation in
manv case^.
ml
Horn and whalebone may be employed in thin plates, or in the form
of narrow strips quilted into cloth ; but they are expensive, and possess
no special value except in an emergency. Reeds, the coarse rank grass
which grows in swamps, flags, willow branches, and unbroken wheat
straw, may be quilted between two thicknesses of cloth in the same
manner, and form very excellent temporary splints. I have esp>ecially
found t convenient to use wheat straw in the form of junks. Gather-
ing up a bundle of unbroken straws of the size of my arm, I roll them
snugly in a broad piece of cotton cloth, cut off the projecting ends, and
then stitch up the cloth neatly. We have thus a splint of considerable
firmness, and one which is cool and especially adapted to the summer,
allowing the perspiration to evaporate freely. Straw splints were em-
ployed sometimes by Ambroisc Par6, by J. L. Petit, Larrey, and I have
seen them in the wards of certain European hospitals, although I am
unable now to say under whose direction. Mr. Tuffnell, of Dublin,
has especially recommended them in the form of junks.^
Wooden splints, made of pine, willow, white or linden wood, or of
some other light and easily wrought timber, are probably of more
g:eneral application, and possess grcjiter intrinsic value than splints
oonstnictei from any other solid material ; but I wish at once, and for
all, to disclaim any intention of giving even a qualified approval of
any of those carved, polished, and generally patented wooden splints,
which are manufactured and sold by clever mechanics, and which one
may see suspended in almost every doctor's office, whether in the city
» Tuffnell, New York Journ. Med., March, 1847, p. 264.
50 GENERAL TREATMENT OF FRACTURES.
or in the country. Constructed with grooves and ridges, and variously
inclined planes, for the avowed purpose of meeting a multitude of indi-
cations, such as to protect a condyle, to press between parallel bones,
to follow the subsidence of a muscular swelling, etc., they never meet
exactly a single one of these indications, whilst they seldom fail to
defeat some other indication of equal importance. They deceive espe-
cially the inexperienced surgeon into the belief that he has in the splint
itself a provision for all tnese wants, and consequently lead him to
neglect those useful precautions which he would otherwise have adopted.
If carved wooden splints are employed, they ought to be made espe-
cially for the case under treatment. But this requires time and some
more mechanical skill than can always be commanded ; and when ac-
curately fitted, it is quite probable that the subsidence or increase of
the swelling will, within the next forty -eight hours, render some change
in the form of the splint necessary, or compel the surgeon to throw
it aside.
We much prefer to use plain, straight strips of wood, of the requisite
width and length, which may be cut at any moment from a shingle or
a thin piece of board ; but in order that these splints may adapt them-
selves to the inequalities of the limb, and properly support the frag-
ments, they ought to be covered with a muslin sack, open at both ends;
into which, and on the side of the splint which is to be placed against
the limb, bran, wool, oakum, curled hair, or cotton batting, may be
presse<l, until it is made to fit act»urately. I generally prefer cotton
batting. Bran is liable to get displaced, and curled hair does not pack
firmly enough. When the sack is sufficiently filled, the two ends must
be stitched up. This mode of constructing the splint is simple and
easy of accomplishment; the splint can be fitted very accurately; the
padding never l>ecomes displaccil ; and when the bandages arc applied,
they may be pinned or sewed to the cover in such a way that they
shall not slide or loosen.
If pads are employed separate from the splint — and for this purpose,
also, I generally prefer the cotton batting — they ought to be made and
fitted with the same care, and neatly stitched together at their ends,
rather than ninned. Cotton batting laid loosely next to the skin, or
underneath tlie splints at any |)oint, will not keep its place so well as
when it is inclosed in covers — it is more liable to get into knots, and
it has altogether a slovenly apjKiirance. The pads may Ih» stitehcHl to
the roller, and in this way secured effectually in place, but loose cotton
is subject to no control.
When I sjK^ak of pads, it must not be understood that I inti*nd to
recommend them for compresses, or for the purpose of |)r(*ssini^ frj»j;-
ments into place. Nothing could be a greater soun^e of mischief in the
dri»ssing of a broken limb. I have only directed their employment as
a means of adaptation, and to prote<*t the skin agaiuat the diriM't prts-
6un^ of the splint.
Dr. Jacol>s, of Dublin, says that he has seen an excrllent splint made
from the ** fresh bark of a tree, taken off while the san is rising." "It fits
a<lmirably," says Dr. Jacobs, "just like jwistelwanl soaketl in water.'**
1 Jaoobf, New York Journ. Med., March, 1847, p. 265, from Dublin Med. PrcM.
OESEBAL TBEATMENT OF FBACTUBBS. 51
Dr. C. C. Jewett, of tbe 20lh Mass. Vols., recommends for the same
pnrpose the bark of the liriodendron, or tulip tree.
Hemlock-tanned, undressed, sole leather, cut into shap and soaked
tfewminutesiu water, adapts itself easily to tbe limb and is sufficiently
firm. It is especially applicable to fractures of the larger limbs. At
Bellevoe Hoepital it ha.s for several years taken the place of almost all
other materials, for the construction of movable splints. Oak-tanned
kather is less flexible than the hemlock-tanned, and does not make so
good a splint. The specimens selected should be of medium thickness.
Before applying the splint the edges should be bevelled on the inner
side, and the comere rounded, and a piece of woollen cloth should be
interposed between the splint and the skin. The leather will become
hard within twenty-four hours, and at the next dressing it may be re-
moved, covered with a sack made of woollen or cotton cloth and replaced,
A splint is also occasionally made of thin calfskin, veneered with
some light timber, such as linden or white wood, the latter being sub-
eeqnentTy split into stripe of from half an inch to
one inch in width, so aa to combine a certain de-
gree of flexibility with the requisite firmness.
The Tnrks use, according to Scdillot, in a similar
manner, the " nervnres " of palm, laid upon sheep-
skin, and fastened with wooden thongs ;' and Pack-
ard mentions that he has seen narrow slips of some
light wood glued in the same way upon soft pieces
of buckskin, and then fastened together with two
rtrips of buckskin, which were also elued to the
BpHVtS.' W«d.,»ll^,b«.pll»L
Common, unpolished pasteboard, cardboard, or the stout millboard
used by bookbinders, constitute invaluable domestic resorts, since they
can generally be found in the house of the patient; and if in no other
ny, pasteboard may generally be had at the expense of some paper
U)x or of the loose cover of some old I>ook. For small Irenes, the
thinner sheets afford a sufGcient support ; but for large bones the thick
binder's board is necessary. In preparing the latter for use, it ought
to be moistened with water; but if soaked too much it will separate
ind fiill into pieces, or lose its firmness when dry, in consequence of
having parted with some of its paste. This splint may be ajiplied to
the limb without the interposition of anything but a few folds of
muslin cloth, or a piece of Hannel ; or we may use instead a single
dwet of cotton wadding. It must be bound to the limb by the roller
vbile it is moist ; and, as it dries speedily, it forms a smooth. Arm, and
leliable splint.
Felt, made of wool saturated with gum shellac, and pressed into
sheets, makes an excellent moulding tablet for splints. This may be
obtained at any hat manufactory. Until recently thev were manufac-
lored, and moulded into a great variety of forms, by br. David Ahls,
at York, Pennsylvania. A much cheaper material, however, and
vhich has nearly all the qualities of the real felt, may be made from
52 GENERAL TREATMENT OF FRACTURES.
old pieces of broadcloth, or from any similar closely woven texture, by
saturating it thoroughly with gum shellac, the gum being dissolved in
alcohol in the proportions of one pound of the former to two quarts
of the latter. Thus prepared, it is to be spread ujwn both surfaces of
the cloth with a common paint-brush. When this first coat is well
dried by suspending the cloth where the air will have free access to
both surfaces, a second must be spread upon one of the surfaces ; and
then a third ; the cloth being allowed to dry after each successive
coat. Finally, the sheet is to be folded upon itself, so as to bring the
most thickly covered surfaces together, and pressed with a liot ilatiron.
If it is necessary to have greater strength, more gum may be laid upon
the cloth, and it may be again folded and pres^sed. When used, it is
to be dipped into boiling water or held near the fire until it becomes
flexible. It hardens very rapidly in cooling, and demands, therefore,
some (juickness in its application ; but once a|)plied and fitted, it forms
a hard but smooth splint, well adapted for all the pur|K)ses for which
it is designed. It is well to mention, if one wishes to keep any por-
tion of the solution which is not used, that, in order to prevent evajx)-
ration, the vessel in which it is contained must be closely covered, I
have reiH?ntly seen a similar splint made of strong canvas cloth, satu-
rated with gum shellac, for sjile by the instrument-makers in this city.
The principal objeirtion to all of those forms of splints which cont^un
gum shellac Is, that they harden so rapidly after being made flexible
by exiK)sure to heat, that it is often found difficult to give them an ac-
curate mould to the limb.
Dr. Jacobs says he has sometimes found an old hat to furnish a very
efficient splint in the small fractures of children.
It has been objected to the felt splint occasionally, that it is imjwr-
vious to air and moisture, and that it confines the insensible j>erspira-
tion; an objection which may be obviated in some measure by rubbing
the surface which is to Ix; laid against the limb, with pumice-stone,
until it is roughened or until a short nap is raise<i. But as I never
use splints o{ any kind without underlaying them with compresses, or
woollen cloth, which act sufficiently as al)sorbents, I have never been
aware of any inconvenience from this source.
Dr. R. (). Cowling, of Louisville, Ky., has callwl attention to the
value of Manilla j)aper in the construction of splints.* A limiteil use
of this material satisfies me that it posscss<»s in an eminent degree m<i«t
of the (qualities of a good splint. It is cut into strij>s, stiffene<l with
starch and applieil longitudinally or spirally, as may be ne^-essiiry to
cover the limb completely and smoothly. For the lower extremities
six to eight layers are re<|uireil. The material may be obtaineil at
most large pajwr stores.
Within a few yeiirs, sheets of gutta jKTcha have been brought into
the market, varj-ing in thickness from one-sixteenth to ont»-<juarter ol
an inch ; the use of which for side splints was first suggi»ste<i and pnicv
tictni by Oxiey, of Sinc^apore. For fractures of the thigh, and for the
large bones generally, 1 prefer a thickness of alx>ut one-sixth or one-
^ American Practitioner, Jan. 1S71.
GENERAL TREATMENT OF FRACTURES. 53
fifth of an inch ; but for the fingers or toes it need not be more than
one-sixteenth of an inch in thickness. In its natural state^ and at the
ordinary temperature of the body, it is nearly as hard and as inflexible
as bone ; but when immersed in hot water it almost immediately
softens, and would become too soft to be conveniently handled unless
soon removed. It can therefore be adapted to any surface, however
insular, and its form may be changed as often as may be necessary.
It does not harden as rapidly as felt, and it possesses, therefore, in this
respect, an advantage, since it allows the surgeon more time for ad-
justment; while, on the other hand, it hardens much more rapidly than
either starch, paste, or dextrin. Ten or twenty minutes is all the time
usually required for gutta percha to acquire that degree of firmness
which will prevent it from yielding under the pressure of a bandage.
To use gutta percha skilfully requires some experience, and I have
known surgeons to reject it after a single trial ; but by those who have
acquired the necessary skill it is generally regarded as an invaluable
resource.
When constructing from this material a thigh-splint, we should
order a very large tin pan, or some open, flat tray, in which we may
lay the splint at full length. If the splint is required to be twelve
inches long, and six inches wide, we must cut it about fourteen inches
long by seven wide, so as to allow for the contraction which always
takes place more or less when the hot water is applied. It is then to
be laid upon a sheet of cotton cloth of more than twice the width of
the splint, in order that the cloth may envelop it completely when it is
folded upon it; and the cloth should be enough longer than the splint
to enable us to handle and lift it by the two ends without immersing
oar fingers in the hot water. Beside, if the gum is not thus covered
and supported, it will adhere to the vessel, to the fingers, to the sur-
fece of the limb, and indeed to whatever else it comes in contact with ;
it may even fall to pieces, or become very much stretched and distorted
by its own weight. The cloth cover will generally adhere to the splint,
and may be permitted to remain upon it permanently.
Place the splint, thus covei'ed, in the basin, and pour on the water
slowly. As soon as it is sufficiently softened, lay it over the limb,
moulding it carefully with the hands, or by pressing it against the limb
with a pillow. If it does not harden rapidly enough, this process may be
hastened by sponging the outer surface with cold water; and as soon as
it has acquired sufficient firmness to suppport itself, it may be removed
and immersed in a pail of cold water or placed under a hydrant; after
this, it is to be neatly trimmed and wiped dry, when it is ready for use.
When gutta percha remains a long time exposed to the air, it gradu-
ally oxidizes, its color becomes darker, it loses its tenacity and flexi-
bility. This may be prevented by keeping it constantly immersed in
cold water. It may be sufficient to place it in a damp cellar.
The same objection has been made to gutta percha which is occasion-
ally made to felt, namely, that it confines the perspiration, but to this
we have already sufficiently replied.
There is scarcely any fracture demanding the use of a splint in which
I have not demonstrated its utility^ but it is especially valuable, as I
GENERAL TREATMENT OP FRACTUHES.
shall have occasion to mention again, as an interdental splint in frao-
tures of the jaw, and as a moulding tablet in all fractures occurring in
the vicinity of joints.
Sheets of guttu percha of any required thickness may be obtaine<l in
this city of Sir. Bishop, the manufiicturer, on Twenty-fifth Street near
the East River. One pound will make about four thigh-spHnt/i.
Benjamin Welch, of Lakeville, Conn,, has contrived a very ingeni-
ous apidication of gutta percha to the purposes of a splint, by veneer-
ing a thin plate of the gum with equally tliiu plates of elastic wood.
The veueerinK is laid upon both sides, and then it is pre!i-!ed into form
in moulds. The elasticity of the wood, together with the plasticity of
the gum, enables the surgeon to change its form somewhat at pleasure,
by dijtping it into hot water. Its form cannot, however, be changed to
any groat extent, and by frequent immersion in hot water the veneer-
ing is apt to loosen from the gutta percha.
The moulding tablet of Alfred Sniee, composed of gum Arabic and
whiting, spread upon cloth,' has nothing special to recommend it, any
more than the cloth splints, hardened with the whites of eggs and flour,
used by Larrey.' Starch and alum, glue, pitch, and various other ma-
terials of a similar character deserve only to be mentioned as having
been occasionally employed, but which
have never succeeded in securing for
themselves the confidence of surgeons.
Immovable, or PermuneiU ItremtinffK. —
In 1834, Seutin, of Brussels, intrmluceil
the use of starch asa means of hardening
the bandages ; his method of using which
is essentially as follows : a dry roller is
first applied lo the skin, and then smeared
with starch ; all of the bony prominences
and irregularities of the limn are filled
up or covered with cotton batting, char-
pie, down, etc. ; strips of pastelxianl, or
of binders' board, moistened and covered
also with starch, are now laid alongside
the limb, over which again arc turned in
succession one, two, or three layers of the
6tarchc<1 roller; the number of rollers
and the thickness of the pastel>oanl l>eing
pro]>ortioned to the size of the limb or to
the required strength of the splint. The
whole hi completeil by starching the out-
side of the last bandage.
This dressing will generally become
dry within from thirty to forty hours;
which process may be cxptHtited by ex-
(msing its sidcn as much as jKtssible to
Jan. -ib. 1840.
■ Aiiiar. Juurn. Med. Scl., vol. ii, p. 216, Hbt,
TOl. i».
I, M»y, 1B40; froiu Londi
; l^om Journal dc* Progri*,
GENERAL TREATMENT OF FRACTURES. 55
the air, or by the application of artificial heat with bags of dry sand^
or with hot bricks. As a temporary support until the drying is com-
pleted, some surgeons lay upon each side of the limb additional splints,
securing them in place with tapes.
As soon as the bandages are dry, they are to be cut along the front
to a sufficient extent to permit of an examination of the limb, and then
closed with an additional roller. For the purpose of opening the band-
ages, both at this period and subsequently, Seutin uses a pair of strong
scissors or pliers, such as are represented in Fig. 12.
On the third or fourth day, or as soon as the subsidence of the swell-
ing may render it necessary, the bandages should be cut open through
their whole extent, the edges pared off and brought together again
sungly with an additional roller.
Fig. 12.
Seutin's pUen.
In 1837, Velpeau substituted dextrin ("British gum"); a kind of
glue or jelly obtained by the continued action of diluted sulphuric acid
upon starch at the boiling-point. It is prepared for use by dissolving
it in alcohol or tincture of camphor, or camphorated brandy, until it
has acquired about the consistence of honey ; at this point hot water
should be added, reducing its consistence to that of thin treacle, when,
after one or two minutes' shaking, it is ready for application. Accord-
ing to F. D'Arcet, the proportions most favorable to the drying and
solidifying of the apparatus are, one hundred parts of dextrin, sixty
of camphorated brandy, and fifty of water. Malgaigne, to whom I am
indebted for this observation of D'Arcet, says, also, in a note, " As
regards dextrin, an important point was recently brought practically
under my notice, viz., that, as sold in the shops, it is often unfit for
making an agglutinative mixture; it forms lumps with alcohol, as
starch does with cold water, without cohering ; and twice in succession
I have been obliged to change the supply at the H6pital Saint Antoine.
The dextrin thus deteriorated is whiter and less saccharine; it crepitates
more in the fingers ; and on pouring a few drops of tincture of iodine
into the solution, there is produced a violet tint, indicating the presence
of fecula; while true dextrin, treated with iodine, gives a vinous red,
or the color of onion-peel."
Velpeau soaked his bandages with the dextrin before applying
them, but, like Seutin, he applied his first roller dry. He used but
one bandage, which he carried first from below upwards, and then
from above downwards ; and he rarely thought it necessary to employ
the pasteboard as a collateral support.
A mixture composed of equal parts of precipitated chalk and gum-
56 GENERAL TREATMENT OF FRACTURES.
arabic, reduced to a proper consistence by boiling water, applied to
rollers while they are being applied to the limb, forms a firm and light
splint. It has the advantage also of hardening quickly.
Startin and Tait, of Ix)ndon, recommend pai'affin, which, being thor-
oughly melted, is cooled a little, to render it more viscid, and then
rubbed into the meshes of the bandage, during the process of applica-
tion with a paint-brush.
Silicate of soda, of potassa, or of magnesia, have also been employed
in the same manner. A saturated solution is prepared, and applieil
with a brush. It hardens speedily, and forms a light, firm, and neat
splint.
For myself, I have been more in the habit of using wheat-flour jyaste
than either of the other materials named, and, if properly made, it ilries
about as quickly as the starch, and is equally as firm.
Whatever material is used — whether starch, flour paste, dextrin,
solutions of the silicates, gum shellac, or plaster-of- Paris — in the con-
struction of what is now usually termed the " immovable apparatus,"
or, as Seutin has more lately callcnl it, the " movable immovable appar-
atus" (" movo-amobile"), in reference to his practice of opening it at
an early period, it is still the same apparatus in effect, and is liable to
the same judgment — a judgment which we shall find it very difficult
to declare, since, from the day in which this practice was fii'st recom-
mende<l by Seutin, to the present moment, it has been t*onstantly ex-
periencing the most extraordinary vicissitudes in the public favor. At
one time, and by the most ex)>erienced surgeons, extolled as a niethwi
unec^ualled in its simplicity, elficiency, and safety; and at another, and
by surgeons of equal experience, denounced as eminently lacking iu all
of the true essentials of an apparatus for broken limbs. These con-
flicting opinions, which it is impossible to reconcile, have nevertheless
Bome foundation iu truth. Tlie immovable apparatus, of whatever
materials constructed, is under some circumstances a very simple, siife,
and efficient dressing, while under other circumstances it is, as we
think, eminently unsafe and inefficient. Thus, in all of those fractures
which are accompanied with such injury to the sofl parts as to render
subsequent inflammation inevitable or probable, this form of dressing
exposes to congestion, strangulation, and gangrene. Whatever its ad-
vocates may say to the contrary, the simple fact is before us, that the
uuml)er of accidents resulting from this practice is out of all proportion
with any other yet introduced. I have met with them myself in all
parts of my own country, and the journals al)ound with reconls of
disasters from this source*.* Nor is it a sufficient reply to this state-
ment, that, with nrojKir care and prudence, such accidents may be
av(»i<ltMl. We think they could not always be avoided. But admitting
that they could, it is still undeniable that in certain (uses, the immov-
able ap|)aratus demands extraordinary attention ; and what is the need
of multiplying our cares when already they are more than sufficient?
Many circumstani^es, over which he has no control, may prevent the
* Amcr. .J on rn. Mod. Sii., vol. xxv, p. 400, Fob. 1840; n\*o vol. xxxi, p. 212.
Med. Record, Nov. 1, 1873; New York Med. Journ., Aug. 1874, Oct. 1874.
OENEBAL TBEATlfENT OF FBACTUBES. 57
Burgeon from giving to the limb the full amount of attention which is
required ; and for this reasoo that apparatus is the best whicli, whilst
it answent the indications equally well, exacts the least amount of skill
and attentioQ on the part of the surgeon.
ImmoTable dressings are not oaly liable to become too tight as the
swelling augments, but, on the other hand, the sui^eon may omit to
notice that as the swelling has subsided it has become loose. Portion^
of the limb may vesicate, ulcerate, or even slough, without the knowl-
ed^ of the surgeon. If, however, the bandages are frequently opened,
tnd all the proper precautions are taken, it is possible that these acci-
^ta may also be avoided; but unfortunately experience has shown
that they have not been avoided in too many instances.
The cases, then, to which this apparatus seems to be especiallv
adapted, are a few examples of transverse or serrated fractures in which
the bones have not become displaced, and in which little or no swell-
ing is anticipated; and certain fractures which were originally more
(oni plicated, but in which a partial union, and the subsidence of the
inflammation, have reduced them to a more simple coudition; and espe-
n&IIy is it adapted to cases of delayed union. If now the dressings are
ipplied carefully, the bandage being only moderately tight; and a
pr>rtion of the extremity of the limb is lefl uncovered so that we may
observe constAutly its condition, and at proper intcr\-alB the apmratus
ii opened completely, in order that wc may subject the whole limb to
a thorough examination ; in rach cases as we have now indicated, and
Tiih sncD precaatioos, we admit that the " apparatus immobile " con-
(titutes aa invaluable aargical appliance, and one of which no surgeon
an well afford to be deprived.
I have even met with examples of compound iracturen in which it has
Kerned proper to apply this dressing; and especially when a sufficient
time had elapsed to render it probable that there would be no sudden
icceseioo of swelling in the Itmb. In such cases I have preferred
grawally to la_y the several totiis of the roller directly over the sup-
ponUing woand in tbe same manner as if no wound existed, and to
■ake a valvular opening, or window, with the scissors, on the following
di^, io order to aUo'w- tbe matter to escape, af\er which the valve may
68
OESERAL TllEATMENT OF FRACTURES.
Tilliid o
igipoiiud frac-
bo laid down and stitched, or the piece may be removed entirely, and
a new piece of* bandage drawn closely around the limb at this point.
This may be repeated once or twice daily. If
''"*■ "■ an opening is left by the roller, and no addi-
tional bantlage or compre^ is laid over it, the
mar|rins of tlio wound soon iKwrnc <£demati)ii8
iirid protrude, making an ugly-looking und ill-
conditioned sore.
Plaster of Paris moulds, employed occasion-
ally from a very early period, and more lately
recommended by Hendriksz, Hubenlhal, Keyl,
and Dieffenbach, are not entitled to seriou.s con-
sideration. Heavy stone coffins, they might
serve well enough the purposes of interment,
but they are wholly unsuited to the purposes
of a splint.
Plnetcr of Paris has, however, been from a
laler period, emnloye<l In another form, as an
"immovable" <lressing. I allude to the so-
called " plaster of Pai-is bandages," which v
first introduced to notice by Mathiesen, of Hol-
land, in 1852. In 1864, Pirogoff, surgeon in
chief of the RuK^ian armies, called att«ntioQ to
the plaster of Paris dressings, but in a form
differing somewhat from that employed by
'""■ Mathiesen.
Recurring to the history of the immovable dressings, as briefly nar-
rated in the preceding jHigcs, and as more fully rccor<k^ in the medi-
cal journals of the next eighteen or twenty years, we shall find that it hml
steadily declined in public favor, on account of the numerous accide:
resulting from its use, many of which became the subjects of litigation
in the American courts; so that neither the suggestions of ^lathieiwti in
1852, nor the great name and influence of Pin^fl", in 1854, nor the
advocacy of Hunt of Birmingham in 1855, nor of Gamgee in 1866,
were sutlieient to seonre for jila-ftcr of Paris the confidence of the pro-
fcnsion. The period was unfortunnte, and surgeons were scarcely will-
ing to give these gentlemen a respectful hearing, inasmuch as tncy at
once recognized these modes of uamg plaster of Paris, as only modifica-
tions of tlie method of Seutin, which, for giwKl reasons, thay had jnat
laid aside.
Since Sfathiesen wrote, however, a new generation has arisen ; a gra-
eration of active, able, and hoi)eful men ; with no jircjudices of experi-
oneo to overcome ; to whom the " primary bandage " and Scutin'» " ap*
jtanitus immobile," convey no apprehensions of danger; and now
again, following this time the lend of the German surgeons, we flod
lh(^«<^' mcth'xls in [lopular favor, Ixilh at home and abroad. It will be
Uic iMirt of wisdom, while we obxerve carefully the ex(>erience of tha
prcitent, to recall the lessons of the past.
At Bellevue, during the lastsixor seven years, plaster of Paris band-
agoi have been used quite extensively, and, afler a careful obacrvatioB
GENERAL TREATMENT OF FRACTURES. 59
of the results in my own wards and in the wards of my colleagues, I
find no occasion to recall anything I have said of this, as one form of
the immovable apparatus, in the preceding pages ; the dangers have
not been overestimated, yet I must say that in fractures of the leg,
whether simple or compound, when great care is exercised in the man-
agement of the case, it is in some respects superior to any other form
01 dr^sing. I shall describe the cases to which it is applicable, more
particularly, when speaking of these fractures. I am not at present,
however, prepared to speak of it so favorably in the fractures of any
other long bones.*
The manner of using gypsum bandages generally preferred at Belle-
vue Hospital, may be thus briefly described. Thin, rather coarse un-
glazed cotton cloth, torn into strips, is laid upon a table and the dry
plaster rubbed into it until its meshes are full. It is then rolled, and
made ready for use by immersing it a few minutes in hot water. The
limb, being held in a proper position, is first inclosed in soft dry flan-
nel cloth, and the rollers are then applied. In most cases two or three
thicknesses of bandage are found to be sufficient. A more full descrip-
tion of this method, known generally as Mathiesen's, will be found in
the chapter devoted to the consideration of fractures of the femur.
Another method of using the gypsum bandages, not generally prac-
ticed at Bellevue, is as follows : A dry roller is first applied to the
limb, or it may be covered with a single piece of cloth of any kind,
and the irregularities are filled up and protected with cotton-wool, the
same as we have directed when about to apply the starch bandage.
The remaining dressings being now at hand and ready for use, we pro-
ceed to mix the plaster. For this purpose we must select the fine,
fresh, well-dried, white powder. The gray does not solidify well, nor
that which has been a long time ground, or is moist. The proportions
of water and plaster usually required are about equal parts by weight.
For the thigh it may require, perhaps, seven or eight pounds of plaster,
and for the 1^ or arm much less. It is probably a better rule to
direct the gypsum to be added to the water until it is of about the con-
sistence of cream. The water should be cold and the gypsum thrown
in not too rapidly, at least not more rapidly than it can be thoroughly
mixed, otherwise we shall not be able to determine precisely its con-
sistence. If, while applying the paste, it begins to harden in the bowl,
we must not add more water, as this will again interfere with its final
solidification upon the limb. It must be thrown away and some fresh
immediately prepared ; or the crystallization may be retarded by throw-
ing in a few drops of carpenters' glue, or a little starch, dextrin, or
glycerin. The solidification may be hastened by adding a little salt to
the water. When the plaster is good, and it is properly mixed, we
may allow ourselves from five to eight minutes in the application. A
large paint-brush is the most convenient thing for spreading it, but the
hands will do very well in an emergency.
' Treatment of Fractures of the Femur by the Immovable Apparatus, b}' the au-
Ibor. New York Med. Journ. Aup. 1874. A comparison of the results of treatment
of 308 fractures of the thigh at Bellevue Hospital, by Frederick E. Hyde, M.D.
Kcw York Med. Journ., Oct. 1874.
60 GENERAL TREATMENT OF FRACTURES.
Everything being ready, tlie limb is to be seized by assistants at
both of its extremities and held in a position of steady extension until
the dressing is completed, and for several minutes longer, or until the
(blaster is hard. The surgeon then proceeds to lay a long piece of
inen — old sack will answer as well as any — folded three or four times,
and saturated with the paste, parallel to the two sides of the limb,
around which are to be immediately placed, horizontally and at several
points, short and wide strips of the same material. These latter are
intended to increase the strength of the apparatus, and to bind on the
side strips. Finally, the whole may be painted with the solution. It
is very well, however, not to cover the front of the limb, or a narrow
strip somewhere in the line of the axis of the limb, with the plaster, as
this will not diminish materially its strength, and it will enable the
surgeon to open it more easily with the scissors. Pirogoff accom-
plislies the same purpose by laying a piece of narrow tape, soaked in
oil, along the line through which he wishes to make the section of the
splint.^
Prof. James L. Little, of this city, makes his plaster splints of two or
three thicknesses of muslin, or of canton flannel, which being saturated
with fluid plaster, are laid upon the limb previously shaven and oiled,
and secured in place with a roller. He advises that the roller shall
be removed as soon as the plaster is set and a fresh one applied, which
can afterwards be easily removed.*
Some surgeons prefer to construct the plaster splint in the following
manner : Two pieces of flannel are laid one upon the other, and being
stitched by a straight scam along the centre, the inner layer is carefully
folded around the limb, and made fast by a needle and thread. Fluid
plaster is now spread over the outer surface of the inner layer, and the
inner surface of the outer layer, when the two are brought in contact
upon the limb, and the whole secured by a roller. After the splint is
thoroughly dry it may be cut in front and opened like the cover of a
book. Hence it has been called the " book-back " method. It is also
known as the Bavarian.
There are other modifications of the methods of using plaster of
Paris, which will be more appropriately described in conpection with
special fractures.
In removing the plaster we generally employ a shoemaker's knife,
softening the plaster as we proceed, with a 8i)onge dipped in hot water.
As cutting pliers for this purpose, no instrument has been found suf-
ficiently powerful except that introduced by Dr. Victor von Brun, of
Tubingen.
Professor B. W. Dudley, of Lexington Ky., one of the most success-
ful surgeons in this country, but e8|>ecially distinguished as a lithoto-
niist, for many years employed in the treatment of fracture* nothing
but a roller, regarding both side-splintj> and extending ap|mratus us
* Weber on PUntorof Vnnn BnndiiKP. New York Journ. Med., May, ISM, p. 841.
* Little. On the Uw of Planter of Pari«, in the Treatment of Fracture*, by Jamet
L. Little, turgeoD to St. Luke's ilofpiul, etc. Med. Kec.| Nov. I, 1S7S.
, TREATMEST OF t'RACTUHKS.
not only useless, but absolutely i>ernicious.' This prantioe, which
seems to have originated with Ridley, of England, has not found,
hitherto, in this connlry or elsewhere, raauy imilatora.
Still more unscientific and irrational was the practice of Jobert, of
Paris, who employed neither side-splints nor bandages, but only exten-
sion, in the treatment of all, or of nearly all fractures of the long bones.
The side or coaptation i-pliutH bring the fragments into more complete
Urposiiion, and secure a more prompt and certain union. They ought,
fore, never to be omitted, unless the condition of the limb pre-
!i their application,
to the quet=tion of permanent extension in fracturea, and the
EBos by which it may be most effectually accomplished, nothing need
1 said at this time, inasmuch as it relates only to the fractures of
Ktain bones, and to certain forms of fractures ; we must therefore
■ its consideration to those chapters which treat of individual
\ In the treatment of coTftminu/fd fractures, no pains ought to be spared
I bring the fragments as nearly as possible into apposition ; and if
H^e exists at the same time an external wound, and the fragments are
mall and loose, they ought to be removed carefully. Nor, indeed,
'tould we lie deterred from the attempt to remove them by finding
ttt tliey are somewhat adherent, if still they are very easily moved
iwut with the finger.
In coiupound fractures, not unfrequently the end of one of the frag-
ils protrudes from the wound, and its reduction may be attended
h considerable difSculty. My practice is usually in such cases to
lerapt the reduction first, by simple extension and counter-extension;
It if tilts (a'lU, 1 introduce my finger into the wound, and endeavor to
ch the akin over the sharp jioint of hone ; or I make use of a
patula formed from a piece of shingle, or of any suitable piece of
tal which may be at hand; finally, but not until alt otiier exi>edi-
s have failed, I enlarge the wound sufGciently to insure its return,
sthetics may be employed, also, to facilitate the reductiou.
' Dudley, Tran». Amer. Med. .
,,vol. iii, 1B60, p, MD.
62 GENERAL TREATMENT OF FRACTURES.
There are some cases, however, in which the surgeon may feel justi-
fied in sawing off the projecting end ; as when the periosteum is com-
pletely torn from it by its having penetrated a boot, or even sometimes
when its extremity is very sharp, and there is reason to suppose that it
would prick and irritate the tissues. In these cases, also, surgeons
have proposed to secure the fragments in apposition by metallic liga-
tures or sutures. In a few instances the practice has been attended
with success, but in most cases the wires have failed utterly of their
purpose, and have only proved sources of additional irritation.
Ruptured arteries, if within reach, ought always to be tied ; and if
arteries situated remote from the surface bleed freely and for a long
time, we may make some effort to find the open mouths in the wound;
but in this we rarely succeed, nor is it safe generally to trust to a liga-
ture of the main branch which supplies the limb. Fortunately, this
bleeding, although at first profuse, generally ceases in a few hours
under the steady employment of cold lotions, moderate compression,
arid rest. If it does not, the chances are that the case will call for am-
putation.
The rule generally laid down by surgeons, that we should at once
close the wound in compound fractures, with sutures and adhesive
straps if necessary, or with bandages, is far too absolute. This prac-
tice will do when there is no great contusion or extravasation of blood ;
but if blood is flowing, it is much better to leave the wound oj)en, so
a^ to permit it to escape freely ; and if the severity of the injury war-
rants the supposition that much inflammation is to ensue, tne danger
of gangrene is greatly lessened by thus allowing the opening to remain
as a channel of exit for the inflammatory effusions.
It has, however, been claimed of late by Mr. Lister, of Edinburgh,
aqd by many others who have adoptc<l his practice, that by the use
of carbolic acid^ in the manner which will presently In? dcscril)e<l, we
may again return safely to the old practice of closing at once all wounds
connected with fractures, without regard to the degree of contusion,
laceration, or comminution ; indeed, it is affirme<l that by the adoption
of this method of treatment we may avoid suppuration and its conse-
quences in a very large pro|>ortion of cases. It is believed by Mr. leis-
ter that suppuration is mainly due to the presence of certain germs
which constantly float in the air, and which carbolic acid is fully able
to destroy. Every possible prcK^juition is therefore taken to exclude
the air, and to disinfect that which is unavoidably brought in contact
with the wound. The interior of the fresh wound is fully injected with
carbolic acid of the strength of one part of carUiIic acid to twenty of
water; nor does he hesitate to throw this into wounds communicjiting
with joints. The fluid being afterwanls carefully exprcsstnl, the sur-
face of the wound is covered first by the " protet*tive," which is apiece
of oiled silk coate<l with a thin layer of a mixture composted of one
part of dextrin, two of |)Owdere<l starch, and sixteen of a cold solution
of carbolic acid ; the latter being of the same strength as the solution
employed for injecting the wound. Over this Mr. Lister's lac plaster
is applied, surrounding the entire limb and extending several inchc*s
above and below the wound. Dr. A. R. Stracban, of this citv, who
DELAYED AND NON-UNION OF BROKEN BONES. 63
has been kind enough to furnish me with these details, taken from his
own notes as they were made under Mr. Lister's instructions, is unable
to give me the formula for the lac plaster. At Belle vue we use a lac
composed of gum shellac three parts, and carbolic acid crystals one
part ; the shellac being stirred in gradually while the crystals are heated
nearly to the boiling-point.
The subsequent dressings must be made as often as the character
and amount of the discharge may seem to require ; but at each dress-
ing care must be taken not to admit the air to the surface of the wound ;
and for this purpose Mr. Lister conducts the changes in the dressings
under a stream of the watery solution of the carbolic acid, which is
continually playing upon the part.
Many years since, Dr. J. Rhea Barton introduced into the Pennsyl-
vania Hospital what has since been called the " bran dressing " for the
treatment of compound fractures of the leg; the limb being made to
repose in a box filled with this material.* I have used it very fre-
quently in Bellevue and in other hospitals, and can speak of it as pos-
sessing many qualities of excellence, especially as a summer dressing.
The particular mode of using this apparatus I shall describe more
minutely when treating of fractures of the leg.
The treatment of inflammatory symptoms, and of the later accidents,
such as suppuration, oedema, gangrene, tetanus, etc., must be left mainly
to the good judgment of the surgeon. Gentle manipulation, uniform
support, rest, and sometimes cooling lotions constitute the most impor-
tant means by which inflammation is to be controlled. Bleeding is
rarely necessary, and in a large majority of cases it might prove inju-
rious by lowering too much the vital forces, which need to be hus-
banded in view of the requirements of the process of repair and of the
long and exhausting confinement. Cathartics should also be admin-
istered cautiously for the same reason, and because they are liable,
especially in fractures of the lower extremities, to occasion a serious
disturbance of the limb.
CHAPTER VI.
DELAYED UNION, FIBROUS UNION, AND NON-UNION OF
BROKEN BONES.'
Most surgical writers concur in the statement that non-union of
broken bones is an uncommon event. Walker, of Oxford, affirms
» Pupcr on Bran Dreasin^, by Reynell Coates, of Philadelphia. Amer Journ.
Med. 8ci., April, 1842, p. 515; from the Med. Examiner, Nos. 9 and 11, vol. i,
Kew Series. ^ -nr xr ; i*
« I ihskU in this chapter avail myself freely of the labors of George AV. Norm, of
Philadelphia, whose paper, entitled "On the Occurrence of Non-union after Frac-
tur«, itsCHUaes and Treatment." published in the American Journal of the Medi-
cal 8cience« for Jan. 1842, constitutes the most complete and reliable monograph
open this subject contained in any language.
64 DELAYED AND NON-UNION OF BROKEN BONES.
that of not less than one thousand fractures which have come under
his treatment at some period of the repair, he does not recollect more
than six or eight instances. According to Lonsdale, not more than
five or six cases of false joint, excepting those within a capsule, have
occurred out of nearly four thousand fractures treated at the Middle-
sex Hospital. In a table of 367 cases, collected and arranged by W.
W. Moriand, from the books of the Massachusetts General Hospital,
extending through a period of nineteen years, only one example of
false joint is recorded ; but as only seventy-four days had elapsed
when this patient was discharged, it is doubtful whether this might
not have proved to be a case of delayed union simply.' In 946 cases
of recent fracture treated in the Pennsylvania Hospital, between the
years 1830 and 1840, there was no instance of false union.* Sir Ste-
phen Hammick, Mr. Listen, and Malgaigne affirm also the infrequency
of these accidents in the cases which have come under their personal
treatment. I have myself seen a large number of examples of non-
union, but in not one of my own patients, whether in hospital or pri-
vate practice, except, in cases involving joints, has the bone refused
finally to unite ; and my opinion is, that, in proportion to the number
of fractures everj- where, these cases are very rare, perhaps not in a
larger proportion than one in five hundred.
The humerus and femur would appear to be the bones most liable
to non-union, as shown by Norris's statistics ; in which forty-eight be-
longt^d to the humerus, forty-eight to the femur, thirty-three to the leg,
nineteen to the forearm, and two to the jaw. In my own experience,
I have found the humerus ununited much more often than the femur.
B^rard hjis shown that in the growth of the long bones the period
at which the epiphyses are united to the diaphyses dej)end8 uj)on the
direc'tion of the nutritive artery; for example, "It is found that in the
humerus, where the direction of this vessel is from above downwards,
consolidation takes place soonest at its inferior extremity. In the fore-
arm, the course of the nutrient vessels is from below upwards, and
here consolidation of the epiphyses is found to occur at the elbow
sooner than at the wrist. In the inferior members, on the contrary,
the epiphyses coni|>08ing the knee are the last which become firm,
because in the femur the nutritious artery runs upwartls, and in the
bones of the leg it (*ourses from above downwards. A knowledge of
these* facts let! Gu6retin to inquire into the influence of these arteries
ui>on the consolidation of fractures; and the cases collecte<l by him
did indeed sei»m to show a positive relation between the direction of
the artery and the union of the Ix^ne ; that is to s;iy, the examples of
non-union wert» chiefly found where the fracture had taken place on
that side of the nutritious fiiramen frt>m which the arterv entered, as
if to imply that the non-union was in s<»me measure due to the im|)er-
fet^t nutrition of this extremitv of the bone. In thirtv-five cases of
non-union analyztnl by Gu^retin, ten belonged to that {)ortion of the
* Ad^l^^'^• on Fr«clun*«, bv A. L. l*ierM»n, read before the MaJ4«chu.<etU Med.
8i>o.. M«v 27, IWO.
• Norri*, luc. cil.
DELAYED AND NON-UNION OF BROKEN BONES. 65
bone which was traversed by the artery, and twenty-five to the other
portion. But an analysis of forty-one cases, made by Norris, does not
seem to confirm this observation of Gu^retin, since twenty-seven were
in the direction of the nutritious arteries, and only fourteen in the
opposite portion, or in that which is supposed to be less nourished.
Another observation, made by Curling, that in fractures of the long
bones the portion below the entrance of the nutrient artery, or on that
side of the nutrient foramen toward which the blood flows, being
defrauded of its proper supply, is subjected to a species of atrophy, pre-
senting a larger medullary canal, with thinner walls, and a spongy
tissue less dense, also needs confirmation. Malgaigne has not noticed
this fact ID any of the specimens contained in the public museums of
Paris ; and we do not know that any other writer nas made the ques-
tion a subject of especial inquiry.
According to Norris, there are four principal kinds of false joint :
In the first, the bones are united and completely enveloped in a car-
tilaginous mass or callous tumor, but, in consequence of some retarda-
tion in the process, bony matter is not deposited, and, as a consequence,
it wants solidity, the part continuing easily movable. This may be
regarded as a proper example of delayed union, as distinguished from
complete non-union, or false joint.
In the second, there is entire want of union of any sort between the
fragments, the ends of which seem to be diminished in size and ex-
tremely movable beneath the integuments. The limb in these cases is
found wasted and powerless.
In the third and mast common class, the medullary canal is oblite-
rated in both fragments, and the ends are more or less absorbed,
rounded, and covered, in part or in whole, with a dense tissue resem-
bline the periosteum. A connection also exists between the opposing:
fi^ente in the form of strong liga- ^^ ^
mentous or fibro-ligamentous bands, _ ^'°- ^^•
which, if of any length, are quite
flexible, and allow of considerable
motion at the seat of fracture. ciavIcle united by ligamentous bands.
In the fourth, '^a dense capsule
without opening of any kind, containing a fluid similar to synovia, and
resembling closely the complete ligaments, is found." In these cases
the points of the bony fragments corresponding to each other are
rounded, smooth, and polished, in some instances eburnated, and in
others covered with points or even thin plates of cartilage, and a mem-
brane closely resembling the synovial of the natural articulation. It
is in this kind of cases, Norris remarks, that the member affected may
still be of use to the patient, the fragments being so firmly held toge-
ther as to be displaced only upon the application of considerable force.
The existence of these newly formed joints, or true diarthroses, has
been called in question by Boyer, Hewson, Chelius,^ and others; but
* Malad. Chirurg., t. iii, p. 108, Paris, 1881 ; North Amer. Med. and Surg.
iaurn.,No. ix, p. 7, 1828; Trait, de Chir., trad, par Fign6, p. 150, 1886. (Norris,
loc cit)
66 DELAYED AND NON-UNION OP BROKEN BONES.
the observations of Sylvestre, Brodie, Beclard, Home, Howship, Otto,
Kuhnholtz, Houston, Cooper, Langenbeck, and Breschet prove that
such examples are occasionally found.^ I have myself met with several
examples.
A case is reported as having occurred in Boston, Massachusettes, in
which a young man, aet. 18, broke his humerus near its middle. Before
union had been completed it was accidentally refractured, and from this
time the fragments showed no disposition to unite; oa the contrary, a
gradual process of absorption took place, until at length the whole of
the humerus disappeared ; and that, too, " without any open ulcer."
Eighteen years later he was perfectly well, and the arm was strong and
useful, but no portion of the bone had been reproduced.*
Norris is a disciple of Dupuytren, and accepts his doctrine of the
formation of callus, without reservation; conseouently he finds no ne-
cessity for but one form of delayed union, namely, that which we have
described as l)elouging to the first class. In all of this class he assumes
the existence of a cartilaginous ring or ferrule ; but we think the error
of this exclusive theory has been sufficiently shown by the observations
of Paget and others, and we should be warranted therefore in affirming
the existence of as many varieties of delayed union as there are varieties
in the majiner and position of the deposit of callus, even if their actual
existence had not been repeatedly demonstrated by dissections.
The causes of delayed union and of non-union are either constitu-
tional or local.
The constitutional causes are chiefly those conditions of the general
system which manifest themselves by amcmia, debility, or some pecu-
liar dyscrasy.
Sanson, Bt»ulac, Condie,' and many others have mentioned cases in
which the existence of syphilis in the system has seemed to prevent
the fonnation of callus ; but, on the other hand, Lagneau and Oppen-
heim^ incline to the opinion that syphilis exerts in this res|XJct but
little influence ; and even B^rard, who admits the pertinence of one
case observed by Nicod, concludes, after numerous researches, that it
has been very rarely shown to affect the formation of callus.*
Pregnancy and lactation have been known to intAjrfere with the
union of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard,
of New York, and Condie, of Philadelphia,^ have all rejK)rteil examples,
* NouvflN'n de 1h Kepiib. des Lett res ilc* Bayle, p. 718, 1C85; Lend. Mod. Giiz ,
xiii, p. 67, 18:13; B^'fUirJ, G«*n. A nut., trHiis. l»v Hnvward, pp. 149, 248; Triins«c.
M<d.-('hir. S<.c. of Kdinburi;h, i, p. 233, 1793; Mod -Chir. Trans., viii, p 617,
1817; Oitn's Path. Anat., trans, by South, i, p. 188; Joiirn. Complement., ill, p.
291 ; Dub. M<k1. Journ , viii, p. 493 ; Cooper on Frac. and Disbn.'., fourth London
ed., p. 6U8 ; K«ibcrcb. sur les Formation du Cal, 1819, p. 34. (Norris, loc. cil.)
» B«»j*l(»n .Mrd. and Surg J«»urn., Julv 11th, 18C8, p. 308.
• Diet, do Med et Chir. Prat., iii,p. 492; Journ.de M6d. Chir. et Pharm., t. xxv,
p. 210. (Norri«, lot-, oit.)
* Expose do.-* Mvnip. de la mal. Yen., p. 525; Oppcnhcim on False Joints, 1837.
(Norris, loc eit )
» Op. oit , p. 21.
• CoeperS Die, od. 1838, p. 64C : Opera Hild., 1681; Wilson on the Human
Skoloton. p. 214 ; Bib. Choi.sie de M^l., xxiv, p. 595; Med. Obs. and Inquiries, 4,
1772; Philotoph. Trans., xlvi, p. 897, 750. (Norris, loc. cit.)
DELAYED AND NON-UNION OP BROKEN BONES. 67
in some of which the process of union was resumed and brought to a
rapid completion so soon as the period of pregnancy was closed, or
when lactation ceased ; but three cases reported by Sir Stephen Love
Hammick would seem to show, what, indeed, other evidences render
probable, that the delay was less due to the fact of the pregnancy and
the lactation than to the debility occasionally consequent upon these
conditions.^
As to the question whether cancer ever causes a delay in the union
of bones, it may be said that where the fracture arises in consequence
of a true cancerous deposit around or in the interior of the bones, pro-
dacing absorption of their tissue, no union takes place ; but that the
mere presence of the cancerous cachexy does not usually prevent the
formation of callus.
Scurvy, fevers of a low type, and, on the other hand, fevers of a
highly inflammatory character, profuse uterine and vaginal discharges,
and rachitis, conduce to the same result.
The withdrawal of an habitual stimulus, and especially a change from
a good to a low diet, or copious bleedings, may either of them delay
the deposit of ossific matter, or prevent it altogether.*
Bonn has furnished two cases in which advanced age seemed to
have retarded the formation of callus, but Horner saw a fracture of the
humerus in a woman ninety years old unite in five weeks.^ I have
myself noticed a good many similar examples in advanced life, and
it is now rendered quite probable that surgeons have generally over-
estimated the influence of age upon the formation of callus.
The local causes are, arrest of, the arterial circulation by bandages;
arrest of the venous circulation by pressure, by rupture of veins, or by
the formation of venous clots;* paralysis or impairment of the nervous
circulation; the occurrence of the fracture within a capsule; obliquity
of the fracture; overlapping of the fragments; interposition of a piece
of bone, of a tendon, muscle, or of a clot of blood, or separation of the
fragments from any cause whatever; erysipelas; acute phlegmonous
inflammation ; suppuration ; necrosis ; too much motion ; exclusion of
light and air inducing local scurvy ; wet, and especially cold and moist
dressings ; too early use of the limb, etc.
In order to hasten the consolidation when it is simply delayed, we
resort to all of those expedients which are calculated to invigorate
the general system ; and for this purpose the employment of a nutri-
tious diet and the use of mineral or vegetable tonics may not be prop-
erly omitted ; but in our experience nothing has proved so efficient as
encouraging the patient to leave his bed and get out into the open air ;
for which purpose, if the fracture is in the lower extremities, crutches
will be necessary.
As local means, we may enumerate first the removal of those local
causes which seem to have interfered with the consolidation or with
the uuion. If the fn^ments have been officiously disturbed, it may
* Prictical Remarks ou Amputations, Fractures, etc., p. 121. (Norris, loc. cit.)
* Norris, loc. cit.
» Ibid., p. 29.
* George W. Callender, Brit. Med. Journ., Nov. 80, 1872.
68 DELAYED AND NON-UNION OP BROKEN BONES.
be sufficient to impose upon the limb absolute rest for a certain length
of time ; and the fragments may l^ more closely pressed against each
other; in other cases it will be found necessary to remove the band-
ages, expose the limb freely to the light and air at least once or twice
daily, and to rub it gently with the dry hand or with some moderately
stimulating oil, so as to induce a more healthy condition of the soft
parts, and encourage the natural circulation.
Moving the fragments freely upon ciich other, sufficient to determine
a d^ree of excitement in the adjacent tissues, and upon the opposing
surfaces of the bones, and then confining them during one or two weeks
in firm and well-fitting splints, will sometimes succeed when other
means have failed.
Indeed, I may say that by one or another of the simple methods
now enumerated I have never failed, sooner or later, to effect consolida-
tion in recent fractures ; and it has only been in fractures of at least four,
six, or eight months' standing that I have been compelled to resort to
more extreme measures.
As a means of combining immobility with compression and health-
ful exercise, the "apparatus immobile, in many of its forms, is pecu-
liarly adapted. White, of Manchester, employed a firm leather sneath
for the thigh. H. H. Smith, of Philadelphia, recommends a more
complex artificial support, uiK>n which the limb may be allowed to
rest while in the act of progression.* With some surgeons, the object
of allowing the patient to walk, in fractures of the thigh or leg, is chiefly
to excite in the tissues adjacent to the seat of fracture some degree of
iuflammator)' action ; but which, as the result in one of White's patients
has sufficiently shown, may be carried too far, and even determine a
suppuration.
Dr. E. R. Hudson, artificial limb maker, of New York, has applied
in similar cases, which have come under my observation, an apparatus
of his own construction, made of willow, and secured in place by leather
straps. In case the purpose of the apparatus is to encourage bony
union, no motion is allowed at the knee-joint.
Blisters, mustard cataplasms, the tincture of iodine,* caustics,* etc.,
applied externally over the seat of fracture, can have no other effect
than to increase moderately the congestion of the tissues, and in so far
they may aid in the accomplishment of the bony union ; but in this
respect they are inferior to the violent twistings, flexions, and rubbings
of the broken ends of which we have already s|K)ken.
Electricity wva^ first employed by Mr. Birch, of London, but Dr.
Valentine Mott obtained no effect from it in two cai^es where he seems
to have given it a fair trial.* Lente, of the New York Hospital, has
furnished an account of three cas(« treateil in that institution by elec-
tricity in connection with acupuncturation ; tlie mode of using which
was to |>ass a needle down to the {)eriosteum on each side of the bone,
and to attach the ]K)les of the battery to these opposite {)oints. Lcnte
* U. H. Smith, Amcr. Journ. Med. Sci., Jan 1855.
* Hartshorno, EcNvtic Kop., vol. iii, p 114. 1813.
* ^Villnughhy, Am. Journ. Mcni. Scl., Aug. 1884, p. 444,
* Mott, Med. and Surg. Kop., p. 21, p. 876.
DELAYED AND NON-UNION OP BROKEN BONES. 69
thinks that electricity employed id this way is much more efficient
than Then the poles are merely applied to the surface. He informs U8
also that other cases than these now reported have been treated suc-
cessfully in this hospital by means of electricity.'
Mercury will no doubt prove serviceable occaaionaliy hy virtue of
its powers as an anti-syphilitic, but ite beneficial influence in other
cases is far from having been established.
The seton is said to have been first suggested by Winslow, in 1787;
bat, what is of much more consequence, the credit of its first successful
application and its general introduction into practice is .due (o Dr.
Philip Syng Phyaick, of Philadelphia, by whom it was employed io
1802.^
Physick need for his seton, generally, silk ribbon, or French tape;
and this he introduced by means of a long seton needle, between the
ends of the fragments. He recommended that the seton should remain
in place four or five months, and longer if necessary, and it was his
opinion that the foilares were generally due to its being removed too
70 DELAYED Al^D NON-UNION OF BROKEN BONES.
Fio. 19.
early. At the present day, however, surgeons who employ the seton
think it serves its purpose better when it remains in place but a few
days, not longer, perhaps, than ten or fifteen, always taking care that
it is removed before excessive suppuration is induced. It has been
found especially valuable in fractures of the inferior maxilla, clavicle,
and of the upper extremities; but in the case of the femur, it has so
frequently failed, that Dr. Physick himself did not recommend its use.
In case the seton cannot be passed directly between the opjxxsing
fragments, as recommended by Physick, we may adopt the practice
suggested by Oppenheim, and carry two setons, one on each side, close
to the bone.
Somm6, of Antwerp, preferred a loop of wire to the silk seton em-
ployed by Physick.* Seerig passed a ligature around the ligamentous
mass connecting the two fragments, and then
proceeded to tighten the ligature until it fell off.'
Dr. Hulse, of the U. S. Navy, employed stimu-
lating injections with success in a case of non-
union, accompanied with an external and fistulous
opijning.' In 1848, DieflTenbach recommended
that ivory pegs be introduced into holes previ-
ously made in the bone,* by means of a gimlet or
drill, and Mr. Stanley has succeeded once by this
method.* Mr. Hill introduced the ivory j)egs in
a case of ununited fracture of the femur, pya?mia
supervened, and the patient died.*
Malgaigne, in 1837, tried to introduce acu-
puncture needles between the ends of an united
fracture, but although he thrust the needle down
to the bone thirty -six times, he was unable to
make it pass once between the ends of the fi^ag-
ments.^ Wiesel succeeded better. In a case of
ununite<l fracture of the ulna, of nine weeks'
standing, having passed two needles between the fnigments, at the end
of six days, the needles being removed, consolidation rapidly ensued.*
This practice does not differ essentially from the metallic loop of »Somm6.
It is only a mollification of the seton.
Brainard, of Chicago, has attempted to show that setons of any
kind, whether of wood, ivory, or metal, placed in contact with the
bone, occasion absorption, caries, and necrosis, but that they never di-
rectly give rise to l)ony callus ; and that the occasional success of the
seton, which success he believes to have been greatly exaggerated, lias
not resulte<l from anv tcndencv to favor the formation of callus, but
PiefllenbAch's drills for uo-
united fracturv.
* Amor. Jnurn. Mini. Sv'x , vol. vii, p. 497.
' N»»rrif», l<»o. cit., p. 46.
■ Hiilni', Amor. Journ. Mod. Sci., vol. xiii, p. 874.
* Mitl^aigno, lriin§. by Pnckard, op «'it., p. 258, note.
* Su*nU'v, Now York Journ. Med , Nov. 1854. p. 441, from Dublin Pre*t.
* Nt'w i'ork Med. Gaz., July 4, 1808, from the London Lnncet.
' MHl^nitjnt'. op cit.
* VVii'jjel, Amor. Journ. Med. Sci., vol. xxxiv, p. 254, July, 1844.
BELAYED AND NON-UNION OP BROKEN BONES. 71
from the iDduration and tenderness of the soft parts produced by it ;
circamstanees which, by conducing to rest, indirectly favor the consoli-
dation.^
In May, 1848, Miller, of Edinburgh, reported five cases treated
successfully by subcutaneous puncture. The operation consisted in
passing the point of a needle or small tenotomy bistoury down upon
the ends of the bone, and freely irritating the surfaces at several points.'
George F. Sandford, of Davenport, Iowa, has successfully imitated
this practice in two cases.*
In 1850, Dr. William Detmold, of New York, performed the ope-
ration of drilling or perforating the fragments in a case of ununited
fracture of the tibia, employing for this purpose a large gimlet. He
first bored two holes between the opposing fragments, and then, intro-
ducing the gimlet one and a half inch below the fracture, he penetrated
the tibia upwards and inwards until he had traversed, also, the upper
fragment to the extent of an inch. In three weeks the bone appeared
firm, but from this time the patient was not seen.*
Brainard employs for this same purpose a strong metallic perforator,
consisting of a handle, into which points of different sizes may be in-
serted, and which have been hardened so as to penetrate the hardest
bone or even ivory in every direction easily. The points are " some-
what awl-shaped ; but more pointed in the middle rather than like a
drill, which leaves chips." His manner of using this instrument is as
follows : " In case of an oblique fracture, or one with overlapping, the
skin is perforated with the instrument at such a point as to enable it
Fig. 20.
Brainard'B perforator, reduced one-half.
to be carried through the ends of the fragments, to wound their sur-
feces, and to transfix whatever tissue may be placed between them.
After having transfixed them in one direction, it is withdrawn from
the bone, but not from the skin, its direction changed, and another
perforation made, and this operation is repeated as often as may be de-
sired.'* Dr. Brainard, who succeeded by this procedure in a number of
cases of ununited fracture, thinks it is better to commence in most cases
• with not more than two or three perforations, in order that the effect
produced shall not be too severe. It is scarcely necessary to add that,
after the punctures have been made, the limb should be put completely
at rest in appropriate splints, or in apparatus of some kind.
Mr. Tieman has made for me a bone-drill which is rotated by the
^ Brainard, Trans. Atner. Med. Assoc., vol. vii, 1864: Prize Essay. Report on
Surgery to Illinois State Med. Soc, May, 1860.
' Miller, New York Journ. Med., July, 1848, p. 134.
* Sandford, Trans. Amer. Med. Assoc , vol. iii, p. 355, 1850.
* New York Med. Gazette, Oct. 12, 1860.
72 BELAYED AND NON-UNION OF BROKEN BONE8.
movement of a handle upon a rod or shaft composed of twisted wire,
and which possesses the advantage of being worked with great facility
and rapidity. Perforators of any size or shape may be fitted to the
Fio. 21.
The author's bone-drilL
shaft at pleasure. In most cases I have found Brainard's drill a better
instrument than my own.
Scraping or rasping the ends of the bones is a practice which dates
from a very early period. Mr. Brodie scraped the ends of the bones,
and then interposed a bit of lint.* Mayor, in 1828, contrived to in-
troduce an iron, previously heated in boiling water, through a canula,
and thus brought the heat to bear directly upon the ends of the frag-
ments; and by repeating the application several times, a cure was
effected.'
Resection of the ends of the bones, first brought into notice by
White, of Manchester, in 1760,' and opi)osed by Brodie* as dangerous,
and by Malgaigne regarded as generally useless or unnecessary, has
still bec^n practiced a great number of times, with m()i*e or less success.
It is especially applicable to su[)erficial bones, and in cases where the
bones overlap.
Roux practice<l resection in one instance, and then managed to en-
gage the point of one of the fragments in the medullary canal of the
other.* I have succeeded in doing the same.
White, of Manchester, Henry Cline, of London, Hewson, Barton,
and Norris, of Philadelphia, have applied caustics directly to the ends
of the fragments, after having exposed them by a free incision.* Petit
applied the actual cautery.^
Tying the fragments together by means of metallic ligatures after
a recent fracture, is as ola as the days of Hippocrates; but in 1806
Iloreau adopted the same procedure in a case of ununited fracture.*
Since which date it has lx?en practiced successfully by many surgeons.
My own experience confirms the value of the metiiod, especially when
the fragments overlap.
1 Brodio, Lond. Med. Gaz., Julv, 1834. * Norm, loc. cit., p. 48.
> Dic-t. do Mod., vol. xxiii, p. 5()3.
* Hrndio, Now York Journ., vol. viii, Ist scr., p. 188.
• Norrii, loc. cit., p. 49. • Ibid. ' Ibid. • Ibid.
DELAYED AND NOX-UNION OF BROKEN BONES. 73
R S. Gaillard, of Louisville, Ky., proposes to secure the fragments
in place by means of a metallic pin. The instrument which he em-
ploys is composed of a steel shaft with a handle, a silver sheath, and a
bra&j nut. For a broken femur, the shaft is six inches long, its lower
extremity being constructed like a gimlet, while two and a half inches
of its upper extremity are cut for a male screw, being intended to
carr}' the brass nut. The sheath is three inches long.
Through an incision made over the seat of fracture, the sheath, de-
tached from the shaft, is carried down to the bone. The shaft is then
pas-ied through the sheath, and made to penetrate and transfix the two
fragments; as soon as this is accomplished, the nut is turned down
Fio. 22.
GaUlard's iDstrument for ununited fnicturea.
firmly upon the top of the sheath, and apposition of the fragments is
thus secured. The whole instrument is permitted to remain until bony
union is effected.^
Finally, having thus brought rapidly before us all of the various
modes of treatment which have been suggested and practiced for non-
union of broken bones, we are prepared to affirm the following con-
clusions, or summary of what has been our own practice, and of what
we believe ought to be the general course of procedure in these cases :
First. Improve the condition of the general system.
Second. Remove as far as possible the local impediments, such as
a separation of the fragments, local paralysis, local scurvy resulting
from long exclusion from light and air, congestions, etc.
Third. Increase the action of the tissues immediately adjacent to the
fracture, upon which tissues, rather than upon the bone, as Malgaigne
thinks, the formation of callus depends. A theory which, as applied to
old and ununited fractures, we are not prepared to deny. This may be
sccomplishcd by frictions, and violent flexions of the limb at the seat
of fracture; possibly in some measure by the application of vesicants
or of other stimulants to the skin itself
Fourth. Employ again compression and rest for a period of from
two to four or eight weeks.
Fifth. Resort to the method recommended by Brainard.
Sixth. If in the lower ex'tremity, allow the patient to walk about
with the fragments well supported.
Seventh. If the fracture is not in the femur, and as an extreme
measure, employ the seton, or resection.
» B. S. Gaillard, New York Journ. Med , Nov. 18G5.
6
74 BENDING, PARTIAL FRACTURES, AND FISSURES.
Where these measures have failed, after a fiur trial, we should either
abandon the case as hopeless, only supporting the limb by such appa-
ratus as may be found most serviceable, or we should recommend
amputation.
CHAPTER VII.
INCOMPLETE FRACTURES.
BENDING, PARTIAL FRACTURES, AND FISSURES OF THE IX)NG BONES.
i 1. Bending of the Long Bones.
Strictly sneaking, no bone can be much bent without being also
more or less broken, and that whether it immediately and sf^ionta-
neously resumes its position or not ; for, if the bending and straighten-
ing of the bone be rei>eated a sufficient number of times, the yielding
of the fibres will become apparent, and at length the separation will be
complete. The first of this series of flexions was quite as much respon-
sible for this result as the last, and, no doubt, performed its share in
the production of the complete fracture.
There could l)c no impropriety, therefore, in speaking of a bending
of the bones as a variety of incomplete fractures, as I have done in the
first section of my *' Report on Deformities after Fractures," made to
the American Medical Association in 1855.*
They have been called, not inappropriately, interperiosteal fractures,
since in these cases the periosteum is not broken ; M. Blandin thinks
that the outer and semicartilaginous lamina? of the bone also do not
break, while the d(»cper lamime suffer an actual disruption.* But it is
3uitc as probable that in a majority of castas the true pathological con-
ition is a compression of the bony fibres upon one side, with a cor-
responding expansion uj>on the op|K)site side, with only a slight inter-
stitial fracture, too trivial to Ik? easily rwognized even in the dissection.
Sometimes, as I have several times observe<l in my exjwriments on the
l)oncs of chick<'ns, when the lH)nos are small, and the bending is near
the <»t»ntre of the shaft, the whole of the laminte on the side of the retir-
ing angle* prcMhu^ed by the bending are doubl(Hl in, or indented toward
the hollow of the bone, so that the fibres on the si<Ie of the salient
angle are not even stn»tche<l, and much less broken. In puch uis^'S,
the interstitial disruption, if it exists at all, and I think it dix^, first
takes placi» in the dee|)er layers of the retiring angle.
I niight, therefore, feel just ifieil in continuing to call these cases par-
tial fractures, or, jwrhaps, interstitial fractures, but I believe that the
whole subjec»t will be rendered more intelligible if I call them simply
» Op cit,, pp. 4J1-4'JU.
• Mnrkhnin'< Oh*. (n» the Surg. Praclicc of Paris, London Mt*<l.-Chir. Rev., vul,
ixxiv, p. 473. 1S41.
BENDING OP THE LONG BONES. 75
bending of the bones, as distinguished from those other and more pal-
pably partial fractures of which I shall speak presently.
1. Bending with an imTnediate and spontaneous restoi'ation of the bone
to its original fomi. — The possibility of this accident, to which, how-
ever, surgical writers have hitherto made no distinct allusion, is ren-
dered certain by the following experiments :
Erperiment 1. — July 16, 1857. I bent the tibia of a Shanghai
chicken, four weeks old, at about the middle of the bone. It was bent
to an angle of quite twenty-five degrees, but it was not felt or heard
to break. It immediately and spontaneously resumed the straight po-
sition.
July 18, two days after the bending, I dissected the limb, and found
DO trace of the injury, either within or without the bone, unless I ex-
cept a very minute blood-clot in the centre of the shaft.
Ecpenment 2. — I bent the leg of a chicken, four weeks old, at the
same point and to the same degree. It immediately resumed the
straight position.
Dissection after two days. Nothing abnormal except a small blood-
dot in the centre of the bone, and a slight disorganization of the
ffleilulla.
Erperimenis 3 and 4. — Bent both legs of a chicken, four weeks old,
at the same point and in the same manner. They immediately re-
sojued their positions.
Dissection after two days. No lesions or morbid appearances which
I could detect.
Erperimenis 5 and 6. — Bent both wings of a chicken four weeks old.
Bent the right wing to an angle of thirty-five degrees. I did not feel
them break. Both resumed their positions spontaneously.
Dissection after tiro days. No lesions or other morbid api)earances.
Experiment 7. — July 16, 1857, 1 bent the leg of a Shanghai chicken,
five weeks old, l>elow the knee and about the middle of the bone. It
was bent to an angle of about twenty-five degrees, but the lx)ne was
not felt or heard to break. It immediately and spontaneously resumed
the straight position.
July 20, four days after the l>ending, I dissected the leg, but could
not discover any trace of the injury, except that there was a very mi-
nute ossific deposit in the centre of the bone at the point at which I
suppose It to have been bent.
Erperiment 8.— July 16, 1857, I bent the right leg of a Shanghai
chicken, five weeks old, at the same point as in the first experiment,
lod to the same extent. The bone did not seem to break, but it im-
mediately and spontaneously resumed the straight position.
Dissection after four days. Nothing appeared to indicate the seat of
the bending except a small clot of blood in the centre of the shaft.
Erperiment 9. — Bent the leg of a chicken, six weeks old, in the
same manner and to the same degree as in the other examples. It re-
aimed its position spontaneously.
Dissection after ten days. No evidence of injury of any kind ; the
hone being sound and straight.
These experiments were made in connection with others to which
76 BENDING, PARTIAL FRACTURKS, AND FISSURES,
more eapwial reference will hereafter be made. They are selected, and
conslitiile the whole number of thtwe in which I did not feel llie bone
break or crack under my fingers. In every inntance the bone .apriinjf
back immedJBtcty and spontanenusly to its natnr»l form. In no in-
stance conid I afterward discover any trace of lesion or sign indicatin)
the point at which the bone had been bent before dissection, nor dH
diseectioD itself disclose anything but the motit inconsiderable marUay
and tlmt in but three examples.
I infer, therefore, not forgetting the caution with which the conclu-
sions from all such experiments ought to be applied to similar accidents
upon the hnman skeleton, that whenever the bones of healthy infimt»
have been slightly bent and not broken, they will, probably, in most
oases, unless prevented by causes foreign to the bones themselves, spoil'-
taneously and immediatelv resume their position, and that no sign wilt
remain to indicate that a bending has occurred. The accident will natt
be reeogniited, and, as a farlher inference, this bending does not belonj
to that class of cases of which I shall next speak.
2. Beading without immediaie and spontaneous restoratitm of the bona
to its original foi-m. — " Dethleef, believing that he had broken the tw
bones of the leg of a dog, found the fibula bent without a frai^nn
Similar results were obtained by Duhamel upon a lamb; by Tnni;
upon a pigeon; and I have myself twice succeeded in liending tot
fibula wliile breaking the tibia. The possibility of simple cnrvatuN
is then not contestable " (the writer means to say that tne pnt^ibiHn
of a simple curvature remommjpennawen^/y bent is not eonteslableh
" but we must observe that they have never been obtained except utKMi
young animals, and that they have been unable to maintain thenisefve
permanently except through the aid of a fracture and displaoenient o
a neighljoring bone; and there is a wide difference between these and
vhich sonic Ijelieve they have seen in man,
nintains itflelf, and resists perfect reductioai
until the fracture is complete.'"
In this single paragraph Malgaignc seems to have given a fiiir sum
raarj* of the testimony upon this point. With the exception of thcs
and a few other similar examples, some of which I think I have ob*
served myself, where one of the Iwnes of tiie forearm has been broktM
and the other bent, I know of no well-attested cases of » ixTmanoit
bending; using tlic term bending in a sense distinguished from a paf
tial fracture.
If, in numerous cases mentioned by surgical wnters, there has Memfli
to t)e probable evidence that the permanent tK?nding \rwi unaccompAnict
with tracture, there has always \wea wanting, so far as I know, the pim
live evidence of dissection. The example of partial fracture mentioned
by FergUBsou, and rcprecentol by a drawing, is described na havim
also, "towanl the lower extremity, a slight indentation and curve.''
This Vi-M the radius of a child; but how long the child aurviv^ b'
those pretended curvatures which some Ijelie
in which the curved bone — '■-'-'■-- u^-ic ~.
r L. F. MiilKHlenc. torn, i, p. 48.
kVllllam FerguMon, 4lli Am. «d., p. i
BENDING OP THE LONG BONES.
77
;!(IeDt, and what was the condition of the ulna, we aro not iiifonnccl.
• ob^r^'atioiiR made by Jiirine, of Geneva, in Switzerland,' by
rton'and Korris,' of Philadelphia, all fail to furnish
f sueb conclusive evidence of the correctness of their
views. Norrie says that " Thierry, of Bordeaux,
rtiu, and Chevalier, had iill met willi and puhli^lied
s of this kind prior to ihe apjwarance of Jitrine's
jer(in 1810), tbe former of whom asserts that Haller,
tx per! men ting upon the subject, had been able satis-
rily to produce the same accident in youug ani-
For mj-self, I cannot say how much confidence
Highl to place in tlieseassertionsof Thierry, Martin,
I Clievalier, havin)r never seen the papers referred
; but since Dr. Norris has neglected to inform us
letJier any di§ions were ever made, we shall not
xpected to regard their testimony as conclusive.
i\'ith the qualifications now made, Gibson was more
arly right when he said, " Dupuytren and Dr. John
[Ilea Barton have each furnistied accounts of betU bones.
e are no such injuries, however, in my opinion; FErguiMo.
Ii cases being, in reality, partial fractures from which
" ' s result upon the same principle that a piece of tough wood,
jak or hickory, if broken half through, may be inclined to one
• and shortened, although still held together by interlocking of
Many specimens in my cabinet, and in the Wistar Museum,
t the accuracy of this assertion.'"
I my own experiments upon the chicken, the bones uniformly re-
^ their original position as soon as the restraining force was
ived, unless a fracture occurred, and this notwitlistaiidlng the
5 were bent quite abruptly and to an angle of twenty-five degrees.
Ttaiuly, if the bones of children may be bent during life and be
'; to retain this position without a fracture, then the same thing
it be done upon the bones of children recently dead, and, by sue- '
aful cxjieri merits, this long-agitated question might be easily and
ever put to rest.
II will be uiv:lerstood that our observations are confined to the long
hones. Tiwt the flat bones, and especially the bones of the cranium,
in childhood, may be indented by blows, and remain in tins condition,
if aadeniable, Scultetus says he had seen "the skull pressed down in
children, without a fracture, so that those who touch or look upon it
«wi perceive a small pit,"' and it has been mentioned by many svriters
Biuw, and perhaps before his day. I have myself published two ex-
inplcs of it in the second volume of the Buffalo Medical Journal' and
sitn« tbe date of that publication I have met with others.
' JiHirn, da CorritHrt el Boycr, torn, xx, p. 278, olc.
• niU. M.'d. lUi'ordor, 1821.
' PliiU, HkI. Jonrn.. vol. xxix, p. 288, 1842
IV'*"'""*""' PrHClieeofSurcerj, hy Wm, GibEinii. Pliiln.; 18il, vol, i, p. 2G4.
Th» Cbirur)rn>n'i SwrohoiiM.liy Jobunne* S<.'Ultelus. 1674, p. 120.
»^ eit . p. W, 1846, CRara 1 and 2.
78 BENDING, PARTIAL FRACTURES, AND FISSURES.
{ 2. Partial Fracture of the Long^ Bones.
1. Partial Fracture with Immediate and Spontaneous Restoration of
the Bone to its Original Form, — No writer seems to have given any
special attention to tlie form of fracture now under consideration, al-
though its existence appears to have been occasionally recognized. In
the case reported by Camper, in 1765, of a partial fracture of the tibia,
the bone had regained its natural form, but whether immediately after
the accident occurred, or at a later period, I am not able to learn.'
Jurine, Gulliver, and others, have noticed a gradual straightening of
the bone after a partial fracture, so that its complete restoration lias
been accompHshea after several weeks or months ; but this, although
partly due to the same cause which produces occasionally an immediate
restoration, namely, its elasticity, is in part also due to other causes,
and will be more prpperly considered under the next division of partial
fractures.
Says Malgaigne: "Finally, at other times the fracture takes place
without opening and without curvature ; the only sign which one can
recognize is a yielding of the bone under the pressure of the finger,
at the point of fracture; yet upon the living subject we may see the
same symptom pertain to complete and simple fractures without dis-
placement."*
In the following report of one of M. Blandin's clinics the accident
is descril)cd a little more distinctlv : *' In some cases of fracture of the
clavicle occurring about the middle of the bone in young subjects, dis-
placement of the fragments does not immediately take place, thus giving
rise to a risk of an error in diagnosis, by which the ultimate probability
of a cure is diminishe<l. A lad seventeen years of age was recently
admitted into the Hotel Dieu, under the care of M. Blandin, having,
a few days previously, fallen upon one of his comrades while playing
with him, when he instantly experienced pain and a cracking sensation
al>out the middle of the left clavicle, where there soon formed a tumor,
which increasing, induce<l him to enter the hospital. On examination,
the swelling was found to occupy the middle of the clavicle; it was
al>out as large as half a hen's egg, ovoid in sha|)e, well circumscribwl,
colorless, and hanl, but sensible to pressure. There was not any de-
formity of the shoulder, nor any abnormal modificjition of the axis of
the l)one, to indicjite the existence of a fracture; and although the dif-
ferent movementsof the arm caused pain in the shoulder, yet they could
l)e made without much diflicultv.
"The symptoms in this cjise would lead to the l)elief that it was a
case of simple |K»riostitis, caustnl by external violence; but M. IMandin
at ontH* dt^t'idcil that there existe<l a fnictun* of the l)one, having seen
a sinjilar cas<» previously at the lios|>ital l^iuijon, where the tumor was
tn»at(sl as traumatic |K'riostitis, the |)atient merely «irrving his arm in
a sling, until, by a sud<len movement of the limb, displacement of the
fragments was pr<Kluce<l, and clrarly demonstrated the existentv of a
* Kj»*Hyf« nnd Oh**. Phy». and Lit. of Sue. of Edinburgh, vol. iii, p. 527.
• Op. cit., torn, i, p. M.
PARTIAL FRACTURE OF THE LONG BONES. 79
fracture. A Becond case occurring soon afterward, M. Blandin profited
by the experience gained from the preceding, and by moving the frag-
ments of the broken clavicle on each other, obtained motion and crepi-
tus. Still these indications were not so clear, that M. Marjolin could
diagnosticate a fracture ; he was of opinion that the case was one of ex-
ostosis, probably syphilitic, and the crepitus, he believed, depended on
an erosion of the osseous surface. In consequence, the patient was left
to himself, until a movement of the arm gave proof of the fracture by
the displacement of the broken portions of the bones.
"Two other cases occurring in young subjects have been admitted
since in the Hotel Dieu, under the care of M. Blandin, one of whom
was purposely left without surgical assistance, while Desault's bandage
was applied to the other. The former soon showed evidence of con-
secutive displacement; the latter was cured without any deformity fol-
lowing.
" The surgeon may diagnose a fracture, without displacement of the
middle portion of the clavicle, when a circumscribed tumor forms in
that part of young subjects, consecutive on a fall on the shoulder, and
motion of the fragments, with crepitus, can be detected, there not being
any syphilitic taint in the constitution."*
The following examples, which have come under my own observa-
tion, will illustrate more completely the usual history and symptoms
of these cases :
A. B., aged three years, fell from the sofa upon the floor, striking,
it is thought, on her right shoulder. Two days after this, she fell
a^n, and then for the first time, Mr. B. noticed the deformity. She
was brought to me three days after the second fall. There existed
then a round, smooth projection at the outer end of the middle third
of the clavicle. It felt hard, like bone. The line of the clavicle was
not changed. I advised a handkerchief sling, simply to steady and
Ripport the arm. Seven months afl^r the accident, she fell sick and
died. The projection continued at the time of death, only slightly
diminished.
H. S., aged six years, was thrown from a horse, partially breaking
his left clavicle, near its middle. Dr. Sprague, of Buffalo, was em-
ployed. The projection in front was for several days very apparent, and
was examined by myself at Dr. Sprague's request. The bone did not
seem to \ye out of line. Five years after the accident, I examine<l the
lad, and could not find any trace of the original injury.
September 25, 1855. Mrs. T. C. brought to me her infant child,
then but two weeks old. Upon the left clavicle, at a point a little
n€arer the acromion process than the sternum, was an oblong swelling,
three-quarters of an inch in length, smooth and hard like callus; the
skin was not reddened, nor tender. There was no motion or crepitus,
and the line of the axis of the bone was perfect. The mother, who had
been put to bed by a midwife, thinks the injury occurred in the act of
birth, although she did not notice the swelling until a week after.
» Am. Journ. Med. Sci., vol. xxxi. p. 473, from Journ de Med. ct Chirurg, Prat. ,
Julr, 1842.
80 BENDING, PARTIAL FRACTURES, AND FISSURES.
October 20. Nearly one month later, I found no change in the con-
dition of the bone; the hard lump remained, but it was still entirely
free from tenderness. I have not seen the child since.
An infant boy, three years old, fell, August 12, 1857, from the
hands of the nurse. The child cried, but the point of injury was not
detected until the third or fourth day, although the mother examined
the shoulders and neck carefully at the time. She is quite certain
that if any swelling or discoloration had been present, she would have
seen it then, or on the subsequent days, while washing and dressing the
child. When first seen it was very distinct, but not so large as at
present.
August 19. The child was brought to me. A little to the sternal
side of the middle of the right clavicle there was an oblong node-like
swelling, of the size of the half of a pigeon's egg, hard, smooth, and
feeling like bone; there was no discoloration or swelling of the integu-
ments; no crepitus or motion; the line of the clavicle seemed nearly or
quite unchanged.
I have not noticed this variety of accident in any other bone except
the clavicle, yet it is not improbable that it happens occasionally, and
perhaps quite as often, in other long bones, but that its existence is not
elsewhere so easily recognized.
Of one hundred and forty-two fractures of the clavicle recortled by
me, twenty-nine were i)artial fractures; and of these at least aix were
8iK)ntancously and immediately restored to their natural axes.
In explanation of the fact that hoi?pital surgeons have not observed
so large a proi>ortion of partial fractures of the clavicle, it must be stated
that most of these cjises of partial fracture were drawn from private
[)ra<'tice. Accidents of this class may be often met with in dispensaries,
)ut they are seldom found in hospitals.
KxperimeuL — In fourteen experiments upon the bones of chickens,
a paitial fracture, with imme<liate and spontaneous restoration, has
occurre<l but once. In nine of tlu^se cases the bones were only l>ent,
and in five they were partially broken; an immcHliate restoration has
occurred, therefore, in <»ne c:ise out of five of partial fracture; while in
my R'|)orted examples of partial fracture of the clavicle it has been
noticed about <mce in every three or four cases. The following is the
ex|KTiment to whi(»h I have referriHl :
I produce<l a partial fracture of the tibia in a chicken six weeks old.
The fracture was near the middle of the Iwne. I felt it break umier
my finger; but on removing the pressure, it immeiliately and s|K)n-
tan<HHisly resuiniHl the straight position.
I dissei*te<l the limb on the tenth dav. The line of the axis of the
b<">ne was pcrfwt ; hut on the fractunnl side was a ncxie-like enlarge-
ment, sufficient to be di>tinctly felt and seen before the soft jKirt** were
P<ttholof/y, — In no ca<e, excej>t in my single ex|)eriment u|K>n the
l)one of a chicken, has the actual condition been determined by dis-
sivtion, and if any qu(*stion has exisieil heretofore as to the possibility
of an inime<liate an<l s|M>ntaneous restoration after a (>artial fracture,
this ex[>eriment ought to decide it in the affirmative; but then the first
PARTIAL FRACTURE OP THE LONG BONES. 81
nine experiments already quoted have shown that a mere bending with
immediate restoration leaves no such traces or signs as have been de-
scribed as following these accidents. We have, therefore, the negative
aigument that, since a bending with restoration leaves no signs, these
examples, reported by myself and others as having occurred, and as
having l)een followed by a node-like swelling, etc., must have been
partial fractures. Moreover, in one of the cases of immediate restora-
tion reported by Blandin, there was a feeble crepitus ; and in another,
the subsequent displacement proved the correctness of his diagnosis.
We conclude, then, that these are examples of partial fracture, but
that the number of bony fibres which have given way are too incon-
siderable, as compared with those not broken, to affect materially the
elasticity of the bone.
Diagnosis, — The diagnosis will depend somewhat upon the history
of the accident as well as upon the present symptoms. In no instance,
where I could ascertain the cause, have I known an incomplete frac-
ture of this variety produced by any other than an indirect blow ; and
where the clavicle has been the seat of the fracture, the counter-blow
has been received upon the end of the shoulder. The fact possesses,
therefore, equal significance in its relation to either of the varieties of
partial fracture; but in the case of a partial fracture with a permanent
curvature, the diagnosis would be complete without the history, while
in this case it might not be, and a knowledge of the manner in which
the accident occurred w^ould, therefore, be of great importance.
The signs, then, after a knowledge of the fact that a blow has been
received upon the shoulder, are a node-like swelling upon the anterior
or upper face of the clavicle, generally in its middle third, this swell-
ing being bard, smooth, oblong; the skin only slightly or not at all
swollen or tender, and in no way tliscolored, as it would have been
had the swelling upon the bone been the result of a direct blow, and
the line of the axis of the bone unchanged. I have never detected
motion or crepitus at the point of injury, yet we have seen that Blandin
was able to detect both in one instance ; nor has it ever occurred to
me to see the swelling upon the bone until two or three days after the
iDJurr was received. We are not likely, therefore, to recognize this
accident immediately after its occurrence.
Treaiment — In the case of the clavicle, neither bandages, slings,
compresses, nor lotions, can be of much service. Yet no harm can
arwe from employing a simple sling and roller to confine the arm;
and it is always proper to enjoin some degree of care in using the arm
of the injured side. The consolidation will be speedily accomplished,
and after a time the ensheathing callus will wholly disappear.
If a similar accident should occur in any other of the long bones,
as retentive and precautionary means, splints ought to be applied, at
least for a few days.
2. Partial Fracture withtnU immediaie and spontaneous restoration of
the bene to its natural fomi. — The causes of this accident are the same
with those which produce simple bending, or partial fracture with im-
mediate and spontaneous restoration, from which latter they differ prob-
ably in tlie greater extent of the bony lesion. Perhaps, also, they differ
82 BENBINOy PARTIAL FBACTURES, AND FI88URE8.
K^mietimefl in the peculiar form and degree of the dentieulation at the
ficat of the fracture ; in couHequence of which an antagonism of the fibres
Fio. 24.
Fio. 25.
pArttal ririiftun* with*
Wki rrttorRlioD «tf the
booe to its imtuml fttriu.
Partial (Vaciure of the cluriclo without spoDtaneous restoraiioo.
nature; taken three weeks after the accidcfnt.
takes placCy preventing a restoration of the bone to
itH original form.
They constitute a large majority of those ex-
amples of {Nirtial fracture which come under our
observation in the various long bones. In one
hundreil and forty-two fractures of the clavicle, it
has lHM}n ol)serviHl by me twenty times. In two
hundred and nine fractures of the radius and ulna,
it has occurre<l twelve times. Similar examples are
mot with, but much more rarely in the humerus, ribs, femur, tibia, and
fibuhi.
Vorj* few surgtH)n8 have sjwken of partial fractures in the clavicle,
whiK» Jurine, Symc, Liston, Miller, Norris, and many others, have
dtvhinnl that it is much mon^ fre<|ucnt in the l)ones of the forearm
tlian clst»\vhcn\ This dtH»s not agn»i» with mv ex|x>rience, according to
which it tHvurs oAoncr in the chivide than m the forearm ; a dist*rep-
ancy which 1 i*;uint»t very well explain, exwpt by sup|)osing that, in
the itist* of the chivicio, the atvitlcnt has either l>een overlookcnl en-
tirt»ly or misjipprchcntliHl. Klandin, who, we have seen, has reported
five castas of {virtial fnictun* t>f the clavicle with immetliate restoration,
Ktates distinctly that in two of thcsi* muH^s tlistinguishe<l surgenns of
IlApital IU*tiujtm and IlAtcl I>icu failinl to nwgnizc it.
Sjivs Tumor: " Tho next I shall di^r^vud to is that of the clavicle
or *>»llar-Unu\ which 1 Iiavo found the nuv»t iVt^juontly ovorKioked, I
think, of any other, till it luv> Uvn SiMuotimos ti»o late to n*nuHly, es-
IHvially anuni^ tlio ohildn»n of |HH»r |HN»plo : lor, though they find those
ittio oni*H tw wiuiv, M^ntinu or cr}\ \\\%n\ the taking off or putting on
their cloth***, yet, Mving tliat tluw suffer the haiuiling of tfieir wrists
mihI anus, though it U* with |«in, thoy siis|Hvt only simie sprain or
trench, that will p) away i^ itself, withiHit rei^anUng anything further
PARTIAL FRACTURE OP THE LONG BONES. 83
or looking out for help; whereas, this fracture discovers itself as easily
as most others. For not only the eye, in examining or taking a view
of the part, may plainly perceive a bunching out or protuberance of
the bones when the neck is bared for that purpose, with a sinking
down in the middle or on one side thereof, which will be still more
obvious on comparing it with its fellow on the other side ; but when
it is more ol>scure, and the bone, as it were, cracked only — a semi-
fradurcy as we say — yet, by pressing hard upon the part, from one
extremity to the other, you will find your patient crying out when
you come upon the place ; and by your fingers, so examining, some-
times perceive a sinking farther down, with a crackling of the bone
itself."*
Erichsen, who regards all of these cases as mere bendings of the
bones, remarks that it " most commonly occurs in the long bones, es-
pecially the clavicle, the radius, and the femur."^ He says, moreover,
"Fracture of the clavicle in infants not unfrequently occurs, and is
apt to be overlooked. The child cries and suffers pain whenever the
arm is moved. On examination, an irregularity, with some protuber-
ance, will be felt about the centre of the bone. ^' The reader will not
fail to recognize in these symptoms the incomplete fracture of which
we are now speaking, although Erichsen evidently believes them to be
examples of complete fracture.
In addition to this testimony as to the frequency of these fractures
in the clavicle, I will only mention that Johnson, in his review of
Markham's ObservcUiona on the Surgical Practice of Paris, says that
" many surgeons have noticed the incomplete fracture of the clavicle,
as of other bones, which takes place in the young."*
Pathology. — The following experiment will assist in the elucidation
of this point of our subject :
Experiment. — I bent the leg of a chicken five weeks old. It cracked
under my fingers, and remained bent. Having waited a few seconds,
and finding that it was not restored to position, I pressed upon it and
made it straight. The chicken walked off without any limp.
On the fourth day, before dissection, the bone looked as if it was
still bent; but on removing the soft parts, the line of the axis of the
bone was found to be straight. The areolar tissue under the skin was
infiltrated with lymph, which was most abundant near the fracture, and
gradually diminished toward each extremity of the limb. This effusion
was confined almost entirely to the front of the limb, or to that side
which had been broken, and constituted the greater part of the enlarge-
ment, which I had noticed before the dissection was commenced, and
which then felt like bone.
On the front of the bone, also, underneath the periosteum, there was
a loose, honeycomb deposit of ensheathing callus, about one line in
thickness, and extending upwards and downwards about half an inch.
* Art of Surpery, by Daniel Turner, London, 1742, vol. ii, p. 255.
* Science and Art of Surgery, Phila. ed., 1854, p. 180.
■ Op cit, p. 205.
* Lond. Med.-Cbir. Rev., vol. xzziv, p. 474, 1841.
84 BENDING, PARTIAL FRACTURES, AND FISSURES.
Fio. 26.
This callus surrounded the bone in three-fourtlis of its circumference ;
but there was no callus on its posterior surface. It was also deficient
exactly along the line of fracture, in front and on
the sides, in consequence of which an oblique groove
remained, indicating the seat of the fracture.
In three other experiments, the particulars of
which are detailed in the earlier editions of this
book, similar results were obtained.
So early as the year 1673, a dissection made by
Glaser demonstrated incontestably the existence of
partial fractures in the shaft, and in the direction
of the diameter of long bones.* Camper, in 1765,
again described a specimen which he had seen ;* and
Bonn, in 1783, added a third positive observation.*
M. Gimele is, therefore, in error when he ascribes
to Campaignac the credit of having first proven by
dissection their existence, in a paper communicated
to the Academy of Medicine at Paris, in 1826.
Campaignac, however, seems to have been the first
who described very particularly the condition of this
fracture. He has recorded the history and dissection
of two cases, one of which occurred in tlie fibula, and
one in the tibia. The first of these cases was a girl
twelve years old, who survived the accident ju;»t
eight weeks. The fracture had occurreil near the
middle of the bone, and u[H)u the interior and in-
ternal side; in which direction, resting against the
tibia, the bone was found inclined. " The bony
fibres had been broken at different lengtlis, almost
exactly like what takes place in the branch of a
tree which has been |)artially broken ; and, as we see sometimes in
this latter case, the bundles of splintereil bony fibres abutted uj^on
themselves, and did not take their places when we endeavored to re-
store them ; so the abnormal angle which the fibula represented could
not be etraivil, the ends of thedivideil fasciculi not restornig themselves
to their resj)ective place***. This disposition might Ikj es|>ecially seen
toward the anterior |)art of the internal face, where a packet of fibres,
coming from below, wjis braced against the upper lip of the division,
which it thus held o[)en. This o|)ening at first made me think that
the fragments could not have been well consolidateil ; but I assured
rnvsi'lf that it was, and the fact was subse<iuentlv confirmed bv the
At-ademy of Meilirine ; all the {xnnts which were in contact were
found intimately uniteil."*
I>iaf/ntMfiK, — The diagna«*is is not difficult. The distortion indicates
sufficiently the existence of a fracture, while the complete absence of
* M«li:ttii:n»», nn. cit.. p 44, from Th. Honoti S«*pii]rhrt»tutn, 1700, tom ili, p. 4-4.
» K-HV* Hii.i OM. Phy*. and Lit. of Smv of K.iinhursrh, 1771. v.il iii. p. r»:i7
* MnliTMiirn**, op rit.. p. 44, fnmi I)«**4Tipt. Th«^ (K!»ium Morh. H«)Tiiini. 1783.
* !)«•• Frmtiirv!* Inot»inplot«M oi Jp* Fraotiirf^ Longituvlinalcj) dos O* dv** Mcinbre* ;
f4ir »I A J. riinipnigntto. pHri*, 1829. pp. O-lO.
Partial frartun'; after
union is consumioated.
PARTIAL FRACTL'BE OF THE LONG BOSES. 85
pTcpitus in nearly all pases, ami of either uverlapping or Inleml ilia-
ptacemeot, mast generally, efliieeially where the aceidoiit has wviirred
in a child, sufficiently indicate that the fraeture ie incomplete. It will
assist the diagnosis, altio, to notice that thrae accidents are almost oon-
fioed to the middle third of the long bones; and they arc produced
tLMially by a bending of the bones, the forces operating u|Hjn the ex-
Irerailiis, and not directly u|ion the point which is broken.
In (wmplete fractures, also, preternatural mobility is so constant a
sign as to be regarded as diagnostic, while here there is ulmrwt always
B great degree of immobility at the seat of fracture. The angle made
by the pngecting extremities is usuully rather gentle and smooth; at
other times it is abrupt, indicating a greater amount of fracture, or
that the outer fibres are broken more irregularly. The [Miwer of using
the limb is generally sensibly impaired, but not completely lost.
Traiimftd. — .Tnrine, Murat, Campjiignae, Gulliver, Malgaigne, with
some otherfi, have notii^ the fnct that it is of^en difficult, and some-
times quite im possible, to restore thi'se bones to position; a circum-
ttanoe which they have justly ascribed to that condition of the frag-
ments described byCampaignac. The broken extremities of the fasciculi
become braced against each other, and effectually resist all elforta
to straighten the bone; unless, indeed, so much foree is used an to
fender the fracture complete: a result which, if it should chance to
luppen, need not occasion any alarm, since, while it enables us at once
to restore the bone to line, it does not much increase the danger of
lateral displacement and overlapping. Thut the fracture has become
eumplele we may know by a eunaen sensation of cracking, by the in-
(Teflsed mobility, and by the crepitus, which is now easily developed.
But we need not, on the other hand, be over anxious to straighten
e bone completely, since experience has shown that after the lapse of
a few weeks or montlis the natural form is usually restored sponta-
neously, lam not uow speakingof those cases in which the restorattou
[Kcurs immediately, where it is probable that the splintered fibres offer
no resistance to the restoration; but only of those in which the bone
ilraighiens so gradually as to induce a belief that the broken euds are
the cause of the feeistance. To this variety of at^cident belong cases
one, five, six, seven, and eight, published in my Roimrt on Deformities
after Fractures ;' in one of which the natural axis was resumed in less
than fuur weeks. In a case mcntione<I by Gulliver, It required about
the same time to render the bones of the forearm perfectly straight;
■nd in one case mentioned by Jurine, at the end of six months it was
"difliL-ult to say which arm had been bnikeu, and at the end of one
trar it was impossible."
Jariue attributes this restoration to " muscular action, or more espe-
««Ut to the reaction of the compresse<l bony plates;" but while it is
«*)■ In understand how the reaction of the compressed fibres may ac-
wiiipliah the gradual restorntiou, I am unable to undcr:^tand in what
Manner musciilar action contributes to this result, since most of the
muscle attached to the long bones operate so much more enei^tically
86 BENDING, PARTIAL FRACTURES, AND FISSURES.
in the direction of their axes than in the direction of their diameters.
Indeed, we have often seen these bones bent after complete fractures,
and before the union was consummated, by muscular action alone.
I repeat, then, that the gradual restoration of these bones is due to
the same circumstance which produces at other times an immediate
restoration, namely, the elasticity of the unbroken fibres, but which
elasticity, in this latter instance, is, for a time, effectually resisted by
the bracing of the broken fibres. At length, however, in consequence
of the gradual absorption of the broken ends, the resistance is removed,
and the bone becomes straight. If this absorption refuses to take
place, and the fibres continue pressed forcibly against each other, as in
the case described by Campaignac, then the bone remains iKjrmanently
bent.
Having straightened the bone as far as is practicable, it only remains
to secure the fragments in place by suitable bandages or splints. If
the restoration is incomplete, these means may assist the efforts of
nature in accomplishing a gradual restoration.
It is scarcely necessary to say that extension and counter-extension
avail nothing in partial fractures.
{ 3. FisBures.
These constitute the second principal form of incomplete fractures,
or those in which the fracture is accompanied with no appreciable
bending, which occur almost exclusively in inflexible bones, such as
the compact bones of adults, and more often in the direcjtion of their
axes than of their diameters. They are complete so far as they extend,
but they do not completely sever the bone so as to form two distinct
fragment.*^. They have been most frequently observed in the flat bones,
such as the bones of the skull, and in the upper bones of the face ; oc-
casionally in the long bones, both in their diaphyses and epiphyses,
and rarely in the short bones.
M. Gariel has rejmrted, in the BuUcthis <le la S(K*ieie Anat.y for 1835,
a case of fissure of the inferior maxilla, occurring in a lad sixteen or
eighteiMi years old. Palletta found a fissure extending partly through
the third dorsal vertebra, in a man who had fallen upon his back
eleven days before ; and M. Lisfranc has mentioned a remarkable case
of fissure and partial fractuiv, with l)ending of five ribs in the same
jK'rson.' Malgaigne Ix^lieves that he hjis seen one example of this
variety of incomplete fracture of the scapula, occurring through a |>or-
tion of the infraspinons region. I have myself elsewhere recorded
another, as having IxKiu found in the skeleton of Ximham, an Oneida
Indian, who was a groat fighter, and who dicnl when about forty-five
vears old, in conscfjuencc of severe injuries re(»eive<l in a street brawl ;
but his <leath did not occur until four or five months at\er the receipt
of the injuries.
In ad<lition to this fracture of the right scapula, five of his ribs were
broken, and both legs, all of which, exc*ept the scapula, had united
completely by intermediate and ensheathing callus.
* DcB FiHct. Ificom|>lut. ct d«M FU*ure8, p*r J. A. J. Cani|migDac, 1829, p. IH).
FISSURES. 87
The scapula was broken nearly transversely, the fracture commencing
opon the posterior margin at a point about three-quarters of an inch
below the spine, and extending across the body of the bone one inch
and three-quarters, in a direction inclining a little upwards, being
insularly denticulate and without comminution. The fragments were
in exact apposition, and, throughout most of their extent, in immediate
contact. They were, however, not consolidated at any point, but upon
either side of the fissure there was a ridge of ensheathing calhis, of from
one to three or four lines in breadth, and of half a line or less in thick-
ness along the broken margin, from which point it subsided gradually
to the level of the sound bone. The same was observed uj)on the inner
as well as upon the outer surface of the scapula. This callus had as-
sumed the character of complete bone, but it was more light and spongy
than the natural tissue, and the outer surface had not yet become
lamellated. Its blood-canals and bone-cells opened everywhere upon
the surface.
Directly over the fracture, and between its opposing edges, no callus
existed, but as the bone had lain some time in the earth before it was
exhumed, it is probable that a less completely organized intermediate
callus had occupied this space, and that, owing to the less proportion
of earthy matter which it contained, it had become decomposed and
had been removed.
M. Voillemier found the head of the humerus penetrated by two or
three fissures;* and M. Campaignac has reported the case of a lad ten
or twelve years old, who was compelled to submit to amputation of his
arm at the shoulder-joint, in consequence of a severe injury, in which
the humerus was found fissured from the insertion of the deltoid to near
the condyles, extending through the entire thickness of the bone, and
the edges of the fissure so much separated toward its lower extremity as
to admit the blade of a knife.^ Chaussier has related a case in which
a criminal, who died soon after having submitted to the torture, was
fonnd to have a nearly longitudinal fissure of the radius in its upper
fourth, and which penetrated half-way through the thickness of the
bone.^ Gulliver saw a fissure in the pelvis of an infant.* Malgaigne
has seen two specimens of this fracture in the iliac bones, both of which
belonged, as he thinks, to adults ; in one, the fissure was limited to the
internal table ;* and in the case of the lad reported by Gariel, as having
a fissure of the inferior maxilla, there wtis also found a fissure of the
left ilium, but which was limited to the outer table.*
M. J. Cloquet has mentioned a case of fissure of the shaft of the
femur passing through the condyles and extending upwards to near the
middle of the bone. The fissure was produced by a bullet, which had
completely traversed the bone from behind forwards, a little above the
conayles.^ M. Malgaigne has also represented, in one of his plates, a
* Malgmigne, op. cit., p. 85
p 24
Des Frac,
He., ptr Cain|Miign«c, 1829, p. 19.
88 BENDING, PARTIAL FRACTURES, AND FISSURES.
fi&sure of the femur extending along the front of the bone, somewhat
irregularly, from a i)oint a little below the trochanter minor to near
the condyles.* The bone was presented to the Museum of Val-de-
Gr^ce, by M. Fleury ; but it is to be regretted that we have no farther
account of this remarkable specimen. Certainly, in the complete
absence of any farther history of the case, one might be justified in
expressing a doubt whether it was not a fissure occasioned by the con-
traction consequent upon exposure and drying after death.
The following account of a fissure of the neck of the femur, of the
same character with those which now occupy our attention, is copied
from the proceedings of the " Boston Society for Medical Improve-
ment," at its regular meeting in September, 1856 :
" Partial Fracture of the Neck of the Femur in a man cet. 44 years.
Specimen shown by Dr. Jackson. The fracture, which appears as a
mere crack in the bone, commences anteriorly just above, but very
near to, the insertion of the capsular ligament, runs along this insertion
for about an inch, and then extends directly upward to the margin of
the head of the bone. From this last point it crosses the up|>er surface
of the neck almost in a straight line, and at a little distance from the
margin of the head, but afterward approaches very closely to this
margin posteriorly; it then turns downward and obliquely forward,
and stops at a jwint about half way l)etwecn the small trochanter and
the head of the femur, and two-thirds of an inch or more anteriorly to
the line of this trochanter. The fracture then involves about three-
fourths of the neck of the bone ; the inner-anterior portion only being
spared. There is considerable motion between the neck and the shaft,
and the fracture could undoubtedly be completed without the appli-
cation of any extraordinary force. Dr. J. referred to other cases of
partial fracture ; but a fracture of this sort, as occurring in this situa-
tion, and in a fully adult subject, he l)elieved had never before l)een
descril)ed. There was, also, in this case, a transverse fracture of the
same fcnuir midway, with a split extending upward nearly to the neck
of the bone; and still further, a fracture of the spine. The jmtient, a
laboring man, fell through two stories of a building and down upon a
hard floor. On the same day he entered the Massachusetts General
Hospital, and on the eighteenth day from the time of the accident he
died. The femur is perfwtly healthy in structure, and no changes are
observable in the bone about the fmcture."'
Whatever doubts may have l)een thrown upon the possibility of this
accident, as applied to the ne(?k of the fenuir, by the ingenious argu-
ments of RolKTt Smith, of Dublin,' the nu(»stion is now at lea*<t deter-
niine<l by an incontestable fact. Dr. Smith had rendereil it quite prob-
able that lK)th Colics and Adams were mistaken, and that the cases
<k»scribed by them were exani|)les of im|)acteil fracture, and not of
partial fracture; but, in arguing the improbability of its occurrence,
' Op. cil.,p. 37, pi. 1, flg 1.
' B«»*t. M«'d. MM(1 Siiru. .Journ., vol. Iv, p X')!. 8iH>, ml»o, Amcr. Journ. Mod.
Soi. for 1S57, p. aiKi, wiili cnj^rnvinij; mihI Hiirflow on Hip Joint, p 187.
• TrPMli»«» (»n Krnctiin'M in the Vicinity of Joints, etc., by Robert Wm. Smith,
Dublin, 1864, p. 44 et f^eq.
FISSURES.
89
from the infrequency of fractures of the neck of the femur in early
life, he overlooked the fact that there were two forms of incomplete
fractures, and that it was only the "green stick" fracture which be-
longed mostly to childhood, " fissures being found most oflen in the
bones of adults. Indeeil, I think the example recorded by Tournel in
the Archives de Midecine had already, so early as the year 1837, estab-
lished the possibility of a " fissure " in the neck of the femur ; although
bv Malgaigne this case has been mentioned as an example of that other
variety of partial fractures which is almost peculiar to childhood, and
in which the bones yield quite as much by bending as by breaking.
But the man was eighty -five years old, and, having died three months
and a half after the accident, a long crevice was found, extending
Dearly through the neck of the femur, partly within and partly without
the capsule.
I have seen, in Dr. Mutter's valuable collection of bones at Phila-
delphia, a specimen of fissure of the trochanter major, tvhich, it is be-
lieved, occasioned the death of the patient by haemorrhage.
Gulliver says there is an example of a fissure in a patella belonging
to the museum of the Edinburgh College of Surgeons, the fissure
traversing its articular face only.*
The first example of a fissure of the tibia is recorded by Corn. Stal-
part Vander-Wiel, in 1687 ; and indeed this is, according to Camimi-
gnac, the first exact observation of this species of fracture which our
jscience possesses, although its existence had been recognized by the
most ancient authors. A servant had been kicked by a horse, and
after a time, pain continuing in the limb, his surgeon, Dufoix, suspected
a fissure of the tibia, and having cut down to the bone, a cure was soon
effected.*
In the Dupuytren Museum, at Paris, there are two tibiae with linear
fractures, one without history, and the other presented by MM. Mar-
jolin and RuUier, "and which had been broken by a ball."' In the
example related by Campaignac, a woman, having leaped from a
second-story window, died immediately, and upon examination she was
found to have three fissures in the upper portion of the left tibia, one
only of which entered the articulation.^
Many examples of fissure from " perforating " gunshot wounds of
the bone have been observed during the late war in this country ; but
as these examples belong peculiarly to military surgery, they will be
discussed more at length in the chapter on gunshot fractures.
Duvemey saw a priest who had fallen and bruised the mKiclle ot nis
lefl leg, the swelling and pain consequent upon which were subdued
after a few days. The patient believed himself cured, and acted ac-
cordingly. Suddenly, in the night, he was seized with an acute pain
in the limb ; and on cutting down to the bone, a bloody serum ^^^^P^
from between it and the periosteum, and the bone was discovered to be
figured longitudinally. Subsequently the tibia was trephined, but the
* Malgaigne, op. cit., p. 85.
* Malgaigne, op. cit., p. 86.
2 CampHiirniic, op. cit., p. 17.
« Cnnipaignac. op. cit., p. -I.
90 BENDING, PARTIAL FRACTURES, AND FISSURES.
fissure (lid not reach the marrow. He recovered completely in less
than two months.
The same writer mentions another case, in* which a soldier received
the kick of a horse in the middle of his left leg, which w^as followed
immediately by great pain, and subsequently by much inflammation^
and even gangrene of the skin. The wound, however, cicatrized
kindly, but after three months he was seized suddenly with a severe
pain in the limb, and, after the trial of many remedies, resort was
finally had to the knife, when the tibia was seen to be discolored and
cracked longitudinally. On the following day the l)one was o|)eneti
over the course of the fissure with a chisel and mallet, and the ]>atieut
was at once relieved by the escajKJ of a yellowish and very offensive
matter. At the next dressing the bone was opened more frtH.»ly by
sevenil appliciitions of the trephine, and an abscess was exposi^d in
the centre of the bone. The patient finally recovered after alxiut four
months.* M. Oampaignac saw, also, at tlie hospital La Charito, the
tibia of a woman, tet. 38 years, upon which were found four fis<urcs,
the report of which case is accompanied with a woodcut illustration.-
Fissures may occur probably at all periods of life, but they arc* more
frequently found in the bones of adults. Campaignac, however, men-
tions a fissure of the humerus in a child ten or twelve years old, and
Gulliver has s<*en a fissure in the pelvis of an infant.
Efioloijif, — They may l)e occasioned by most of those causes which
produce fractures in general, such as direct or indirect sluwks; but
thev are occiu^ionetl much more often by direct blows, esiKrially when
inflicted ujhju bones imperfectly covered by soft parts, such as the tibia.
Bullets, having violently struck or peneti*at(jd the bone, have frinjuently
occitsionctl fissures.
Their course may be parallel with the axis of the bone, oblicjue, or
transverse; they arc often multiple; some merely enter the outer 1am-
inir, others ojkju into the cellular tissue, and others still divide lM>th
surfaces of the bone through and through ; and, according as they |>ene-
trate more or less deeply the bone, their lips will l>e found to Ik* nu^re
or less separated. Tluy frequently extend into the joint surfaces.
DldfjnoHis, — The signs which indicate the existence of a fi^^sure mu>t,
in a large majority of <*ases, l)e insufticient to determine fully the diag-
nosis during the life of the patient. It is not pr<»bable that sueh fissures
<*()uld ever be rlearlv made out bv the touch alone, where the skin is
not broken, since the pain, swelling, sup|)uration, etc., an.' only I'hanic-
teristi<r of inflammation of the bone or of its coverings, and might be
e<iually present whether a fracture existed or not. In tlio>c' ran* iiuh^s
only in which the flesh is torn ofl*, and the surface of the b(»m* is bnuigiit
diret'tlv umler the observation of the eve, will the dia;;nosis InHNune
certain.
Treatment. — Fortunately, an error in ju<lgment in this matter will
not materially, if at all, pn;judic<.» the interi'>ts of the patient ; sincv,
whatever may Ih» the fact in other resjR'cts, if the Ikuic, or its jHTios-
tcum, or its medullary tissue, is inflamed, and n-st, with antiplilogis-
' Mnlgiiignc, up. cit., ]». 30 et Wi\. ' Cttinimignac, op. oit., \*\*, *Jl-22.
OSSA NASI. 91
tics, does not accomplish its speedy resolution, incisions and perfora-
tions become inevitable, if we would give either safety or relief to the
saflPerer. Accordingly, in the inflammation and suppuration consequent
upon these fractures, we have seen that it has been occasionally found
Decenary to lay open the soft tissues freely, and even to trephine the
bone at one or more points.
Fissures in Cartilage, — I have once met with a fissure in the thyroid
cartilage, which constitutes, so far as I know, the only example upon
record of a fissure in cartilage.*
CHAPTEK VIIL
FRACTURES OF THE NOSE.
i L Ossa Nasi.
Of twenty-five cases of fracture of the ossa nasi recorded by me,
only fourteen were seen by a surgeon in time to afford relief. It
seerac<l to me necessarj'^, therefore, that the student should be instructed
how frequently the nature of this accident is overlooked by the friends,
ami even by the surgeon himself, to the end that he might be thus
admonished of the necessity of always instituting, in such cases, careful
and thorough examinations. In some of the cases recorded in my notes,,
where surgeons were called in time, and a deformity remains, it is not
improbable that the accident was not recognized. The rapidity with
which swelling ensues after severe blows upon the nose, concealing at
once the bones, and lifting the skin even above its natural level, ex-
plains these mistakes. The nose, also, is remarkably sensitive, and
the patient is often exceedingly reluctant to submit to a thorough cx-
aminatiou. It ought, however, not to be forgotten that the omission
on the part of the surgeon to do his duty will not always be excused,
€\eD though the patient himself has protested against his interference,
especially where an organ so prominent, and so important to the har-
mony of the face, is the subject of his neglect or mal-adjustment; since
the most trivial deviation from its original form or position, even to
the extent of one or two lines, becomes a serious deformity.
When the ossa njisi are struck with considerable force, from l>efore
ami from above, a transverse fracture occurs usually within from three
to six lines of their lower and free margins, and the fragments are sim-
ply displaced backwards; or if the blow is received partially upon one
bide, they are displaced more or less laterally. This is what will hap-
pen in a great majority of cases, as I have proven by examinations of
the no;«es of those i)ersons who have been the subjects of this accident,
ajid by repeated experiments' ujK)n the recent subject.
^ Buffmlo Med. Journ., vol. xiii, article entitled Fracture of the Thyroid Carli-
sle.
92 FRACTURES OF THE NOSE.
These fragments are generally loose, and easily pressed back into
place by the use of a projwr instrument. A silver female catheter,
which we have seen recommended by surgeons, may answer well enough
in a few instances, but it will more often fail. The diameter of the
meatus at the point where the instrument must touch in order to make
effective pressure upon the ossa nasi, is on the average not more than
two lines; and when the membrane which lines it is injured, it l)ecomc8
quickly swollen, and reduces the breadth of the channel to a line or
less. Under these circumstances, any instrument of the size of a female
cathetercouldonly l>e made to reach and press against the nasal process
of the su|)crior maxilla, which is too firm and unyielding to allow it to
1>as8 without the employment of unwarrantable force. In this way it
iap|)ens that the operator is occasionally surprised to find how much
resistance is op|)os(Hl to his efforts to lift the lx)nes, and, after reix^ated
unsuc«»ssful attempts, the case is not unfre<iuently given over. If,
however, he had used a smaller instrument, he would have found almost
no resistance whatever. A straight steel director, or sound, or some-
tim(»s even a much smaller instrument, if |>ossessing sufllicient firmness,
is more suitable than the catheter. For the same reason, also, one ought
never to wrap the end of the instrument with a piece of cotton doth,
as some have, I suspe<*t, without much consideraticm, recommended.
What I have said of the facility with which these bones may be re-
placed, when a projHjr instrument is employeil, is true only when the
treatment is adopted immediately, or at most within a few days aflcr
the accident.
Boycr, Malgaigne, and others have notic*ed the fact that these frac-
tures are repaire<l with great rapidity. Hip[K)cnitt*8 thought fhe union
was genenilly complete in six days; and in a case which hjis come
under my own observation, the fragments were quite firmly united on
the seventh day.
Xor has Malgaigne, whose observations are always verj* awMinitc,
overliM»ked the fact, also, that their repair is etrcctecl without the inter-
S>sition of |)rovisional callus, but, as it were, " par premiere intrnthnJ**
_ Jy <»wn ol)servati«)n (*onfirms this statement. Among all the siKMMtnens
which I have seen in the various college and private collwtions illus-
trating fractures of the ossa luu^i, and amounting in all to over forty,
in no instance luis there Ik^cu dct<H'te<l, after a careful examination, the
slightest tnice of provisional callus.
I am not ci»rtain that it will always be found so easy to retain thi*?;©
loose fragments in plact*, as it is to n»place them. The very swelling
which takes plaix? so promptly under the skin tends to depn^s the fnig-
ments, unsup|N>rteil i\s the\ arc by any counter-fonr ; a tend<'ncy which,
po>sibly, is in some instances incrcasiHl by attempts on the part of the
patient to clear his nostrils by snulling and hawking. 1 have, in one
instan<v, notieiMl very plainly a motion in the fragments when such
efforts were made. I low we are to renuHly this, I am not pn»panMl to
say. X<me of the plans which I have se<»n sugg(»>tiil |m>ss<»ss, in my
estimation, ver^- mueh praetical value. Few patients will c«»nsi»nt to
the intnxluction of pliMljrots of lint, or of stuffeil bags, or, iiuUihI, of
any tiling else*, HuHiciently far uj) into the nctstrils to answer any useful
E
08SA NASI. 93
purpose. The membrane is too sensitive and too intolerant of irritants
to enable us to have recourse generally to such methods. Then, too, it
would require, on the part of the surgeon, more than ordinary tact to
accomplisli so nice and delicate an adjustment of the supports from
below as these cases demand, where the slightest excess of pressure, or
the least fault in the position of the compress, must defeat the purpose
of the operator.
Yet, if one were disposed to make the attempt in certain cases where
the comminution was very great, or where, for any other reason, the
fragments would not remain in place, I think there could be no better
Ian than to push up in succession a number of small pledgets of patent
Int, smeared with simple cerate, to each one of which there has been
attached a separate string, so arranged as that their relative position
may be recognized, and that they may at a suitable time be removed in
the order of their introduction.
The employment of canulas, as recommended by Boyer, B. Bell, and
others, allows of the nostrils being stuffed without interfering materi-
ally with the breathing; a provision, however, which is quite unneces-
ary with a majority of persons, so long as there exists no impediment
to the free admission of air through the fauces.
With nicely adjusted compresses made of soft cotton or lint, and
seeure<l upon the outside of the nose with delicate strips of adhesive
plaster or rollers, we shall be better able to prevent the fragments from
beoomiog displaced outwards than by moulds of wax, of lead, or of
gutta percha, under which it is impossible to ^see from hour to hour
what is transpiring.
The complicatea apparatus devised by Dubois and recommended by
Malgaigne, to lift the bones and retain them in place, seems to me inde«J
very ingenious, but destitute of a single practical advantage.
A more considerable force than that which I have first supposed will
break, generally, the ossa nasi transversely and a little above their mid-
dle, while, at the same time, the nasal processes of the superior maxil-
lary bones may suffer slightly.
With neither of these accidents is the cribriform plate of the ethmoid
likely to be broken or disturbed. Indeed, in numerous experiments
made upon the recent subject, and in which the force of the blow was
directed backwards and upwards, breaking and comminuting the nasal
bones above and below their middle, with also the nasal processes of
the superior maxillary bones, and the septum nasi, the cribriform plate
of the ethmoid was, without an exception, uninjured. The exceeding
tenuity and flexibility of the septum nasi at certain points prevents
cfiectually the concussion from being communicated through it to the
base of the brain. If, therefore, after thase accidents, cerebral symp-
toms are occasionally present, as I have myself twice seen,^ they must
be due rather to the concussive effects of the blow upon the very sum-
mit of the nasal bones^ where they rest immediately upon the nasal
^ine of the os frontis, or to some direct impression upon the skull itself.
The amount of force requisite to break in the nasal bones, at their
> Beport on Deformities after Fractures, Cases 16 and 18.
94 FRACTURES OF THE NOSE.
upj)er third, is very great; no less, indeed, than is requisite to fracture
the OS frontis. If they do finally yield at this |)oint, then no doubt the
base of the skull must yield also. Nor do I think patients could often
be expected to recover from an accident so severe. To this class of frac-
tures belongs the specimen contained in my museum, in which not only
both of the nasal bones are sent in — the nasal spine being broken at its
base — but also the os frontis is depressed ; the nasal processes of the
upper maxillary bones are broken and greatly displaced, and the an-
terior half of the cribriform plate of the ethmoid is forced up into the
base of the brain. If it is meant that in Ovese cases the patient is in
danger from injury done to the base of the skull through the fracture
and depression of the ossa nasi, we can apprec^Jate the value of the
opinion; but we do not understand how this danger can exist when the
nasal spine of the os frontis is not broken, and the upjKjr ends of the
nasal bones are not displaced backwards. But, admitting that it were
possible in this way to force up the base of the skull, it does not seem
to me that we ought to attach any value to the advice occasionally
given, to attempt to restore the broken ethmoid by seizing u}x>n the
septum and pulling downwards. A force sufficient to break the base
of the skull never fails to comminute and detach almost completely the
septum nasi. We are to |)roceed in such a case as we would in a case
of broken skull. We must lay open the skin freely, and with appro-
priate instruments seek to elevate and remove, if necessary, the frag-
ments. Indeed, after such accidents, we shall generally see plainly
enough that death is inevitable, and that our services will be of no value.
Occasionally, I have observed, the bones are neither broken at their
lower ends nor through their central diameters, but only at their lateral,
6ernited,or imbricatwl margins. This is rather a displacement, or dis-
location, than a fracture. It is more likely to hap|)en, I think, in
childhood than in middle or old age, as in the following example:
Thomas Kelley,aged four years, was kicked by a horse. Two hours
afterwards, when he was first seen by a surgeon, the nose and face were
much swollen, and the fmeture was overlooked.
One year after the accMdent, I found both nasal bones depressed
through nearly their whole length, and especially in the lower halves.
The right na^l process was also much depresse<l, and the right nostril
obstructeil. The lachrymal canals upon this side were closed.
Sometimes the lower en<ls of the nasal bones are Ix'ut bai»kwards, or
laterally, constituting a partial fracture.
A lad, agcil ten years, was hit by one of his matins accidentally with
his elbow, up(m the left side of his nose. I was immediately calliHl,
and found the lower end of the let\ os nasi disphuxnl latenilly and
Imckwanis, so that it reste<l under the lower end of the right i>s nju*i.
Then* did not ap|)ejir to l>e any fracture bi^yond that which was in-
evitable by the niert* sepanition of its serratinl margins from the \xme
adjoining. The angle formed by the lione at the jK>int where the land-
ing had occurred was smooth and r(»undei],and not abrupt as in a com-
plete fractun».
With a steel instrument, introductnl into the left nostril, I attempted
to lift the bone to its place. The membrane was very sensitive, and
OSSA NASI. 95
the patient very restless under my repeated efforts. I pressed upwards
with considerable force, and succeeded at length in bringing the bone
nearly into position.
If there is more complete displacement, the upper ends are not
iKoally forced backwards, but rather a very little forwards, from their
articulations with the os frontis, and the bones then swing, as it were,
upoD the lower ends of the nasal spine, as upon a pivot. In this condi-
tion they are very firmly locked, and it requires considerable force,
applied under their lower extremities, to restore them to place.
Such seemed to be the position of the bones in the case of the lad
Kelley, already mentioned, and also in a German, whose nose was
flattened by a severe blow when he was eleven years old, whom I saw,
thirteen years after the accident, in the Buffalo Hospital. In this last
example the bones were very much displaced backwards.
In children, also, the nasal bones may be spread and flattened, the
lateral margins not being depressed or displaced, but only the mesial
line or arch forced back, so as to press aside the processes of the supe-
rior maxilla ; which deformity may become |>ormanent.
A block of wood fell upon a child three weeks old, as she was lying
in the cradle. The nature of the injury was not understood by the
parents, and no surgeon was called. The ossa nasi are now, twelve
years after the accident, much widel* than is natural, and depressed ;
the nasal processes of the superior maxilla appearing to have been
spread asunder.
Jacob Kibbs,a German, aged seven years, fell from a height of forty
feet, striking on his face. His parents did not suspect the injury, and
no surgeon \va.s called. Twenty-four years after this, I found the nose
almost flat. The nasal bones appeared unusually wide, and were
sunken between the processes of the upi)er maxillary bones, which
latter might be recognized by two parallel ridges on each side, slightly
rising above the level of the ossa nasi.
Ik^njamin Bell and others have spoken of tedious ulcers, polypi,
necrosis, fistula lachrymalis, abscesses, impeded respiration, and impair-
ment of the sense of smell and of speech, as circumstances apt to result
from these injuries, and it is certain that such consequences have occa-
Honally followed ; but they must generally be regarded as accidents
due to the state of the general system, and as having no connection
with the fracture, except as this injury served to awaken certain vicious
tendencies.
A gentleman twenty-five years old was struck accidentally upon the
right side of his nose by a board, and the ossa nasi were displaced to
the left. A surgeon made an attempt to reduce them, but did not suc-
ceed, and they have remained displaced ever since. The nose for a
time was much swollen. A few months after the accident, a purulent
discharge commenced from the right nostril, and at length an alw^M^H
formed in the right cheek. Two years later, when he came firnt uwU'r
mv notice, the nose still continued to discharge pus, and (HriMiounWy
it bled freely. There was also a perforation of the septum, of thi; hi/a
of a three-cent piece, which had not ceased to enlarge.
No hereditary maladies exist in the family, except that, on Uin falUtr^
96 FRACTURES OF THE NOSE.
side, it has been generally observed that wounds do not heal kiudlv.
The same is the fact with him. When a child, he was also very sub-
ject to epistaxis; at sixteen, a pulmonary difficulty began, and he had
more or ]c«s cough, with haemoptysis, for two years. Since then his
health has been good. He is a lawyer by profession, but of late he
has lived in the country, upon a farm, and has accustomed himself to
much outdoor exercise.
As to the prognosis in these fractures, I can only say that either
owing to the ignorance and carelessness of the patients themselves, who
neglect to call a surgeon in time, or to the difficulty of diagnosis, or to
the grejiter difficulty in maintaining an adjustment of the fragments,
it has hitherto hapiKined that, after a fracture of the ossa nasi, more or
less deformity has usually remained. I have seen but few whicli
could be said to be perfectly restored.
2 2. Fractures and Displacements of the Septum Harinm.
Fractures or displacements of the septum narium must occur to some
extent in all fractures of the ossa nasi accompanied with dej>ression ;
but they are also 0(Xjasionally met with as the results of a blow ujxju
the nose which has been insufficient to break the bones, and in which
only the cartilaginous portion of the nose has been l>ent inwards upon
the septum.
Of these simple, uncomplicated accidents, I have seen eight; in
four of which no surgeim was employed, or surgical treatment of any
kind adopted, and it is quite probable tliat only in a small pn>portion
of all the cases was the nature of the accident recognized. Such, at
least, has been generally the statement of the i>atients tlicmselves.
The same causes will explain this which have lx»en invoked to explain
similar oversights in cases of broken ossa nasi. To which we may
add, as an additional reason why it may be overlooked, the fret]uency
of lateral distortions or deviations in the natural development of this
septum.
The airtilaginous portion of the septum is that which is most fre-
quently displace<l by violence, and tlien it is usually at the point of
its articulation with the l)ony septum. Next, in point of frequency,
the |KT|xindicular nasal plate is broken, and especially when* it ajn
proaehcs the vomer. We omit in this enumeration, of course, those
ca-i<»s where th(! nasal bones themselves are broken down, in most or
all of which, as we liave alrejidy said, the iKTj)endicular plate is more
or less fracturwl an<l displactnl. We cannot say how often the vomer
is broken, since it is iK'yond our observation, except in autopsies. It
is prolxible, however, that the force of the concussion rarely reaches it,
the cjirtilage or the jK?r|>eiidicular plate giving vay first and ejisily.
Where the deviation is (»nly lateral, the results an^ less serious, yet
sufliriently so, in a few instanws, to demand our attention. I^iteral
oblitiuity of the lower |>ortion of the nose follows generally, but not
uniformly, a lateral displa«*ement of the cartilage, and when it does
exist, it is not always proi^ortioned to the amount of disjdmremeut
existing in the septum, so that the septum is then mode to project
FRACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 97
obliquely across the nasal passage, causing often a serious obstruction
aod permanent inconvenience. In one instance, also, I have known it
to occasion a chronic catarrh.
A lad, set. 15, was struck violently on the nose, which became im-
mediately much swollen, but no surgeon was called. Eight years
after I found the septum displaced laterally, and to the left side, pro-
ducing also a slight lateral inclination of the end of the nose. He
was unable to breathe freely through the left nostril, and from the
same side a catarrhal discharge had continued from the time of the
accident.
The following example, in which the accident has been followed by
a morbid condition of the cutaneous glands, is of more difficult expla-
nation :
A young man, set. 23, called upon me, supposing that he had a
polypus nasi. I found that in consequence of a fall upon the ice, seven
years before, the septum narium had been displaced to the right so as
to almost completely close this nostril. In very cold weather, when
the vessels of the membrane are contracted, the passage is more free.
The left nostril is proportionably wide.
During the last four or five years, the right side of his face has been
subject to profuse perspiration. It is almost constant in summer, and
only occasional in winter. The line of division between the perspir-
ing and non-perspiring portions of the face passes perpendicularly from
the top of the centre of the forehead, along the ridge of the nose, and
down to the centre of the chin. The phenomenon is due, perhaps, to
an increased vascularity in the right side of the face ; possibly to some
peculiarity in the condition of the nervous trunks, occasioned by the
nasal obstruction.
A depression of the cartilage forming a portion of the ridge of the
nose is necessarily accompanied with a corresponding degree of lateral
displaoemeDt, with or without fracture, of its perpendicular portion,
and produces, therefore, not only great deformity, sometimes a complete
flattening of the end of the nose, but, also, in some instances, complete
obstruction of the nostrils.
We conclude, from all that we have seen, that fractures and dis-
placements of the septum narium are generally followed by permanent
deformity, and occasionally with still more serious results. We suggest,
therefore, a more careful examination in recent injuries, with a view to
the ascertainment of its lesions, and it would be well, certainly, if we
oould devise some reliable mode of treatment.
It is doubtful whether a partition so thin and unsupportc<l can ever
be well adjusted and supported by artificial means. We p<jssess, how-
ever, name advantages in the treatment of this accident which we do
not in the treatment of broken ossa nasi, viz., facility of observation
wd of approach, and if we can do little with plugs and supports in
the one case, we may po^ibly do more in the other. Nothing seenis
nwre rational, then, than to plug carefully and eoually each nostril
^th pledgets of lint, while we cover the outside of the nose completely
^th a m'celv moalded gotta-percha splint or case, which ought to be
»»ade to presB sooglj open the sides, and permitting these to remain
98 FRACTURES OF THE KOSE.
for several weeks, or until the cure is completed. The papier machi
of Dzondi, employed by him in cases of broken ossa nasi, would be
equally applicable here; but the gutta-percha, as being more plastic,
and hardening more quickly, ought to be preferred.
Attempts to remedy the deformities of the nose, at a later period,
belong to the department of anaplastic surgery, and the modes of pro-
cedure must be varied according to the circumstances of the case.
The following example will serve as an illustration of what may
sometimes be accomplished in these cases:
A young man fell from a two-story window, striking upon his face.
A surgeon was called, but he did not discover the nature of the injury
to the nose.
One year after the accident he called upon me for relief. The car-
tilaginous portion of the septum was broken just at the ends of the
nasal l)ones, and forced backwards al)out three lines, prtxlucing a strik-
ing depression at this point of the ridge of the nose, while at the same
time the end of the nose was thrown up. The deformity was very
unseemly, and annoying both to himself and to his friends, who at first
could scarcely recognize him.
I introduced a narrow, sharp-pointed bistoury through the skiu of
the nose on the right side, and resting its edge u[>on the ridge at the
junction of the cartilage with the ossa nasi, I cut the cartilaginous
septum directly backwards about three lines, and then making a
gradual curve with my knife, I cut downwards about eight lines to-
ward the end of the nose. The intercepted jwrtion of cartilage t*ould
now be easily lifted with a probe, and the line of the ridge of the nose
completely restored. It was at once apparent, also, that lifting the
cartilage would depress the tip of the nose and restore its symmetry.
To retain the cartilage in |)lace, I constructeil a gutta-jwrcha splint
of the length and sha|)e of the nose, but so forme<l along its middle as
that it would not press uj>on the cartilage which I had lifted, resting
well u|>on the ossa nasi, but not touching the ridge from the lower
ends of tluse bones to the tip of the nose, at which latter |K)int it agnin
rcHH'ived supiK)rt. I now passe<l a neiMlle, arnunl with a stout ligature,
through the up|)er end of the uplifted cartilage, transfixing, of course,
the skin on both side's of the nose, and this I tied firmly over the splint.
This accomplished the important object of pressing backwanls and
downwards the tip of the nose, and thus tilting up the upper iMirt of
the ridge and septum, and of more effectually si^niring the cartilage iu
|)la(*e by lifting it directly with the ligature. On the set»ond day the
igature was removcvl, but the splint was <»ontinue<l two weeks, during
most of which time a band was kept drawn across the lower end of the
splint, and tie<l iK'hind the neck.
To prevent the cartilage from falling Ixack when final cicatrization
cKMuirrtKl, I prt»ss<Hl the sidi*s of the splint firmly towanl each other,
just Ik'1«)w the incision, so as to fonn* lus much as |)ossible the walls of
the nares into tln» fissure of the septum, mad<» by lifting it up. The
result is a complete and j)erfect restoration of the nose to it^ original
form.
Dr. James Bolton, of Richmond, Va., has devised a very ingt>nioii8
FRACTURES OF THE MALAR BONE. 99
mode of rectifying an old displacement of the septum nasi. He makes
a stellate incision of the septum in such a manner as to form of it about
eight triangles with their apices converging to a common centre. He
then seizes each triangle separately with a pair of forceps, and breaks
it at its base without detaching it. Having thus comminuted the sep-
tum, he is able to restore it to position and retain it until consolidation
is effected.*
CHAPTEK IX,
FRACTURES OF THE MALAR BONE.
I HAVE been unable to find any records of a simple fracture of the
malar bone, that is to say, of a fracture unconnected with a fracture of
other bones of the face. It is probable, however, that it sometimes
occurs, but that, not being accompanied with much displacement, it is
overlooked. I have myself seen a fracture of the upper margin, or
of that portion which constitutes a part of the orbital border, in two
or three instances, while I was unable to detect any other fracture
among the bones of the face ; but it is by no means certain that other
fractures did not exist, perhaps in some of the bones which form the
socket, or in the superior maxilla, as mere fissures, or as fractures with
(mly slight displacement. The prominence of the malar bone, and
especially the sharpness of its orbital margin, would enable the surgeon
to detect easily the smallest displacement, or even a fissure, while a
much more extensive displacement elsewhere would escape detection.
The two upper maxillary bones form, as they are placed opposite
to each other, an irregular arch, one end of which rests upon its fellow,
at the intermaxillary suture, and the other end rests upon the nasal
and frontal bones ; while over the centre of the arch is situated the
malar bone. The force of a side blow upon the malar bone will ex-
pend itself, therefore, chiefly upon the base of the maxillary apophysis,
as being in the line of the direction of the force. The force continuing
to act, after the apophysis is broken, the portion of the superior max-
illa above the floor of the nares will fall inwards toward the septum,
while the portion below will tilt outward, and open the intermaxillary
sotore along the roof of the mouth. This suture will also open more
widely in front than behind, owing to the greater depth of the suture
in front.
These observations I have verified by several experiments made
with a hammer upon a clean skull.
One might suppose that it would be a very easy matter to restore
these bones to place upon the naked skull, after such an accident.
Certainly it would be very desirable to do so, were this accident to
occur to any patient^ since the malar bone is slightly depressed, the
' Bolton, Bicfamond Med. Journ., April, 1868, p. 241.
E
100 FRACTURES OF THE MALAR BONE.
nostril upon this side is nearly closed, and the line of the teeth is dis-
turbed, and it is possible also that an opening might be established
between the nose and mouth immediately back of the incisors. In
fact, however, I found the restoration impossible. It could not be ac-
complished by an instrument within the nose pressing outwards, nor
by pre-^sing inwards upon the teeth and alveoli ; not, certainly, without
very great and unwarrantiible force. The difficulty consisted simply
in the antagonism of the serrated margins of the intermaxillary suture,
which, projecting one or two lines on each side, could not be ma<le to
interlock again, but were firmly braced against each other.
I shall not find it necessary to report in detail the results of the cx-
>eriments, l)ut shall content myself with stating that by the second
low, in the last experiment, the skull was also found broken at its
base through the lesser wings of Ingrassias; the force of the blow
having been conveyed, apparently, along the orbital plate of the supe-
rior maxilla and os planum.
This is the only example from four experiments in which the frac-
ture extende<l through the dental arcade, and it was the result of the
first blow. The fracture of the base of the skull by the second blow
indicates the possibility of producing a fatal lesion of the brain or of
its blcKKl vessels by a blow upon the malar bone.
General Summari/, — A fracture of the superior maxilla has occurred
in every instance ; and twice when the malar bone was not bn)ken : in
each of the two last cases the antrum alone was broken, and the de-
))ression of the malar bone was scarcely noticeable. In the second of
these cases, the fracture extended also through the dental arcade.
In three rases the nasal aj>ophysis has broken near the base, and in
one case at two |>oints. One of the three fractures of the nasal apophy-
sis was accompanied with a diastasis of the superior maxilla througli its
intermaxillary suture.
The malar bone has been broken twice by the first blow, and always
when the blow has l>een repeated. The orbital margin and orbital
Elate have Ikm^u fissureil twic»e, the outer |)ortion of the orbital plate
L'ing pushed a little into the socket. Once this plate has been pushed
downwards.
The zygoma has bciMi broken three times, and always transversely,
a little Ix'vond its centre, or where the bone is the most slender and
most convex.
The ethmoid has l>een broken three times, and always longitudinally
through the orbital plate.
The sphenoid has l>een broken once, at the base of the skull.
In addition to tlu^se observations ujM)n the naked skull, I have seen
at least four examples, which illustrate the relative infrequency of frac-
tures of the malar bone, Jis (Compared with fractures of the superior
maxilla and of the other Ikmics of the face, even when the blow is re-
ceived directly uiM)n the malar bone.
Pat. Malonev, let. 55, fell about twenty fcH»t and struck uyHm his
face. Six weeks after the accident, while an inmate of the HufTalo
Hospital of the Sisters of Charity, I found the right malar bone de-
FRACTURES OP THE MALAR BONE. 101
pressed, but I could not trace any line of fracture in the malar bone.
I think the antrum of the superior maxilla was broken, and the malar
bone forced in upon it.
Thomas Crotty, let. 20, was struck with a hoop, August 15, 1855.
He was seen immediately by a surgeon in Canada, but the fracture
i»-a? not recognized. Five days after, he called at my office. I found
the outer portion of the right malar bone lifted slightly, and the lower
and anterior angle depressed about three lines, as if this portion had
been forced in upon the antrum.
The third case will be found reported under fractures of the su|>erior
maxilla, and the fourth has been brought under my notice in the prac-
tice of Dr. Wadsworth, of this city, the fracture having been occ4isioned
by collision with the head of another man.
Prognosis. — The malar bone may be depressed, as we have seen, to
the extent of two or three lines, without being broken. This accident
will be more properly considered under fractures of the upper maxilla.
A fracture of the malar bone implies, therefore, generally, that great
force has been applied, and that other fractures exist as complications.
This may not be true, however, when only the orbital margin of the
socket is broken. If the orbital plate is broken, and a jwrtion of it is
poshed into the socket, it may occasion a slight protrusion of the ball,
as in two eases related by Dr. Neill as fractures of the upper maxilla,
and as has been noticed in the experiments already referred to. This
protrusion of the eyeball will probably continue, in some degree, as
k>ng as the bones remain displaced. It is quite probable, however,
that in some cases, after severe injuries of the face, a moderate protru-
sion of the eyeball is due entirely to extravasation of blood in the
focfcet ; a circumstance which would be likely to follow a fracture of
the bones of the socket, and to increase temporarily the protrusion of
the eye.
If the body of the bone is broken entirely through, and coma super-
venes upon the accident, there is some reason to fear that the skull is
fracturwl at its base, and the prognosis ought to be grave.
Treatment. — If there is only a fissure of the orbital margin, it will
not require attention ; but if the fissure extends through the orbital
plate, and at the same time the anterior and inferior margin of the
bone is depresse<l, in consequence of w^hich the orbital plate is tilted
upwards and made to push forward the eyeball, the propriety of surgi-
cal interference may be considered. If this protrusion is considerable,
and evidently due to the displaced bone, an attempt should be made
to lift the body of the malar bone, and thus to restore to position its
orbital plate. The method of accomplishing this I shall describe par-
ticularly when speaking of fractures of the superior maxilla with de-
preseion of the malar bones.
102 FRACTURES OF THE UPPER MAXILLARY BONES.
CHAPTER X.
FRACTURES OF THE UPPER MAXILLARY BONES.
These fractures assume so great a variety in respect to form, situa-
tion, and complications, that it would be impossible to s{)eak of them
systematically, or to establish anything but very general rules as to
treatment and prognosis.
They may be broken, or loosentKl from each other or from the other
bones with which they are articulated, with or without any farther
fracture ; the nasal processes may be broken, and generally this accident
is acvompanied with a fracture of the nasal bones also ; the malar bones
may l>e forceil in, carrying with them a j>ortion of the outer wall of the
antrum ; the alveoli may be broken and more or less completely de-
tached ; and either of these several fractures may he complicated with
fractures of the other bones of the face, or of the base of the skull even.
Treatment, — When the harmonies of the upper maxillary bones are
only slightly disturbed, nothing but a retentive treatment is necessary,
A man wiis thrown backward from a loadal cart, one wheel of the
cart pas>ing over his face. He was taken up unconscious, but when
I saw him on the following morning, his consciousness had returned.
The right malar bone was broken, and forced down uj)on the antrum
about thr(v lines. Both suiK^rior maxillo) were looseneil from their
articulations, and could be moved laterally, the motion pro<lucing a
slight grating sound. The same motion and grating occurred when-
ever he attempted to swallow. No effort was made to elevate the
malar bones, nor did I find any means ncnrcssary to retain the maxil-
lary bones in |)lace, the amount of disphicement being very iuconsid-
erabh?, and never sufWcient to be observed by the eye. Cool lotiuus
were a|)plied constantly to the face, and the patient was sustained by a
li(juid diet. On the ninth day all motion of the fragments had ceased,
and on the twenty-seventh day the patient was completely recovered,
with only the depression of the malar bone remaining.
Sargent, of Boston, reports a similar citse, in which a slight scjuira-
tion of the maxillary bones unittnl promptly and without any retentive
aj>paratus.'
But in a ciu^c in which the superior maxillary lK)nes had been more
completely torn from their connections, complicjited with otiier wvere
injuries, I found it ne<*essary to sup|H)rt the fragments by closing the
lower jaw u|)on the upj)er, and by suitable bandages. The patient
die<l, however, on the twelt'th day."
(jracfe recommends, where the bon(s are thus extensively se|mrateil
and displaced, an apparatus made of stiH'l, and suitably covereil, wliich
> Boston M'mI. and Surij. .lourii.. v*!. lii, p. 378.
' Ro|M)rt «»n Dcfoniiiiii*:} after Frailiiru. Trail:*. Amer. Mi'd. Ashuc'intion, vol.
viii, p. 375, Cav.' IV.
FRACTURES OP THE UPPER MAXILLARY BONES. 103
is to be applied against the forehead and buckled under the occiput.
From the two sides descend a couple of steel plates, which, having ar-
rived at the free border of the upper lip, are reflected upon themselves,
and are made to support upon their extremities long silver gutters, in-
tended for the reception of not only the displaced teeth and alveoli, but
also those teeth which are firm.^ Vulcanized rubber might be substi-
tuted for the silver in this apparatus.
Wiseman having been summoned to a child with his whole upper
jaw forced in by the kick of a horse, " beating the ethraoides quite in
from the os cribriforme," and forcing the palate bone against the back
of the pharynx, found great difficulty in securing a permanent read-
justment. At first he attempted to introduce his finger back of the
bone, but failing in this, he bent an instrument into the form of a
hook, and passing it between the bone and the pharynx, he easily re-
placed the fragments. But, on removing the instrument, they were
again displaced. Immediately he had constructed an instrument by
which the bones could be not only easily reduced, but also retained iti
place, extension being made by the hands of the child, his mother, and
others, alternately. In this way the reunion was finally effected, and
" the face restored to a good shape, better than could have been hoped
for.'^
Harris, of New York, mentions a case in which a child, two years
old, having fallen from a height of fifly feet upon the pavement, was
#found to have a diastasis of both the superior maxillary and palate
bones; the separation being sufficient to admit the little finger, and
extending from between the alveoli which supported the central in-
cisors, to the soft palate. It is not said whether any efforts were made
to reduce the bones, but six weeks after the injury was received they
were still open, and it was proposed to close the space by a plastic
operation as soon as the condition of the patient would warrant such a
procedure.^
I suspect that in this example, as in my experiments referred to
under fracture of the malar bone, it was found impossible to adjust the
bones and close the intermaxillary suture, and for the same reasons.
If, in consequence of a blow received upon the ossa nasi, the nasal
processes of the superior maxillae are broken down, they may be lifted
and adjusted in the same manner as the ossa nasi.
I have seen several examples of this accident, and I have in my
cabinet a specimen, in which the nasal bones being driven in by the
tick of a horse, the nasal process upon the left side is broken off just
above the root of the cuspid tooth, and ita upper end inclined inwards
toward the nasal passage and backwards, until it is completely buried.
In this situation it has become firmly united to the bony and soft tissues
into which it was brought in contact.
The following example will illustrate some of the complications and
difficulties connected with a depression of the malar bone, and conse-
<iuent fracture of the antrum nuixillare.
' Trait^ des Frac. etc., par L F Malejaigno, p. 373. •
* Chirurgical Treatises, by Richard Wiseman, 1734, p. 443.
• New York Journ. Med., vol. xiii, 2d ser., p. 214.
104 FRACTURES OF THE UPPER MAXILLARY BONES.
^r. P., of Colc*svill(», ixrrQil about 34 years, was thrown from a height,
ptrikiiij; upon his face, forcing; the right malar hone down upon the
antrum of the superior maxilla. Dr. L. Potter, of Viiryssburg, and
myself were called.
The deformity produced by the sinking of the malar bone wa<» very
striking, and both the patient and myself were very anxious to have it
remedie<l, if |)ossible. We found some of the teeth upon the side of
the fracture loose, and we detcrmineil to extract them, and pres.< up
the bone with an instrument intnMluced through the empty sockets.
The lirst attemj>t to extract a molar tooth, however, brought down
si»veral teeth, and the whole floor of the antrum. The detachment of
this fragment was also now so complete that we believed it necessary
to remove it entirely, a labor which was accomplished with intinitc
difficulty, and with no little hazard to the patient, as disswtion had to
\)Q extendcil very far back into the throat, and in the end it was not
eifected without bringing out, attached to the fragment of maxillary
bone, a considerable |K)rtion of the pyramidal process of the os palati.
The time occupi(Ml in this operation wius at least (me hour, during
which we were every moment in the most painful apprehensions h»st
we .**hould reach and wound the internal carotid, whicli lay in such
close ju\ta|)osition to the knile that we could distinctly fivl its pulsa-
tion. Alter its removal, the luemorrhage was for an hour or ni«»ri»
quite profuse, and could only be restrained by spongt* compresses pn»MseJ
firmlv back into the mouth and antrum.
When the lucmorrhage was sutliciently controlle<l, we prcK'i»e<led to
examine the antrum, th(^ floor of which l)eing removed entire, |>or-
mitted the finder to enter freelv. The restoration of the nialar bone
was now accom[)lisheil without much ditticulty, and with only nunl-
erate force.
Two years after the accident the face presented, externally, no tnioos
of the original injury. The malar l>one seemc<l to Iw as prominent as
n|)on the opposite side, and there was no pcrcej)tible falling in wheri*
the teeth and alveoli were removed. During several months after the
removal of the bone, the antrum c(»ntinue<l to discharge pus, but at
lenj;lh a semi-«'artilay:innus structure c1os<k1 in the cavitv Ik'Iow, en-
tirelv re<'(in^iruetin<r its fl<M>r, and the discharj^e c<nised. Sino* tlien ho
has experienn'd no further inconvenien(*e.
I wi>h to prnpo-c two or three expedients for lifting the malar Ume
when it ha^ bt'cn thru^^t down, whicli mav in c<'rtain (-asts Ik' substi-
tutcil f«»r the nuMle whieh has been heret<»fore generally adopttnl.
In manv in>tan<-e> no dillienltv will be experienceil in n'sortinir to
the usual method. The recent Ios> of t»ne or more tei'th opjMKiie iho
floor of the broken antrum, or the complete; disphuvment of a toinh
by th<* a<*«Mdent it.-elf, will give an opportunity tor the |MTforaiitm of
the antrum through the open HH'ket, and tor the intnNJuetinn i»f a
>uitabK' in-trument inv lifring the depresst»<l Imhic. Unless, however,
the opening i^ tpiite large, the instrument em|>loyiil must l)e sti small,
sn<*h as a straight >teel sound or a female catheter, sis to ex|>os<» t\w
part-^ ag:iin«»l whi»'h its vnd is ma<le to press, to simie risk «)f iK'injj
brokiMi and |K'neti*ati*d. It is even p(»ssible in this way tu {lenetrate
FRACTURES OP THE UPPER MAXILLARY BONES. 105
the socket of the eye, and thus inflict serious injury upon the eye itself.
Yet^ with some care, such accidents may be avoided, and it is probable
that in the cases supposed, where the sockets of the teeth opposite the
base of the antrum are open, this method will continue to have the
preference.
Bat if the teeth remain firm in their places, or if they have been
some time removed, and the sockets are filled up, and we wish to enter
the antrum at its base, we must either drill through its anterior wall
above the roots of the teeth, or we must proceed to extract a tooth.
The first method gives an inconvenient opening, and one through
which it will be necessary to use a curved instrument ; but yet it is a
method far less objectionable than the extraction of a tooth which is
firm, or which is even tolerably firm, in its socket, and which may
require the forceps for its removal. The objections to this latter pro-
cedure were suggested by the tedious and painful operation already
detailed. The first attempt to extract a tooth brought down the whole
floor of the antrum, with all its corresponding teeth, and the pyramidal
process of the palate bone. The tooth was already loose, and we
thought it might easily be taken out, but it had not occurred to us
that it was loosened by the comminuted condition of the walls of the
ftDtnim, and of the dental arcade. The experiments made upon the
dead subject would seem to show that this fracture and comminution
of the alveoli is not a very frequent result of a fracture of the antrum
produced by a blow upon the malar bone; yet it may happen, and
whenever it does, the attempt to extract a tooth must always expose
the patient to the same hazards. Certainly it is no trifling matter to
pall away all of a man's upper teeth upon one side, and to open freely
into a broad cavity which might never close again, and which, in this
event, must always serve as a place of lodgment for particles of food,
and for foul secretions, to say nothing of the external deformity which
it is likely to produce, and of the severity and even danger of the
operation.
I wish, then, to suggest certain procedures, the value of which I have
been able to determine by experiment upon the living subject in two
or three cases, and which I have carefully and frequently tested upon
the cadaver.
Fin«t, we ought to attempt to lift the bone by putting the thumb
under its zygomatic process and body within the mouth. If the bone
is thrown directly downwards, or downwards and backwards, this
method can scarcely fail ; and even when it is thrown downwards and
forwards, so as to press into the antrum, it is likely to succeed. If,
however, for any reason, the thumb cannot be brought to bear upon
its under surface, we may make a small incision upon the cheek over
the anterior mai^n of the masseter muscle, where its insertion into the
loalar bone terminates, and pushing a strong blunt hook under the
bone, we may lift it with ease.
Where the depression of the malar bone is in the direction of the
toterior and superior angle, these means may not be found available,
and we may then employ a screw elevator, an instrument which I find
already constructed in a case of trephining instruments made for me
8
106 FRACTURES OF THE UPPER MAXILLARY BONE&
by Mr. Luer, of Paris, and which I have often used, and constantly
recommended to my pupils, in certain cases of fractures of the skull.
The instrument ought to be made of the best steel, and with a broad,
sharp-cutting thread. A slight incision being made through the skin,
and down to the centre of the malar bone, the elevator is then screwed
firmly into its structure, and now its elevation and adjustment may be
accomplished with the greatest ease.
Malgaigne remarks: **In all complicated fractures of the upper jaw,
there is one principle which surgeons cannot too much study, namely,
that all fragments, however slightly adherent they may be, ought to be
most carefully preserved, and they will be found to unite with wonder-
ful ease. This remark had already been made by Saviard, Larrey
insists strongly upon it, and we have seen that M. Baudens, so great
an advocate for the removal of loose fragments, has declared for these
fragments a special exemption."^
Malgaigne has here es|>ecial reference to fractures of the dental
arcade, and to fractures implicating the alveoli, and extending more or
less into the body of the bone.
It would be an error, however, to suppose that a reunion will in
these casi»s uniformly take place. Exceptions have (X*curred in my
own practice, the fragments l)ecoming loosened and completely detached
after the lapse of several weeks. In the case related by Miller, the
whole floor of the antrum having been broken off, in an unskilful
attempt to extract the second right upper molar, it was found impoe-
sible to make it unite, and it was subsequently removed.' Such un-
fortunate results wrtainly may sometimes be reasonably anticipated.
Yet they occur so seldom as to justify the opinions and practice advo-
cateil by Malgaigne.
In some instaiu^es, where fragments are displaced, carrying with
them seveml teeth, while others in the same row remain firm, it will
be sufficient to close the mouth and apply a bandage as for fracture of
the inferior maxilla; in others, the teeth and their alveoli ought to be
fastened with silk, or gold or silver thread ; gold, silver, gutta-|)erchay
or vulcanite clasps may Ix* applied to the teeth and jaw.
In a (iise of fracture of the right superior maxilla, rcjiorted by Baker,
of Norwich, N. Y., (»omplicat(»<l with a fracture of the inferior maxilla,
the alveoli were rotain(Hl in plac*e very perfectly by a mould of gutta-
percha.* Ncill, of Philadelphia, has also reported three cases of frac-
ture of the Iwnes of the face, involving the superior maxilla, in two of
which the eyes were made to pn>trude more or less from their sockets.^
The l(>os«Mied alveoli were made fast by wire. The subsequent dc-
formitv was incimsiderable, vet in no instance was the restoration com-
plete.* The saine mctluxl was adopted successfully by a surgeon in
Virginia, in the case of a negro fifty years old, where most of the teeth
* Dp oit » vol. i, p 876 Pnrii* ed.
' Nf^w* L«»tti'r, April, 1854. Al«w», Bout. Mod. and Surg. Journ , vol. II, p 264.
• N«'W York Journ. of M»^i.» vt>l. i. li^\ *or.» p. S«2.
♦ S»N» •» Ol>!»«»rvrtii.»n*,*' und^r FrMottiriv* of tlu» Malar Bone; in which the orbital
pluli* of th»» ninUr In^no wa« pu^^hed int»» the juvkols.
* l*Uil MihI. Emm., V(»l. i, new »er., pp. 466-8.
PRACTUBE8 OF THE ZYGOMATIC ARCH. 107
of the left upper jaw were forced into the mouth, carrying with them
their corresponding alveolar processes. The teeth remained firm in
their sockets, but the separation of the bone was complete, the fragment
being held in place only by the mucous membrane of the mouth. On
the eighth day the surgeon found that the negro had removed the wire,
and also the cork from between his teeth, and the maxillary bandage;
but the soft parts had already united, and the bones showed no ten-
dency to displacement. His recovery was speedy, and it was accom-
plished without any farther treatment.^
Our experience during the war of the rebellion in this country con-
firms most of the observations heretofore made in relation to these
fractures. Owing to the extreme vascularity of bones composing the
upper jaw, the fragments have been found to unite, after the most
severe gunshot injuries, with surprising rapidity ; the amount of necrosis
and caries being usually inconsiderable, compared with the amount of
comminution. The same anatomical circumstance, nanvely, the vas-
cularity, has rendered these accidents peculiarly liable to troublesome
hferoorrhages, both primary and secondary.
The Surgeon-General reports that of 4167 wounds of the face, tran-
scribed from the reports from the beginning of the war to October,
1864, there were 1579 fractures of the facial bones, and of these 891
recovered, 107 died — the terminations are still to be ascertained in 581
cases. He farther remarks that secondary hemorrhage has been the
trincipal source of fatality in these cases, and that frequent recourse
as been had to ligation of the carotid^ with the result of postponing
for a time the fatal event.'
CHAPTER XL
FRACTURES OF THE ZYGOMATIC ARCH.
The zygoma, strictly speaking, is formed in a great measure by the
body of the malar bone, and it is broken whenever the malar bone is
completely separated through any portion of its body ; but I propose to
confine my remarks to that portion only which is composed of the
two processes, called respectively the zygomatic processes of the malar
and temporal bone.
Duvemey relates a case in which a young -child, having .in his mouth
the end of a lace-spindle, fell forwards and thrust the spindle through
the mouth from within outwards, breaking the zygoma in the same
direction, and leaving the fragments salient outwards.' To which case
of outward displacement Packard, in a note to Malgaigne's work on
fractures, etc., has added a second.*
* Amor. Med. Oa^otte, vol. viii. new eer., p. 106.
» Circular No. 6. Washington, Nov. 1, 1865, p 20.
* Bulletin de la SociSU Anutomiquo, p. 138, 1810.
* Op. cit., p. 289, vol. 1.
108 FRACTURES OF THE ZYGOMATIC ARCH.
I know of no other examples in which the fragments have been
thrust outwards. A reference to my experiments upon the naked skull
will, however, show that the zygoma may be broken and displaced in
the same direction, by any force which shall fracture the superior
maxilla, and depress the anterior margin of the malar bone. In my
experiments this lias happened three times, and always at the same
point, viz., a little beyond the middle of the zygoma, near where the
suture which joins the two processes terminates below. The fractures
were always transverse, and not in the line of the suture. They were
therefore fractures of that portion of the zygoma which belongs to the
tem[X)ral bone.
I suspect, also, that to this class of cases belongs the example re-
lated by Dupuytren, in which the patient having died on the fifth day,
from the effects of the cerebral concussion, the autopsy disclosed "a
fracture through the zygomatic arch ; and that part of the superior
maxillary bone which c»onstitutes the antrum was driven in."*
In another case mentioned by Dupuytren, pnxluced by a direct blow,
the fracture was compound and comminuted, and although the frag-
ments were raised easily by an elevator, suppuration ensued beneath,
and the matter was discharged within the mouth.*
Tavignot reports a case of fracture of this arch which was not dis-
covered until after death, the fragments not being at all displaoe<l.'
Dr. John lioardman, one of the surgeons to the Buffalo Hoo^pital of
the Sisters of Charity, informs me that he has met with a fracture of
the zygoma in a man about thirty years of age, occasioned by a blow
from a cricket-ball. Dr. Boardman saw him on the fourth day, and
ascertiiineil that immediately on the receipt of the injury he felt slightly
stunncnl, and that he soon recovenxl from this, but was unable to o|k?u
his mouth except by pulling it o[)en with his hand; neither could he
close it except in the same manner. This immobility of the jaw «)u-
tinucil several days with only very slight improvement; at the end of
five weeks, however, when hist seen, the mobility was nearly, but not
quite, restored. The depression, a little in front of the centre of the
zygoma, was discx>vere(.l by the jxitient himself imme<liately after the
n-ceipt of the injury, and he says he triwl jit once to tiscertain whether
he could not push the fragments Imck by moving the jaw. He was
unable to make any impression ujMm them by this manoeuvre. Tlie de-
pression still remains, but it is not so distinct as it was when first swn,
Barney Quinn, presente<l himself at the IWIevue Disiiensary, April
17, 1871, stating that he had been hit by a stone, in blasting, three
weeks l)efore. There was a fracture, with depression, at or ne:ir the
junction of the malar and temporal pr(XM?sses. The malar bone H'as
elevateil a little. From the time of the accident he had Ikh-mi unable to
0|)en his mouth more than half an inch.
January 2, 1874, Anna McQuirk fell u|>on the side of her face.
St»vcn days after the accident she consulteil me. There was a fracture
* Injuries and Discuses of Bonei*, bv lUroii Dupuvtn'n. Svd. ed., L<>tidoii, 1S47,
p. Z'M\.
' Op. cit., p. 8.15.
* Bulletin du la S<»c. Atmt., 1810, p. 18S.
FRACTURES OF THE ZYGOMATIC ARCH. 109
with depression at the junction of the malar bone with the zygoma.
At first, and for a day or two, she could open and close her mouth
easily, but when I saw her, the act of opening the mouth was painful
and difficult. Having introduced my fingers into the mouth, I at-
tempted to press the fragment out, but was unable to make any impres-
sion upon it.
It is plain that in this latter case, the inability to open the mouth
was due to the inflammation resulting from the injury and not to the
displacement of the bone, and that as the inflammation subsided the
disability would disappear.
Symptoms. — An irregular projection or depreasion of the fragments
is the only sign which can be relied upon to indicate the existence of
this accident; and this must often be concealed by the swelling which
follows so rapidly wherever the integuments are severely bruised over
a superficial bone. This displacement can scarcely occur in but two
directions, either outwards or inwards; since the attachments of the
temporal aponeurosis above, and of the masseter muscle below, must
effectually prevent its descent or ascent.
Neither motion nor crepitus will often be present. In some few cases
the difficulty in opening or shutting the mouth, occasioned by the pro-
jection of the fragmente toward or into the tendon of the temporal
muscle, may assist in the diagnosis.
Prognosis. — If the fracture has been produced indirectly by a de-
pression of the malar bone, the prognosis must depend upon the amount
of mjury done to the other bones of the face ; in itself, the fracture of
the zygoma cannot be a matter of any moment. The same remark
might apply also to any fracture of the zygoma in which the angles
were salient outwards. If, on the contrary, the angle is salient inwards,
the fracture having been produced by a blow inflicted directly upon the
zygomatic arch from without, or by a blow upon the outer portion of
the malar bone, it may, perhaps, occasion some embarrassment to the
action of the temporal muscles.
If the force which produces the fracture has acted more upon the
temporal portion of the arch, near where the process arises from the
temporal bone, it may be accompanied with a fracture of the skull, and
with serious cerebral lesions, as in one of the cases already alluded to as
having been noticed by Dupuytren.
The abscess which followed in the case of the compound, commi-
nuted fracture, quoted from the same author, indicates the danger of
this complication ; but it must be noticed that its evacuation resulted
in a rapid cure, and that no deformity or difficulty in moving the jaw
remained.
Treatment. — A fracture, accompanied with an outward displacement,
and occasioned by a depression of the malar bone, will be adjusted by
a restoration of the malar bone in the manner already described, when
speaking of fractures of the superior maxilla, etc. If the fragments
are displaced outwards, in consequence of a direct blow from within,
then they may be replaced by pressing upon the projecting angle.
In this way Duverney easily reduced the bones in the case which I
have cited.
110 FRACTURES OF THE ZYGOMATIC ARCH.
When the fragments, in consequence of a direct blow from without,
have been driven inwards, and, as a consequence, serious embarrass-
ment to the motions of the temporal muscle ensues, an attempt ought
to be made at once to replace them ; if, however, no impediment to the
action of the muscle exists, it is scarcely necessary to say that no surgi-
cal interference will be required. It is quite probable, indeed, that a
slight amount of embarrassment may be the result of the direct injury
to the muscle inflicted by the blow, without reference to the displace-
ment of the bone, and that a few days will suffice to remedy this evil
entirely ; and, moreover, experience teaches that in the case of a frac-
ture in other bones, where the fragments actually penetrate the muscles
and remain thus displaced, the i)oints are gradually absorbed, and
rounded, so that after a time they constitute no impediment to the
action of the muscles. It is proper to infer that the same thing will
occur here. The surgeon may oe reminded, also, that it is not the
muscle but its tendon which is liable to be penetrated; and tliat this is
usually protected, somewhat, by a plate of soft adipose tissue lying be-
tween the tendon and the arch.
If to these considerations we add the difficulties which we shall be
likely to encounter in the reduction, wc shall expect to find but few
cases in which a resort to surgical interference will be necessary.
Duverney says that he restored a fracture of this arch, accompanied
with depression, by pressing against the zygoma from within the mouth;
but an examination of the interior of the buccal cavity will convince ua
that this is impassible when the fracture is at any [>oint near the middle
of the zygoma ; and that it can be only when the fracture is at or near
the junction of the zygoma with the Ixxly of the malar bone, that any
effective pressure can be made from this direction. In such a case, we
may, perhaps, lift the portion of the zygoma remaining attached to the
malar bone, by the same means which have already been suggested for
lifting the bone itself.
If the lK)nc is driven toward the tendon of the temporal muscle at or
near its centre, as happens almost always, then if its restoration be-
comes necessary, it can be accomplished only by approaching the boue
from without.
Dupuytren found an external wound through which, by the aid of a
levator, he easily restored the fragments to plact;.
M. Ferrier, however, of the Hospital of Aries, in a case brought
before him, made an incision through the integuments down to the
bone, and then attempted to slide underneath the small extremity of a
s[)atula ; but the a|)oneurosis would not yield, and he was obliged to
out it also. He was^ now able to lift the fragments easily. The wcHind
heale<l rapidly, and the imtient was dismissed without any deformity.'
^ fiulletin de8 Sciences M6d., torn, x, p 160.
FBACTDBES OF THE I^OWEIt JAW.
CHAPTER XII.
FRACTURBS OF THB LOWER JAW.
Divimon, — Of 45 examples of fracture of this booe which have been
recorded by me, not including gUDnhot fmcturee, 42 were broken
through some portion of the body. ^
Having made an analysis of 35 of the above examples, I £nd that
13 were broken completely asuoder at two or more points, constituting
double and triple fractures; and of the remaining 22, 5 were accom-
panied with detachment of portions
of the alveoli, and 1 with detach- Piq. it.
ment of a considerable fragment
from the body.
19 of the 35 were comminuted
fractures. 12 were compound; not
iocluding in this enumeration sev-
eral examples iu which the partial
w complete dislodgment of a tooth
might entitle them to be called
componnd.
Four fractures through or near
the symphysis were nearly or quite vertical, and 20 of the remainder
were k□o^^'Tt to be oblique. Malgaigne has remarked, also, that in
fractures of the body of the bone the direction of the obliquity is
generally such that the anterior fragment is made at the expense of
the internal face of the bone, and the posterior fragment at the expense
of the external face; this latter overriding the furmer. Buck, of New
York, lias seen the fragments in an opposite condition, requiring the
ose of the knife and the saw for their extrication.' I have myself
recorded ooe similar example, but in which the fragments were easily
replaced.
In 22 examples of fractures through the body, not including frac-
tures of the symphysis, the line of fracture has been observed to be 15
times at or very near the mental foramen, twice between the first and
second incisors, three times behind the last molar, and twice between
the last two molars.
Syme, Liston, and Miller have remarked, also, the greater frequent^
of fracture near the anterior mental foramen ; but Mr. Erichsen thinks
he has seen it most frequently broken near the symphysis, between the
lateral incisors, or between these teeth and the canine. Boyer observes
that it is generally somewhat in front of the foramen ; for which reason,
a^ he thiuks, the dental nerve is rarely torn.
112 FRACTUKES OF THE LOWER JAW.
Says Boyer, in his Traiti dea Maladies ChirurgicaJes, " A fracture
never takes place in the central point of the length of the jaw, called
the symphysis of the chin ; but when the solution of continuity occur
toward the middle of the bone, it is upon one or the other side of the
symphysis, which remains always upon one of the fragments." An
opinion which, however, he does not seem always to have entertained,
since Rieherand, in a report of his lectures, has made him say that a
fracture sometimes takes place " near the chin, but seldom so as to
produce the division of the symphysis of that part, though it be not
impossible." But many surgeons since his time have noticed this
fracture, and IVlhlgaigne assures us that J. Cloquet has demonstrated
its existence upon an anatomical specimen.
• Stephen Smith, of New York, has seen two examples,* Lonsdale men-
tions three,^ and Gibson has seen one,' and I have met with two, both
of which are recorded in the early editions of this book.
Velpoau, Fergusson, Gibson, Henry Smith, and others, have re-
marked that a separation at the symphysis takes place usually in in-
fancy or childhood. But in the eight examples in which I find the
ages reported, only one, a case mentioned by Lonsdale, occurred in a
person as young as ten years; in one of the cases seen by myself the
patient was seventeen years old, and the remainder have ranged from
twenty-five years to sixty; and the average age of all is thirty-two
years.
I have seen one example of a fracture of the ramus, in a man twenty-
three years old, who had been struck by a wooden bhxjk on the side of
his facxi. The ramus was broken just above the angle, and the body
was broken, also, obliquely near the symphysis. The intercepted frag-
ment was carried inwards;* and in May, 1869, I met with another
similar case at Bel lev ue Hospital, in a woman ; a pharyngeal abscess
resulteil, threatening suffocation ; for which my house surgeon, Dr.
Frank Bos worth, performed tracheotomy successfully. Ledran men-
tions the case of a child, ten or twelve years old, in whom the fracture
was double also ; one fracture having taken place through the body,
and one extending obliquely from the root of the coronoid process to
the neck of the condyle. The intercepte<l fragment was, however, so
little displacHxl that the fracture of the ramus was not discovered until
after deiith.* Malgaigne refers to this as the only example recorded ;
but Stephen Smith, of the licllevue Hospital, has met with it four times:
in one case the ramus was broken on both sides ; in two cases one ramus
onlv wa^ bmken ; and in one the body was broken on the right side
an(i the ramus on the left.* In two of those examples the fragments
were not displaceil.
' N«*w York Journ. Mod., Jan. 18A7, HospitHl Roports.
' Prnolicul Tr<»Hti«oon Fmctiin**. By Edward F. Lonsdale. Ijondon, 1888. p 226.
* In-tituten and Practice of Surg. By William Gibson. Philadelphia, 1841, p.
sni.
* Tran*. Amer. Med. A*<c>c. Report on " Deformitien after Fracturef," vol. viii,
p. 88:». (We 17.
* Mal^Hii^ne, op. cit., p. 887, from Le<1ran, Observ. (^hiruru , torn, i, ob«. viii.
* N»'W York Journ. of Mini., Jan. 1867. Bellevue Ilt»sp. Reports.
FRACTURES OP THE LOWER JAW. 113
The coronoid process is so well protected by muscles and by the sur-
rounding bony projections, that it is very rarely broken.
Houzelot mentions a case in which a fall from a height produced at
the same time a fracture of both condyles, of both coronoid processes,
and of the symphysis.^
With this single exception, I am not able to find a recorded example
of a fracture of this process.
At least nine cases have been reported of fracture of the condyles, in
all of which the separation occurred through the neck, viz., three by
Ribes, two by Desault, one by B6rard, one by Houzelot, one by Bichat,
one by Packard, of Philadelphia, and two by Wat*?on, of New York ;
the firacture always occurring through the neck and just below the
insertion of the external pterygoid muscle.
According to Malgaigne, the analysis of these cases, excepting those
mentioned by Packard and Watson, shows two classes of examples ;
the one occasioned by falls or blows upon the chin, and producing a
simple fipacture of the neck of the condyle; the other occasioned by in-
juries inflicted upon the side of the face, and producing a fracture of
the neck on the side corresponding to that upon which the injuries are
received, and at the same time a fracture of the body upon the opposite
side. These two varieties seem to be about equally common.
In the case mentioned by Houzelot, and already cited, there existed
at the same time a fracture of both condyles, of both coronoid processes,
and at the symphysis. The man also whom Watson saw in the New
York Hospital had fallen from the yard-arm of a vessel, breaking his
thigh and arm bones and both condyles of the lower jaw. " His face was
somewhat deformed by the retraction of the chin ; the mouth could not
be opened so as to protrude the tongue to any great extent beyond the
teeth, and the teeth of the upper and lower jaws could not be brought
into contact. In attempting to move the jaw, the patient experienced
pain and crepitation just in front of the ears ; the crepitation could
easily be felt by placing the fingers over the fractured condyles.
Nothing was done for the fractures of the jaw. In a few weeks the
rubbing of the broken surfaces and attendant soreness ceased to trouble
him ; but the shape of the jaw, and difficulty of opening the mouth to
any great extent, still remained unaltered."^
liiolo^y. — The causes, in such cases as I have myself investigated,
seem generally to have been direct blows, in most instances inflicted by
a club, or by the kick of a horse ; in two examples the blow was in-
flicted by the fist. I have also seen a fracture immediately in front
of the right cuspid, in a lad eight years of age, produced by being
pressed between two wagons, the pressure being made upon the two
angles of the jaw. In ten of eleven cases mentioned by Stephen Smith,
the causes were direct blows. Examples of fracture of the inferior
maxilla from indirect blows have, however, been mentioned by other
surgeons, the angles of the bone being pressed together by the passage
1 MAl^atgne, op. cit., p. 400.
■ New York Journ. of Mod., Oct. 1840. Hospital Reports.
114 FRACTURES OF THE LOWER JAW.
of a wheel, and the fracture taking place usually toward the sym-
physis.
\Ve have already alluded to the observation of Malgaigne, that frac-
tures of the condyles belong to two classes ; the one ueing ocxaieioned
by falls upon the chin, and the other by blows upon the side of the
face ; the former acting as a counter force, and the latter as a direct.
The coronoid process can only be broken by a direct blow.
Symptoms. — Fractures of the body of the bone are characterized by
the usual signs of fracture elsewhere, namely, displacement, mobility,
crepitus, and pain.
The displacement is generally present; but its direction and amount
vary accrording to the situation and course of the fracture, and also ac-
cording to the violence and direction of the force producing the frac-
ture. I have seen several cases unaccompanied with displacement, and
one of these I think ought to be regarded as an example of a partial
fracture.
A lad, ffit. 9, was kicked by a horse on the 22d of June, 1858, the
blow being received on the right side of the jaw. I saw him very soon
after the accident, but could not detect any fracture, only the body of
the jaw seemed to be bent in. On the third day, however, while en-
deavoring to straighten the jaw by violent pressure from within out-
wards, I detected a feeble crepitus, which on more careful examination
proved to be opposite the second incisor of the right side. I was also
able to detect a slight motion at the same point. It was found impos-
sible to rectify the bending, and no farther efiTorts were employed.
After the la|)se of nearly a year, the natural curve was found to be par-
tially, but not completely, restored.
I.ic<lran and other surgeons have also seen examples where neither
the j>eriosteum nor mucous membrane was torn.
Generally, in fractures of the body, the anterior fragment is de-
pressed ; and Malgaigne affirms that where an overlapping occurs, the
anterior fragment lies, generally, within the posterior; a fact which he
explains by the direction which the line of fracture usually takes, namely,
from without, inwards and backwards, as we have already mentioned.
In one instance, reported by me to the American Medical Association,
where the jaw was broken at the symphysis and also on both sides
through the Ixxly, the central fragments were found, after about four
weeks, lifte<l two lines al>ove the lateral fragments, and also slightly
carried backwards.^ I have twice also met with examples in which
the |)osterior fragments were inclined to fall inwards toward the mouth,
a circumstance which seemed to indicate that the course of the obliquity
was in a direction op)>osite to that which Malgaigne has observed to
be most fre(iuent. lu each of tlu^se examples the jaw was bi\>ken
upon both sides, by blows inflicted with a club, and the fractures were
situate<l well back.^ It is |>osHible, however, that the position of the
fragments was due rather to the direction and force of the impression
than to the direction of the line of fracture.
* Tmns. Amor. M«h1. Amoc., vol. viii, p 880, 1856, Cmie 6.
> Ibid., C««iNi 1 tttid 10.
FBACTURES OF THE LOWER JAW. 115
As to the action of the muscles in the production of displacement,
Boyer, S. Cooper, Erichsen, and Malgaigne have observed that their
action upon the anterior fragment is greater in proportion as the frac-
ture is nearer the symphysis, and less in proportion as it approaches
the angle. So that in the former case the attempt to close the mouth
is sometimes attended with a depression of the anterior fragment, caus-
ing a separation of the fragments at their alveolar margins; while in
the latter case the attempt to close the mouth forcibly is occasionally
attended with separation of the fragments along the line of the base.
While I am not prepared to deny the accuracy of these observations,
it is proper to notice that Listen found the greatest displacement when
the fracture was opposite the first molar; and I must confess that the fact,
as stated by Boyer and others, does not seem to admit of a satisfactory
explanation ; since the number, and consequently the power, of the
muscles which act upon the anterior fragment from below is greater in
proportion as the line of fracture is farther back. These muscles,
namely, the tligastricus, the genio-hyoglossus, and the mylo-hyoideus,
with several other muscles which act less directly, all tend to depress
the anterior fragment, and in some slight degree to carry it backwards;
a direction which, indeed, it usually takes, and which it would prob-
ably always take if left alone to the action of the muscles. If the frac-
ture has occurred through the angle, or at any point within the attach-
ments of the masseter muscle, the action of those fibres of thLs muscle
which remain connected with the anterior fraorment will sufficiently ex-
plain the fact that it is not now so easily depressed below the level of
the posterior fragment ; while the separation of the fragments along
the line of the base when an attempt is made to close the jaw forcibly,
is probably due to the loosening and partial dislodgment of some of
the molars, which, being pressed upwards, act as a pivot upon which
the fragments are made to bend.
Boyer affirms, also, that " the fractured portions are never deranged
so as that one passes on the other, or in the direction of their length ;
for the action of none of the muscles of the lower jaw is parallel to the
axis of that bone; besides, its extremities are retained in the glenoidal
cavities of the temporal bones." But this theory is too exclusive, since
the fragments may have become displaced in any direction indepen-
dently of the muscular action. Moreover, the action of the muscles
attached to the anterior fragment, although not parallel to the axis of
the bone, does somewhat favor a displacement in this direction ; and
the action of the pterygoid muscles upon the posterior fragment still
&rther favors this form of displacement.
An overlapping of the fragments in the direction of the axis is, in
simple fractures, no doubt, exceptional, and in such examples as I have
seen, it was very trivial. It occurred in case "three" of my "Report,"
the fracture being near the mental foramen ; in case " two," the frac-
ture being just anterior to the last molar ; and also in case " six,"
where the bone had been broken through the centre of the body on
both sides and through the symphysis; but in neither case did the
overlapping exceed two or three lines, and it was always easily over-
oome.
116 FRACTURES OF THE LOWER JAW.
The mobility of the fragments is not so striking in these accidents as
in fractures of the long bones, yet it is generally sufficiently marked,
and especially where the bone is broken upon both sides at the same
time. If only one side is broken, both motion and crepitus will be
most easily detected by lateral pressure upon the posterior fragment,
which, being the smallest and the least supported by antagonizing
muscles, will be found to be the most movable. If the fracture is. upon
both sides, mobility and crepitus will be most readily developed by
seizing upon the anterior fragment and moving it gently up and down,
while the finger rests upon the alveolus within the mouth.
Sometimes a slight swelling or tenderness at some point of the den-
tal arcade, or the loosening or complete dislodgment of a tooth, will
indicate the point of fracture.
Pain, e«*pecially when the fragments are moved, is here more con-
stant than in most other fractures, owing perhaps, in part, to the super-
ficial pasition of the bone, which renders the soft parts lying over it
more liable to injury from the causes of fracture ; but also, in part, to
the lesions which the inferior dental nerve may have suffered. It is,
indeed, a matter of surprise that injury to this nerve does not oftener
seriously complicate these accidents, coursing, as it does, through so
large a jwrtion of the angle and body of the bone. One might naturally
sup]>ose that its complete disruption would often occasion paralysis of
those |)ortions of the face to which it is finally distributed, and that its
partial lesions and contusions would create, in many cases, the most
acute and constant suffering. It is rare, however, that we have present
an amount of pain which might not be attributed to a severe shock, or
a slight stniin upon its fibres. I have myself never seen any extraor-
dinary suflTering distinctly attributable to an injury of the dental nerve
after fracture ; nor any degree of facial pamlysis, except in the case to
1m» her^^aftcr descrilKnl. Rossi relates a case in which convulsions fol-
IowchI this accident, and in which, as a final remedy, he proj)08ed to
exiH)se and bisect the nerve ; and Flajani saw a patient, whose jaw had
been broken, die in convulsions on the tenth day, the muscular con-
tractions having commenced as early as the fourth day after the acci-
dent. The autopsy disclosed a rupture of the dental nerve, but no
injury to the bniin.
Boyer explaincnl the infrequency of severe injury to the dental nerve
by the sui)|K)sition that the ** grcjiter jmrt of these fractures take place
betwet»n the symphysis and the foramen by which this nerve coraw
out." An opinion which may be correct, but nctnls confirmation. I
have sei»n the lx)dy or angle broken at points jxjsterior to the mental
foramen, and where the nerve lies within its bony canal, at least thirteen
times, and in front of the mental foramen nine times; at other times
the jM)int of fni(*ture has not Inrn note<l with such accuracy as to enable
me to sav whether it was in front or bi»hind the foramen.
I suspect that a better explanation may l)e found in the fact that the
fragments 8<>ldom overlap, to any appreciable extent, and that even the
disphu^cment in the dirtH'tiim (»f the diameters of the bone is generally
inconsiderable ; or if it d(K?s exist, the fragments are easily and promptly
replaced.
FRACTURES OP THE LOWER JAW. 117
If the displacement is sufficient to occasion a complete disruption of
the nerve, some d^ree of temporary paralysis in the portions of the
face supplied by it must be inevitable; and, perhaps, this occurs oftener
than it has been noticed, since, during the confinement of the jaw by
dressings, it is not likely to be observed, and after the lapse of a few
weeks it will probably cease altogether.
Boyer remarks that when it is torn, "the square and triangular
muscles of the chin are paralyzed. The skin of that part and the in-
ternal membrane of the under lip preserve their sensibility, which it
ap()ears they owe to some threads of the portio dura of the seventh
pair ; but the paralysis of these muscles does not prove of itself that
the jaw is fractured." Boyer has, however, noticed this result but
once, and then in a case where the bone was broken upon both sides
and the soft parts greatly contused. The triangular and square muscles
were paralyzed, in consequence of which there was a slight contortion
of the mouth. A. Berard has also mentioned a case of vertical frac-
ture occurring between the second and third molars, without displace-
ment, which W3S accompanied with complete insensibility of the lip on
the same side throughout the space comprised between the commissure
and the median line, and between the free border of the lip and the
chin. The paralysis disappeared after a few days.*
At my request, Dr. Frederick S. Dennis, junior assistant at Belle-
voe Hospital, has furnished me with the following account of a case
lately presented in one of my wards. I shall take the liberty of con-
densing somewhat the very full and interesting history which he has
ibmished me; remarking, however, that the observations are all the
result of his own careful investigation.
Kate Campbell, set. 30, was admitted, December 11, 1874, suffering
from an attack of acute tonsillitis. I subsequently opened an abscess
in the tonsil, and she was soon discharged cured. While taking notes
of her case. Dr. Dennis learned the following facts. More than a year
before she had received a fracture of the lower jaw, right side, and
a distinct callus remained near the angle of the jaw to indicate the
point at which the fracture had occurred. Since that time there has
existed complete insensibility of that portion of the face which is sup-
plied by the inferior dental nerve and its branches. Careful experi-
m«its were made with different substances, and with sharp instruments,
all of which indicated "that the nerve was destroyed in the immediate
vicinity of the dental foramen. The gustatory nerve, as well iis the
chorda tympani from the facial, maintained their full physiological
functions, both in reference to general sensation, and the siKicial sense
of taate. The mylo-hyoid branch of the inferior dental, which is given
off just before the nerve enters the dental foramen, and which is motor
in action, was not in the least impaired." Over the entire region
supplied by the inferior dental nerve there was complete anffisthesia.
Pins, thrust through the integument into the buccal cavity, caused no
sensation. " The gums as well as the teeth, on the side corrcspondmg
to the fracture, were in a state of analgesia."
> Maigaigne, from Gazette des Hdpituux, 10 Aoiit, 1841.
118 FRACTURES OF THE LOWER JAW.
The case above described furnishes an example of permanent paral-
ysis of the inferior dental nerve, from fracture ; and upon this point
the following comments, made by Dr. Dennis, are of ajxjcial interest:
" Hiemorrhage into the dental canal, or a slight laceration of the
inferior dental nerve, with little displacement of the fragments, may
cause a paralysis, which, in the former case after absorption, and in the
latter case after repair of nerve-tissues, eventually terminates in com-
plete recovery ; but in the case under consideration there is no hope of
the restoration of the function of the nerve, as too long a time has
intervened, according to the views of the most sanguine neurologists.
" Malgaigne has never seen a case of total destruction of the inferior
dental nerve, in which j)ermanent paralysis followed, fn)m a fracture of
the lower jaw. He l)eliev(»s the severe j)ain, which frequently occurs,
to be due to cerebritis rather than to injury of this particular nerve.
He further states, in his work on Fractures, that the cases in which
the nerve is injured, even in a slight degree, are very rare.
" Petit, Rossi, Flajani, Foucher, Robert, and many other writers on
this subject, give examples where the paralysis was of short duration ;
and they say that they have never seen a case where the paralysis re-
maine<l |HTmanent. The only case that can be found, in the researches
that have ham made, where the paralysis was i)ermanent, is one re-
{)orte<l by Desirabmle in the Joum, deft Connaimances, 1857, No. 20,
p. 538 ; and in this cjise the symptoms of injury of the inferior dental
nerve are identical with those found in the case of Kate Campbell.
The paralysis, in the case which Dt^sirabode re|X)rts, was caus«l by a
crude dental instrument, which tore the alveolar processes of seven
teeth, ami expostnl the dental canal."
To these signs now enumerated, we may add as occassional compli-
cations, rather than as diagnostic symptoms, salivation, swelling of the
submaxillar^' and sublingual glands, al)scesses, necrosis, etc. If the
blow has lK»en vertical upon the chin, and the direction of its force has
bei»n toward the articulations, the Ixmy structure of the ear, and even
the brain, may have suffertHi serious lesions, which may be indicated
by a dc»afness or a roaring in the ears, by bleeding from the external
meatus, and bv fatal coma. Tt^*^ier saw a man who had received the
kick of a h<n*se exactly ujxm the c(»ntre of the chin, breaking the Ixmc
on lK>th sidles, and who, in (M>nseipien(»e, bled freely from his ears ;* and
Alix relates the cast» of a young man who, falling from a height and
striking u|M)n his chin, had bn)ken his jaw. Insensibility immeiliately
followcil ; convulsions also ensued u|>on the fourth day, and he dic^I
U|Kin the sixth.^
If the fnictun* is at the symphysis, it is generally vertical, ami either
fragment may be found slightly displacinl upwards or downwanls. In
one of the exampUs mh^u bv myself, t\\e left fragment fell three lines
Im'Iow the right, and in another the right side had fallen al>out one line.
In a cnise mentione<l bv 8vme there wa^ sc*arcelv anv displacenient.'
» Mul^Hiuno. n|>. 38;t nm\ 38r», fn.m Journ. de MM.. !7H9, torn, \xx\x, p. 246.
• llml., I* .'ISri, from Allx, OWjmtvhIm Chir , fk-cic. 1, ob«. 10.
• AfiH-r. Journ. Mt»d. S<'i., vol xviii, p. 243.
FRACTURES OP THE LOWER JAW. 119
Liston remarks that it is usually slight. Erichsen and B. Cooper
have observed the same.
The signs which indicate a fracture tlirough the angle have already
beea sufficiently considered when speaking of fractures of the l)ody ;
from which it only differs in the less degree of dis])lacement, and in
the feet that the posterior fragments are a little more prone to fall in-
wards toward the mouth. I have noticed, also, that, owing probably
to the loosening and partial dislodgment of the last molar, it is some-
times difficult to close the mouth, the same as in the fractures a little
fiuther forwards.
In each of the two examples of fracture of the ascending ramus
which I have seen, the bone being broken also 'through its body, the
fracture of the ramus was recognized by both crepitus and mobility.
As to the signs which indicate a fracture of the corouoid process, I
am only able to infer them from its anatomical relations. There must
be some embarrassment in the motions of the jaw, occasioned by the
detachment of a portion of the fibres of the temporal muscle; and it is
probable that an examination by the finger within the mouth would
readily detect mobility and displacement.
A fracture through the neck of the condyle is characterized by pain
at the seat of fracture, especially recognized when an attempt is made
to open or shut the mouth, by embarrassment in the motions of the
jaw, by crepitus, which may usually be felt or heard by the patient
himself, by mobility and displacement.
The upper fragment, if disengaged from the lower, is drawn forwards,
upwards, and inwards, by the action of the pterygoideus externus; and
it is felt not to accompany the movements of the lower fragment.
The lower fragment is at the same time drawn upwards, in conse-
quence of which the lower part of the face is distorted ; a circumstance
first noticed by Ribes, and which supplies an important diagnostic
mark between a fracture of one condyle and a dislocation. In dislo-
cation, the chin is commonly thrown to one side, but it is to the side
oppotiite that on which the dislocation has occurred, while in fracture
the chin is drawn to the same side.
Prognosis, — Physick, of Philadelphia, saw a case of non-union of
the body of this bone, which had existed nine months.^ Dupuytren
mentions a case which had existed three years.^ Stephen Smith, of
New York, reports a case of fracture of both the body and the ramus,
io a man forty-five years old. The severity of the injury, with the
supervention of delirium tremens, prevented the application of dress-
ings until the thirteenth day. On the twentieth day, about a pint of
blood was lost by hsemorrhage from the seat of fracture. He re-
mained in the hospital one hundred and thirty-seven days, and was
finally dischaiwd, the fragments not having yet united.^ I have seen
one example of fibrous union in the case of a man who broke the body
of the jaw by a fall upon his chin. Malgaigne says that Boyer has
seen several examples, but I know of no other cases, unless as the
* PhilH. Med. nnd Surg Jourfi., vol. v. * Le^ona Orales.
* Smilh, New York Journ. of Med. and Siirg., Jan. 1857.
120 FRACTURES OF THE LOWER JAW.
result of gunshot injuries, which have been recorded. In no instance
of a simj)le fracture which has come under my personal care, has the
bone refiLsed finally to unite, although I have seen the union delayed
six, seven, ten, and even eleven weeks or more.* In three of these
cases the fractures were either compound or comminuted ; but in one
case the fracture was simple, the delay in the union being due to a feeble
condition of the system, and in part, perhaps, to neglect of proper
treatment. Since the commencement of the late war I have met with
several examples of non-union, and of fibrous union, after gunshot
fractures ; but, so far as I can rememl)er, in all of these cases necrosis
existe<l, or some portions of the bone had been carried away.
The infrequency of 'non-union after this fracture is a feet worthy of
esixKrial attention, l)ecause of the extreme difficulty, if not actual ira-
possibility, in many cjises, of wholly preventing motion between the
fragments, by any mode of dressing yet devised. Any one who has
observed attentively, must have seen, not only that his dressings are
more often found disturbed and loosened than in the case of almost any
other fracture, unless it be the clavicle, and thus the fragments have
been through all the treatment subjected to frequent changes of posi-
tion ; but, also, that even while the dressings remain snugly in place,
the patient seldom is able to i>erform the necessary acts of dc^lutitioD,
or tc» spejik, even, without inflicting some slight motion upon the frag-
ment^.
IndetMl, the rapidity as well jls certainty with which this bone unites,
h:is, I think, bwMi observed by other surgeons, and I liave myself uo-
ticcnl one instance*, in an adult |)erson, in which the bone was immova-
ble at the sciit of fracture on the seventeenth day, and jierhaps earlier.
In otIuT instances, the union has been speedily effected after the re-
moval of all dressings.
The amount of deformity resulting, also, from these fractures is
usually very trifling, whatever treatment has been adopted. Only
nine of the unitcnl fractures, seen and re<M>rdetl by me, are imperfect,
an<l in none of these is the im|)eriection such as to be noticed in a casual
examination of the face. The deformity which is usually found, is a
slight irregularity of the teeth, produciHl, in most cases, by a falling of
the anterior fragment, but in one easc^ by a slight elevation of the an-
terior fragment. But even this d(x*s not always interfere with masti-
cation, an<l would often pass unnoticinl by the patient himself. It is
probable, to«», that time, an<l the <Y>nstant use of the lower jaw in mas-
tication, will gradually ettW-t a marked improvement in the ability to
bring the op|H)sing teeth into contact. I think I have observed thia
in si'vc»ral instan(»<*s.
Chdins remarks that in "double or obi i(jue fractures it is verj' diffi-
cult to keep the broken ends in tlH'ir pro|MT phu^e ; defotmity antl dis-
phuvment of the natural positicMi of the teeth commonly remain."
In the s<MM>nd example of fra(*tiiiv through the symphysis mentioned
bv me, tin* left fragment remaiiie<l slightly elevated, and the |)atient*
could not close his teeth iH-rfectlv, vet he (*ould close them suOicientIv
' M\ U«'|H»rt ini lM*oriimu>!> ufn?r Fractiin'*, Ctt»o« 2, M, 16, IS,
FRACTURBft OF THE LOWER JAW. 121
tar the purposes of mastication. It is probable, however, that ordina-
rily uo difficulty will be experienced in accomplishing a perfect cure
when the^paration has taken place only at the symphysis.
In fractures of the condyles, more care is requisite to retain the frag-
ments in apposition, and sometimes it may be found to be impossible.
Richerand mentions the case of a man, who, having been three months
in the " Hdpital de la Charity," for a double fracture of the lower jaw,
one fracture being near the middle, and the other near the right con-
dyle, left before the cure was complete. Seven or eight months after,
he called upon Boyer, who extracted from a fistula in the meatus audi-
torius externus, a bony mass which had evidently the form of the con-
dyle.^ Bichat mentions a similar case as having come under the ob-
servation of Desault;^ possibly it was the same which Boyer saw.
Ribes says that a Parisian surgeon treated a double fracture of the jaw
in a gentleman, one fracture being through the body and the other
through the na^k of the condyle; and, in spite of the most assiduous
and skilful attention, the patient recovered with a lateral distortion of
the jaw, occasioned by the displacement of the fragments.^ Ribes him-
self had to treat an accident of a similar character, and, notwithstand-
ing all his care, the result was the same as in the other example just
cited.* Fountain, of Iowa, was much more fortunate, having made a
complete and jjerfect cure.*
The proximity of this fracture to the articulating surface may occa-
sion contraction of the ligaments about the joint; and a degree of em-
barrassment to the motions of the jaw has followed in the experience
of Desault and others, even when the cure has been most complete;
bat this has usually remained only for a short period.
Sanson asserts that when the coronoid process is broken, the fracture
never unites ; but that mastication is performed very well, the masseter
and pterygoid muscles then fulfilling the office of the temporal.^
Treatment — The few attempts which I have made to restore a com-
pletely dislocated tooth to its socket, or to retain it in place when very
much loosened, have generally resulted in its removal at some later
day, and especially where the fracture has been near the angle and a
molar has been disturbed. I believe it would be better practice always
to remove the molars under these circumstances, unless they remain
attached to the alveoli, and cannot be removed without bringing them
away also ; and this, whether the loosened teeth are situated in the
line of fracture or not. It is seldom that they can be made again to
occupy their sockets perfectly, and where the teeth are in the line of
the fracture, the attempt t6 restore them to place will sometimes pre-
vent the proper adjustment of the fragments. In cases, also, in which
the teeth farther forwards are completely dislodged at the seat of frac-
ture, it is scarcely wortli while to replace them.
* Boyer, Lectures on Dis. of Bones, p. 68, Phi la. ed., 1805.
' Deiiaul^, Treatii^e on Fractures and Luxations, Phila. ed., 1805, p. 3.
' Malfrniirne, op. cit., p. 40 J.
' ml p^ 402/ '
' Fountain, New York Jour. Med., Jan. 1800.
' 8. Cooper's First Lines, Amer cd., 1844, vol. ii, p. 31 1.
9
122 FRACTURES OF THE l6wER JAW.
As to those teeth whose loosened condition is due only to a splitting
of the alveoli in a longitudinal direction, the same rule will not always
apply. Sometimes, afler a careful readjustment, the fragments will re-
unite, and the teeth remain firm.
If the bone is chipped off upon the outside, through or near the line
of the sockets, the teeth may not \ye always much disturbed, and the
loss of the fragments may be of less consequence, nor have I generally
succeeded in saving them ; yet if they remain adherent to the soft parts,
it is proj)er to make the attempt.
The exjMHlients to which surgeons have resorted for the purpose of
retaining in place the fragments, when the bone is broken through its
body, may be arranged under the names of ligatures, splints, bandagcA,
and slings.
The ligature has been applied both to the teeth and to the l)one itself.
Thus, in an oblique fracture near the angle, where the fragments
could not otherwise be prevented from falling inwarcl*^, Bandens passed
a strong ligature, forme<l of thread, around the frajs^ments and in im-
mediate contact with them, tying the ligature over the teeth within the
mouth. No accident followe<l, and on the twenty-third day, when he
removed the ligature, the bone had united firmly and smoothly.*
In the case of the frac^ture of the inferior maxilla, rcjK)rtecf by Dr.
Buck to the New York Pathological Society, and already referred to,
the bon(; "was broken l)etween the two incisor teeth of the left side;
the |>art of the bone on the left* of the fracture was driven in, and in-
tcrloc*ked l)ehind the end of the right portion, so as to Iw sefwimted by
a finger's brea<lth. Finding it imjK»ssible otherwise to n»dnce the frac-
ture, Dr. B. dissected off the under lip, so as to expose the fracture.
He found that the right anterior j)ortion of the frac'tured Imne termi-
nated in an angular projection as far as on a line l>elow the left angle
of the mouth. The lip was then divided to the chin, and the soft |^iartfl
holding the fragments together incised. A chisel was then insinuutcil
behind the projecting angle of the Ixme, while it was lK?ing excised
by the metacarpal saw. When the bone was restore<l to its natural
position, it was found so apt to l)ecome disj)lace<l, tliat holes were drilled
at the lower angle of the fracture, and adjustment maintaine<l by wiring
them together, the \vire passing out through the h)wer angle of the
wound. Sutures and adhesive straps, with a bandage, were employed
to maintain the adjustment of the parts. So far the ))atient ha^ done
well, 1km ng suj)|K)rted by liquid nourishment introduce<l thn>ugh a tulie
passcnl through the spaw left by one of the incisors, which, on account
of its l<M)seness, was n'moved."* Dr. R. *A. Kinhx^h, of Charleston,
S. (-., Ims rej)orted a similar au<», in which he employed suixMSiwfully
the wire'
In May, 1858, while trephining at the angle of the jaw for the pur-
pose of cutting out a |)ortion of the dental nerve in a {uitient suffering
from ncundgia, I awidcn tally broke the jaw in two at the point at
which the trephine was appli(Nl. I imme<liately borwl m hole in the
> Mnlijjnuno, op. cit , p. 3(W
■ Nrw York .lourn of M.mI.. oU\, Mnn-h, 1S47. p •ill.
* Kinluch, Am. Journ. Mini. Sci , July, 1869, p. tt7.
r
PHACTURES OF THE LOWER JAW. 12
oppoeitv extremities of the two fragments, and fiidtpned tlieni tojielher
j^ith a silver wire, t>y which I was able to niuiniain wnnplpte u|>po-
HkkH), and in three weeks the union was nccnniplished, the wire sepunit-
^Bk and fulling nut of itself. No splints were ever ti^.'
^B~Sl'ith these exeeptions, so far a!d I am aware, the tigutnre has been
employed as a mains of retention only, by fastening it upon the teeth,
cither upon thow which are nituated on the opi)osite sides of the frao-
tiire, or upon others a little more remote, or uiK>n the corresponding
teeth of the upper jaw, or upon the teeth on the opposite sides of the
same jaw.
Ordinarily the ligature, composed of either fine gold, platinum, or
silver wire, or of firm silk or linen threads — (Celsus advised the uw of
~" sehair)— has been iipplie<l to the two teeth on the op]K»8ite sides of
I fracture, or if these have not been sufliciently firm, to the next
eth. This practice, recommended first by Hippocrates, has received
! occasional sanction of RyH', Wulner, Chelius, Lizars, Erichsen,
Miller, B. Cooper, Skey, and others, hut by Buyer, Gibson, and Mal-
Igugnc it has been disapproved.
l>r. 8, G. Ellis, of New York, as we have already seen, has treated
■ fracture, occurring through the symphysis, in an adnlt, by placing
the mainspring of a watch within the dental arcaiie, and securing it in
flaw with silver wire. The month was kept closed by l>andagp« ear-
ri«! under the cliin. The fragments united with only a .slight vertical
ilisplacement.'
I)r, Oeorge Hayward, of Boston, surgeon to the MatssachnsettsOen-
m\ H'^ipiial, says: "When the bone is not comminuted and there
«rt teeth on each side of the fraciure, the ends of the bone can be kept
in exact apposition by passing a silver wire or stronc thrcsid around
these teeth and tying it tightly. In sevend eases of fracture of the
JBw, in which the iMine was broken in one place only, 1 have, in the
OHiijcof the last few years, adopted this practice with entire siiccesa,
ami without the aid of any other means. It will be found very useful,
alsi IIS an auxiliarv, in more severe cases, in which it may be required
splints and bandages, or to insert a piece of (»rk between the
s recommended by I)el[>e(>h. It requires some mechaniiiil <lcx-
rily (ii apply the thread neatly ; hnt in large cities we can avail onr-
Jvffiiif the skill of dentists tor this purpose,"* I have myself in two
irthrw instances used a linen thread with excellent results,
Gaillunmc de Salicet advises to secure wilh a silk thread, at the
c moment, the teeth belonging to tlie two fragmenls, and the e<tr-
pnixliog teeth of tlie upper jaw ;' while the dentist Ivemaire, Ix-ing
\ lo by Dupnytren to secure in place the nnunileit tragments of
Mitcn jaw, fiLsrened the two left tanine teeth to each other \ry a wire
if plHlinum, as had been already suggeHted by Guillaume de Sidicet;
to these he addwl two other modes of ligature which were altogether
> Ku<r.la M<n1. Journ., vol. iiv, p. US.
'T-.n., Amer. Me.1. Absmc. My report un ■■ Di^for,," etc., rol. viii, p. 3R1,
' Rn*ion Ki-i. iind 8urg Jniirn., vol. jiix, p. 133, 1B38.
1
d
124 FRACTURES OF THE LOWER JAW,
original. One wire, made fast to the last molar upon one side trav*
ersed the mouth and was secured to one of the bicuspids upon the
opposite side ; the other was stretched from the first inferior bicuspid
on the right to the first superior bicuspid on the left. A cure was ac-
complished at the end of two months, but one of the wires had nearly
bisected the tongue ; and as it had gradually become imbedded, the
flesh had closed over it until it rested like a seton through the middle
of the tongue.*
None of these various methods, however, will in general be found to
possess much value ; for besides that they ai*e all of them, in a large
majority of cases, wholly unnecessary, and in other cases, owing to the
absence of the teeth, or to their loosened or decayed condition, or to
the closeness with which they are set against each other, absolutely im-
I)ossible, it must be seen, also, that they will generally prove feeble
and inefficient. The wires act only upon the upjwr extremity of the
line of fracture, leaving its lower portions liable to be disturl)ed by
trivial causes ; they tend gradually to loosen even the firm teeth which
they embrace, and not unfrequently, after having been made fast with
much labor, they soon become disarranged or break. They require,
therefore, almost always the additional protection afforded by Imndages,
interdental splints, etc. Alone they are usually insufficient, and if
pro|)erly constructed bandages, slings, interdental splints, etc., are em-
ployed, they are not needed. Sometimes, moreover, they are actually
mischievous, as when they loosen a sound tooth or press u})on and in-
flame the gums. A. B^rard passed a silver wire twice around the
necks of two adjoining tc^eth on the opposite sides of a fracture. It re-
tained the fragments perfectly in apj)osition during several days; but
soon the gums swelled and became painful ; the teeth loosened, and it
was found necessary to remove the wire. Chassaignac sought to avoid
tlu?sc evils by placing the wire upon the middle of the crown, free from
the gums, and by including four teeth instead of two. A waxed linen
thread was made fiist in this manner, in a case of simple fracture, on
the seventh day. On the following morning the thread was found
broken. He applied then a silk ligature in the same manner. On
about the third day this also wits disarranged; the ligatures were now
dis(M)ntinued until the eighteenth day, when he renewcnl the experi-
ment with a piece of gold wire. Fourtwn days after this the ligature
remained firm, but the gums were red and bleeiling. The patient not
having again returne<l to Chassaignac, the result is not known.'
As to the method suggesteil by Guillaume de ISalicet, it presents no
advantages to compensate for its inconvenieiut^s ; while that lu^tually
practiced by the dentist I-«omaire, sucx'cssful iiKhnxl, threateneil to sub-
stitute a loss of the tongue for an ununited fracture of the jaw.
Splints have lx^»n empl«»yetl in various ways. First, simply interden-
tal splints, laid along the crowns of the teeth, and only sufliciently
grooved to Ixr easily retainwl in place ; siH'ond, clasiw, which are aiiplied
over the crowns and sides of the twth, o|K'rating cliiefly by their lateral
' Journ. Univor. doH Sci. Mwl., torn, xix, p. 77.
' Lv»nd. Med. and Pbyd. Juurn., >iov. 1822, p. 401.
FRACTURES OF THE LOWER JAW. 125
pressure, or made fast by screws ; third, splints applied to the outer and
inferior margin of the jaw; fourth, interdental splints combined with
outside splints.
Interdental splints have been recommended by many surgeons from
an early day, and they continue to be employed occasionally up to this
moment.
Beyer advises the use of cork splints, placed one on each side be-
tween the upper and lower jaws, in a few exceptional cases. Miller
recommends the same in all cases, the " two edges of cork sloping
gently backwards, with their upjjer and under surfaces grooved for the
rweption of the upper and lower teeth." Fergusson also has usually
adopted the same practice. Muys and Bertrandi employed ivory
wedges.*
Oik the other hand, interdental splints are rejected entirely by Syme,
Chelius, Skey, Erichsen, and Gibson.
The objections which have been stated to their use are : that they are
unsteady and become easily loosened and disarranged ; that they occa-
^ooally press painfully upon the inside of the cheeks ; that they accu-
malate about themselves an offensive sordes ; and finally that they are
onnecessary, since experience has proven, says Gibson, that " there is
always sufficient space between the teeth to enable the patient to im-
bibe broth or any other thin fluid placed between the teeth.''
It is not strictly true, however, that in all cases there will be found
saflScient space between the teeth, when the mouth is closed, for the
imbibition of nutrient fluids. I have myself seen exceptions ; and in
such a case the patient, if the mouth were closed in the usual way,
would have to be fed through a tube conveyed along the nostrils into
the stomachy as suggested by both Samuel and Bransby Cooper in cer-
tain bad compound fractures, or through an opening made by the ex-
traction of one of the front teeth ; neither of which methods ought to
be preferred to the interdental splints ; but then the separation of the
front teeth for the purpose of receiving food, is by no means the only
object to be gained by their use, nor indeed the principal object. Their
great purpose is to act as splints whenever the absence of teeth, either
in the upper or lower jaw, renders the two corresponding arcades un-
equal and irregular, and prevents our making use of the upper as a
kind of internal splint for the lower jaw.
It is with a view to the accomplishment of this important end that
they are often valuable, and ought sometimes to be considered as indis-
pensable. I believe, also, that many of the inconveniences which have
been found to attend the use of cork or wood, are obviated by the sub-
stitntion of gutta percha in the manner which I recommended to the
profession in 1849,* and also again in my report to the American
Medical Association, made in the year 1855.
The mode of preparing gutta percha, and of adapting it between the
teeth, is as follows: Dip a couple of pieces of the gum, of a proper
ri», into hot water, and when they are softened, mould them into
• Lond. Med.-Chir. Rev., vol. xx, p. 470.
• ButTalo Med. and Surg. Journ., vol. v, p. 144, Aug. 1849.
126 FRACTURES OF THE LOWER JAW.
wedge-phapecl blocks, and carry them to their appropriate places be-
tween the back teeth on each side of the mouth; taking care, of course,
that on the fractured side the splint extends sufficiently far forwards to
traverse thoroughly the line of fracture. Now press up each horizontal
ramus of the jaw until the mouth is sufficiently closed, and the line of
the inferior margin is straight; in this position retain tlie fragments a
few minutes, until the gum has well hardened. Meantime it will be
practicable, generally, to introduce the fingers into the mouth, and to
press the gutta percrha laterally on each side toward the teeth, and
thus to make its position more secure. When it is hardened, remove
the sj)lints, for the purpose of determining more precisely that they
are properly sha])ed and fitted.
It is scarcely necessary to say that in carrying the long wedge-
shaped block into the mouth, the apex of the wedge is to be introduced
first.
The superiority of this splint is now at once perceived. If properly
made, it is smooth u|)on its surface, and not, therefore, so liable to irri-
tate the mouth as wood or cork, and it is so moulded to the teeth that
it will never become displaced. It |)ossesses this advantage, also, that
in case more or less of the teeth are gone in either the upper or lower
jaw, it fills up the vacancies, and renders the support uniform and
steady.
The " clasp," applied over the crowns and sides of the teeth, is not
intende<i to act as an interdental splint ; but by its lateral pressure it
is ex|KHrted to hold the fragments in apposition upon nearly the same
principle with the ligature.
Mutter, of Philadelphia, and N. R. Smith, of Baltimore, employ for
this purpose a plate of silver, foldeil snugly over the tops and siiles of
two or more te<»th adjacent to the fracture.
Nicole, of NuremlKjrg, employ wl for the same purpose a couple of
steel plates fitted accunitely ahmg the anterior and jKWterior dental
curvatures, securwl in place by a steel clasp, the clasp being furnished
with a thumb-screw, in onler the more effectually to accomplii^h the
latcnd pressure.
Malgjiigne has extendetl the idea of Nicole, by substituting for the
two stiHil plates a single plate c»om|)ose<l of flexible and ductile iron,
which is fitteil accurately to all the irn»gularities of the posterior dental
arch. From the two extremities of this plate, and from two other in-
termc<liat^* })oints, four sniall steel shafts arise )>erpendicularly, croeM
the crowns of the tcH^th at right angles, and then fall down again per-
{K'ndicularly upon the anterior dental arcade. Each steel shafl being
furnished with a thun)b-s(^rew, the iron plate (^n now be made to l)ear
against the tc^eth so as to form a posterior dental splint. The teeth are
also pn>tccted in front against the <lirect action of the thumb-screw by
the interpHition of a leaden plate.
J. B. Gunning, dentist, of New York, has substituted for all these
materials vulcanized india-rubl)er, which he employs both as a cla<p
an<l a^ an intenlental splint; and, according to Dr. Covey,* the same
> BcAn, Richmond Med. Juurn., Feb. 18d6.
FRACTURES OF THE LOWER JAW. 127
material has been used with excellent results by J. B. Bean, dentist,
of Atlanta, Ga. The following is Dr. Bean's plan of procedure.
An impression is taken in wax of the crowns of the teeth of the
uninjured jaw, and of each fiagnient separately of the broken jaw.
When, in doing this, the ordinary "impression cup" used by dentists
cannot Ije introduced, one composed of a thin metallic plate, whici) is
covered with wax and stiffened by a rim of wire, may be substituted.
" From these impressions are made casts of plaster of Paris, very
carefully prepared, so as to produce a smooth, hard surface, and giving
as perfect a representation of the teeth as possible. These plaster
models are then adjusted, properly antagonized in their normal posi-
tion and placed in the ' maxillary articulator.'
"The fragments of the model representing the broken jaw are held
in their proper position by wax, l)eing secured thus one to the other,
and to the remaining plate of the articulator." . . . The model jaws
are now opened from three to five lines, and a wax model of a splint is
buih up between the molars, covering also the inner and outer surfaces
of the teeth. A connecting band of wax is laid from one side to the
other behind the upper front teeth, leaving thus an opening in front
for the reception of the food. This wax and plaster model, now com-
poe«ing one piece, is then removed
from the articulator, and placed fio. 28.
in a dentist's ** flask," and a com-
plete mould of the model is again
formed from plaster laid on in sec-
tions, in a manner which those ac-
customed to make plaster moulds
will readily understand. The
plaster having fairly set, the flask
and mould are opened, the wax
carefully removed, and the spaces
thus left in the mould at once Max nUry Articulator.
filled with the rubber rendered i' '' !^r?rf 'T' ''"'''*
Ai 1 . mL ij • • 2, 2. Adjustable rods.
fiott by neat, ine mould ls agam s, s. Adjustable hinge.
closed, replaced in the flask, and by
heat the rubber is thoroughly vulcanized. The flask is again opened,
the plaster removed, and an interdental splint of rubber remains,
whien is fitted accurately to all the surfaces of the teeth both above
and below.
The splint is now placed in the mouth, adjusted to the teeth, and the
lower jaw secured in position by the apparatus represented in the ac-
companying woodcut.
Dr. Covey says, that during the late war Dr. Bean was placed in
diarge of a hospital at Macon, Georgia, devoted exclusively to the re-
oeption of this class of injuries, and that over forty cases were treated,
and with eminent success.
My own judgment of this apparatus is, that so far as the substitution
of vulcanized rubber for gutta percha is concerned, it is wholly un-
necessary in the great majority pf simple fractures of the jaw. Gutta
pereha is applied with great facility, and with equal accuracy to all the
128
PHACTUHES OP THE LOWER JAW.
dental surfaces, and it speedily hardens sufficiently for all practical
purposes.
In gunshot fractures, however, and in certain other Imdiy commiDutod
fractures, I can well understand how the surgeon may a(Ivant]^;eously
avail himself of vulcaniz^il rubber,
wliicli, l)eing somewhat harder, may
be made to grasp the teeth attat-hcd
to the several fragments more firmly ;
and indeed may, iu a few canes, allow
of the teeth being made fast to the
splint by screws.
It will I>e observed that these are
the cases which Dr. Bean has had
chiefly under treatment.
An examination of the ca.*!es re-
ported by Dr. Covey will also show
that the ap|mratus was never applied
earlier than the tenth day, even when
the patients were under the charge of
Dr. Bean from the first, and tliat in
most cases the application' of the ai>-
|>aratus was delaye<l to a much later
period, Indecil, it is apparei.it that
there nmy be the same reasons for occasional delay in the appliestion
of vulcanized rubbiT as in the application of gutta percha, or any other
mode of support and dressing.
In reference to the head apparatus, or sling, as used by Dr. Bean, we
have oidy a single remark to make. It is a modification of the ap|ia-
ratus cniploycil for many years by myself— the m<Klifimtion eon-^isting
in the us(> oC a horizontid piece of woo<l siip]K>rting a cup which is
plaeeil under the chin, the purptisc of which is to prevent the lateral
prefwnrc usually made by the maxillary Immls. The ne«essity of
avoiding lateral prepare iu certain ca-ics, has long been recognized
by myself and others; and it has been found to be ps[>ecially im-
portant in all comminuted and gunshot fractures. To the attain-
ment of this ]mrpose, I have employed usnnily a firm gutta ]M'reha
splint luxler the chin, to the pmieetiiig latend extremities of which the
maxillur}' bands have been attached ; and I think it much better than
Dr. Bean's jiiwc of wood. In a grrat majority of aties, however, oc-
curring in civil pnicticc, that is to say, in most simple fmctures, thi«
submental splint is unnecessary-, since the latend pressure is harmleiw,
t]i«p<rially when the intcnteiital .-splints uf gutta ]»erelia or of vulcanieeil
rublx-r are employed.
In short, while I am prepare<l to admit that Dr. Bean has by his
apjHtrfU, anil by the application of great nitvhanical skill, talent, and
inaustry, trcalcil sin •<•«<* fully many i-ases which by other applinnccsi and
in other hands might have resulted most unfortunately, yet it is plain
that his melhcxl will find its field of usefulness in civil practice liraited
to exceptional eas«i<.
Dr. J. S. I'rout, of Brooklyn, New York, has su^eatcd to me a very
LOWER J A
inf^nioiis mode of ptnpioying the intenlenta) splint and wire ligature
conjointly, and which method, at my request, he adopted recently in a
rase under my care at Bellevue Hospital. A plate of gutta pcrcha was
placed upon the lop of the teeth across the line of fracture, and this
was secure*! in position by silver wire, which had been made to grasp
firmly the crowns of the adjacent teeth and was then brought over the
liorixontiil gutta-percha plate. In this case it accomplished all that
was desired.
External splints, appliwl along llie base or outside of the jaw, were
^^tt recommended by Par6, who used for this purpose leather; and
^Hkr have beef employed in some form, occasionally, by most surgeoD^i.
^Kaierally they have been comi)osed of flexible materials, such os wetted
pasteboard, first recommended by Heistcr, felt, linen saturated with the
whites of eggs, paste, dextrin, or starch; piaster of Paris has also been
ii>«xl; and they have been retained in plat« by either bandages or the
sling. As belbro stated, I have myself used for this purpose gutta
pcreha, but I shall speak of it as one form of the sling dressing.
Undoubtedly useful, and even necessary in some cases, especially
where there exists a great tendency to a vertical displacement, they will
be found, also, in many eases, to render no essential service, and may
properly enough l>e dispensed with.
Whatever objections hold to the use of metallic clasps, must apply
in wme degree to the use of those forms of apparatus in which it is
ntieinpted to secure the fragments by means of a combination of these
cIaf<fKwith outside splints, and in which it is proposed to dispense with
all bandages or slings, the month being permitted to open and close
ffwiy during the whole treatment. Motion of the jaw cannot be per-
miitwl in any case where the fracture is far back, since it is then im-
[■oa'ible lo grasp the posterior fragment betiveen the two parallel splints.
Nothing but complete immobility of the jaw will now insure immo-
bility to the fracture. Some of these fiirms of apparatus are liable to
additional objetrttons, which will be readily suggested by an explanation
_(rf their mode of construction.
■ Chopart and Desault originated this idea as early ns 1780, for frac-
es occnrring upon both sides; in which cases they advised "liand-
s composed of crotchets of iron or of steel, placed over tfie teeth,
pen the alveolar margin, covered with cork or with plates of lead, and
llen«l by thumb-screws to a plate of sheet-iron, or to some other
_ ■tcrial under the jaw."
The apparatus invented by Rutcnick, a German surgeon, in 1799,
u>d improved by Khige, is thus described by Dr. Chester: "It con-
Hsls, Isl, of small silver grooves, varying in size according as they are
I" be placed on the iucisoro or molars, and long enough to extend over
Uwcmwns of four teeth ; 2d, of a small piece of board, adapted to the
lower surface of the jaw, and in shape resembling a horseshoe, having
u id two horns, two holes on each side ; 3d, of steel hooks of various
'ii», each having at one extremity an arch for the reception of the
loTW lip, and another smaller for securing it over the silver channels
■M the teeth, and at the other end a screw to pass through the horse-
^ splint, and to be secured to It by a nnt and a horizontal branch at
130 FRACTURES OF THE LOWER JAW.
its lower surface; 4th, of a cap or silk nightcap to reraain on the head;
and 5th, of a compress corresponding in shape and size with the splint.
The net or cap having been placed on the head, and the two strapB
fastened to it on each side, one immediately in front of the ear and the
other about three inches farther back, which are to retain the splint in
its jKwition by passing through the two holes in each horn, a siivtf
channel is placed on the four teeth nearest to the fracture; on this the
small arch of the hook is placed, and the screw end having been i^assed
through a hole in the splint, is screwed firmly to it by the nut, after a
compress has been placed between the splint and the integuments below
the jaw.
"If there is a double fracture, two channels and two nooks must of
course be used."*
Bush invented a similar apparatus in 1822,' and Houzelot in 1826;
since which the apparatus has been variously modified by Jousset,
Lonsdale, Malgaigne, and perhaps others.
Lonsdale says he has employed his instrument in numerous cases,
and with complete success.^ Rutenick succeeded with his apparatus
in a case where the displacement persisted in spit« of all other means.^
Jousset was also successful in two cases.* Wales, Asst. Surg. U. S.
Navy, succeeded with an instrument of his own invention.®
But others have not been equally fortunate; or if they have succeeded
in holding the fragments in apposition, and in securing a bony union,
other serious accidents have followed.
In the first case mentioned by Houzelot, the instrument was kept on
thirteen days, after which an attack of epilepsy derangcil everything,
and the patient was transferred to Bic^tre. The second patient com*
plained immediately of an intense pain under the chin, and a profuse
salivation followed. These symptoms were subdued by the sixth day,
but, for some reason, the ap|)aratus was finally removed on the tenth
day. The fragments hereafter showed no tendency to derangement.
Seven days after its removal, an abscess, which had formed under the
chin, was opened. In the third case the apparatus was left in place
thirty days, and an abscess formed also under the chin. Neucourt ap-
plied it in a double fracture where the central fragment was much dis-
placed. The apposition was well preserved, but he was obliged to
remove it on the seventeenth day on account of a phlegmon which was
forming under the chin. The patient to whom Bush applied his ap-
paratus, would wear it but a few days. Malgaigne had the same ex-
perience with Bush's apparatus.
In addition to the pain and inflammation, followed by submaxillarjr
abscesses, which have been such frequent results of its use, Malgaign
has noticed that it is exceedingly inclined to slide forwards and becun
displaced.
^ London Med -Chir. Rev., vol. xx, p. 471, from Monthly Archives of the UA:
cnl Science*, 1831.
• Mnl^nifCne, op. cit., p. 895.
• Lon^lnle, Prttcticiil TreHtii»e on Fractures; London, 1S88, p. 284.
« Miilf(ni|cne, op cIt., p. 896. » Ibid., p. 896,
• Wales, Am. Journ. Med. Sci., Oct. 1860.
FRACTURES OF THE LOWER JAW.
131
^Iq short, notn'ilhstaiiHiiig the unqual iii(«l testimuny of Lonsdale in
_*■ f this method of treatment, especially in fraeturcs at the sym-
pliVMB, aad in fnictiiree tlimu^^h any partion of tlie tihafl anterior to
the iiiasseter muscle, it is, in iity judgment, sufficiently ptiiin that it is
applicable to only a very limited nnniWr of cases; but if I were to
recommend any form of apparatus constructed with a view of iier-
miiting mobility of the jaw:^ during the process of union, it wonid be
that invented by Norman Kingsley, dentist, of this city, and which I
have seen usetl with cxcctlent results at Bcllevue Hospital.
Impressions in plaster are first taken of both npper and lower jaws.
Models made from these impre^ions will represent the lower jaw
brukea and tlie fragments dis-
l.la«<J. The model of the lower '^''■*'-
jaw is then 6C|>arated at [he point
representinj; the fracture, and the
fn^mentsadjusteil to the model of
the upper jaw. In most cases the
position which these fragments
assume when thus placed, deter-
mines accurately the original form
nud jKR^ilion of the lower jaw.
U|>on tlie plaster model of the
lower jaw, obtained and rectified
in this way, a splint or clasp of
vulcanite rubber ie then made, embracing the arms, which are made
of steel wire, one-sixteenth of an inch in diiimctcr. The urm« must
I've upwards a little as they emerge from the mouth, to avoid prcs-
« upon the lips, and then curve backwards, terminating near the
llnof the jaw.
When the apparatus is applied, the teeth must be pushed into the
RIngilcf 'i ippinlui nnncd.
wielB of the eplint with some force. The dressing is now completed
WselinK made of strong musliu, extending beneath the chin from one
»nu tn the other.
(itOTBe L, Fitch, dentist, California, believes that "dental gutta
p^k" may be made to answer the same purpose as vulcanite ruober.
FBACTHEES OP THE LOWEB JAW.
in the construction of this and other Bimilar eplinte.* In this opinion,
however, Dr. Kingsley does not>5oncur.
The treatment of fractures of the inferior maxilla by a single-headed
bandage or roller, numbers among its dintingiiished advocates the
names of Gibson nnd Barton ; indeed, I
think the practice is at the present time
peculiar to a few American suif^ns.
Gibson gives the following directions
for applying his roller: "A cotton or
linen compress, of moderate thickness,
reachingfrom the angle of the jaw nearly
tn the chin, is placed beneath, and held
by an a>wistant, while the surgeon takes
a roller, four or five yards long, an inch
and a half wide, and ptLSses it by several
successive turns under the jaw, up along
the sides of the face, and over the head ;
now changing the course of the bandage,
he causes it to pass off at a right angl«
from the perpendicular cast, and to en-
circle the temple, occiput, and forrhnd,
horizontally, by several turns ; finally, to render the whole more secure) '
several additional horizontal turns are made around the back of the .
neck, under the ear, along the base of the jaw, under the point of the
chin. To prevent the roller from slipping or changing its position, k
short ple<« may be secured by a pin to the horizontal turn that eneir-
elcs the forehead, and pa.«sed backwards along the centre of the head
> Fitch, New York Hed. Omietle, 16S9.
FRACTURES OF THE LOWER JAW.
133
r fmr as the neck, wlierc it must be tacked to tlie lower horizoattil
•n — takiug care to fix one or more^iiis at every point at which the
pUer ttaa vrossed."
I Barton employ's, also, a compress, and a roller five yards long ; the
plication of wliii'h is thus cleaGri)>ed by Sargent: Place the initial
Btreintty of the roller upon the ocuiput, just
wluw its proluberancf, and conduct the ''"' ^*
grlinder obtiqutly over the centre of the tel't
Kfarietal bone to the top of the head ; tlience
descend across the right temple and the zy-
gomatic arch, and pass beneath the chin lo
the left side of the face ; mount over the left
n-gt>nia and temple to the Bumniit of the
craninm, and regain the ^starting- point at the
ofciput by traversing obliquely the right
panctal Imne ; next wind arorind the biise of
he lower jaw on the left side to thi' chin,
lul ihenee rctnm to the occijnit along clio
ighi side of the maxilla ; repeat the ^me
WKt, step by step, until the roller is spent, frncinmi j>«'
ad tht^n confine it^ terminal end.
These bandages possess the advantages of being easily obtained, of
mplicity and facility of appli^tion, and, we may add, if considered
B relation to the majority of simple i'ractures, of tolerable adaptation
vtbe ends proposed. The only objections to their use which I have
nr nutice<i, are occasional disarrangements, and the tendency, as in
U other continuous roller^, to draw the fmgmenta to one «ida or the
er,accordingasthe8nccessivetnrns
|f the bandage are carried to the right Fm.aj.
r left. There is one other objection,
ving rcfcrentv to the occasional in-
X|«ncv of this dressing to prevent
^VfTMpping of the fragments; to j* >. i .
ich objection also the sling, as J^Ki^.,'^\!^
ally constructed, is e<iually obnox-
!),and of which I sluill speak pres-
ly.
Finally, it is to the sling, in some
" its various forms, with or without
_ t interdental splint, that surgeons
Wc fcenerally given the preference.
The »ltng is known, also, by the name
of llii; four-headed or the four-tailed
mll(T (ir iHindagc.
B. Bell, Boyer, Skey, S. Cooper,
KC'oii(nT, 8yme, Fei^iisson, Mayor,
I'liC^R, and Cheliut* employ the sling,
Beiully ; and the favorite mode is to
>w ftir this purpose a piece of muslin cloth about one yard long and
Wr inches wide, torn down from its two extremities to within about
;.-r
134 FRACTURES OP THE LOWER JAW.
three or four inches of the centre. Otiiers have used leather, gutta
percha, adiiesive straps, gum-eliAtic, etc.
Where the muslin is used, it is quite customary to lay against the
skin a piece of pasteboard, wetted, and moulded to the chin, or simply
a soft compress ; and some choose to open the centre of the bandage
sufficiently to rewive the chin. The middle of this bandage being
laid upon the chin, the two ends corresponding to the up|>er margin
of the roller arc now carried across the front of the chin, behind the
nape of tlie neck, and made fast ; while the two lower heads are brought
directly upwards from under the sides of the chin, along the sides of the
face, in front of the ears, and made fast upon the top of the head. The
dressing is completed by a short counter-band extending across the
top of the head from one bandage to the other ; or the several hands
may he made fast to a nightcap, in which case the counter-band will
be unnecessary.
It only remains for me to describe my own method of dressing these
fractures with the sling.
Having frequently noticed the tendency of the sling, as ordinarily
constructtnl, and of Gibson's roller, to carry the anterior fragment
backwards, cs|)e<^ially in doul)le fracture where the body of the bone
is broken u|)on both sides, I devised, some years since, an ap})aratus
intended to obviate this objection, and which I have used now many
times with entire satisfaction.
It is conjpose<l of a firm leather strap, called maxillary, which, pass-
ing perpendicularly upwards from under the chin, is made to buckle
upon the to|> of the head, at a i>oint near the situation of the anterior
fontanel Ic. This straj) is supjwrted by two counter-straps, made of
strong linen webbing, calle<l, respectively, the (Kvipito-fnmtal and the
vertical. The ocvipito-frontal is loo|)ed u|)on the maxillary at a point
a little above the caix, and may be elevated or depressed at plea<<nre.
The o(vi|)ital |H)rtion of the strap is then carried backwanls and buckled
nmhr the (K»ciput, while the frontal |K)rtion is bu<^kled across the fore-
head. The vertical stra|) unites the occi|>ital to the maxillary across the
top of the head, and prevents the upjwr part of the latter from lx?com-
ing displace<l forwards. At each )X)int where a buckle is used, a ymd
must Ik' plac(Kl betwcH'U the strap and the head.
The maxillary stnip is narrow under the chin, to avoid pressure u|K>a
the front of the ne<*k, but imme<liately lMHX>mes wider, so as to cover
the sidc^ of the inferior maxilla ami facv, after which it gradually di-
minisius, to accommtKlate the buckle upon the top of the hwid. The
anterior margin of this ban<l, at the iM>int corres]M>nding to the syra-
phy>is menti, and for aUnit two inches on each si<le, is supplied with
thread-holes, f )r the pnrpo<^ of attaching a piwe of linen, which, when
the ap|)aratus is in plac<\ shall cross in front of the chin, and prevent the
maxillary strap from sliding Iwick wards against the fn>nt of the neck.
The advantage of this dn^ssing over any wliich I have yet seen, con-
sists in its capability to lift the anterior fragment almcwt vertically,
while at the same time it is in no danger of falling forwanls and
downwanls upon the forehead. If, as in the (-ase of most other dresii-
ingH, the (M*«ipital stay had its attachment op|M>site to the chin, its
FKACTUREB OP THE LOWER JAW.
effert would be to draw the central fragment backwards. By using a
firm piere of leather, as a maxillary band, and attaching the occipital
day above the ears, this difficult)- is completely obviated.
Having removed such teeth as are much loosened at the point of
fiadure, and replaced thoee which arc loosened at other points, unless
it be &r back in the mouth, and ad-
jured the fragments accurately, the
lower jaw is to be closed completely
npon the upper, and the apparatus
ongly applied. It is not necessary
in mart cases to buckle the straps
with great firmness, since experience
Im shown that a sufficient degree of
imoiobility is usually obtained when
ibe apparatus is only moderately
tight.
If the integuments are bruised and
tender, a compress made of two or
morethicknes^esofpatent lint should
be placed underneath the chin, be-
tween it and the leather.
If tiie inability to introduce
notirishment between the teeth when
the mouth is closed, or the irr^u-
Wity of the dental arcade renders
the i»e of intenlental splints neces-
nry, giitta percha, as I have already explaineil, ought, in general, to
be prefcrrefl to any other material.
The patient must be forbidden to talk or laugh, and when he lies
down, his head should rest upon its back, for whatever mode of dress-
ing is employed, and however carefully it is appHe^l, it will be found
tlut a sn;rht motion and displacement will occur whenever the weight
of the head rests aj.on the side of the face.
Ocrasionally, indeecl, as often as every two or three days, the appa-
rata« may l»e lot^cncd or removed, only taking care generally not to
dignrb the intenlental splints, when they are used, and to su|>port tiie
■ jaw with the hand, during its removal ; and, at the same time, the face
may be sponged off with warm water and castile soap. It should not
be left off entirely, however, in less than three or lour weclis, even
where the fracture is most 8im])le, nor ought the patient be allowed to
at meat in less than four or five weeks.
To rIeaiiM the mouth and prevent offensive accumulations, it should
W washed several times a day with a solution of tincture of myrrh,
pivpami by adtHng one drachm to about four ounces of water.
The same apparatus, and without any c-scntiiil modification, is ap-
plicahle to fractures of the symphysis ami of the angle of the inferior
■uilla, as weJJ as tn fractures of the body of the bone,
Ii»te»l of the leather, I have in a few 'instanres, especially of com-
poawtfnctarpe where it became neeessar\- to allow the pus to dischat^
oienaUv iL^ed a sling ora splint comiMised of gutta percha, susjieuded
136 FRACTURES OF THE LOWER JAW.
by bands carried over the top of the head. The piece from whieh.this
splint is made should be three or four lines in thickness, covered with
cloth, and padded under the chin. It will be found convenient to
cover it with cloth before immersing it in the hot water. The water
should be nearly at a boiling temperature, so that the splint may be-
come perfectly pliable; and it should be laid upon the face and allowed
to mould itself while the patient lies upon his back.
Having thus fitted it accurately to the face, it may be removed and
o|>eniugs made at points corresponding with the wounds upon the skin,
before it is reapplied.
As has been already explained, the gutta percha, if sufficiently thick,
and if the lateral wings arc allowed to project a little on either side,
will serve effectually to protect the sides of the face against pressure
from the bandage; and being more easily moulded to the base* and
front of the chin than any other material which has yet been employed,
must have the preference. The necessity for its use, however, is only
occasional.
In fractures of either condyle, unaccompanied with displacement,
the simple leather or muslin sling will sometimes accomplish a perfect
and speedy cure, as the two cases re|)orted by Desault will sufficiently
demonstrate. But if the fragments have become separated, the replaoe-
ment is difficult, and tlie retention uncertain.
Ribes was the first to sugg(»st and to practice a very ingenious
method of reduction in these cases. Having seen two examples which
had resulted in deformity under the usual treatment, whicJi consisted
in simply pressing forwards the angle of the jaw, it occurre<l to him
that while the upper or condyloidean fragment was not acted upi>n at
the same moment by pressure from the opposite direction, a reduction
must be impossible. The case of a cannoneiT whose jaw was broken
through the neck of the condyle on the right side, and through ita
IkkIv on the left, aff*orded him an opportunity to determine the prao*
ticability of a method of which he had as yet only conceived the idea.
Malgalgne thus descrilK»s his procedure : " With the left hand seize the
anterior |H)rtion of the jaw, for the puriK)se of drawing it horizontally
forwards, while you ciirry the index finger of the right hand to the
lateral and sujKTior part of the pharynx. You will meet at first the
projection fornuHl by the styloid process, but, moving your finger for-
wanls, you will find soon the posterior border of the minus of the jaw;
and following this bonier from below upwards, you will arrive at the
inner side of the condyle, which you will push outwanls in such a
manner lus to engage it upon the either fnigtnent. This maua^uvre
umnot l)e made without cjuising nausea, a.^ the finger always does when
ciirried into the |K)sterior part of the pharynx ; but this is a slight in-
convenience. The rtMluction obtained, iKiir the jaw u{lwards and back-
wanls in onler to press and fix the condyle between it and the glenoid
cavity, tlu'ii fasten it in pljice with a sling.'' The fragments were thus
easily brought into apfxisition in the case reported by Ribcs, and the
[mtient was cured without any deformity.
In addition to these means, the angle of the jaw ought to be pressed
permanently forwards by means of a compress placed between it and
FBACTUBES OP THE HYOID BONE. 137
the mastoid process, and held in place by a suitable bandage ; or we
may adopt the method which proved so successful with Fountain,
n&mely, wire the front teeth of the lower jaw to the front teeth of the
npper in such a manner as to draw the chin forwards, and thus main-
tain apposition.
If the coronoid process be alone broken, it is sufiBcient to close the
mouth with any form of sling or bandage which may be most conve-
nient.
CHAPTER XIII.
FBACTUBES OF THE HYOID BONE.
M. Obfila has reported the case of a man, aged sixty-two years,
who had been hanged, and whose os hyoides was broken through its
body on its right side.* M. Cazauvieilh has also seen a fracture of
this bone in two persons who had been hanged : in one of which iho
fracture was probaoly in the body of the bone, and in the other throug.i
one of its comua.*
Lalesque published in the Journal Hebdomadaire for March, 1833, a
case which occurred in a marine, sixty-seven years old, " who, in a
quarrel, had his throat violently clenched by the hand of a vigorous
•dversary. At the moment there was very acute pain, and the sensa-
tion of a solid body breaking. The pain was aggravated by every
effort to speak, to swallow, or to move the tongue, and when this organ
was poshed backwards, deglutition was impossible. The patient could
not articulate distinctly; and he was unable to open his mouth without
exciting a great deal of pain. He placed his hand upon the anterior
and superior part of his neck to point out the seat of the injury. This
part was slightly swollen, and presented on each side small ecchymoses;
(me above, more decided, immediately under the left angle of the lower
jaw. The large comua of the os hyoides was very distinctly to the
right side/^ and it could be felt on the left deeply seated by pressing
with the fingers; in following it in front toward the body of the bone,
a very sensible inequality near the point of junction of these two parts
coold be perceived. By putting the finger within the mouth, the same
prr^ections and cavities inverted could be felt, and even the points of
the bone which had pierced the mucous membrane, etc., were evident.
Having bled the patient, and placed a plug between his teeth to keep
the month open, tne broken branch was brought by the finger back to
the sarfaoe of the body of the bone, and easily reduced. The position
of the head inclined a little back; rest, absolute silence, diet, and some
nomine fomentations, composed the after-treatment. To avoid a new
dislocation bj the efforts of swallowing, the oesophagus-tube of Desault
I Traits de M^. legale, troisieme ^., torn, ii, p. 428.
> CMkzmuvieWhf da Suicide, etc., p. 221.
10
138 FRACTURES OP THE HYOID BONE.
was introduced, to conduct the drinks and liquid aliments into the
stomach; this sound was allowed to remain until the twenty-fifth day;
at this time the patient could swallow without pain, and bc^n to take
a little more solid nourishment, and at the end of two months the cure
was complete. By placing a finger within his mouth, a slight nodosity
could be felt in the place where, in the recent fracture, the splintered
points were perceptible.*
Dieffenbach has also recorded a fracture of the great right horn, pro-
duced in the same manner, by grasping the throat between the thumb
and fingers, which occurred in a girl only nineteen years old. Very
slight pressure upon the side of the bone was suflScient to move the
fragment inwards, and to produce a crepitus; but it immediately re-
sumed its place when the pressure was removed. There being, there-
fore, no displacement, the cure was effected in a short time without
resort to any remedies except tisans and antiphlogistics. She was not
even forbidden to speak.^
Aul)erge saw a similar case, in a person fifty-five years old, occasioned
by grasping the throat. The fracture was in the great horn of the right
side, and the displacement was so complete that crepitus could not be
felt, and the mucous membrane of the pharynx was penetrated by the
broken bone.'
The following example is reported by Dr. Wood, of Cincinnati,
Ohio, as having come under his observation in the year 1855 :
" Through the kindness of our friend Dr. P. G. Fore of this city,
we were invited to examine a case of fracture of the os hyoides, that
had occurred about one week before we saw it, in one of his patients.
The patient was a female, about thirty years of age, who had fallen
down the cellar steps, striking the prominent parts of the larynx and
hyoid bone against a projecting brick, severely injuring the larynx as
well as fracturing the bone.
" The fracture was on the left side, and near the junction of the
great horn with the body of the bone. Crepitus was distinctly felt on
pressing the bone between the thumb and finger ; or when the patient
would swallow; though, at this time, the severe symptoms that fbl-
lowe<l the accident, and continued for several days, had somewhat sub-
sided.
" Immediately after the accident there was profuse bleeding from
the fauces, and she experienced great difficulty and pain in the act of
swallowing, and the i)ower of speech was almost entirely lost. On at-
tempting to depress or protrude the tongue, she felt distressing symp-
toms of 8uffoc*ation. Considerable inflammation and swelling of the
throat and larynx ensued, and continued in some degree up to the time
of our visit.
" To-day (about four weeks since the accident) Dr. F. informs us
that the patient Ims so far recovered as to l>e able to converse, though
> Am<T. Jniirn. Med. Sci., vol. liii, p. 2r»0.
» M*^\k\ VtTeinMeltunj: fUr PreuMon, 1883, No. 8; Oazetto M^., 1S34, p. 187.
> Kevue Med , July, 1885.
FRACTURES OF THE HYOID BONE. 139
the voice is soroewliat impaired. She is yet unable to swallow solid
food, and is wholly sustained by fluids.^'*
ilarcinkovsky saw a woman in whom both the lower jaw and the
left horn of the os hyoides were broken by a fall from her carriage
against a wall. She died in about twenty-four hours, from sutfoca-
tion.*
Dr. Grunder reports the following :
"A laborer, set. 63, fell from a wagon on his face, and discharged a
large quantity of blood by the mouth. He found he could not swal-
low, and when seen twelve hours afterward, complained of severe pain
Id the neck and nape, with inability to turn his head, though no injury
of the vertebrae could be detected. His voice was hoarse and difficult.
On attempting to drink, the fluid was rejected with violent coughing,
the patient declaring he felt it as if entering the air-passages. An ex-
amination of the fauces led to no explanation of this condition. The
epiglottis did not, however, appear to completely close the larynx, or
to be in its exact position. Tne tongue was movable in all directions,
and pressing it down with a spatula caused no inconvenience. The
hyoid seemed to possess its continuity. No crepitation or abnormal
mo\'ability could be perceived, and no pain at the root of the tongue
occurred on attempting to swallow. After repeated examinations, the
case was concluded to be one in which the functions of the nervus
vagus had undergone great disturbance, or the muscles of the larynx
had become torn or paralyzed. Medicine and food were administered
by means of an elastic tube. The patient had a good appetite and
slept well ; the pain of the neck was lost, and its motion recovered ; a
hectic cough, from which he had long suffered, alone remaining. After
continuing, however, to go on thus well for six days, the cough in-
creased; the appetite failed; strength >vas lost; the voice was scarcely
audible; and in five more days the patient died exhausted. At the
aotopsy a fracture of the os hyoides was found. One of the large cor-
nua was broken, and had become firmly imbedded between the epi-
glottis and ritoa glottidis, inducing the raised position of the epiglottis,
lose of voice, and diflSculty in swallowing. The fi^cture -was probably
produced by muscular action, a cause first assigned in a case occurring
to Ollivier d'Angers.''*
I think it more probable that this fracture was the result of a direct
blow, than of muscular action. In the case referred to, however, as
having been reported by Ollivier, there can be no doubt that the frac-
ture was due to muscular action alone.
A woman, fifty-six years old, made a misstep and fell backwards,
and at the same moment that her head was thro\vn violently back, she
felt dbtinctly a sensation as if a solid body had broken, in the upper
part of her neck and upon its left side. An examination showed that
she had fractured the great left horn of the os hyoides. Inflammation
* Wwti^n Lancet; a1»o N. Y. Journ. Med., vol. xv, p. 162.
' Medic. Vereinsreilung fur Preiween, 1833, No. 15; Gazette M^icale, 1833, p.
' Srhmidt's Jabrbucb., vol. Ixviii; also Amer. Journ. Med. Sci., vol. xlix, p.
2», Jan. 1852.
140 FRACTURES OF THE HYOID BONE.
and suppuration followed, and finally, after about three months, the
posterior fragment made its way out in a condition of necrosis, and the
fistula promptly healed, but there remained for many years a sense of
uneasiness about these parts when she swallowed, sometimes amounting
to pain.^
Etiology, — Of the ten cases which I have found upon record, three
were produced by hanging ; three by grasping the throat between the
thumb and fingers ; three by direct blows, or by falls upon the front of
the neck ; and one by muscular action alone.
The observation of Mr. South, that fracture of the bone " is almost
invariably found "^ in persons executed by hanging, is probably incor-
rect, since although a large proportion of these subjects are submitted
to dissection both in this and other countries, yet I know of but these
three examples which have been published.
Pathology^ Symptomatology , and Diagnottis. — The body of the bone
seems to have been broken in all of those cases which resulted from
hanging ; while in all of the other examples the fracture has occurred
in one of the great horns, or at the junction of the horns with the body.
Generally the displacement inwards of one of the fragments has been so
complete that crepitus could not l>e detected. It was present, however,
in the examples mentioned by Dieffenbach and Wood. In two in-
stances the mucous membrane has been penetrated, and in one the
fragment was ])rojected between the epiglottis and rima glottidis.
The accident has been characterized by a sudden sensation as if a
bone had broken ; in a few instances, by profuse blee<ling from tlie
fauces; by difficulty in opening the mouth; by impossibility of deglu-
tition, and by loss of voice in others; with great pain in moving the
tongue, the pain being especially at its root; in one instance the toneue
was |)crceptibly drawn to one side. There is usually more or less
swelling and soreness about the neck, with ecchymosis; and at a later
period, cough, expectoration, hoarseness, etc. The circumstances which|
however, indicate certainly the nature of the accident, arc preternatural
mobility of the fragments, with or without crepitus, and the angular
inward projection, which may in most cases be distinctly felt in a care-
ful examination of the pharynx.
In the case related by Griuier, the only symptoms were a loss of
voice, difficulty of deglutition, and a sensation, when the attempt was
made to swallow, as if the fluids passed into the windpi[)e ; with also
an imfXTfect closure of the epiglottis Hjwn the rima glottidis. No pre-
ternatural mobility or irregularity in the fragments could be detectetl,
nor was there cR>pitus, and it was concluded that the bone wik^ not
broken, yet the autopsy showed that the fragment was imbedded di»eply
between the epiglottis and the rima glottidis.
Prognosis. — It is only in view of its complications tliat thk< accident
can Ik' regarded as serious; where the severity of the iniurj* has been
Huch as to fracture the lower jaw at the same time, as in the case related
by Marcinkovsky, or such as to bury the fragment deep in the tissues
' Mnlf^AifCno, op. cit, p. 405.
* Nute Uf Chelius't Surgery, Amer. ed., vol. i, p. 581.
THYROID CARTILAGE. 141
about the rima glottidis^ as in the ease mentioned by Griiner, a favor-
able termination could scarcely have been expected ; and these are the
only cases yet published in which the death was in any way connected
with the fracture. One-half of the whole number have died, but of
these^ three have died by hanging, and the remaining two from the
causes named. Of the three in which the accident resulted from a
direct blow, only the patient of Dr. Fore, of Cincinnati, has survived ;
while of the three whose fractures resulted from lateral pressure upon
the comua all recovered ; so, also, did the patient in whom the fracture
was produced by muscular action.
TVeatment — No doubt when the fragments are displaced an attempt
ought to be made to replace them by introducing one finger into the
mouth, while with the opposite hand the fragments are supported from
without. Lalesque found this a matter of some difficulty, but Auberge
experienced no difficulty at all. I suspect, however, that the amount
of difficulty will very much depend upon the degree of displacement,
and the consequent lacerations of the soft tissues about the bone. But
however this may be, it must be altogether another thing to be able to
keep in exact apposition the broken ends of a bone whose diameter is
so inconsiderable, and upon which it is quite impossible to apply any
apparatus or dressings to retain the fragments in place. Lalesque
threw the head of his patient slightly back, with the view of making
" permanent extension '' upon the fragments through the action of the
muscles and ligaments attached to the bone, and he recommends this
Sdtion as that which is best calculated to preserve the coaptation,
algaigne, on the contrary, without having himself seen any example
of this fracture, believes that the position of flexion of the neck, with
entire relaxation of the muscle^ would be most suitable.
In all cases it will be proper to enjoin silence, and to adopt suitable
measures to combat inflammation ; such as general or topical bleeding,
fomentations, moistening the mouth with cool water, or permitting
small pieces of ice to rest in the mouth until dissolved, without in
eeneral allowing the fluid to be swallowed ; but in some examples, no
doabt, the patient may be permitted to swallow.
CHAPTER XIV.
FRACTURE OF THE CARTILAGES OF THE LARYNX.
2 1. Thyroid Cartilage.
The examples of fracture of the larynx which may be found upon
wsord are also very few. M. Ladoz examined the larynx of a man who
^ been assassinated, and upon whose neck he found a handkerchief
bonnd 80 tightly as to leave, after its removal, a deep furrow ; but the
^Bhowed also distinct marks produced by the fingers and thumb.
142 FRACTURE OF THE CARTILAGES OF THE LABYSX.
There was a fratture of the thyroid cartilage which extended obliquely
duwiiwords and outwards through its right wing. The whole of the
larynx was very much OEsilied, alUiough the eubject was only tlurty-
sevcn yeara old,'
In 1823, M. Ollivier communicated to the Academy of ^f(.■dicine a
CBJie in which, this cartilage being broken, the patient died of suffoca-
tion.'
M. Marjolin says: "Two women at the hospital being engt^ed in a
quarrel, one of them seized her antagonist by the throat, and griped
her 80 strongly that she broke the thyroid cartilage from its upper to
its lower margin. You will imagine that it was oot very difficnlt to
determine the existence ol' a fracture, and that no retentive ap|)aratua
was demanded. Silence, regimen, a small bleeding, and the cure was
accomplished."'
Habicot operated successfully, in 1620, by introducing a leaden lube
into the trachea in a case in which the thyroid was " daraage<i." Gibb,
Norris, Nelaton, and Keuderliue have each reported examples of frac-
ture of this cartilage alone'
\ 2. Thyroid and Cricoid Cartilagru.
Plenck saw a fracture of both the tliyroid and cricoid cartilages
Eroiluced by falling upon the rim of a pail.' Morgagni also siiys tliat
e had seen fractures of the laryn.x; and Remcr mentions a fnurture of
the larynx found in a person who had been liaugcd;^ but in neither
case is it said in which cartilage tike fracture occurred, or whether it
had not occurred in both.
Dr. O'Brian, of Bilinburgh, rei^rls in vol. xviii of the ICdinUurgh
Med. and. Surg. Journ., a case of fracture of liotli cartilages, involving
the trachea also, in a woman who had received a kick under the jaw,
and who died on the following day. Hunt has collected other cases,
some of which involved the arytenoid cartilages, the hyoid boofl, the
trachea, etd
I am able to furnish, from my own observation, another example of
fracture of both the thyroid and cricoid cartilages:
JohnCulkins, of Collins, Erie Co., N. Y,, set. 41, is suppostfl to lia%-«
l}een kicked by a young horse on the 10th uf November, 1866. He was
alone in the stables when the accident occurred, and, being stunned hw
the blow, he could not himself give any account of the manner in whioi
the injury was received. When found, he was sitting upright, bnt
unable to articulate except in a whisiwr, Drs. Barber and Davis, of
Golden, saw him about two hours after. His coniitenaneo was anxious ;
his pulse fi-eble; extremities cold; aud be was breatbiug with great
I Gniottn MMIiwIo, ISSS, p. IDR.
■ Ari-hivei G£ii«r>1)u in MMoclnp, tome ii, p. 807.
■ Mnrjolin, Couri du Pittbolog. Cblr., p. SM.
• H.i.11. Frio, of Lnrjnx, oU. Am. Journ. Mud. Scl., April, 1866.
• Hnlgn'gnn. of. elt., p, iW.
• HnrRitgni, do itcdibiu, olo , EpTit. 10, num. 13, U, et 16 ; Itomer, Anmln
d'HjgUn*! tumi Iv, ]>. 171 i IVom Uklgftigne.
THYROID AND CRICOID CARTILAGES. 143
difficaltv. A small quantity of blood was issuing from his fauces.
His upper lip was cut, and a few of his teeth dislocated; the wound
appearing as if inflicted by one of the corks of the horse's shoes.
There was no other wound; but over the left wing of the thyroid car-
tilage there was a slight discoloration, pressure upon which produced
intense pain and suffocation, and disclosed the fact that the thyroid
prominence was depressed very much and broken. Cold lotions were
directed to be applied, and as the thirst was excessive, but deglutition
impoasibley he was permitted to hold pieces of ice in his mouth. This
plan, with but slight modifications, such as the substitution of warm
fomentations to the neck for the cold lotions, was continued until the
following evening, when, at the request of the attending physician. Dr.
Barber, I was called to see him. The symptoms remained nearly the
same as at first. He was unable to speak audibly, or perform the act
of deglutition ; his breathing was diflScult, and at times threatened
suffocation. The lateness of the hour, with other circumstances, de-
termined me to defer surgical interference until morning. At day-
l>reak of the 12th I made the operation of laryngotomy, and introduced
a large double canula into the crico-thyroidean space. This operation
was rendered difficult by the great amount of swelling about the neck,
due both to emphysema, and bloody with serous infiltrations. The
breathing immediately became easy, and gradually the appearance of
asphyxia disappeared from his face; but after about six or seven hours
he began perceptibly to Ml in strength, and died at 3 o'clock p.m. of
the following oay, apparently from exhaustion rather than from suffo-
cation ; having survived the accident about seventy-two hours, and the
operation aboat thirty-four hours.
The autopsy disclosed a comminuted fracture of the thyroid cartilage,
with a simple fracture of the cricoid. The thyroid was broken almost
perpendicularly through the centre ; the line of fracture being irregu-
lar, and inclining slightly to the left side. The left inferior horn was
broken off about throe lines from its articulation with the cricoid car-
tilage. The right ala was broken also in a line nearly vertical, but
irregular, at a point about six lines from its posterior margin. The
pomam Adami was depressed to the level of the cricoid cartilage, and
the left ala, being completely detached, was thrown inwards and up-
^^ards several lines. Underneath the perichondrium, especially upon
^ inner side, there was pretty extensive bloody infiltration. Ossifi-
cation of the cartilages had commenced at several points, but it had
mde but little progress. The central fracture of the thyroid was
through cartilage alooe. The fracture of the right ala was through car-
tilage until it reached a bony belt comprising the two inferior lines of its
^^^' T^« left lower horn was ossified, and the fracture was through
this bony structure. The fracture through the cricoid cartilage com-
nienced close upon the margin of a bonv plate, but in its whole course
It traversed only cartilage. It was on the left side. There was also
ao mcomplete fixture on the right ala of the thvroid cartilage, com-
mencing in the line of the principal fracture and 'extending obliquely
downwards abom three lines, until it wa- arrested bv the bony plate
which constitoted die kwer margin of this wing '
144 FRACTURE OF THE CARTILAGES OF THE LARYNX.
A ragged, lacerated wound in the back of the larynx, above the
cricoid cartilages, communicated directly with the oesophagus.
2 3. Cricoid Cartilage.
Both Valsalva and Cazauvidilh have each met with a single example
of this fracture, without fracture of the thyroid cartilage; and Weiss
has found the cricoid cartilage broken into numerous fragments, and at
the same time separated from the trachea.^
General Etioixkjy of Fractures of the Laryngeal Carti-
lage,— As a predisposing cause, advanced age, with its usual con-
comitant, partial or complete ossification of the cartilages, has been
thought to occupy a prominent place. In the case re|K)rted by Plenck,
the cjirtilages were already very much ossified, although the subject \vas
only thirty-seven years old. Morgagni observed that in his experience
it had occurred always in advanced life. In my own case, however,
the cartilages were only slightly ossified, the patient being forty-one
years old ; nor did the lines of the several fractures indicate a prefer-
ence for the bony plates; but it seems to me that they rather avoided
them, and in the case of the incomplete fracture the bone ap{)cared to
have arrested the fracture. In fact, a few experiments have satisfied
me that the adult laryngeal cartilages are quite as brittle as bone, and
consequently, that ossification in no way increases their liability to
fracture.
Hunt ascertained the age in fifteen cases, and but one of the whole
number was over 45 years ; five occurred in children, one of whom was
only four years old.
The imme<liate causes have been direct blows, as falling upon the
edge of a pail, a kick from a horse, or pressure, as in hanging, or in
grasping the larynx strongly between the thumb and fingers.
General Symptomaix)Logy, Etc. — The signs of this accident are
such as may attend any severe injury of this organ, whether accom-
panied with a fracture or not, such as jwiin, swelling, difficult degluti-
tion, embarrassed respiration, loss of voice, cough, and perha|)S bloody
expectoration, with emphysema, etc.
But none of these can be regarded as diagnostic ; although, when
taken in connection with the history of the accident, es|>ecially if a very
severe and direct blow has been received, or more certainly still when
symptoms so grave and complicated have followed an attempt at stran-
gulation by grasping the throat, they may be regarded as probable or
presumptive evidences.
A {)ositive diagnosis must depend u|)on the presence of a sensible
displacement, or motion of the fragments, with crepitus.
In the case relateil by Plenck, death followed almost immediately,
with convulsions, and without any outcry ; indicating, probably, some
severe lesion of the spinal marrow ; while in M. Ollivier's patient
suffocation ensued, at first intermittent, and finally permanent.
' MalgAigne, op. cit., p. 40S.
CRICOID CARTILAGE. 145
In my own case, suffocation was throughout a prominent symptom,
with only such slight intervals of amelioration as might have been
occasioned by the extrication of the blood or mucus from the larynx.
General. Prognosis. — The prognosis ought to depend rather upon
the complications and upon the gravity of the symptoms, than upon
the simple decision of the question of fracture. A fracture produced
bj grasping the wings of the thyroid cartilage, and without any great
contusion or laceration of the soft parts, might reasonably be expected
to terminate favorably under judicious management; but when, on the
contrary, the fracture is the result of great violence inflicted directly
Dpon the front of the cartilages, producing severe contusion and lace-
ration, and is followed by great swelling, emphysema, very difficult
respiration, complete aphonia, impossibility of deglutition, etc., the
prognosis cannot but be unfavorable.
General Treatment. — In examples of simple, uncomplicated
fracture, "silence, regimen, and a small bleeding" may suffice; but in
other cases it may become necessary to introduce a tube into the
^mach, to supply the patient with food and drink, since deglutition
may be impossible. If, also, suffocation is imminent, there may remain
no alternative but a resort to tracheotomy or to laryngotomy.
Indeed, one of these operations ought, we think, to be resorted to in
all cases in which emphysema is prominent. Dr. William Hunt, of
the Pennsylvania Hospital, in his excellent paper on " Fractures of the
Larynx and Ruptures of the Trachea,'^ in which he has arranged a
tabalar synopsis of twenty-nine cases, says that of twenty -seven cases
tm recovered and seventeen died. Of eight cases in which tracheo-
tomy was performed, but two died. In the four cases in which re-
cover}- took place without an operation no mention is made of bloody
expe^radon or of emphysema.^
As to a "reduction of the fragments by manipulation, I believe it
will be found generally, if not always, impracticable. Whatever dis-
placement exists must be mostly inwards, and we can have no means
of forcing them again outwards. Nor, if once replaced, do I see any
leasoo to suppose that they would not become immediately displaced.
Chelios has suggested the propriety, in such cases, of cutting open
the coverings of the larynx freely in the median line, and, afler stanch-
ii^ the bleeding, proceeding at once to divide the larynx itself in its
whole length, and then replacing the broken cartilages.' The pro-
oedare has an aspect of severity, but I can well conceive of circum-
stances which would justify its adoption ; not, however, so much for
tlie purpose of replacing the cartilages, as for the purpose of arresting
tmal internal hemorrhage, and of giving a free admission of air to the
lungs. If this operation were to be practiced, the wound ought to be
kft open for a sufficient length of time to allow of the subsidence of
the inflammadoo, and then permitted to close with such precautions as
> Hunt, Amer. Journ. Med. Sci., April, 1866.
' System of Surgery, Philadelphia ed., vol. i, p. 581, 1847,
experience
opened.
neck, so far
important
treat mi^nt.
My own
di&iolve in
au external
FBACTUBES OF THE VEBTEBB^
teaches are usually necessary' af^r the windpipe has been
intiphlogistic measures, combined with fomentations to the
as these latter are found to be agreeable and practicable, are
measures, and not to be overlooked in the general plan of
patient, also, found small pieces of ice, permitted slowly to
the month, very grateful ; but he preferred very much, as
application, the warm fomentations to the cold lotions.
CHAPTER XV.
FRACTUBES OV THE VBRTEBRiE.
It will be convenient to divide fi-actures of the vertebrse into fr«e-
tures of the spinous processes, transverse processes, vertebral arches^
and bodies.
i 1. Fractares of the Bpinons Froce»ei.
Fractures of the spinous apophyses, independent of a fracture of the
arches, may occur at any point of the vertebral column ; and they may
be occasioned by a blow received upon either side of the spinal columo;
or by a foret- directed from above or from below.
Sumptoins and Pathology. — These accidents may be recognized by
the lively i>ain at the point of fracture, produced especially when the
patient Uinds forwards, wliich position renders the skin and muscles
U.-\iw and drives the fragments into the flesh ; by the swelling, tender-
ness, and discoloration ; but chiefly by the lateral displacement of the
broken process, and the mobility.
I>uvern«7 met with a fracture of two of the processes in the satne
person, and which could only be recognized by the mobility, since, as
the autopsy proved, there was no dis-
placement. Xor would it be surprising
if the displacement was absent in a ma-
jority of these accidents, inasmuch as the
attachment of the ligaments from above
and below with the strong and short
muscles upon either side, mnsi prevent ft
deviation in any direction until these
tissues were more or less torn. Sir Astlcy
CoojKir nienlionx a case in which, how-
I'vcr, snch lacerations did occur, and tlw
lateral defi)rniity was quite conspicuous.
A boy hod been cndcnvoring (o aa|H
port a heavy weight upon his shoulden,
when he fell bent double Immediately
he had tlie appearance of one suffering
under a distortion of the spine of long
fltunding. Three or four of the processes were broken off, and the oor-
FRACTURE OF THE SPINOUS PROCESSES,
respoDfling Diuscles were detached so as to allow the processes to &l\
oS to the opposite side. There was iio paralysis, and he was soon dia-
chai^red with the free use of his limbs, but the deformity remained,'
If the fragment is thrown directly downwards, as it possibly may be,
ispecially in the cervical or lumbar region, yet not without a rupture
of ihe supraspinous ligaments, or of the ligamcntum nuchte, then the
displacement will be more difficult to detect, and it may require some
more care not to confound it with a fracture of the vertebral arch or of
the plates from which the s{)inous processes arise. The process not
being felt in its natural position, nor upon either side, it may seem to
liave been forced directly forward.s, when in fact it is only thrown
downwards towards its fellow. The danger of error in the diagnosis
will be increased when to these conditions arc added paralysis of those
portiona of the body which are below the seat of the fracture, and
which, in this cose, may be the i-esult of an extravasation of blood or
of simply a concussion of the spinal marrow. Nor do I think it would
'b possible now to determine positively whether it was simply a frac-
e of a spinous process, of the arch, or of tlie body itself of the ver-
In case, however, the paralysis results from concussion, the fact
I in most cases soon become apparent by a return of sensation and
^the power of motion,
I Prognosis. — Hippocrates affirmed that here, as in fractures of other
Miigr bones, the union took place speedily. It is quite probable that
inis venerable father of surgery has stated the fact correctly, and yet
in llie only example known to me where the condition of this process,
as proved by dissection, has been carefully stated, the fi-agraent had not
uniteil by bone at all. This is the case related by Sir Astley Cooper
as Imving been examined by Mr. Key. A subject was brought into
thedl^Kectiog-room, in which one of the processes had lieen broken,
^^Std, on dissection, a complete articulation was found between the
^^bpken surfoi'es, which surfaces had become covered with a thin layer
^^m cartilage. The false articulation was surrounded with synovial
^^piinbraue and capsular ligaments, and contained a fluid like synovia.*
L Ordinarily the displacement continues, whatever treatment may be
ailouied ; but Malgaigne says he has seen one instance in which the
twcltth dorsal spine, being broken and displaced laterally, resumed its
plaiv spontaneously after a few days. Aurran mentions a similar ex-
inijile.'
IWatnumt, — If in any case it should be found possible to act upon
lilt fntgroent, an attempt might be made to press it into place, and to
Rain it there by means of a compress and bandage ; but even this
«iHild not be admissible so lone as any doubt remained whether it was
rot a fracture of the vertebral arch, since, if it were, any attempt to
iwtore the bone to place by pressure would be likely to drive it more
"Wply upon the spinal marrow. Yet what need is tliere of sui^ical
interference of any kind ? If the apophysis remains displaced it can-
out nsult in any serious, perhaps we may say in any appreciable de-
' S' Aitlojr Cooper, op. cit., j
' Utlgmgne, op. cit , p. 112.
' lb., p. 459.
148 FRACTURES OF THE VERTEBRAS.
formity. The surgeon has therefore only to lay the patient quietly in
bed and in sueh a position as he finds most comfortable, enjoining upon
him perfect rest, and employing such other means as may be proper to
combat inflammation.
2 2. Fractures of the Transverse Process.
A fracture of a transverse process can scarcely occur except as a con-
sequence of a gunshot wound. Dupuytren relates a case of this kind
in which the 1ml 1 harl penetrated the transverse process of the second
cervical vertebra. The man bled very little at the time, and his symp-
toms progressed favorably for ten days ; after which secondary bsemor-
rhage occurred, of which he ultimately died. The autopsy showed
that the vertebral arter}' had been injured, and that the inflammation
of its coats being followed by a slough, caused his death.*
I have also elsewhere reported the case of Charles Harkner, of
Buffalo, X. Y., who was shot with a pistol on the 21st of Jan., 1851.
I did not see him until the following day. The ball had entered the
chin, a little to the left side and below the inferior maxilla, but its
place of lodgment could not be discovered. He lay with his face con-
stantly turned to the right. The left side of his neck was swollen and
crepitant ; the left arm and leg were paralyzed ; he slept most of the
time, but could be easily aroused, and when aroused he seemed to be
conscious, but was unable to speak. By signs he indicated to us that
he was suffering no pain. He gradually sank, without hsmorrhagei
and died in thirty-six hours from the time of the receipt of the injury.
The autopsy, made four hours after death, enabled us to trace the
wound from the chin, through the left ala of the thyroid cartilage, and
also through the roots of the transverse process of the fourth cervical
vertebra; immediately behind which, lying imbedded in the mascles,
was the bullet. The cavity of the tunica arachnoides contained con-
siderable serous effusion.
The emphysema in the neck was occasioned, no doubt, by the wound
of the lannx, the ball having opened freely into its cavity. This cir-
cumstance also explained the aphonia ; but the immediate cause of his
death seems to have been arachnoid effusion as a result of meningeal
inflammation.
The symptoms arising from this accident can only refer to the com-
plications, since a mere fracture of the process is not likely to present
anv pec'uliar signs which could be recognized. Concussion or bloody
efiiision may take place so as to occasion more or less paralysis, or, at
a later period, inflammation and its consequent effusions may give rise
to the same phenomenon.
In itself considerwl, and independent of these com plica tions, it i$
sufiiciently trivial, but inasmuch as it has not been known to occur
except from gunshot wounds, nor is it likely to occur except from pen-
etrating wounds of some kind, the accident must always be regarded
as exceedingly grave, if not actually fatal.
* Dupuytren, DUeasct, etc., of Bones, Syd. ed., p. 860.
FBACTDBES OF THE VEBTEBBAL ABCHES. 149
As to the treatment, nothing but strict rest and antiphlogistic rem-
edies can prove of any service.
i 3. Fracturef of the Vertebral Arclie*.
The vertebral arches, upon which both the spinous and transverse
processes have their principal support, may be broken at any point of
their circumference, by a blow received upon the spinous jirocess ; but
generally it is the lamellar portion, or
the "vertebral plate" which gives way
rather than the neck or pedicle of the
arch ; and in ail of the cases recorded the
plat^ have been broken upon both sides.
On the first of May, 1851, during a
violent storm of wind and rain, a balus-
trade fell from the top of a high build-
ing, striking a man named John Larkin,
who was about forty years of age, upon
the back of his head and neck. He fell
to the ground instantly, and did not
again move his feet or legs, although he
oever lost bis consciousness until he died.
I found the bladder paralyzed also, and
bis left arm, but hb right arm he could
move prettv well. He conversed freely up to the last moment, and
sud tnat fie was suETering a good deal of pain, which was always
greatly a^ravated by moving. His death took place thirty-six hours
ifter the receipt of the injury.
Dr. Hugh B. Vandeventer, who was the attending sui^eon. made a
dissection on the following day in my presence, which disclosed the
&ct that the plates of the sixth cervical vertebra were broken upon
each side, and that the spinous process, with a small portion of the arch
iltached, was forced.in upon the spinal marrow. There was no blood
efused or serum at this {>oint, but about one ounce of serum was found
in the cavity of the tunica arachnoides at the. base of the brain. The
bodies of the vertebra were not broken. It was our opinion, therefore,
tbt the immediate cause of his death was the direct pressure of the
tpinons process.
In the case related by Prout, of Alabama, the man having died
within forty-eight hours after the receipt of the injury, the arch of the
fifth cervical vertebra was found to be broken in three places, and the
mrnMS process was driven in ujKm the spinal marrow. There was a
%ht effusion of blood between the sheath of the spinal marrow and
tbe bone, and a considerable effusion between the sheath and the cord.
There was no material lesion of the cord or of its membranes, and the
Wy of the bone was neither broken nor dislocated.'
It ia probable, also, that in the following esaraple the arch was
'Pn>iil.Ainer. Journ. Hed. 8ci„NoT. 183T,ToI. ii1,p. 276, Trom Wcitern Journ.
«( Hed. ud Pb j«. Sci.
150 FRACTURES OF THE VERTEBR.fi,
broken, but that the force of the blow having been somewhat oblique,
the process was but little if at all thrown in upon the spinal marrow.
R. L., of Erie County, N. Y., aged about forty years, was thrown
from a loaded wagon in February of 1851, striking, as he thinks, upon
the back of his neck. He was stunned by the injury, and remained
insensible several hours ; on the return of consciousness, he found that
his lower extremities and bladder were paralyzed. During four weeks
his bladder had to be emptied by a catheter. Nine months after the
injury was received he consulted me, and I found the spinous process
of the last cervical vertebra pushed over to the left side. His head
was strongly bent forwards, and he was unable to straighten it. He
could walk a few steps, but not without great fatigue; and he suffered
almost constant pain in his lower extremities, accompanied with exces-
sive restlessness and watchfulness, for which he was obliged to take
morphine in large quantities.
In the case related by Alban G. Smith, of Kentucky, to which I
shall refer again presently, the deviation was lateral, and so also in
Ollivier's case, mentioned by Malgaigne.
Symptoms, — We can imagine a case of fracture of the vertebral arch^
with a lateral displacement only, in which the symptoms might not
differ essentially from a simple fracture of the spinous process ; and it
is quite possible that some of the cases which have been supposed to
be examples of this latter accident, and in which a speedy recovery has
taken place, were really examples of fracture of the arches; yet it
must be admitted that such a fortunate result is only possible, since
the arches can hardly be broken without communicating a severe con*
cussion to the marrow, nor without lacerations, inflammation, and eflfu-
sions, which will be mostcertiiin to produce compression and paralysis,
and probably death.
If, however, it is possible for us to confound a fracture of the process
with a fracture of the arches, it is still more possible for us to confound
a fracture of the arches with a fracture of the bodies of the vertebra.
If, as is usually the fact, the process, in case of a fracture of the arch,
is less prominent than natural, and that portion of the body receiving
its nervous supply from below this point is paralyzed, we may have
reasons to believe that the arch is broken and the process driven in
upon the spine; but dissections have shown that in many of these
cases, or in most of them, indeed, the bodies of more or less of the
vertebra? are broken also, and in still other cases the bodies were alone
broken.
If, as in the case mentioned by Ollivier, we can feel the plates move
separately, the diagnosis might be made out, so far at least as to deter-
mine that the plates were broken ; but we should be still unable to say
that the Ixxlies of the vertebne were not broken also.
Something perhaps may be inferred from the direction and manner
of the blow which has pro<luced the fracture. Thus, a fiill upon the
top of the head would most often produce a comminution of the iMidies
by crushing them together, while a blow upon the back could ncaroely
break one of the vertebrae without breaking the corresponding arcli
also. We might thus be led to infer, in the first instancei that the
AL ARCHES.
urhcs were not broken ; and, in the second instance, if we could con-
vince ourselves that the arches were not hroki?n, we might rest pretty
well fliS^nred that the bodies were not.
In the ease related by Prout, there was no external mark of injury
nver the point of fracture, but a distinct crepitus was perceptible on
TrfJitment. — If the fragments are not displaced, i
Cftoling regimen are indicated ; but if they arc forcetl i
lothing but rest and
_ " ' " I upon the
marrow, an important question is presented, and which has received
fmm different surgeons difTerent solutions. Shall an effort be made to
reduce (he fragments? and if so, by what means shall the indication be
attempted ?
It will be remembered that in nearly all of thew cases we must re-
main in doubt, even af\er the most careful examinntion, as to the actual
condition of the fracture. It may be that what we suppa-te to be a
H Jnctnre of the arfh is only a fracture of the apophysis, or tliat on the
Hpther hand, it is a fracture of the body of the bone itself; and if we are
H|p|)ert enough to make out clearly a fracture of the arch, it is not pos-
■■^le for U8 to say that the bodv is not broken also, indeed it is quite
probable that it is broken. With a diagnosis so uncertain, can we
ever find a justification for surgical interference? Mr. Cline and Mr,
Cooper thought that we might. According to them, the case presents
in no other direction a point of hope or encouragement. Death is
iamiable, (iooner or later, if the fragment is not lifted, and we can
wwvely make the matter any worse by interference. If it proves to
be a frarturc of the apophysis, as happened to be the case in a patient
upon whom Sir Astley operated ,' our interference was unnecessary, but
il has done no harm. If the body of the bone is broken, the operation
nfTurda no resources, but the patient is probably beyond suffering dani-
»pr at our hands. If the diagnosis is correctly made out and the arch
only iti broken, and if, as was the fact in the case of I^rkiii already
ini?ntionc<l, there is no bloody effusion, or iawration of the membmnes
w rif the marrow, and if the concussion was not sufficient to determine
mm-h inflammation of the cord, then it would seem possible that an
nperition might save the [«tient.
Pauhis yEginela first suggested that the compressing fnigments
onghl to be removed by excision; and iu 1762 I^uis removed from a
mtn wild bad received a gunshot wound in his bach, after the lapse of
five days, several loose pieces of bone belonging to the arch of the
wnebra, and the patient recovered, but not without a. partial paralysis
I (if hie lower extremities. Of course nothing could be more rational
I W simple than this procedure, adopted by Louis, in any case of an
a wound, where the fragments could be easily reached ; but the
rjonager Cline was the first, in the year 1S14, to put into practiw the
« aoeient suggestion of Paulus JEgiueta, namely, to attempt the
I nooval of the fragments in a ease of simple fracture. He made an
I tBci^ioo upon the depressed bones as the patient was lying upon his
I ■», taited the mu.'fclea covering the spinal arch, removing, by means
152 FRACTURES OF THE YERTEBR^G.
of a circular saw, chisel, mallet, and trephine, etc., the spinous processes
of the eleventh and twelfth dorsal vertebrte, and the arch of one of the
vertebne. The (xitient was in no manner relieved, and died on the
fourth day after the receipt of the injury and the third after the opera-
tion.* Mr. Oldknow repeated this operation in 1819 in a case of frac-
ture of the arch of the seventh vertebra. The patient died on the
sixth day.- In 1822, Mr. Tyrrell operated at St. Thomas's Hospital
on a man who had been injured four days previously, removing the
spinous pnicesses of the twelfth dorsal and first lumbar vertebra. The
operation was accomplished with considerable difficulty, and resulted
in only a (>artial return of sensibility. He died on the thirteenth day
after the operation.^ In 1827, Tyrrell operated a second time, and
death resulted on the eighth day.* On the 30th of August, 1824, Dr.
J. Rhea Rarton, of Philadelphia, operated upon a man who had been
received into the Pennsylvania Hospital twelve days before, with a
fracture of the arch of the seventh dorsal vertebra. On the third day
he was attacked with a violent chill, and death took place twelve hours
after. The dissection showed about half a gallon of blood in the pos-
terior mediiistinuni, and bloody eftusion existi'd along the whole length
of the spinal canal.' The patient whom I^ugier trephined at the base
of the spinous pnx*oss of the ninth dorsal vertebra, died on the fourth
day.* The ojH»ration has been repeated unsuccessfully by Wickham,
Attenburrow, Holscher, Heine, and Roux.^
February 5th, 1834, Dr. David L. Rogers, of New York, operated
uj>on a man who had fallen two days before, breaking the arch of the
first lumbar vertebra, and forcing the spinous process upon the oonL
This man died on the eighth day.*
In 1854, Dr. Blackman, of Cincinnati, operated, his patient dying
on the fourth day. During the same year also, Dr. B. removed a por-
tion of the siKTum for an injury of four years' standing, with no bene-
fit.' In 1858, Dr. Stephen Smith, of Bellevue, removed tlie amh of
the tenth dorsal vertebra, death occurring soon after.*** December 29thy
1857, ten days after the receipt of the iiyury. Dr. J. C. Hutchinaoiiy
of Brooklyn, <)|K»rattHl upon a man at the City Hospital, Brooklyn, re-
moving the spinous j>rocesses of the eighth, ninth, and tenth dorsal
vertebne, with the posterior arch of the latter. The patient survived
the operation ten days." Rillingall says a Dr. Blair has o|)erated suc-
cessfully, but no particulars are given.
Dr. H. A. P<>tter, of Geneva, N. Y., informs us that he has operated
* ('line, Chi-lius'* SurpTv, Ainor. ihI., vol. i, p. 600.
' Sir A. Con|MT on Dislmv and Frur., Amor, od., 18.')]^ p. 470.
■ Sir A. C«»o|M'r'8 Loc, bv Tvrn»ll, 3d Amer. od., 18:U, vol. ii, p. 17.
* M-d.-Chir. \i<\., vol. x, p." 601.
• HHrton, («<Klmun\< od. of Sir A. Coo|>cr on Disloc., etc., p. 421.
• -MnlicHii^n**, Amor, cxi., p. 341.
^ Ch«*liu.-> S«iri»ery, Amer. od., vol. i, p. 690. Also, Velpeau's Op. Surgery, Ift
Ami'r. od., v«il. ii, p! "37.
• Koiji'r-, Amfr. Jnurn. M»Mi. Soi., May, 1835.
• V<flfrt»ttij'ft Siiri:«'rv, Blaokman'tf od., vol. ii, p. 892;
Wr. Trnnn. N Y. St Mi-d. 8i»c., 18»il.
»• N«-w York Joiirn. M<»d., IK.V.i, p. 87.
" lluuljin»iin, Tmni. W. Y. Mod. Soc., 1861, p. 98.
^ . . . *'*^» ^^' Hi»tcbin«on*i
FRACTURES OF THE VERTEBRAL ARCHES. 163
three times. In the first case he states that he removed the posterior
portion of the three lower cervical vertebrae. The patient died on the
fi>arth day. In the second case the doctor removed the spinous pro-
cesses of the fifth and sixth cervical vertebrse, and the entire posterior
arch of the fifth. The sheath was not broken, " but the cord was much
injured.'* There was almost complete paralysis of the extremities, and
this condition was not remedied by the operation. Three years later,
the patient being still alive, but only a very slight improvement having
taken place, Dr. Potter " removed the fourth, sixth, and seventh cervi-
cal vertebrae.^' (We presume he intends to say the " posterior arches.")
At the time of the report, Jan. 1863, there was no further improvement.
Finally, the doctor reports a completely successful case. The injury
was of *^ five months' standing."* Packard says, in a note to his trans-
lation of Malgaigne, that Dr. Potter operated on a case of three months'
standing, and the patient died on the eighteenth day. I suppose this
to be the same case.
These are all of the cases of which we have any information in
which this operation has been made, and they have all, excepting the
two cases reported by Potter and the one by Blair, terminated fatally
in a very few days. The case reported by *Alban G. Smith, of Ken-
tucky, IS not related in such a manner as to enable us to make use of
it safely, nor is it stated how long the patient survived the operation ;
Gibson says it gave no permanent relief. The example mentioned by
an English writer is equally unreliable, inasmuch as it is given only
upon rumor, and but a '* few months " had elapsed since the operation
was performed. It was said to have been made in the year 1838, by
a surgeon of the name of Edwards, in South Wales ; and it was affirmed
that the compression was relieved and that the patient "did well."*
So unique a case would certainly have found before this an ample con-
firmation. Indeed, we mast say that none of the cases reported as
fiuooessful give any evidence of authenticity.
Experience, then, seems to have shown that we have little or nothing
to expect from this surgical expedient ; and, notwithstanding the strong
hope expressed by Sir Astley Cooper that Mr. Cline's operation might
bereafler prove a valuable resource, and contrary to the conclusions which
we in common with many other surgeons had drawn from the anatom-
ieal relations of these parts, we are compelled reluctantly to declare
that the expedient is scarcely worthy of a trial. To the same conclu-
sion also many of the most distinguished surgeons have arrived, among
whom we may mention, as especially entitled to confiilence, Brodie,
Listen, Alexander Shaw, Malgaigne, and Gibson.
What more can be said of the attempt to raise the depressed bone
by seizing the spinous process with the fingers, or with a pair of strong
hooked forceps passed through the skin, or finally, if this cannot be
dooe, by laying bare both sides of the process and seizing upon it with
a pair of firm tenacula ? This is the alternative presented to Malgaigne,
and which he ventures to recommend as deserving a trial. In the ab-
» Amer. Med. Times, Jan. 10, 1803
» Edwards, Brillih and Foreign Med. Rev., 1838, p. 162.
11
154 FRACTURES OF THE VERTEBR-fi.
sence, however, of any testimony in its favor, beyond the mere rational
argument adduced by this distinguished writer, we must waive any
farther consideration of the subject; only expressing our conviction
that it will be found, aftei* a fair trial, as useless and as inexpedient as
the more severe operation of CI inc.
Jeifries Wyman,. of Boston, has met with eleven examples of frac-
tures of the vertebral arches occurring in the fourth or fifth lumbar
vertebrae between the lower articulating and the transverse processeSi
all of them old ununited fractures. He has also met with the same
fracture once in the third lumbar vertebra. The frequency of this
j>ecuJiar form of fracture in this region Dr. Wyman ascribes to the
fact that the upper and loAver articulating processes are widely sepa-
rated from each other, and connected only by a narrow neck, in which
respect they contrast vctj strongly with the dorsal vertebrae ; and he
supposes that the fractures may be caiused by either a forcible bending
of the body backwards, or by the shock resulting from a fall from a
lieight in which the force of the concussion is conveyed down>vard8
through the pelvis. In no case has tlu? existence of this fracture been
recognized during life, nor is it probable that its occurrence would
cause any marked symptoms unless it had been caused by a blow re-
ceived directly from behind.^
As to the therapeutical treatment of the various symptoms belong-
ing to these accidents, and in relation to the prognosis, the remarks
which we shall make will be found equally appliaible to finictures of
the bcnlios of the vertebrse, aiid we sliall reserve the consideration of
these topics for the* following section.
{ 4. Fractures of the Bodies of the VertebrsB.
The same causes which produce fractures of the arches may produce
also fractures of the bodies of the vertebra?, that is, blows received
directly ujHm the extremities of the spinous processes; but in these
cases the arches are generally broken at the same time.
In other easels the bodies of the vertebne are broken by falls upon
the top of the head, by which the vertebne are not only driven forcioljr
together, but often doubleil forwanls upon each other ; or the patient
may have alighted upon his fiH?t or upon his sacrum.
Reveillon has reported a case of fracture of the fifth cervical vertebra
from muscular action, which occurred in diving. The man was taken
out of the water unconscious, and ditnl in a few hours, having declared
l)efore death that his head did not strike the bottom, although he had
jum|KHl from a height of seven or eight feet, and the water was only
three feet deep.^ The statement of the sufferer, under such circum-
stances, could not really j)ossess much value, and we think we see good
reasons to sup}K)se that he was mistaken. South also relates a case of
fracture of the fourth and fifth cervical vertebne occasioned by divingi
in which it wa<^ supposeil that the fracture was cause<l by the concussion
of the head ujxm the water.'
* Wyman, Boston M<k!. and Surg. Journ , Au|f. 12, 1869.
* Rt»v««illon, Chflius'ft Surg., note by South, vol. i, p. 684.
> South, ibid., p. 683.
FRACTURES OF THE BODIES OP THE VBRTEBBJE. 155
Malgaigne says the spine bends st three principal points ; comprised,
me first between tlie third and seventh cervical vertebrie, llie second
between the eleventh dorsal and second lumbar, the third between the
fourth lumbar and the sacruni ; and that a majority of tlie fractures of
the vertebra occur at these points of flexion. He makes an argument
from this also that these fractures "are generally the result of counter-
strokes, as the effect of forcible flexion of tbe coUimn eitlier forwawls
or backwards." Malgaigue observes, moreover, that dislocations follow
tbe same rule.
The direction of the line of fracture varies greatly in the different
esanaples which we have seen ; some are crushed, and more or less
com mini I ted. In some cases a narrow piece is chipped from the mar-
pn, others are broken transversely, and others obliquely. In oblique
fractures the line of the fracture is generally from behind forwaros,
and from above downwards. Malgaigue thinks tliat a crushing or
comminution can only occur from a forcible flexion forwards; but I
have seen at least one example in which this was not the fact; the
patient having fellen so as to strike with the back of his neck upon
an iron bar. This wa.s the case of the sailor, to which I shall again
refer more particularly.
The upper fn^raent is almost always that which suffers displace-
ment; sometimes being simply drivendownwards, and thus made to
penetrate more or less the lower fragment ; at other times, as in certain
transverse fractures, it is only displaced forwards, and in still other
eiaiuples, where the fractnre is oblique, the upper fragment is displaced
both downwanls and forwards.
In the fiist and last of these examples the spine becomes bent for-
»anl8 at the point of fracture, producing an angle of which the most
alient point posteriorly is represente<l bv the
eitremity of the spinous process belonging ''"'■ **
to the broken vertebra ; in the second example
the spinous process of the broken vertebra is
(fcprMsod, and the procePs of the vertebra
next below is relatively prominent.
In a pretty large proportion of canes al,-iO
Ae fracture of the body of the vertebra is
complicated, as we have already stated, with
• fracture of the arches, in some instai:ces
*ilh a fracture of the oblique processes, and
nth a dislocation.
Hjpnploms. — Severe pain at the seat of frac-
ture, felt especially when the part is touched
w tbe body is moved, tenderness, swelling,
'Bchymoeis, occasionally crepitus, a slight
«Sf^lar distortion of the spine, or simply a vr».tntb«.
trifling irr^TiIarity in the position of the jiro-
«"«,and paralysis of ail the parts whose nerves take their origin
Wmr the fracture, are the usual signs of the accident.
TTie paralysis may be due to the mere pressure of the displaced
"pnentH, but it is much more often due to a severe and irreparable
156 FRACTURES OF THE VERTEBRiE.
lesion of the cord itself. I have, in one instance, seen the cord almost
completely separated at the point of fracture, although the displacement
of the fragments was inconsiderable.
Accompanying the paralysis of the bladder, there has been generally
observed an alkaline state of the urine, and subacute inflammation o(
the coats of the bladder. Priapism is present in a certain proportioD
of cases.
Those who die immediately seem to be asphyxiated ; while those
who die later seem to wear out from general irritation, this condition
being frequently accompanied with an obstinate diarrhoea and vomit-
ing. A few become comatose before death.
It will be seen, moreover, that a certain proportion finally recover;
but scarcely ever are all the functions of the limbs and of the body
completely restored.
We shall render this part of our description of these accidents more
intelligible if we regard them as they occur in the various portions of
the s|)inal column, since the symptoms, prognosis, and treatment have
reference mainly to the point at which the fracture has occurred.
1 . Fracture of the Bodies of the Lumbar Vertebra,
The spinal conl terminates, in the adult, at the lower border of the
first lumbar vertebra, but in the child at birth it extends as low as *
the third lumbar vertebra. The remainder of the vertebral canal is
occu|)ie(l by the leash of terminal nerves, called collectively the cauda
equina.
The nerves which emerge from the intervertebral foramina below
the fourth and fifth lumbar vertebra?, unite with the sacral nerves to
form a plexus which supplies the sphincter and levator ani, the perineal
muscles, the detrusor and accelerator urinse, the urethra, the ^lans
penis, and a great proportion of the lower extremities. It will be
apparent, therefore, that a fracture, with displacement, of even the last
vertebra of the column, involves the possibility of more or less paralyak
of all those parts supplied by this plexus, and that in proportion aa
the fracture is higher in the vertebral column, will the probabili^ of
additional complications Ik* increased. In other words, in addition to
the more or less comj)lete loss of function in the organs supplied by
the ilio-siicral plexus, there will probably be associated loss of function
in other organs, supplie<l from sources above this point of the vertebral
canal.
A fracture, however, of the bodies of the fourth or fifth lumbar
vertebra, produc»ed by a direct blow, is exceedingly rare, owing to the
protection which it receives from the ala» of the j)elvi8.
Dr. Alexander Shaw has rejMirted four cases of fracture below the
8eiN)n(l lumlmr vertebra, which were unaccom|)anied with any degrtt
of paralysis, and which were followed by sj)eedy recovery,* a circum-
8tani*e which he ascril)es to the fact that the cauda equina is i*oropoeedL^
of nerves [K>ssessing considerable firmness, and suspended loosely
> Shuw, London Med. Qa£., toI. xtU.
FEACTUEES OF THE BODIES OF THE VEETEBB^. 157
gether ; for this reaeon they escape pressure by slipping among them-
selves, and suffer less injary from the same amuunt of compressioD than
tbe medulla spinalis.
In tbe two following cases the results were less fortunate, yet recov-
eries seem to liave taken place.
A boy was admitted into St. George's Hospital, in September, 1827,
with a fracture and considerable displacement of the third and fourth
lumbar vertebrae, the displacement being sufficient to cause a manifest
alteration in tbe figure of bb spine. His lower limbs were paralytic.
Ad attempt was made to restore the displaced vertebra, but it was
attended with only partial success. At the end of a month he had
slight involuntary motions of the lower extremities, and at the same
time he b^an to recover the power of using them voluntarily. Three
or four months after the receipt of the injury he Icfl the hospital, and
tbe history of his case was interrupted at this date.'
Dr. Thompson, of Goshen, N. Y., reports also a fracture of either
the third or fourth lumbar vertebra,fullowed by recovery. The patient
fell from (he roof of a house, striking first upon his feet and then upon
fais buttocks. This occurred in October, 1853. The usual signs of a
fracture were present, such as paralysis, etc. A bed-sore formM above
the top of the sacrum, and a piece of bone exfoliated, which seemed to
belong to the last lumbar vertebra. He was confiacd to his bed seven
months. After eighteen months he began to
use crutches. At the end of about three years
all improvement ceased, at which time he could
QOt quite stand alone ; yet with the aid of ap-
paratu.s he was able to get about the country
aad vend books, prints, etc. This was also his
coadition one year later.'
A patient in Guy's Hospital, under Mr, Key,
with a fracture of the first lumbar vertebra,
lived one year and two days. On examination
after death it was ascertained that bony union
had occurred between the fragments, and that
the spinal marrow was completely separated at
the point of fracture.'
Mr. Harrold relates a case of fracture of the
Gret and second lumbar vertcbrie, in which the
patient 5urv*ived the accident one year lacking
nine days; death having resulted finally from nmi ju.uu.. .^.u^u.-
isore on the tuberosity of the ischium and dis-
ease of the hone. After death it wa" ascertained that the fracture had
united by bone, and that the spinal marrow was almost completely cut
in two, the divided extremities being enlarged and separated nearly an
inch from each other.'
' Brodle, Sir Ast. Cooper on Dialoc., op. cit., p. 471.
■ TbompMin, Amer. Journ. Hed. Sci., Oct. 1857. Lente's piper.
' Kfj, A Cooper on DJsloc., etc., op. cit., p. 467.
• Hirrold, A. Cooper, op. cit., p. 464.
158 FRACTURES OF THE VERTEBR-fi.
2. Fractures of the Bodies of the Dorsal Vertebrce,
In these examples the same organs are paralyzed as in the fractures
lower down, in addition to which there is generally considerable dis-
turbance of the functions of respiration, irregular action of the heart,
indigestion, accompanied with a tympanitic state of the bowels.
Dupuytren, who reports several examples of fractures of the dorsal
vertebra?, has not taken the pains to record the length of time they
survived the accident except in two instances, lx)th of which were
fractures of the eleventh vertebra. One died of suffocation on the
tenth day, and the other on the thirty-second. In Sir Astley Cooper's
cases, mention is made of a fracture of the twelfth dorsal vertebra,
which the patient survived fifty-two days, one of the tenth dorsal,
which terminated fatally in six days, and another of the ninth dorsal,
which did not result in death until after nine weeks.
In 1853 Dr. Parkman presented to the Boston Society for Medical
Improvement a specimen of fracture of the fifth dorsal vertebra, the
bodies of the third and fourth being also displaced forwards, in which
position they had become firmly ossified. The spinal cord had been
completely separated, yet the patient survived the accident two months.*
Dupuytren has related also two examples of fractures, one of the
tenth and the other of the last dorsal vertebra, from which the patients
completely recovered after from two to four months' confinement,* A
similar case is related by Lente, of New York. Barney McGuire,
having fallen a distance of twelve or fifteen feet upon his back, was
found with nearly complete paralysis of his lower extremities and of
his bladder. Swelling existed over the lower dorsal vertebne, and this
point was verj' tender. Subsequently, when the swelling subsided, the
prominence of the spinous processes of the tenth and eleventh dorsal
vertebrae put the question of a fracture beyond doubt. Gradually,
under the use of cu|)s, strychnia, mineral acids, laxatives, buchu, and
electricity, his symptoms improved. In six months he was able to walk
al)out the streets, and four years after the accident he was employed iu
a foundry under regular wages, being able to stand fifteen or twenty
minutes at a time, and to walk half a mile without resting. At this
time there remained no tenderness in the spine, but the projection of
the process was the same as at first.'
3. Fractures of the Bodies of the five lower Cervical Vertebfxt.
We shall now have addeil to the symptoms already enumerated,
paralysis of the upper extremities, greater embarrassment of the respira-
tion, and more complete loss of sensation and volition in the lower part
of the IhmIv. In general, also, the eyes and face look congested, owing
to the im|>erfei*t arterial ization of the blooil, and death is more speedy
and inevitable.
In ten recordeil examples of fractures of the five lower cervical ver-
* Piirkman, New York Joiirn. Mod., March, 1853, p. 2S6.
■ Dupuylrfn, op. cil., pn. 85*5-7.
* Lcnte, Amer. Joutd. Med. Sci., Oct. 1S57, p. 861.
FRACTURES OP THE BODIES OF THE VERTEBRAE. 159
tebrse which I have been able to collect, one died within twenty-four
hours, four in about forty-eight hours, one in eleven days, one lived
fifteen weeks and six days, one about four months, one fifteen months,
and one, reported by Hilton, survived fourteen years.* The most com-
mon period of death seems, therefore, to be about forty-eiglit hours after
the receipt of the injury.
The example of the patient who survived the accident fifteen weeks
and six days, is recorded by Mr. Greenwood, of England. A woman,
Mary Vincent, set, 47, was injured by a blow on the back of her neck,
bat she was not seen by Mr. Greenwood until after eleven days, at
which time she was breathing with difficulty, occasioned by paralysis
of the intercostal muscles, respiration being carried on by the diaphragm
and abdominal muscles alone. This was the extent of the paralysis.
There seemed to be a depression opposite the fourth and fifth cervical
vertebrae, and pressure at this point occasioned universal paralysis, as
did also the action of coughing and sneezing. About three weeks after
the accident, she attempted for the first time to move in order to have
her clothes changed, when she was immediately seized with paralysis
in the right arm and hand. After this she lost her appetite, had fre-
quent attacks of purging, and thus she gradually wore out.*
The patient who survived about four months was admitted into H6tel
Dieu, under the care of Dupuytren, in 1825, on account of a fracture
of the fourth cervical vertebra, caused by a fall on the back of his neck,
and suffering under paralysis of the bladder and extremities. After
two months and a half of entire rest, he was convalescent and quitted
the hospital, with only slight weakness in his left leg, and with his liead
a little bowed forAvards. In returuing from a long walk he fell para-
lyzed, and remained in the open air all night. From this time he con-
tiDoetl to fail, and died thirty-four days after the second fall. On ex-
tmination after death^ the body of the vertebra was found to be broken,
tnd also the processes of the fifth, allowing the fourth to slip forwards
and compress the cord. A true callus existe<l in front of these bones,
which looked as if recently broken. The cord itself exhibited an an-
nular constriction, which Dupuytren conceived to be the seat of the
ori^nal lesion narrowed by cicatrization.*
The following example furnishes a fair illustration of the usual phe-
nomena which accompany fractures of the third or fourth cervical ver-
tebra.
On the 25th of July, 1857, a sailor fell backwards from the wharf,
rtriking with the nape of his neck upon a bar of iron. I saw him on
the following day, in consultation with his attending ]>hysician, Dr.
Edwards. He was lying upon his back, breathing rapidly. His lower
extremities were completely paralyzed; legs and feet swollen and
jwiple; right arm completely paralyzed, and his leR partially ; from a
pwot below the line of the second rib, there wa^ no sensation "whatever ;
his bowels had not moved, although he had already taken active cathar-
tics; the urine bad been drawn with a catheter; the pulse was slower
I giltoriy I>ond. I^ancpt, Oct 27. 1860.
« Oreen wood. Sir A. Coop<?r on DUloc., p. 472.
J x>upuytren, op. cit, p. 308.
160 FRACTURES OF THE VERTEBRA.
than natural, and irrepjiilar. He was constantly vomiting. In replv
to qui^stions, he said that he felt well, articulating distinctly and with
a goo<l voice. His eyes and face were somewhat congested, but with
this exception his countenance did not betray the least physical dis-
turbance. He lived in this condition about forty hours, only breathing
shorter and shorter, and his consciousness remaining to the last moment.
In pnK»eeding to examine the spine a few hours after death, and
before any incision w:i8 made, we were unable, uj>on the most minute
examination, to dete(^t any irregularity of the i)rocesses of the cervical
vertebne, or any crc»pitus; but, on diss^Kiting the neck, we found that
the arches of the third and fourth vertebra? were broken, and the spin-
ous pnK'csses slightly depresse<l upon the cord. The bodies of the cH>r-
responding vertebne were comminuted, and the vertebne al)ove were
driven down npon them, carrying the processes in the same direction.
The theca and the spinal marrow were almost completely severeil upon
a level with the fourth vertebra.
A man residing in Erie Co., N. Y., was thrown backwanls suddenly
from the back end of a wagon, alighting ujwn the top of his head. Dr.
Mixer having retjuestcnl me to see this |)jitient with him, 1 found the
symptoms almost an exact counterpart of those which belongeil to the
case which I have just descril)cd, except that a cn»pitus and a mobility
of the fragnuMits couKl Ix? distinctly felt in the upjwr and back jKirt of
his neck. His death occurred in very much the same manner afler
about forty-eight hours. No autopsy was allowed. We notic*ed in
this case, also, tliat whenever he wit< turiKnl over upon his face, respi-
ration almost entirelv cease<l, but it was imnKnliatelv n»st()reil bv lav-
ing him again on his back. Many other similar examj)k»s have from
time to time come under my notice.
Sf rains of (he LitjamcntH and Jfuscles. — Dupuytren, Sir Astley Coojior,
South, and other surgeons have relate<l cases simulating fracture, but
which proved to Ihj strains of the ligaments uniting the ciTvit'al ver-
t4»bne, accompani(Kl with more or less injury to the spinal nnirntw.
In one insUuu^e, I have met with what has s<'<»med to be a strain uf the
ligaments and musck's of the nci^k, but which presented no symptoms
of scMMous injur}' to the spinal marrow.
John Neuman, of C anada West, jet. 25, fell heiulforemost from a
height of fourteen fiM't, striking u|M>n the top of his hcjul. lie was*
tak(*n up iuMMisible, and remaininl in this condition six hours. Wheu
cons<Mousness returiKNl, his head was very much drawn iKickwanl?*, and
it was im|>ossibl<' to move it from this |M)sitioii. There was no lack of
sensibility or (»f the |M)wer of moti(»n in his limbs, and all the functions
of his ImmIv were in th<Mr natural state; but he hiis suiVenMl with oixia-
sional M'vcH' pains in his arms ever sin<'('. The aivident hap{H*ne«l on
the twenty-fourth of Novemlx'r, 1857, and he calle<l upon me eight
moitths aher. His head wit< then forcibly Iwnt forwanls instmid of
l>:i(*k wards, into which ])osition it had gradually changeil. In the
morning Ik; generally wjis able to erect his head c*ompletely, but after
a few hours it was conMantIv dr.iwn tbrwaitls, as when I s:iw hiiu.
TIktc w:ls no tend<'rness or irregularity f»ver the c^ervical vertebra*, and
he wjts so well its to l>e regularly employeii as a day-laborer.
FRACTURES OF THE BODIES OF THE VERTEBRA. 161
Ckmcu99ion. — Sir Astley Cooper has collected four examples of what
he terms " concussiou of the spinal marrow," all of which recovered
after periods ranging from a few weeks to many months ; but in only
one case is it stated that the recovery was completed Boyer also enu-
merates three cases of concussion which came under his own observa-
tioDy all of which terminated fatally in a short time. In the first
example mentioned by Boyer^ the autopsy disclosed neither lesion nor
effosion of any kind ; in the second case, it does not appear that any
autopsy was made. The third is related as follows : '^ A builder fell
firom a height of fourteen feet, and remained for some time senseless ;
and, on recovering from that situation, found that he had lost the use of
his inferior extremities. He had at the same time a retention of urine,
an involuntary discharge of the faeces, and some disorder in the function
of respiration. Death followed on the twelfth day after the accident.
The body was opened, and the vertebral canal was found to contain a
sanguineous serum, the quantity of which was sufficient to fill a little
more than its lower half."* No doubt some of the cases reported as
concussion were only examples of paralysis from extravasation of blood,
a circumstance which is peculiarly likely to happen as a result of the
rapture of one of those numerous large vessels which surround the ver-
tebne outside of the thecae. It is seldom that the vessels of the cord
itjself give out sufficient blood in these cases to cause compression.
Possibly examples of compression as a result of extravasation of blood
Biay sometimes be recognized by the fact of the gradual approach of
the paralysis after the lapse of several hours, as has occurred recently
in a case brought to my notice at the Bellevue Hospital, and in which
recovery finally took place.
4. Treatment of Fractures of the Bodies of the Vertebrce when the fracture
occurs in any portion of tlie column below the Second Cervical,
In a few instances, I have noticed among the recorded examples of
fractures of the bodies of the vertebrse, that surgeons have made some
flight attempt to reduce the fracture, or rather to rectify the spinal dis-
tortion, generally by the application of moderate extension to the limbs,
and by laying the patient horizontally upon a hard mattress. But I
have not been able to discover that in any case the patients have de-
rived benefit from the attempt, although it has been said occasionally,
hy the gentlemen making the report, that the deformity was slightly
diminished. Nor am I aware that in any instance the patient has suf-
fered any damage from the attempt; at least the reporter has in no
case thought it necessary to make this observation. I am confident,
however, that such manipulation can seldom serve any useful purpose,
and I very much fear that it has been frequently a source of mischief;
although in cases so generally fatal, it might be very difficult to esti-
mate with much accuracy the amount of injury done. If by any pos-
sihilit)' the fragments could be replaced, I know of no means by which
they could be kept in place; and in truth we are much more likely to
> Sir A. Cooper, op. cit., p. 464.
' Boyer, liecture on Diseases of the Bones, Amer. cd., 1805, p. 55.
162 FRACTURES OF THE VERTEBRA.
increase the penetration of the spinal cord and the general disturbance^
than to diminish it, by extension or pressure. Moreover, it usually
inflicts upon the unfortunate sufferer great pain, and for these reasons
it ought generally to be discouraged.
I have, however, met with two cases of fracture of the lumbar verte-
bra?, in which relief was afforded by permanent extension. When the
fracture is below the middle of the vertebral column, extension, if em-
ployed, should be made by adhesive straps, weights, and a pulley, as
will hereafter be directed in fractures of the femur; the counter-exten-
sion being made by the weight of the body. It will be understood,
however, that when paralysis exists the ligation of a limb with band-
ages will expose the patient to great danger of ulceration and sloughing
at and below the points of pressure, and the amount of extension must
be very moderate.
When treating of fractures of the arches of the vertebrae, I took oc-
casion to call attention to Mr. Cline's operation, occasionally recom-
mended and practiced in such cases. I was not ignorant, however,
that Mr. Cline, and several other of the advocates of this operation, had
recommended it especially for fractures of the bodies of the vertebno
when accompanied with displacement. Even Malgaigne has preferred
to consider the merits of this operation in its relations to these latt^
fractures; but while I am prepared to admit the propriety of an argu-
ment as to the value of Cline's operation considered in reference to
fractures of the arches, I cannot admit its propriety in reference to
fractures of the bodies of the vertebne. The proposition appears to me
too absurd to be entertained for a moment.
The treatment, then, ought to be, in a great measure, expectant.
The patient should be laid in such a position as he finds most comfort-
able, and, as far as possible, the spine should be kept at rest, since the
most trivial disturbance of the fragments, and even that which may
cause no pain to the patient, is liable to increase the injury to the
spine, and prevent the formation of a bony callus. Especially ought
the surgiK)n to be careful, while making the examination, not to turn
the patient upon his face, in which position the spine loses its support
and a fatal pressure may be produced. The urine should be drawn
very soon after the acci(lent, and at least twice daily for the next few
weeks. Indeed, it is a better nilc to draw the urine as often as its ac-
cumulation becomes a source of inconvenience, or whenever the bladder
fills, which will in some cas(»s be as often as every four or six hotirek
It is esjx^cially necessar)- to attend to those urgent demands of the patient
during the first few weeks, when the paralysis is most complete gener-
ally, and the mucous surfac^e of the bladder, already irritated and in-
flamed by the excessively alkaline urine, suffers additional injury from
any degree of painful distension of its walls. It is unnecessary to say
that the frequent introduction of the catheter may itself prove a souroe
of irritation, unless it is managed carefully and skilfully. This duty
ought never to be intruste<l to an inex|)erienc*ed operator.
I do not set* what advantage the surgeon can expect to derive from
the administnition of drastic purgatives, such as full doses of jalmp,
castor oil, or spirits of turpentine, at any period. If in the first in-
FBACTUBES OP THE BODIES OF THE VERTEBRJE. 163
Stance the bowels are so completely paralyzed as that they seem to de-
maud such violent measures to arouse them to action, we may be quite
certain that the spinal cord is suffering from a pressure, or from some
lesion, which these agents have no power to remedy. The bowels may
possibly be made to act, but it would be difficult to show how this is
to relieve the suffering cord. So far from affording relief, these meas-
ures add directly to the nervous irritation and prostration, provoke
vomiting and general restlessness. It is not desirable, wc think, to
obtain a movement of the bowels during the first few days by any
means^ however gentle. The effort to defecate, and the consequent
motion, will probably do much more harm than the evacuation can do
good; and especially, for the same reason, ought we to avoid putting
into the stomach anything which will occasion nausea and vomiting.
After the lapse of a few days, if reasonable hopes begin to be enter-
tained of a recovery, it will become important to establish regular
evacuations of the bowels, either by a judicious management of the
diet, by gentle laxatives, or by enemata. At a still later period, when
the inflammatory stage is past, and the nerves remain inactive or para-
lyzed, nothing could be more rational than the employment of strych-
nia in doses varying from the one-twelfth to the one-eighth of a grain
three times daily. Nor do I think that any single remedy has more
often proved useful in my own practice, or in the practice of other sur-
geons with whom I am acquainted. In order, however, to derive ben-
efit from this or firom any other remedy, it must be continued for a
bug time ; perhaps for a year or more. Electricity, setons, issues, and
blisters are no doubt also sometimes useful. Care must be taken that
eetons, etc., do not produce bed-sores. Passive motion and frictions,
good fresh air, and nourishing diet, become at last essential to recovery.
From an early period, and during the whole course of the treatment,
peat attention should be jmid to the prevention of bed-sores, by sup-
porting all those parts of the body upon which the pressure is consid-
erable. For this purpase we may employ circular cushions, air-cush-
ions, and air-beds ; but water-beds are very much to be preferred to
air-beda as a means of preventing bed-sores. Water-beds must be
filled with water of the temperature of 68"^ Fahrenheit, and they must
be secured in position by side boards, or a kind of shallow box, the
rides of which are elevated six or seven inches. Permanent extension
can be employed upon these beds as well as upon ordinary beds.
Sometimes a section of a bed, three feet square, is found quite as ser-
viceable as an entire bed, inasmuch as the back and nates are the only
parts which are liable to bed-sores. They may be obtained from the
mantifiu^rers, Hodgman & Co., corner of Nassau Street and Maiden
Lane, New York City, at prices ranging from $15 to $25. Of late we
have found the wire-beds, manufactured at 59 Pearl Street, Hartford,
Conn., excellent substitutes for water-beds. They are less expensive,
more easily managed, more durable, and admit of a much better rcgu-
iatiOD of the temperature. Whether they are quite as efficient in the
Cevention of bed-sores as water-beds, I cannot say positively, but they
ve been much used under my observation at Bellevue and in the
Hospital for Ruptured and Cripples, and I have seen no bed-sores
occur where they were in use.
164 FKACTURE8 OF THE YEBTEBB^.
When sores have formed, they should be treated, if sloughing, with
yeast poultices, or the resin ointment. I find also the resin oiatment
Fio. 41.
Wire-bed.
an excellent dressing for the sores after the sloughs have separated.
In case the surface is only slightly abraded, simple cerate forms the
best application.
I 5. Fractures of the Axis.
The phrenic nerve is derived chiefly from the third and fourth cer-
vical nerves. If, therefore, the second cervical vertebra is broken, and
considerably depressed upon the spinal cord, respiration ceases imme-
diately, and the patient dies at once, or survives only a few minutes.
In such examples of fracture of this bone as have not been attended
with these results, the displacement and consequent compression have
been inconsiderable, or there has been no displacement at all.
Mr. Else, of St. Thomas's Hospital, says that a woman in the vene-
real ward, and who was then under a mercurial course, while sitting in
bed, eating her dinner, was seen to fall suddenly forwards ; and the
patients, hastening to her, found that she was dead. Upon examina-
tion of her body, it was discovered that the processus dentatus of the
axis was broken off, and that the head in falling forwanls had driven
the process backwards upon the spinal marrow so as to cause her death.'
8ir Astley Cooper also relates the case of a man who was shot by a
pistol through the neck, breaking and driving in upon the spinal
marrow both the " lamina and the transverse process " of the axis.
He died on the fourth day.^
Malgaigne has collected three cases of fracture of the odontoid
a|)ophysis, all of which were accompanied with a displacement of the
atlas. The first, re|>orted by Richet, died on the seventeenth day ; the
second, reported by Palletta, died after one month and six days ; and
the third, by Costcs, lived four montlus and two weeks.
Rokitansky says that there is a s|)ecimen contained in the Vienna
Museum, taken from a patient who survived the accident some time,
although the fragments never united.
The following case is reportcnl by Parker:
^* The patient, Mr. G. B. S|)encer, was a man forty years of age, a
milkman by occupation, of medium height, nervo-sanguine tempera-
ment, of active business habits, and capable of great endurance. His
life was one of constant excitement, and he was addicted to the free
use of liquors. He suffered, however, from no other form of disease
* KUe, Sir A. Cooper on Di«loc., etc., op. cit., p. 462.
' Sir A. Cooper on Disloc., etc., op. cit., p. 47o.
FBACTURES OF THE AXIS. 165
than occasional attacks of rheuraatJsra, for which he was accustomed
to take remedies of his own prescribing, which were generally mercu-
rials followed by liberal doses of iodide of potassium, ' to work it all
out of the system/
"On the 12th of August, 1852, while driving a 'fast horse' at the
top of his speed on the plank road near Bush wick, L. I., he was thrown
violently from his carriage by the wheel striking against the toll-gate.
He alighte<l upon his head and face about fifteen feet from the carriage.
Upon rising to his feet he declared himself uninjured, but soon after
complained of feeling faint; after drinking a glass of brandy he felt
better, got into his carriage with a friend, and drove home to Riving-
ton Street in this city, a distance of more than two miles. There was
so little apparent danger in this case, that no physician was called that
night. Early on the morning of the following day, Dr. B. was called
to visit him. He found his patient reclining in his chair, in a restless
state, and learned that he had suffered considerable pain in the back
part of his head and neck during the night. He was entirely inca-
pacitated to rotate the head, which led to the suspicion of some injury
to the articulations of the upper cervical vertebrae ; but so great a de-
gree of swelling existed about the neck as to prevent efficient examina-
tion. There was no paralysis of any portion of the body, his pulse
was about 90, and his general system but little disturbed. Warm
fomentations were applied to the neck, and a mild cathartic adminis-
tered. On the following day there was no particular change in his
symptoms, but as there existed considerable nervous irritability, tinct.
hyoscyami was prescribed as an anodyne, and fomentations of hops
applied locally. On the third day, leeches were applied to the neck,
and after this the swelling so much subsided, that on the fifth day an
irregularity was discovered to exist in the region of the axis and atlas,
which had many of the features of a partial luxation of these vertebrae.
" At this time he began to walk about the room, having previously
remained quiet on account of the pain he suffered on moving. He
persisted in helping himself, and almost constantly supported his head
with one hand applied to the occiput. He often remarked, if he could
be relieved of the pain in his head and neck, he should feel well. He
began to relish his food, and the swelling nearly disappeared at the
end of a week, leaving a protul)erance just below the base of the occi-
put, to the left of the central line of the spinal column, with a corre-
sponding indentation. Notwithstanding strict orders to remain quietly
at home, on the ninth day after the accident he rode out, and in a day
or two after returned as actively as ever to his former occuj)ation of
distributing milk throughout the city to his old customers. During
the following four months no material change took place in his symp-
toms, although he constantly complained of pain in his head. For
this period he did not omit a single day his round of duties as a milk-
man, which occupied him constantly and actively from five o'clock in
the morning to nearly noon. On the first of November, Prof. Watts
examined him, and inclined to the opinion that there was a luxation
of the upper cervical vertebrw.
"About the Ist of January, 1853, the pains, from which he had
166 FRACTURES OF THE VERTEBRA.
been a constant sufferer, became more severe, and he was heard to
complain that lie could not live in his present condition ; he remarked,
also, that he had heard a snapping in his neck. After going his daily
round on the 11th of January, lie complained of fei'Iing cold, and
afterwards of numbness in his limbs. In the evening ho had a chill,
and complained of a pain in his bowels. He passed a restless nigh^
and arose on the following morning alraut six o'clock ; he was obliged
to have assistance in dressing himself, and experienced a niinibiiesa of
his left, and afterwards of his right side. He attempted to walk, but
could not without help, and it was observed that he dragged bis feet
He sat down in a chair and almost instantly expired, at eight o'clock
A.M., on the 12th of January, precisely live months from the receipt
of the injury.
"The autopsy was made thirty hours after death, by Dr. C. E.
Isaacs, in presence of several medical gentlemen. Muscular develop-
ment uncommonly fine. An unusual prominence discovered in the
region of the axis and atlas. On making an incision from the occipat
along the spines of the cervical vertcbrte, the parts were found to be
very vascular. Tliese vertebra} were removed en masse, and a careful
examiniition institutol. The transverse, the otlontoid (ligamenta mod-
eraloria), as also all the ligaments of this region, excepting the ocoinito-
axoideuni, were In a state of |>erfect integrity ; this latter was )>artiallj
dcstroye<l. A considerable amount of coagulated blood was fouDa
effnswl between the fractured surfaces, some of it apparently recent, bot
much of it wa.-* thought to have occurred at the
^'"^ *'■ time of the accident, and afterwards to have pre-
vente<l the union of the bones. The spinal cord
cxhiliitcd no appearances of any lesion. The
odontoid process was found in the {Kksilion n'ell
repn-senled in the accomjiaiiying illustration,
completely fractured off, and its lower cxtneruity
inclining backwards toward the conl. Deatn
finally look pl:K-c, doubthtss, from the displace-
iiK'Ut of the process during some iiiifortutuite
movement of the hi-.td, by which pressure wm
made ujMm the conl. The dtrstruction of the
occipito-iixuid ligament, which would otlierwiee
have pni|ccte*l the contents of the spinal cavity,
Freriurp uf ths oioDioid miuit liavc favofcd this result.'"
prorfm oMiip««i>. I'sik.i'i. j)p I'liilip Iti-van presented to the Surgical
oduniuij i.rocrts.'""" Socictv of Ireland, in 1862, a R|>ecinien obtaiiwd
fnxii the dead-room, and which was suppiwcd lo
be an epiphyseal separation of the odontoid process, occurring in early
life, Ibc history of the rase is imt known, nlthongh the woman was
forty years old when she dictl. It does not appear very clear to Ui
whether this was really an epiphyseal sejiarution, or the result of some
morbid proetsis.*
FRACTURES OF THE ATLAS. 167
At the meeting of the New York Pathological Society, Nov. 12,
1868, Dr. Austin Flint presented a case of separation of the odontoid
process of the axis.
Dr. W. Bayard, of St. John, N. B., has, however, reported a case of
separation of the odontoid process in a child, followed by complete re-
covery. In August, 1864, Charlotte Magee, of St. John, set. 6 years,
previously in excellent health, fell five feet, striking on her head and
neck, causing an immediate immobility of the head, which continued
tboat two years and a half, when an abscess formed in the back of the
pharynx, and the bone was spontaneously discharged. Since then she
has been able to move the head freely, and her recovery may be said
to be complete.^ The specimen was subsequently presented to the
New York Pathological Society, and no doubt remains that the entire
process was thrown off.
Dr. Stephen Smith, who has written a very instructive paper on this
salject, has collected 23 cases of separation of the odontoid process, at
letst 20 of which must be regarded as fractures. The ages of the
patients range from three years to sixty-eight. Eight of this number
were spontaneous, the separation being apparently due to some progres-
sive disease or atrophy of the bone. Two of these recovered after the
fomiation of abscesses in the pharynx and the extrusion of the bone.
In four cases the fractures were gunshot, and one died. The remainder,
90 &r as ascertained, were in consequence of blows upon the head; and
of these only the girl Charlotte Magee recovered. Of the whole num-
ber, 23, three* were without history, two of them being dissecting-room
cases.*
Symptoms, — ^These will depend much upon the cause and complica-
tions of the accident. In all cases there will be more or less inability
to support the head in the erect posture, and if displacement exists, or
if the products of inflammation form upon the cord, a proportionate
impairment of its functions must ensue.
Treatment — The treatment consists in absolute quietude, with mod-
erate extension, effected by means of suitable apparatus.
2 6. Fractures of the Atlas.
I have been able to find only one example of a fracture of the atlas
alone, and this is the case related by Sir Astley Cooper as having come
under the observation of Mr. Cline.
A boy, about three years old, injured his neck in a severe fall ; in
consequence of which he was obliged to walk carefully upright, as per-
sons do when carrying a weight on the head ; and when he wished to
examine any object beneath him, he supported his chin upon his hand,
and gradually lowered his head, to enable him to direct his eyes down-
wards. In the same manner, also, he supported his head from behind
in looking upwards. Whenever he was suddenly shaken or jarred, the
shock caused great pain, and he was obliged to support his chin with
his hands, or to rest his elbows upon a table, and thus support his
> BayBrd, Canada Med. Journ., Dec. 1S69.
> Smith, Amer. Journ. Med. Sci., Oct. 1S71, p. 83S.
168 FRACTUBE8 OF THE VERTEBRA.
head. The boy lived in this condition about one year, and after death
Mr. Cline made a dissection, and ascertained that the atlas was broken
in such a manner that the odontoid process of the axis had lost its sup-
port, and was constantly liable to fall back upon the spinal marrow.*
i 7. Fractures of the first two Cervical VertebrsB (Atlas and Axis)
at the same time.
A woman, tet. 68, fell down a flight of steps, striking upon her fore-
head, and died immediately. Upon making a dissection, it was found
that the atlas was broken upon both sides near the transverse pro-
cesses, and the odontoid process of the axis was broken at its base.
These fractures were accompanied with a rupture of the atloido-odon-
toid ligaments, and a dislocation of the atlas backwards.*
South says there is a specimen in the museum of St. Thomas's Hos-
pital, showing this double fracture. The man had receiveil his injury
only a few hours before admission to the hospital, and died on the film
day. On examination, the atlas was found to be broken in two places,
and the odontoid process of the axis at its root. The fifth vertebra
was also broken through its body. With neither fracture was there
sufficient displacement to produce pressure, but a small quantity of ex-
travasated blood lay in the substance of the spinal marrow, and its
tissue was at one point broken down and disorganized.'
Mr. Phillii>3 relates that a man fell from a hay-rick, striking upon
the occiput; after which, although momentarily stunned, he walked
half a mile to the parish surgeon, and in two days more he returned to
his occupation. About four weeks after the accident he was seen by
Mr. Phillips, who discovered a small tumor over the second cervical
vertebra, pressure upon which caused a slight pain. He complained
also that his neck was stiff*, and that he was unable to rotate it. No
other disturbance of the functions of the bodv could be discovere^L
After a time the tonsils became swollen, and the patient experienced
some difficulty in deglutition, and, up<m examining the throat, a slight
projection or fulness was discovered at the back of the larynx, op|Kisite
the second cerviwil vertebra. Subsequently he became afflvted with
general anasarca and pleuritic effusions, of which he finally <lied. Up
to the last week of his life he was able to walk about his bcdnH>m, and
his condition presented no other evidence than has been mentioocd,
that he was suffering from an injury of the spine. He died forty -seven
wi»eks after the rei^eipt of the injury.
The auto|>sy disclosed a fracture with displacement of the atlas, and
a fnicture of the (xlontoid process of the axis. The two vertebrte were
uniteil to each other firmly by complete bony callus.^
' ('lino, Sir Astley Coopor, op. cit., p. 469.
* Mftltjaiirno, op. cit., t<»m. ii, p 833.
» C'hcliuh'!* Surj^iTV, note by South, vol. i, p. 68S.
« rhillips, Med.-Chir. Truns , vol. xx. 1837, p. 884.
FRACTUBES OF THE STERNUM. 169
CHAPTEK XVI.
FRACTURES OF THE STERNUM.
Fractures of the sternum are of rare occurrence, owinp, probably,
to the elasticity of the ribs and their cartilages, upon which it mainly
rests, and also, in part, to the softness of its structure. In advanced
life, the ossification and fusion of all of its several portions becoming
more complete, and the cartilages of the ribs also becoming more or
less ossified, its fracture is relatively more frequent.
Qituwaj. — ^They are generally the result of direct blows inflicted upon
the part, such as the passage of a loaded vehicle across the chest, the
fell of a tree or of some heavy timber upon the body ; the fracture imply-
ing always that great force has been applied.
Indirect blows and voluntary muscular action alone have been
known also occasionally to produce this fracture.
David, in his Mhwire sur les ContrecoupSy published as a prize essay
bjr the Academy of Medicine, mentions the case of a mason, who, in
filling from a great height, struck upon his back against a cross-bar
which intercepted his fall, in consequence of which the abdominal and
stemo-cleido-mastoidean muscles were so stretched that the sternum
broke asunder between its upper and middle portions.^ Sabatier re-
port* another case of fracture at the same point, produced in a similar
manner;* and Roland has described a third example in a woman
axty-three years old, who, falling from a height backwards and strik-
ing upon her back, broke the sternum near its centre.^ Gross has re-
corded a similar case.^
Cruveilhier saw a man who, having fallen from a height of twenty
feet apon his nates, was found to have a fracture of the sternum.*
Ca<«^n saw the same result in a person who fell from a third story,
faking first upon his feet and then pitching over upon his back.^
ilaonoury and Thore have reported an analogous case, where a man
fell from a height of twelve or fifteen metres, first striking upon his
feet and then fill ling over upon his back and head.^
Mr. Johnson, late editor of the London MecL-CIiir, Rev., reports a
case as having been received into St. George's Hospital, in which the
man, a healthy laborer from the country, had fallen from the top of a
hay-i-art, striking only upon his head. He walked with his head much
bent forwards, and was incapable of cither flexing, extending, or rotating
Boyop on Bone«, p. 67.
Malgaigne, from Sabatier, Mem. sur laFract. du Sternum.
Ibid., from Bull, de Th^rap., torn, vi, p. 288.
Gross, System of Surpj., 6th ed., vol. i, p. 964.
Malfcaigne, from Bull, de la Soc. Anat , Juin, 1826.
Ibid., from Archiv. de MM., Janv. 1827.
Ibid., from Gaz. Med., 1842, p. 861.
12
170
FRACTURES OF THE STERNUM.
it any farther. The fracture was transverse, and about three inches
below the top of the sternum, opposite the centre of the third rib, the
lower fragment projecting in front of the upper. The fragments were
easily replaced by simply throwing the head back, and fell into place
with an audible snap, but immediately resumed their unnatural posi-
tion when the head was flexed. They finally united, but with a slight
projection and overlapping.*
Malgaigne expresses a doubt whether all these can be considered as
the results of muscular acti(m, since, in a certain number of the exam-
ples cited, the head seems to have been thrown forwards by the con-
cussion, and in others, also, there is no evidence that the muscles at-
tached to the sternum were put upon the stretch. The only remaining
explanation is that in such cases the sternum has been broken by the
violent shock, or contrecoup,
John T. Hodgen, of St. Louis, has reported to me one example of
fracture of the sternum causeil by a crushing force applied to the back,
and in which, we may see plainly, that muscular action was not con-
cerned. A man, seated upon a wagon, was driving under a low bridge
with his head very much bent down. The bridge caught his bacK,
opposite the shoulders and crushed him forwards, "separating the ver-
tebne in the dorsal region, and breaking the sternum about three inches
below its upper end." This man recovered.
Among the most authentic examples of fracture of this bone from
muscular action alone are those in which it has occurred during labor.
Malgaigne has collected three of these cases, and to these the American
tninslator. Dr. Packard, has added two more, most of which took
place at or nciir the junction of the first and second pieces of the ster-
num. Lately Dr. Borland has added one more example, which took
place at a point near the fourth costal cartilage.'
Malgaigne relates also the case of a mountebank, who, leaning back
to lifl with his feet and hands a
weight, felt suddenly a severe
pain in the sternal region, and
fell over with a fracture of this
bone.
Seat and Direction of /Var-
(ure. — The sternum is separated
mast frequently either in the long
central portion, or at the junc-
tion of this with the upper por-
tion, where the bone is weakest.
In fact, a separation at this lat-
ter point may be regarded fre-
quently as a diastasis or dislo-
cation rather than as a fracture,
since the two portions do not
lx?come firmly united by Iwne
until late in life. The verv late
Fio. *?.
Ttme
'f
M'1,0,
iovn after tHt^rtM
SCrrnum. fthowioi; thr ptrUid* at which itt aereral
|v»rt* unite t>y Umr. (Fr«»u lirarj
> Londi»n MtHi.-Chir. Kov,, vol. xvii, new seric*. p. 686. lSS*i.
• J. N. BorUnd, M.D., Bo»ton Med. and Surg. Jour., April 20,
1875.
FRACTURES OF THE STERNUM. 171
ossification and fusion of the xiphoid cartilage with the central piece,
also, will explain the infrequency of its fracture.
Boyer believed that the xiphoid cartilage was not susceptible of
being permanently displaced backwards, except in aged persons, after
it had become ossified, " for," he says, " though violently struck and
driven backwards by a blow on what is vulgarly termed the pit of the
stomach, yet it restores itself by its own elasticity."*
The following case, however, which has come under my own obser-
vation, is conclasive as to the possibility of this accident :
A man, twenty-eight years old, fell forwards, striking the lower end
of his sternum upon the top of a candlestick, breaking in the xiphoid
cartilage. During two years following the accident he had frequent
attacks of vomiting, which were excessively violent and distressing;
the paroxysms occurring every five or six days. Both Dr. Green, of
Ail^ny, and Dr. White, of Cherry Valley, upon whom he called for
relief, recommended excision of the cartilage, but the patient would
not submit to the operation. Twelve years after the accident, in the
year 1848, while he was an inmate of the Buffalo Hospital of the
Sisters of Charity, I examined his chest, and found the xiphoid carti-
lage bent at right angles with the sternum, pointing directly toward
the spine. He now suffered no inconvenience from it, except that it
hart him occasionally when he coughed.^
The upj)er portion of the sternum is rarely broken, unless at the
same time the central portion is broken also.
The direction of these fractures is generally transverse, or nearly so;
occasionally a slight obliquity is found in the direction of the thick-
ness of the bone. In three or four examples upon record, the direction
of the fracture was longitudinal. It is not so unfrequent, however, to
find the bone comminuted. Compound fractures are exceedingly rare.
When the fracture is transverse, the lower fragment is almost always
displaced forwards, and sometimes it slightly overlaps the upper frag-
ment
In one instance mentioned by Sabatier, where the separation had taken
place at the point of junction between the first and second pieces, the lower
fi*agment was displaced backwards, and was also carried upwards under
the upper fi^gment to the extent of twenty-eight millimetres.
I have seen a remarkable case of separation of the manubrium from
the gladiolus, accompanied with a true fracture and other complications.
Louis Wilson, aet. 60, was admitted into the Long Island College
Ho^ital, April 4, 1866, having just fallen through the hatchway of a
vessel. He had a compound comminuted fracture of the right leg, a
fracture of the four first ribs on each side at their necks, a dislocation
of the sternum fi^m the cartilages of both second ribs, a dislocation of
the left third cartilage from its rib, a dislocation of the first from the
second bone of the sternum, and a transverse fracture of the sternum
three-quarters of an inch l)elow the top of the gladiolus. The dislo-
cation of the manubrium was complete, and it was thrust behind the
opper end of the gladiolus, underlapping it half an inch. The trans-
* hoypT on Diseases of Bones, p. 69.
' Buifnlo Med Journ., vol. xii, p. 282, Cases of Fractures of the Sternum.
172 FRACTURES OF THE STERNUM.
verse fracture thrce-quartei's of an inch lower down was also complete,
and the fragment thus separated was divided into two, namely, an
anterior and a posterior fragment, by a transverse sph"tting ; the ante-
rior moiety retaining its attachment to the periosteum below, and not
being displaced, while the posterior moiety retained its attachment to
the periasteum both above and below, and was pushed downwards by
the descent of the manubrium. His mind was clear, but he bad
i)aralysis of the bladder, and was breathing with some embarrassment.
; had no difficulty in (liagnosticating the dislo(?ation of the third car-
tilage, and of the manubrium. There was no swelling or discoloration
on the front of the chest, but it wjis quite tender. His head was not
thrown forwards. He complained of some soreness on the back of his
head. His general condition was such that I did not attempt reduc-
tion. The following day he exjxictorated blood, and on the third day
he (li(^d. The autopsy revealed some effusions of blood underneath
the pleura, but no lesions of the heart or lungs. The evidence is in
this case conclusive that he struck upon his back and head, in fact,
that it was a fracture from counter-stroke, by which the head, neck^
and three or four upi>er vertebra) were bent forwards with great force,
thus doubling forwards the top of the sternum.
Dr. IlolKjrt Watts, Jr., of this city, has reporte<l a very similar case,
in which death occurred on the same day. The fragments of the
sternum were not displaced, but the ribs had sutfered similar l(*sions.'
Diaf/uosis, — In a few cases the patients have felt the l)one break at
the moment of the accident. When displacement exists, it may gene-
rally be easily recognized, and the lower fragment will often lie seen
to move forwards and backwanls at each inspiration and expiration.
Crepitus may also \yc det<H'ted in some of these examples, but it is less
often present where n(» disj)lacement exists. To determine the exist-
enc*e of crepitus, the hand should be placxxl over the supixwcnl «eat of
fracture, while the patient is directed to make forcred inspirations and
expirations, or the ear may be applieil <lirectly to the chest.
Emphvsema has, also, (Mxiisionally been noticeil, indicating usually
that the lungs have l)een penetrated by the broken fragments.
The fre(|uent occurrence of congenital malformations of the sternum
should warn us to exercise great care in our examinatiims, lest we mi.*-
take these natural irregularities for fractures. Bransby Ccxijwr men-
tions a remarkable instanit^ of malformation of the xiphoid c*artilage
which he at first suspectetl to be a fracture. It was so much curved
bac'kwards that, as Mr. Coo|>er thinks, its pressure u|)on the st4.>maeh
prinluceil a constant disposition to vomit whenever he had taken a full
meal, or had taken a draught of water.-
Prof/ntMiii, — In simple fracture of this Ixnie, urnxmiplicated with
lesions of the subja<*ent viscera, and es|MH;ially when the fracture is the
result of muscular action or of a counter-stroke, no serious consetiuences
are to Ix^ apprehendiHl. The bone unites promptly even where it is
found im|>o.ssible to bring its broken etlges into apposition. Indeed,
* Wattti, Am. Mfd. Tiino-*, vol. iii, p. 65.
* B. C«>o|H*r, Princ. and Pract. of Surg., p. 859.
FRACTURES OF THE STERNUM. 173
generally, where the fragments have been once completely displaced,
although it is not difficult to replace them momentarily, a redisplace-
ment soon occurs, and they are found finally to have united by over-
lapping; but no evil consequences usually result from this malposition.
In nearly all of the cases reported in which palpitations, difficult
breathing, etc., have been charged to the persistence of the displace-
ment, the injuries were of such a character as to furnish for these un-
fortunate results other and much more adequate explanations. In one
instance only, already mentioned, serious inconveniences followed from
a displacement of the cartilage backwards.
In other cases, however, where the fracture is the result of a direct
blow, constituting a large majority of the whole number, the prognosis
is often very grave; a conclusion to which one would naturally arrive
from the fact already stated, that the fracture of the sternum thus pro-
duced, in itself implies the application of great force.
An abscess occurring in the anterior mediastinum, and caries or ne-
crosis of the bone, are among the most common results of a blow de-
livered directly upon the sternum ; complications which generally end
sooner or later in death. Blood may be also extensively effused into
the anterior mediastinum.
A remarkable case of recovery after gunshot injury of the sternum
is reported by the U. S. Medical Bureau:
Private C. Betts, 26th N. J. Vols., eet. 22, was struck by a three-
oonce grapeshot, May 3, 1863, in the charge upon the heights at
Fredericksburg, Va, The ball comminuted the sternum, opposite the
third rib on the left side, penetrating the costal pleura. The patient
removed the ball from the wotmd himself. On the following day he
was admitted to the hospital of the second division of the sixth corps.
Through the wound the arch of the aorta was distinctly visible, and its
pul^itions could be counted. The left lung was ool lapsed*; when sit-
ting up, there was but ^ight dyspnoea. Several fragmentts of the
sterna m were removed. The wound soon began to heal, and he made
a complete recovery.*
Where emphysema is present, we niay anticipate inflammation of the
pleura and of the lungs.
In several instances, where death has occurred speedily after the in-
jniT, the heart has been found i)enetrated and torn by the fragments.
Sanson and Dupuytren have each reported one example of this kind.
Duvemey has mentioned two, and Samuel Cooper says there is a speci-
men in the museum of the University College, exhibiting a laceration
of the right ventricle of the heart by a portion of fractured sternum.
Watson mentions a case in which the pericardium was torn but the
heart was only contused.*
Treatment — When the fragments are not displaced, the only indica-
tions of treatment are to immobilize the chest, and to allay the inflam-
mation, pain, etc., consequent upon the injury to the viscera of tlie chest.
The first of these indications is accomplished, at least in some degree,
> Circular No. 6, Washington, D. C, Nov. 1, 1865, p. 23.
> New York Journ. Med., vol. iii, p. 351.
174 FRACTURES OF THE STERNUM.
by inclosing the body, from the armpits down to the margin of the
floating ribs, with a broad cotton or flannel band. A single band,
neatly and snugly secured, and made fast with pins, is preferable to,
because it is more easily applied than, the roller which surgeons have
generally employed; it is also much less liable to become disarranged.
It should be pinned while the patient is making a full expiration. To
prevent its sliding down, two stri{)s of bandage should be attached to
its upper margin, and crossed over the shoulders in the form of siis-
pendere.
Generally the patients prefer the half-sitting posture, with the head
and shoulders thrown a little backwards; and this is the position which
will be most likely to maintain tlie fragments in place, and also to secure
immobility to the external thoracic muscles, while it leaves the dia-
phragm and the abdominal muscles free to act.
The second indication may demand the use of the lancet; but more
often it will be found necessary to allay the pain and dis[K>sition to
cough by the use of opium.
If, however, the fragments are displaced, it is proper first to attempt
their reduction; which, as we have already intimated, is generally more
easy of accomplishment than is the maintenance of them in place until
a cure is effected.
The upper fragment may be thrown forwards, and made to resume
its |)osition sometimes by a single full inspiration; but then it usually
falls back during expiration ; or it may be reiluced by straightening the
spine forcibly, and at the same time drawing the shoulders back.
Verduc and Petit proposed in those cases in whit^h it was found im-
possible to reduce the fragments by these simple means, to cut down
and lift the <lc|)ressed l)one. Melaton suggests the use of a blunt crotchet
intHKluced through a narrow incision; and Malgaigne has thought
of another plan, which is, to ()enetrate the skin WMth a punch, and <!]-
recting it to the broken margin, to push the fragment into its place,
but which he does not himself regard as a suggestion of much value,
since the lK>ne is too soft to affonl the necessary resistance; and, more-
over, this, in common with all of the other similar methods, is liable,
in some degree, to the objection that it may increase the tendency to
caries and suppuration, already imminent. If re<]uce<], the fragmentti
will probably immediately again bi^come displaceil; and more than all,
it still remains to be proven conclusively that the mere riding of the
fragments is in itself ever a cause of subset^uent suffering, or even of
inconvenience.
When an abscess has formed in the anterior mediastinum, surgcims
have 0(*casionally recommended the use of the trephine. Gibson has
twice o|>erated in this manner at the I^hiladelphia Hospital, but iu
each case the caries continued to extend, and the |>atient died; an ex-
|>erience which has inclinnl him latterly to disa)untenance the opera-
tion.*
There are other consi<leratins mcntioneil by Lons<lale, which ought
to decide us never to use the tn^phine in th(»se cjuh.»s. ** For the symjH
* Gib»i'n, lii»titutes tiid PrMctice of Surgery, vol. i, p. 269.
FRACTURES OF THE RIBS. 175
toms denoting the presence of the abscess^ when completely confined
to the under surface of the bone, will be very uncertain ; and when
the matter collects in large quantities, it will show itself at the margin
of the sternum, between the ribs, when it can be let out by making a
puucture with the point of a lancet, without the necessity of removing
a portion of the bone."^ Ashhurst, referring to the same point, re-
marks: "The fact that the mediastinal space can be cut into without
injury to the pleura is shown by many cases, among others by one
which came under my own observation.''^
We have already said that a separation of the first from the second
piece of the sternum^ occurring before ossific union had taken place,
might with some propriety be regarded as a diastasis, or as a dislo-
cation even. Maisonneuve, Vidal (de Casis), Malgaigne, and other
French surgeons speak of it as a dislocation, and Vidal has collected
five examples, in all of which the lower bone occupied a position in
front of the upper. Malgaigne enumerates ten examples. The points
of difference between the dislocation and the true fracture are too
small, however, to demand of us especial attention.
CHAPTER XVIL
FRACTURES OF THE RIBS AND THEIR CARTILAGES.
1 1. Fractures of the Bibs.
Fracti^res of the ribs, observed more often than fractures of the
sternum, are rare as compared with fractures of other long bones.
In my records, not including fractures from gunshot injuries, only
twenty-five patients are reported as having had broken ribs; but as
in several of the cases two or more ribs were broken at the same time,
the total number of fractures is about fifty-eight. If, however, I had
always accepted the diagnosis made by other surgeons, the number
would have been much greater, since I have been repeatedly assured
that the ribs were broken when, uix)n the most careful examination,
DO evidence, beyond the existence of a severe pain and of difficult res-
piration, has been presented to me.
Etiology, — ^The force requisite to break the ribs is scarcely less than
what is requisite to break the sternum ; and in childhood and infancy
it is soraetiraes almost impossible to break them, so that children and
even adults are often crushed and killed outright, where, although the
preij^ure has been directly upon the thorax, the ribs have resumed their
positions, and have been found not to be broken. I have met with
several examples of this kind.
In old age, the cartilages ossify and the ribs themselves suffer a
gradual atrophy, which renders them much more liable to break.
The most common causes are direct blows, of very great force, in
— — . — _ . — ■ ■
* Lon^^iale, Practicul Treatise on Fractures, London, 1838, p. 242.
' Ashhurst, Am. Journ. Med. Sci., Jnn. and Oct. 1862.
176 FRACTURES OF THE RIBS AND THEIR CARTILAGES.
consequence of which sometimes the frap^ments are not only broken,
but more or less forced inwards ; occasionally they are the result of
counter-strokes, and then the fragments, if they deviate at all from
their natural position, are salient outwards; a species of fracture which
I have not met with so often.
Malgaigne has collectc<l eight examples of fractuixjs of the ribs pro-
ducc<l by muscular action, by the Ixjating of the heart, etc., all of which
oc»curre<l upon the left side. It is iH^lieveil, however, that in all of
these ciiscs the ribs had previously become atrophied, and perha|»
undergone other changes in their structure, rendering them liable to
fracture from the action of trivial causes.
PuthoIrKjy^ SccUy etc. — The fourth, fifth, sixth, and seventh ril»s are
most liable to be broken ; the upper ribs, and especially the first rib,
being so well protected in various ways as to greatly diminish their
liability, while the loose and floating condition of the last two ribs
gives them an almost complete exemption.
In my own cases I have found the first, second and third ribs each
broken four times; the fourth, six times; the fifth, twelve times; the
sixth, twelve times; the seventh, nine times; the eighth, ninth, and
tenth, twice each.
Twenty-one were broken through their anterior thirds, generally at
or near the junction of the cartilages with the ribs; ten through their
middle thirds; and twenty through their posterior thirds. Malgaigne
has noti(»ed, also, contrary to the general opinion of surgeons, that the
ribs are most often broken in their anterior thirds, whether the i»ause
has been a direct or a counter blow.
The direction of the fracture is generally transverse or slight I v ob-
lique; sometimes it is quite oblique. It is often com|)Ound; and in a
few instances I have found it comminutwl or multiple. Where the
fracture is compound, it is rendenMl so generally by the fragments
having i>enetrated the lungs, and not by a tegumentary wound. In
only twelve of the twenty-five cases record^l by me, has the fracture
bt*en uncomplicate<l with fractures or dislocations of other bones.
Displacement cannot occur in the direction of the axis of the bone
unless scvend ril)s are broken at the same time. The fragments are
therefore either not at all displactnl, or they fall inwards towani the
cavity of the chest, or outwanls, or very slightly downwanls, in the di-
re<*tion of the intercostal sj)accs. Sometimes the rib moves a little upim
its own axis.
PnxjnoiiiH, — l)<»ath <Kvurs sooner or later in a pretty large minority
of the cases in which the ribs have l)een bn)ken ; yet not often as a
dire<*t cons<»quen<»e of the fractun*, but only as a n»sult of the injury
inflicttnl ujmhi the visc<'ra of the chest, or of other injuries re<*eived at
the same moment. The violent compression of the heart and lungs
ha** frc<|uently pHHluc**!! death, and sometimt»s, as I have mort» than
once seen, almost immeiliately ; (»r the patients have succumbetl at a
later |KTi<Kl to acute pneumonitis, or pleuritis.
I^»ns<lale siw a case in which the IxkIv of a man having been trav-
erstKl by the whet»l of a wagon, eight rilw were broken, and death
having followed almrjst inime<liately, the autopsy disclosed a rent in
FRACTURES OF THE RIBS.
177
the left auricle of the heart, produced l)y one of the broken ribs.^
Soatb says there is such a specimen at St. Thomas's Hospital.^
Dupujtren reports a similar case. The same surgeon has also seen
several deaths produced by the emphysema, independent of the fracture,
t^o of which are particularly descril)ed in his Clinical Lectures.^
Ame^bury has seen a case of death from rupture of the intercostal ar-
tery, where there was no injury of the lungs.*
In several instances observed by me, patients have suffered from
pains in the side, occasionally from cough, etc., after the lapse of two
or more years, and I suspect it is no uncommon thing for these injuries
to entail some such permanent disability, but which is a consequence
rather of the injury to the viscera of the chest, than of any condition of
the broken ribs themselves.
In general, simple fractures of the ribs unite in from twenty-five to
thirty days. Alalgaigne has seen one case of non-union ; Huguier met
with another upon the cadaver, in which a complete false joint existed,
famished with a capsule and lined with synovial membrane;* Eve, of
Xasbville, Tenn., saw a case of non-union, occasioned, probably, by a
caries or necrosis of the bone, since it was accompanied with a discharge
of matter, and in which a removal of the ends of the fragments resulted
promptly in a cure of the sinus f and Samuel Cooper says there is a
specimen id the Museum of the University College, of a fracture of six
ribs where the fragments are only connected by a fibrous or ligamentous
tisiiue."
The union generally occurs with only a slight degree of displace-
ment.
After the union is completed, even where there is no displacement, a
certain amount of ensheathing callus may generally be felt at the point
of fracture. Of five cases which I have carefully examined after re-
cover^', in only one instance was I unable to detect any irregularity at
this point. I have in my cabinet nine specimens of fractured ribs, in
four of which the en-
sheathing callus is com-
pletely formed, but the
fragments are in perfect
apposition : in one, ap-
poBition is preserved, but
there is no ensheathing
eallos ; and the remain-
ing four, all occurring
in the same person, are
onitKi with displace-
ment, but without a pro-
per ef^heathing callus.
In some specimens I
have observed sharp spiculee, in others broader sheets, of bone extend-
• LoDfdale on Fractures, p. 25S. » Chelius'e Surgery, by South, vol. i, p. 699.
• Dafmvtren, op. cit., p. 79. * Araesbury on Fractures, vol. ii, 612.
• Halgaigne, op. cit., p. 486. • Eve, N. Y. Journ. Med., vol. xv, p. 136.
' S. Cooper's Surg., vol. ii, p. 821.
Fio. 44.
Fractured ribs Joined to each other by osseous matter. (From
Dr. Gross's cabinet.)
FRACTURES OF THE RIBS AND THEIR CARTILAGES.
iug along the course of the intercostal muscles frum one rib to the
OLiier, forming a species of anchylosis between their adjacent margins.
SifDiptomatology. — Acute pain, referred especial ly to the point of frac-
ture, sometimes producing great embarrassment in the respiration, and
crepitus, are the most common indications of a fracture. The paiu and
embarrassed respiration are, however, far from being diagnostic, since
they are often present in an equal degree when the walls of the chest
have only been severely oontusul.
The crepitus, also, is often difficult to detect, owing to the tbickm
of the muscular coverings, or to the amount of fat upon the body, or to
the fracture having occurred perhaps directly underneath the mnmms
in the female. In three instances, where the presence of cniphys^^nn
rendered the existence of a fracture quite certain, I have been unable
immediately after the accident to discover crepitus.
The crepitus may be discovered sometimes by pressing gently upon
the seat of fracture, or by applying the ear or the stethoscope over this
point while the patient attempts a full inspiration, or coughs; or we
may pi-ess upon the front of the chest with one hand, while the fingns
of the other hand rest upon the fracture-
Occasionally the patient has felt the bone break, and very often lie
feels or hears the crepitus after it is broken, and will himself indicate
very cleurly the point of fracture.
At the same time that we detect crepitus we are able also to discover-
motion in the fragments, but I have once or twice discovered preier^
natural mobility without crepitus.
Emphysema, which is almost certainly indicative of a fracture, ii
present in a pretty large pro|X)rtion of cases. It has been oliserved by
me in eleven out of twenty-live cases ; generally it did not extend over
more than two or three square feet of surface; but in two coses it finallj'
extended over nearly the whole body. It is remarkable, however, tbsl"
in only four of these eleven cases did the patients expe«'lorut« bloody
and then in a very small quantity, and usually not until tlic second 0
third day.
Desault observes that emphysema rarely succeetls to fractures of th
ribs; an observation which, as will be seen, my experience docs no
coniirro.
Treatment. — In simple fractures, where there is no displacement, o
where the displacement is only moderate, the chest may be incla<eA
with a broad belt or band, ns we have already directed in c;ise of fnu^
lure of the sternum ; provided always that it is not found tu incm
instead of diminishing the ])atient's sufferings. Some patients cam
tolerate this confinement at all ; while with a majority, although it it
at first uncomfortable and oppressive, after an hour or two it sflbidl
great relief from the distressing pain, and they will not consent lo havi
it removed even fur a moment. In nearly all casca of romtninBtedl
fracture it is inadmissible, on account of its tendency to foroc tho pice
iuwimls.
Hannay, of England, has suggested the use of adhesive stripe la
substitute for the cotton or flannel band; the several sucoewive piec
r
PHACTUKEa OF THE RIDS.
being imbricated upon each other until the whole chest is covered.'
The same objection Iiokls to this mode of dressing as to a similar mode
if dm^ing a broken clavicle, which has been recently recommended.
it will certainly l)ecome loosened after a few hours, by the slight but
taiDterruptetl jiiay of the ribs.
I The forearm ought alw to be brought across the chest at a right
ule with the arm, and secured in this position with a moderately
gnt bandage or sling, so as to prevent any motion in the pectoral
Buscles.
\s to position, the patient generally prefers to sit up, or he chooses
witiou only partly reclining npon bis back ; but there is no positive
; tft be observed in this matter, except that such a position shall
[ chosen as shall prove most comfortable to the patient.
If the fragmeuta are salient outwards, the fracture having been pro-
ftioml by a cotmter-stroke, they rnay be reduced by pressing gently
V^n them from without. If, on the contrary, the fn^meots are salient
■BirarcU, they will be found, in a great majority of cases, to have re-
BniriM] their positions spontaneously or through the natural actions of
■Rspiration ; but if they have not, it will be exceedingly difficult to re-
e them. Possibly it may be accomplished by pressing fi)reib]y
n the front of the chest, or upon the anterior extremity of the
skeri rib; yet if the fragments are comminuted, and the ends are
tnnch driven in, this method will avail little or nothing. In such cases
wveral surgeons have recommended that we should cut down to the
l>UDe and elevate the fragments, but Ross! alone claims to have actually
put the suggestion into practice.
No doubt, if the necessity was ui^ent, this method might be success-
fully 3iloptc<l ; or, Instead of cutting down tn the broken rib, we might
rvrnseisH the fragment with a hook, as suggested by Malgaignc, or
nhat in some cases might be even more convenient, with a pair of for-
«p6 winstructed with long teeth, obliquely set upon a firm shaft. Yet
ih"- exigency which will demand a resort to any of these measures will
1* exceed i ugly rare. In gunshot fractures, which are nearly all coni-
poQad and comminuted, the loosened or detached fragments should be
U once removed.
In 110 case do I attach any value or importance to the advice given
bj Petit, that we shall place a compress upon the front of the chest,
underneath the bandage, in order to reduce the fragments, or to retain
diem in iilace after reduction. Lisfranc, who advocated this method,
rlaimed that its advantage consist«il in the increascil length which was
ihu* giveu to the antero-poeterior diameter of the chest, and the consc-
ijueol accumulation of pressure from the encircling band, in this direc-
tion.' The mechanical law is no doubt correctly stated, but its value
■tjce b too inconsiderable to deserve consideration.
e emphysema generally demands no es]>ecial attention, since it is
180 FRACTURES OF THE RIBS AND THEIR CARTILAOE8.
usually too limited to occasion inconvenience; and when more exten-
sive, it generally disappears spontaneously after a few days, or a few
weeks at most. The advice given by some surgeons, that we ought
in these cases to cut down to the pleural cavity so as to allow the air
to escape freely through the incision, seems thus far to have rested its
reputation upon a more than doubtful theory rather than upon any
testimony of experience. Abemethy alone, so far as I know, has acta-
ally made the experiment, and his patient died.
Dupuytren, in the two cases already alluded to, bled the patients
and applied resolvent liquids, with rollers; he also made incisions with
the lancet at various points of the body, more or less remote from the
seat of fracture, a practice, however, in which he confesses he has no
confidence whatever. These patients both died.
Dr. Stedman, of the Massachusetts General Hospital, has reported the
case of a man aged sixty -nine, of intemperate habits, who, in addition
to a fracture of one of his ribs, had also a dislocation of the outer end of
the clavicle. The emphysema commenced immediately, and reached
its acme on the twenty-second day. At this time it had extended over
his whole body ; his eyes were closed, and he breathed with great diflB-
culty ; but on the forty-fifth day the emphysema had entirely disap-
peared, and he was dismissed cured. The treatment consisted chiefly
in the free internal use of stimulants, and in the application of band-
ages ; but the bandages soon became disarranged, and after a few days
they were entirely laid aside.^
In the case of one of my own patients, where the emphysema was
almost equally extensive, the patient recovered after a few weeks, under
the use of a simple diet, and without any special medication whatever.
The 8e(X)nd case of extensive emphysema, observed by me, was as fol-
lows: A man was crushed, under a bank of earth, Sept. 19, I860.
Two hours after the accident I found him greatly prostrated. Six ribs
were broken on the left side near the spine, and one on the right side.
In coughing he expectorated some blood. There was emphysema of
the face and over the front of the chest. He died at 9 P.n., having
survived the accident only about six hours. The autopsy showed the
left lung ])enetrated at two i)oints, and collapse<l ; about six ounces of
blood in the lefl pleural cavitv ; lower lobe of right lung crushed and
disorganized, but the remaincWr of the lung not collapsed. The fea«
tures of the face were almost obliterated by the emphysema, which had
also invaded the mediastinal space, and extended over the body as low
as the knees.
i 2. Fractures of the Cartilages of the Ribs.
Boyer was incorrect when he 6ai<l that the cartilages of the ribs
could not l)e broken until they were ossified. They are often broken
when th^^rc is no ossification, at the same time that the ribs themselves
are broken. Sometimes they are broken alone. Not unfrecjuently,
' Boston Med. and Surg. Journ., toI. Iii| p. 816.
FBACTUBES OF THE CARTILAGES OF THE RIBS. 181
alsoy the separation takes place at the precise point of junction between
the cartilage and the bone.
Pyper relates a case in which the sternum was broken in a man aged
twenty-five years, and also the cartilages of the sixth, seventh, and
eighth ribs of the right side, as was proven by the autopsy, yet the
cartilages were not ossified. The vena cava ascendens was also rup-
tured by the force of the compression.* The reader is referred also to
my own and Dr. Watts's cases reported in the chapter on Fractures of
the Sternum. Since the date of the report of these cases I have met
with several examples of fracture of the cartilages.
Etiology. — ^The causes are the same as those which produce fractures
of the ribs, yet it is generally understood that it will require greater
force, and that consequently the injury done to the viscera of the
thorax will be more complicated and intense.
In the reports of the Massachusetts General Hospital an account is
given of the case of a man aged thirty, who was crushed by the fall of
a heavy weight upon his body, and who died afler about sixty hours.
An examination after death revealed a fracture of the cartilages of the
third and fourth ribs, with a laceration of the intercostal muscles to
snch an extent that a hernia of the lungs had occurred at this point.
This hernia had been discovered and recognized by Dr. Warren soon
after the accident occurred ; the protrusion being at that time as large
as the clenched fist, and regularly rising and falling with each move-
ment of respiration. It was accompanied, also, with a moderate em-
physema.
Pathology. — The fracture is clean and vertical, or transverse ; never
irregular or oblique. The direction of the displacement varies as in
fractures of the ribs, but the anterior or sternal fragment is generally
feand in front of the posterior or spinal.
Union takes place in these fractures, not through the medium of
cartilage, but of bone. Sometimes the new bone being deposited only
between the ends of the fragments, in the form of a thin plate, and at
other times it is formed around the fragments as well as between them.
The latter of these two processes has been most frequently observed.
The ensheathing callus appears to be supplied by the perichondrium,
while the experiments of Dr. Redfern render it probable that the in-
termediate callus may result from a conversion or transformation of
the adjacent cartilaginous surfaces. Paget remarks, also, that the ossi-
fication extends to the parts of the cartilage immediately adjacent to
the fracture.
I have seen one example, in the person of Hiram Leech, aet. 38,
which, after the expiration of more than one year, had not united.
The ftiicture had occurred in the united cartilages of the tenth and
eleventh ribs. The posterior fragment overlapped the anterior, and
they played freely upon each other at each act of inspiration and ex-
piration.
I do not know that any observations have been made upon the repair
of these cartilages in very early life, and it is possible that the process
> Ranking's Abstract, toI. i, p. 147, from the Lancet, Oct. 1844.
182 FRACTURES OF THE CLAVICLE.
may differ from this, which has been described as it has been observed
in the adult.
Treatment — The treatment need not differ from that already recom-
mended for fractured ribs.
CHAPTER XVIII.
FRACTURES OF THE CLAVICLE.
For the sake of convenience, I shall divide fractures of the clavicle
into those occurring through the inner, middle, and outer thirds. By
the " outer third " is meant all that portion of the clavicle incladed
between its scapular extremity and the internal margin of the conoid
ligament. The remaining portion is intended to be divided equally
into two separate thirds. The peculiarities of these several portions,
in respect to anatomical relations, liability to fracture, results, etc., will
explain the propriety of the divisions.
Cau4i€fi, — If we except gunshot fractures, the clavicle is broken, in
a large majority of cases, by a counter-stroke, such as a fall, or a blow
upon the extremity of the shoulder.
Occasionally it is broken by a direct stroke, as when a blow aimed
at the head is received upon the shoulder; it is broken sometimes by
the recoil of an overloaded gun, especially when the person lies upon
the ground, with the butt of the gun resting against the clavicle.
Gibson has seen a c^ase in which it was broken in a child at birth,
by an ignorant midwife pulling at the arm,^ and Dr. Atkinson has
re|>orto<l an example of intra-uterine fracture of the clavicle.^
Gurlt has collected seven cases of intra-uterine fracture of the clav-
icle caused by external violence.^
I have once seen the clavicle broken by muscular action alone. A
large, well-built, and healthy man, age<l thirty-seven, standing upon
the ground, attempted to secure the braces of his carriage-top with hk
right arm, when he felt a sudden snap, as if something about his shoulder
had given way. He did not, however, suspect the nature of the injury,
and did not consult any surgeon until eight days after, at which time
I found the right clavicle broken near its centre, but rather nearer the
sternal than the scapular extremity. The fragments were but slightly, if
at all, displaced, but motion and crepitus at the point of fracture were
distinct. The usual node-like swelling was also present, indicating the
existence of a considerable amount of ensheathing callus. He had been
unable to raise the arm to a right angle with the body since it wa»
broken, but he had suffere<l no other inconvenience from it.
A similar case is rejwrted in the number for January, 1843, of the
' (fih«on, PrincipW of Surg., sixth ed., vol. I, p 27'2.
• Atkinson, Btwt. Med. and Surp. Journ., July 2fl, IBCO:
• Gurlt, Holmos'9 Surgery, ed. of 1870, vol. ii', p. 7W.
FRACTURES OF THE CLAVICLE. 183
American Journal of Medical Sciences, copied from the Revista Medica.
The subject of this case was a colonel of cavalry, about sixty years of
age. In mounting his horse, he experienced a sensation as if something
had broken, followed by acute pain in his left shoulder, and, on exam-
ination, it was found that the clavicle was fractured in the middle.
The health of this gentleman had been impaired, it is further stated,
by repeated attacks of syphilis.
W. E. Whitehead, U. S. N., has reported the case of a healthy and
muscular man, twenty-eight years old, who broke his left clavicle at
the junction of tlie outer and middle thirds, while attempting to raise
him«€lf to a platform eight feet high. The fracture was transverse,
and unaccompanied with displacement.^
Malgaigne has recorded three other examples of fracture of this bone
from muscular action ; and Parker saw a case which was produced by
striking at a dog with a whip. The bone, in the latter case, had been
previously somewhat diseased, yet it united favorably.'
Of these seven cases, five occurred on the right side, and always near
the middle of the bone, if we except one case reported by Malgaigne,
in which the point of fracture is not mentioned. In neither case did
the fragments become displaced, only as they were found, in some of
the examples, inclined slightly forwards.
Gurlt has collected twenty cases of fracture from this cause.'
Pathology. — It has already been observed, in speaking of partial
fractures, that this bone suffers an incomplete fracture more often than
any other, and that in such cases the lesion occurs generally in the
middle third, or rather to the sternal side of the centre, and in a direc-
tion nearly or quite transverse. They are not usually accompanied
with much displacement ; but if a displaceitient exists, it is a slight
forward inclination of the fragments.
Fractures which are complete occur mostly after the bones have
become firm and unyielding. They are also generally oblique, seldom
comminuted, still more rarely compound. The point of tne clavicle
at which a complete fi^cture usually occurs is at or near the outer end
of the middle third, and a little to the sternal side of the coraco-clav-
icalar ligaments, near where the trapezius and deltoid cease their at-
tachments. It might be more exact to say that the fracture extends
from this point downwards and inwards, toward the sternum, embrac-
ing one inch or less of its entire length. In some cases the obliquity
is greater, and the amount of bone involved is much more considerable.
why the bone should break more fi'equently at this point, especially
in the adult and in the male, it is not difficult to understand. It is
smaller here than elsewhere, and less supported by muscular and liga-
mentous attachments. At this point, also, the axis of the bone begins
pretty abruptly to curve forwards, and more abruptly in the adult and
male' than in the child and female. When, therefore, the clavicle is
hroken, as it usually is, by a counter-stroke, the force of the blow,
» Whitehead, Pacific Med. and Surg. Journ., 1871.
» Parker, N. Y. Journ. Med., July, 1852
* Gurlt, Holmes's Surgery, ed. of 1870, vol. ii, p. 765.
FRACTURES OF THE CLAVICLE.
conveyed from the shoulder through the outer portion of the bone, u
suddenly arrei^teil, and expeuds itself upon the point where the direo-
tion of the axis is changed.
In a record of one hundred and forty-two fractures, including partial
and comminuted, and not including gunt<hot fractures, one nuodred
and twelve have occurred through
*^'"**- the middle third; and, with the ex-
ception of the partial fractures, the
fracture has in nearly all of (he casea
taken place near the outer end of this
third. Four have occurred through
the inner third, three of which were
within one inch of the sternum ; and
seventeen through the outer third.
A more practical analysis can be
based, however, upon the point <d
fracture with reference to its cause;
and I have never, but once, seen a
complete fracture of this bone pn^
duccd clearly by a counter-stroke,
whiuh was not near the outer end of
the middle third.
When the fracture is at this point,
Compkid owiqoe fniciure of ci»iicio. or in any portion of the middle third,
the direction of the displacement is
almost uniformly the same. The sternal fragment is slightly titled bj
the action of the clavicular portion of the stcrno-cleido-mastoid muiK-lc^
notwithstanding the resistance of the rhomboid ligament, and the sub-
clavian muscle. On the other hand, the acromial fragment is dragged
downwards by the weight of the arm, aided by the conjoined action of
a portion of the pectoralis major and the latissinius dorsi, feebly resisted
by the tni{ieziiis and other muscles from above ; by the action of the
same muscles, aided by the pectoralis minor, and perhaps by sohm
portion of the subclavius, it is drawn toward the body, diminishiDS
thereby the axillary spa(«; while by the preponderating strength of
the pi-ctondis major and minor, the acromial end of the fragment, with
the shouldtr, is flrawn forwards; the sternal end of the same fragment
l)oing rather displace*! backwards, and at the same time nsting at a
[wint somewhat elevated above the acromial end.
Dcsault has recorded one example of an overlapping by the cle%'a-
tion of the acromial fragment over the sternal ;' and Biehat remarks
that Hip[>ocratc3 sjieaks of the phenomenon as a thing which ma*
familiar to him. Syme has meiitionc^l a ease of this kind which be
had seen.' Gufretin, Malgaigne,' nn<l Stephen Smitli have carh »•
I>orted an example.* In Stephen Smith's ease the fracture occurred in
a man thirty-eight years old. The bone was broken through the outer
third, and transversi'ly. He was treated nt the Bellcvuc Huspiul, but
FRACTURES OF THE CLAVICLE. 185
the overlapping, to the extent of one inch, remained after the cure was
completed.
Margaret O^Donnell, aet. 40, was admitted to the Charity Hospital,
Blackwell's Island, June 1, 1868, with a single fracture of the clavi-
de, near its middle, caused two weeks before, by a fall on the shoulder.
The sternal fragment was lying beneath the acromial, and in this posi-
tion it finally united.
In nearly all the cases of oblique fractures occurring through the
middle third there follows immediately an overlapping, varying from
ooe-<jnarter of an inch t4> an inch, and sometimes, though very rarely,
exceeding this. There is a specimen in the Dupuytren Museum, in
which the shortening equals one-third of its entire length.
Transverse fractures, wherever they may occur, are seldom found
displaced, at least in the direction of the axis of the bone, as the fol-
lowing examples will illustrate :
An old lady, aged eighty years, fell down a flight of stairs, breaking
the right clavicle transversely, about one inch from the sternum. I
saw her, with Dr. Trowbridge, on the day following the accident.
Motion and crepitus were distinct, but there was scarcely any displace-
ment. No dressings were applied, but she was directeii to keep quiet
in bed, and upon her back. In the usual time the fragments had
anited, without deformity.
A man, about forty years old, fell backwards from a wagon, break-
ing the collar-bone near the middle. The fragments were movable,
tut not displaced. He was treated successfully and without any result-
ing deformity, by simple confinement in the recumbent posture during
a few days, and after this by suspending the arm in a sling, while he
was permitted to walk about.
A young man, aged twenty-six, fell while wrestling and broke the
clavicle at the outer end of the middle third. There was some dis-
placement at first, but the fragments being reduced, were found to
support themselves. A cross, secured with straps, w^vm applied to the
back, and on the twenty -eighth day the union was complete, and with-
out deformity.
A child, aged three years, fell about six feet, striking upon his
shoulder. He was sent to me on the same day, by Dr. G. Burwell. I
found the left clavicle broken off completely, about one inch from its
scapalar end. Crepitus and motion were distinct, but the fragments
were not displaced. The arm was placed in a sling, and on the seventh
day both motion and crepitus had ceased. The cure was accomplished
vitbout any degree of displacement
The example of a fracture from muscular action, already mentioned
» having been seen by me, was also probably transverse, and union
lufi occurred without treatment and without displacement.
Stephen Smith, of New York, has met with two examples of trans-
verse fractures without displacement, in a hospital record of eleven
01869. Bichat says Desault has frequently observed the same, it having
been seen three times at H6tel Dieu, in the course of the year 1787.*
1 BeMulton Fractures, op. cit., p. 15
18
186 FRACTURES OF THE CLAVICLE.
Desault thiuks, also, that sometimes the fracture, taking place obliquely
upwards and inwards, the usiial form of displacement is prevented, and
apposition is preserved. In nearly all of the examples of partial
transverse fractures, occurring in children, seen by me, there has beoi
no longitudinal displacement.
If the fracture is near the sternum, and within the fibres of the
costo-clavicular ligaments, as in the case of the old lady just cited, the
displacement is inconsiderable. I have seen one other similar case, in
an adult also. Lonsdale mentions a case, in a child three years old,
which came under his observation in Middlesex Hospital,^ which be
regarded as a separation of the epiphysis, the point of fracture being
half an inch from the sternum ; but the only epiphysis in connection
with this bone, is an exceedingly thin plate at the sternal end, which
does not begin to ossify until about the eighteenth year of life. JN^either
the age of the patient, nor the point of separation, would justify an
opinion that this wa^s an epiphyseal separation. Malgaigne mentions
two other examples, in one of which the fracture was so near the ster-
num tliat it was difficult to say whether it was not a partial dislocation.
The displacement was only trivial.* But the only two specimens con-
tained in the Dupuytren Muse^im oiYcr a considerable displacement,
and in both the external fragn^nt is tlirown downwards and forwards
March 22, 1865, I pn^enttnl to the New York Pathological Society
a similar case, obtained from a patient in Bellevue Hospital. The
man from whom this specimen was taken was forty-five years old, and
the fracture, occasioned by a fall upon the shoulder, extended from the
sterno-clavicular articulation upwards and outwards one inch and a
half. The fragments were overlapped three-quarters of an inch, and
were firmly united. The character of the accident was not recognized
until after death. The speciuiien is uow in the museum of the Belle-
vue Hopital.
With regard to the amount of displacement usually attendant upon
fractures near the outer end of the bone, surgical wrifei*s have generally
uniteil in declaring that it was in a majority of cases ver}' imxinsidem-
ble, while some have even affirnuHl that there would be found no dis-
placement what^'ver; neither of which opinions, according to the ob-
servations of Robert Smith, of Dublin, is strictly (»rrect. He has
examineil eight specimens of fracture of the outer extremity of the clav-
icle, contained in the museum of the Richmond Hospital School of
Medicine ; three of which were broken between the conoid and trape-
Eoid liganvents, and are united with very little displacement, while the
remaining five, broken beyond the trapezoid ligament, present a very
marked deformity.
The following is a sumnuiry of the conclusions to which he has
arriveil :
" When the clavicle is broken between the two fasciculi of the coraco-
clavicular ligament, there is sc'Idom any displacement of either frag-
ment, and always much less than in fracture of any other portion of
^ LoniMJHie on Fractures, p. 200. * M»lgiiigne, op. cit.| p. 4U1.
FRACTURES OF THE CLAVICLE. 187
the bone. "When displacement does occurj it is usually limited to a
dight alteration in the direction of the bone, by which the natural con-
vexity of this portion of the clavicle is increased.
"The explanation of which facts is found in the attachments of the
ligaoients from below to the two fragments ; and in the action of the
trapezius from above, by which they are antagonized.
" But the case is very different when the bone is broken external to
the trapezoid ligament. Here the coraco-clavicular ligaments can have
no direct influence upon the outer fragment, which is displaced now
partly by muscular action, and partly by the weight
of the arm, the sternal end of the outer fragment
being drawn upwards by the clavicular portion of
the trapezius, while, by the action of the muscles
passing from the chest, the entire outer fragment
18 drawn forwards and inwards, so as to bring
sometimes its broken surface into contact with the ^ , . .^ ,.
. . p n At ' o 11* Fracture Oil t Hide of trapc-
aoterior surface or the inner tragment, and placmg «>id ligament, uuitea.
it nearly at right angles with this fragment, in
which position it is generally united. The displacement in this direc-
tion, rather than any d^ree of overlapping, explains also the shorten-
ing which existed in all of these cases, varying in the different specimens
from half an inch to one inch, and averaging about three-quarters of an
inch/'
Such are the views of Mr. Smith, and I see no reason to call in
question their correctness. In my own experience, a fracture occurring
in a child three years old, within one inch of the acromial end, proba-
bly between the ligaments, was never displaced at all ; a second, and
third, occurring in adults, presented no displacement. Two cases were
displaced each one-quarter of an inch, and two cases, half an inch ;
these four latter cases occurred in adults, and always within an inch of
the acromial end of the bone. In one of these last examples, the inner
fragment was rather behind than above the outer fragment.
But it would be unsafe to draw conclusions from an experience which
i? confined entirely to living examples, and in which no dissections
have been made, to verify the exact point of fracture, or the precise
amount and character of the displacement. So far as they go, however,
they seem to me to confirm the general correctness of the observations
made by Robert Smith.
It has happened to me only six times to meet with a comminuted
frM^ure of the clavicle, except in cases of gunshot injuries, all of which
fractures occurred through some portion of the middle third of the
bone; the intercepted fragments being from one inch to one inch and a
half in length, and lying obliquely, or, as in one case observed by me,
at nearly a right angle with the main fragments.
I have never seen a compound fracture of this bone exce|)t as the
wsolt of a gunshot injury, although, in many cases, the sharp point of
aa oblique fracture has seemed just ready to penetrate the skin.
One case is reported as having been presented at St. Bartholomew's
Hospital. It occurred in a boy fourteen years old, and was produced
188
FRACTURES OF THE CLAVICLE.
Fio. 47.
by his having been drawn into some machinery while it was in motion.'
Two similar cases are reported from the New York Hospital, as having
been observed during the last ten years. The whole number of exam-
ples of fracture of the clavicle during this period was 191.*
Lente also mentions a case, seen by himself, occasioned by the fall
of a derrick upon the shoulder. The patient, twenty-four years old,
was admitted into the New York Hospital in August, 1848. The left
clavicle was broken at about its middle, and a large wound in the
integuments communicated with the fracture. The fragments united
firmly in about six weeks, after several pieces of bone had been dis-
charged from the wound.^
A double fracture, or a simultaneous fracture occurring in both clavi-
cles, seldom occurs. I have recorded two cases (four fractures^ three
of which are incomplete), both occurring in young boys.*
Malgaigne says it has only happened to him to see it once in 2358
cases, at the H6tel Dieu, and he can recollect only five other examples.
And of 158 cases of broken clavicles reported from the New York
Hospital, it is stated to have occurred in only four. These gentlemen
however, only report hospital
cases, and they have reference,
doubtless, to complete fractures;
while double fractures, accord-
ing to my experience, occrur more
often in children than in adults,
and are of the character of partial
fractures, without usually much
displacement; which fiiets, if sus-
tained by subsequent observa-
tions, would sufficiently explain
their infrequency in hospital, and
their relative frequency in private
experience.
Symptoms. — In all cases of
complete fracture with displace-
ment, no difficulty will be expe-
rienced in deciding u|)on the
nature of the injury.
The patient is found generally
leaning toward the injured side,
while the opposite hand sustains the elbow of the same side, to prevent
its dragging downwards.
Thf» shoulder falls downwards, forwards, and inwanls; while, at the
same time, the line of the bone is interrupted by the sharp and project-
ing point of the sternal fragment.
If the fracture is the result of a direct blow, a swelling and discolor-
... ■ ;^y:
Complete Fracture. — Oblique; at Junction of outer
aud middle thirds. (From nature.)
* London Mod. Gnx., vol. ii, p. 3S2.
' New York M»»d. Tinn'.s, MMrch 16, IS^Jl.
■ L«*nte, N. Y. Journ. of Med., July, 1S60.
* Ki'p on Dvi. Hfier Frac , Ca»o« 6, 6, 10.
FRACTURES OF THE CLAVICLE. 189
ition may be seen at the seat of fracture; but if it is the result of a
counter-stroke, we must look to the top or point of the shoulder for
the fiigns of a contusion^
The patient also experiences pain when an attempt is made to raise
the arm at a right angle with the body, and especially in attempting
to carry the arm across the body, by which the ends of the broken
clavicle are driven into the flesh. In two cases (Cases 19 and 50 of
mj Report on Deformities) of oblique fracture, accompanied with dis-
EUcement, occurring in the middle third of the bone, I have particu-
irly noticed that the ))atients could easily lift the hands to the head,
aod in one of these cases the patient, a boy fourteen years old, raised
his arm perpendicularly over his head. Such exceptions are not very
aocommon.
Crepitus can be detected sometimes by sim|)ly pressing down the
sternal fragments, but it is almost always present when we draw the
sboalders forcibly back, so as to bring the broken fragments into more
perfect contact.
If there is no displacement, still crepitus may generally be discovered
by grasping the bone between the thumb and fingers, and moving it
gently up and down, or by slight pressure upon the point of fracture.
When the fracture occurs close to the acromial extremity, external
to the coraco-clavicular ligaments, quite frequently there is no percep-
tible or marked displacement, and its diagnosis will require, therefore,
more care and attention on the part of the surgeon.
Prognosis in this fracture deserves especial attention. In no other
bone, except the femur, does a shortening so uniformly result. Of
aeventy-two complete fractures only sixteen united without shortening ;
and of twenty-seven simple, oblique, complete fractures, which occurred
at or near the outer end of the middle third, only one united without
shortening (Case 46 of my Report), and in this case the patient was
but fifteen years old, and the fragments were never much displaced ;
nor can I say that the treatment — ^a board across the back, after the
manner of Keckerley — had anything to do with the result. Six cases
of complete transverse fracture, occurring at the same point, united
without shortening.
The shortening, after the union is consummated, varies from one-
qoarter of an inch to one inch or more ; and the fragments are almost
always, especially when the fracture is through the middle third, found
lying in the position in which we have described them to be at the first :
the outer end of the inner fragment being above, and often a little
in front of, the outer ; sometimes, es()ecially in lean jxjrsons, and when
the fractures are very oblique, presenting a sharp and unseemly pro-
jection.
The greatest amount of shortening is generally found in those frac-
tures which occur through the middle third ; in fractures near the
sternal end there is usually very little permanent displacement; the
»me is true when the fracture is at the acromial end, and between
the ooraco-clavicular ligaments, as the observations of Robert Smith,
ilready quoted^ have sufficiently established ; but if the fracture is
190
FBACTURES OP THE CLAVICLE.
beyond these ligaments, the final displacement and deformity may be
very great.
The presence of a small amount of ensheathine callns soon after the
cure is completed, sometimes increases the deformity. It is rarely
seen to encircle the bone completely, and occasionaly it appears to
be most abundant in the direction of the tvilient points of the fracture,
that is, above and below ; so that, nnless the examination is made with
care, the projecting points of callus which remain, somctim<^« after
many years, may be easily mistaken for an intercepted fragment turned
at right angles to the axis of the bone.
Robert Smith has observed, also, that in cases of fracture external
to the conoid ligament, asseous matter is freely formed a\>nn the under
surface of each fragment, but there is seldom any deposited upon the
upper surface of either. These osseous growths, occupying the situ-
ati(m of the coraeo-clavicular ligaments, freqiiently prolong themstelvcs
as far as the coraeoid process, and in some cases to the notch of the
scapula. Still less frequently these osteophytes become fused with the
coraeoid process, and a true anchylosis exists.
In comminuted fractures the intercepted fragments generally fall off
from the line of the other fragments, and cannot easily be restored.
The clavicle being a spongy and vascular bone, usually unites with
great rapidity, generally within twenty days. In the fourth example
of transverse fracture already men-
F'o- **■ tioned as having been seen by me,
the union seemed to be tolerably
firm in seven days. Wallace reports
one case from the Pennsylvania
Hospital, which was cure<l in eight
days, and another in nine days.'
Vclpoan says the clavicle will unite
in from fifteen to twenty-five daji-s;
Rcnjamln Bell, in fourteen ; Stephen
Smith has seen it 6rin in fifteen
davs.
Whatever may be the degree of
displacement, or tlie condition of
the system, unless in a ca.<e of gun-
shot fracture, it is very sehlom that
it reuses to unite aitogetlicr, or
that the union is ligamentoiui ; and
in the few eases fonnd Hjx>n nvord
of a ligamentous union, the func-
tions of the arm do not scorn to have suffered any serious ultimate
injury, as the following example will illustrate:
E<lmun<] Nugent, a stout Irish laborer, twenty-five vears old. wa»
roceivcl into the IJuffalo Hospital of (he Sistcre of Charity, in March,
IS.Il. Several years Iwfore, he fell from a home and broke his loft
clavicle, at the outer en<l of the middle thinl. This was near Cork,
CummlaulFd Fru
— UniW,
■ Am, Jouro. Hed. Sci., vol. i
I, p. 110.
FRACTURES OF THE CLAVICLE. 191
in Ireland ; and, without consulting any surgeon or " handy man," he
continued at work, holding the tail of the plough, nor from that day
forward did he employ a surgeon, or dress his arm, or cease from his
work.
The clavicle presented the same deformity which many other simi-
lar fractures present after what is usually termed successful treatment,
eicept that it is not united by bone. The outer end of the inner frag-
ment rode upon the inner end of the outer fragment half an inch. The
ligament uniting the two extremities was so long and firm that it could
be distinctly felt, and the fragments moved upon each other with great
fcedom.
In order that we might determine the amount of injury which he
had suffered from the ligamentous union, \Ve directed him to lift
weights placed on a table before him, while he was seated upon a chair.
We ascertained from this experiment that with his lefl arm he could
lift as much, within three ounces, as he could with his right, and he
was not himself conscious of any difference. The muscles of the lefl
arm seemed as well developed as those of the right.
In May, 1868, I found in the Charity Hospital, Black well's Island,
in the person of A. Bragg, »t. 34, a fracture of the left clavicle, which
had united only by ligament. The fracture had occurred, when he was
twenty years old, at about the junction of the outer fourth with the
inner three-fourths. No surgeon was employed, and no treatment had
ever been adopted. The ligament was quite long, and the fragments
moved freely upon each other, yet the arm was nearly as strong and as
useful as before.
Chelius also refers to two cases mentioned by Gurdy and Velpeau,
in which, although an artificial joint remained, the use of the limb was
but little impaired.^
In a case of compound and comminuted gunshot fracture reported
by Ayres, of New York, the recovery was remarkable. The man was
sixty-two years old, and in excellent health, when the injury was re-
ceived. The clavicle was so extensively comminuted that before the
wound closed over one-third of the bone had escaped, and yet at the end
of one year from the time of the accident the shoulder was perfectly
symmetrical with its fellow, without drooping or falling forwards. Dr.
Ayres thinks that all of the clavicle which was lost had been reproduced.
A partial paralysis, with atrophy of the muscles of the arm, accom-
Cnied, also, with more or less rigidity and contraction of the muscles
th of the arm and forearm, is, according to my observation, a more
frequent result of these fractures.
Mr. Earle has recorded a case of comminuted fracture of the clavicle,
in which the nerves converging to form the axillary plexus were so
much injured that paralysis of the arm ensued ; and it was noticed as
an interesting fact, that the patient could not afterwards put her hand
into even moderately warm water without the effects of a scald being
produced^ characterized by vesications, redness, etc.^
' Cholius, Amer. ed., vol. i, p. 603.
» S. Cooper's First Lines, fourth Amor, ed., vol. ii, p. 823.
li)2 FRACTURES OF THE CLAVICLE.
Desaiilt siiw a case at Il6tel Dieu, in which, although the clavicle
wits not broken, the force of the blow upon the clavicle was sufficient
to produce a severe concussion of the brachial plexus, and paralysis
of the arm. A timber had fallen from a building, striking upon the
external part of the left clavicle. A considerable wound, followed by
swelling, pointed out the place on which the blow had been received.
No apparatus was applied, and on the third day a numbness and par-
tial loss of the |>o\ver of motion occurred in the arm of the affected side.
Soon afterward an insensibility came on, and by the seventh day the
paralysis of the arm was complete. It was not until after a tedious
treatment that the limb recovercKl in part its original strength.'
In Cast* 2'i of my report to the American Medical Association, which
was followed by paralysis of the opposite arm, and spinal curvature,
these results were probably due to some injury of the back received at
the time of the accident; but one cunnot avoid a suspicion that the
apparatus, Brasdor^s jacket, contributed somewhat to the unfortunate
result. No axillary pad was employed, but the straps over each
shouhler were buckled so tight that he was compelled to incline his
hea<l constantly to the right side. He was unable to lie down, and
could only incline in a half-sitting posture. This treatment was ct>u-
tinued four weeks; and two months after its removal the paralysis and
spinal <listortion commenced.
In Cast' 38, also, of the same re|)ort, a comminuted fracture, paralysis
with contraction of the muscles extending to the wrist and fingers ex-
ist(Hl, but whether t was due to the severity of the original injur}* or
to the treatment, could not be siitisfactorily ascertaintnl.
(liKson relates a remarkable instance of this kind. A young roan
was struck on the clavicle by the falling limb of a tree, breaking it into
numerous pieces, and bruising the parts so st^verely as to give rise to
violent inflammation. "The fragments had been driven l)ehind and
beneath the level of the first rib, and so compressed the plexus of
nerves as to wedg<» them into each other, and by the snbsiHjuent in-
flammation to blend them inseparably together. Complete p:iralysis
and atn»phy of the whole arm ensued, and the patient's object in visit-
ing Philadelphia was to submit to an operation, in ho[H!s of elevating
the clavicle to its natural height, and taking ott' pressure from the
nerves." Dr. Gibson, however, did not Ixjlieve that the prospect of
suwt^ss was suflicieut to warrant the ojxiration, and the young man was
sent home.'
It will not do to deny, therefore, the possibility of a paralysis as re-
sulting iroin a con<'ussion of the axillary nerves, produceil by a blow
upon the clavicle, nor of a paralysis resulting from a direct injury in-
flicted by the points of the fragments upon this plexus in certain very
badly cMjmminute<l fra(*tures; i)ut it is certain that these conditions
will not satisfactorily explain all of the examples in which paralysis
has followiH:! simple fractures. In some cases it is no doubt due rather
to the injudicious mode of using an axillary {>ad, by means of which
* Det^aiilt on Frac. and Disloc, Ainer. ed., p. 14, 1806.
' Gibson, up. cit., 6th ed., vol. i, p. 271.
FRACTDBES OF THE CLAVICLE.
193
the arm is converted into a powerfnl lever, and thus the brachial
Den'GS are made to suffer from compression along the inner side of the
■nn itself. In short, it must be confessed that it is sometimes due to
the treatment alone, aud not to the original injury.
Parker, of New York, in a note to the edition of S. Cooper's Sur-
gerjrjust quoted, declares that he has seen one patient who had lost
(be use of his arm from the pressure upon the nerves by the wedge-
ib^wd pad, over which the limb was conlined, in order to pry the
ihoutder outwards. Stephen Smith mentions a cu^ of partial paralysis
ftom the same cause.'
A similar case has come under my own observation. A lady, aged
G%-oae yeara, was thrown from her carriage, breaking the right clav-
ide obliquely at the outer end of the middle third. During the first
tiine weeks the arm was dresse<1 with Fox's apparatus, which was at
DO time particularly painful. She was then placed under the care of
iDolher sui^eon, who, finding the fragments overlapped, applied very
Jnnly a figure-of-8 bandage, with an axillary pad, securing the arm
laugly to the side of the body ; hoping by these means to restore the
fragnients to their place. The pain which followetl was excessive, and,
notwithstanding the free use of anodynes, it became so insupportable
that at the end of fourteen hours the dressings were removed by another
surgeon, and Fox's apparatus again substituted. These were also ap-
plied much more tightly than at first, and during the four weeks longer
that they remained on, repeated attempts
were made to reduce the fragments. ^'^ **■
Forty-eight days after the accident,
sbecoDsulted me. The clavicle was then
united, aud overlapped half an inch.
The whole arm was swollen, painful,
and very tender, with total inability to
move it.
I removed all the dressings, and,
daring the time she remained under my
rare, in a private room at the hospital,
there was a gradual improvement in the
condition of her arm, in respect to swell-
ing and tenderness, but the paralysis did
not much abate.
Erichseu thinks he has seen one case
of comminuted fracture, produced by a
direct blov, in which the subclavin artery
was ruptured; great extravasation of
bkwd resulted, and the arm was threat-
ened with gangrene. The patient having
recovered, however, the diagnosis could urypwi, *
not be determined by actual dissection.'
Since among 6ui^;eons some difference of opinion seems to exist as to
194 FRACTURES OF THE CLAVICLE.
the practicability of overcoming the displacement in certain fractures
of the clavicle, it is proper that I should defend the accuracy of my
own observations by a reference to the observations of others.
In nine of eleven cases reported by Stephen Smith, one of the surgeons
at Belle vue Hospital, New York, more or less deformity remained after
the cure was completed. In the two remaining cases the actual results
are unknown.*
Chelius remarks : "Setting of this fracture is easy, yet only in very
rare cases is the cure possible without any deformity." .... " It is
considered, also, that the close union of the fracture of the collar-bone
depends less on the apparatus than on the position and direction of the
fracture (therefore, in spite of the most careful application of this appa-
ratus, some deformity often remains)."^
Velpeau, in a lecture given in 184(>, and published in the Gazette
des UopitauXy declares that with all the bandages imaginable, in the
case of an oblique fracture at the junction of the outer third with the
inner two-thirds, we cannot prevent deformity.
Vidal observes : " Fracture of the clavicle is almost always followed
by deformity, whatever may be the perfection of the apparatus and the
care of the surgeon." '
" Hippocrates has observed that some degree of deformity almost
always accompanies the reunion of a fractured clavicle; all writers
since his time have made the same remark ; ex|)erience has confirmed
the truth of it." *
Turner remarks as follows: "As to the reduction of this fracture, it
must be owned the same is often easier replaced than retained in its
[)lace after it is reduced; for its office being principally to keep the
lead of the scapula, or shoulder, to which, at one end, it is articulate,
from approaching too near, or falling in upon the sternum, or breast-
bone, it happens that, on every motion of the arm, unless great care
be taken, the clavicle therewith rising and sinking, the fractured {larts
are apt to be distorted thereby. Besides, even in the common respira-
tion, the castcB and sternum aforesaid, where the other end of this bone
is adnecteil, together with the motion of the diaphragm, rising and fall-
ing, especially if the same Ix? extraordinary, as in coughing and sneez-
ing, are able to undo your work, not to mention the situation thereof,
less nipable of being so well secured by bandage as many others. All
which, duly considered, it is no wonder that u|)on many of these* acci-
dents, although great care has been taken, these bones are sometimes
found to ride, and a protuberance is left behind, to the great regret
jMirticularly of the female sex, whose necks lie more exposetl, and where
no small grace or comeliness is usually placed."*
Says Johannis de Gorter : " Rcstituiter facile tractis humeris a min-
» Now York .lourn. Med., May, 18r)7, p. 882.
' Sy*tom of SurjriTV. By J.M. Chelius, of Hoidelbcrg, with notes by South.
Fir«t*Ain»'r. o(\., vol. i, pp. 603,005.
• Vidhl ((k* Cnpsis), Paris od., vol. ii, p. 105.
* Tn'Mtiso (m Fr«ctiin»s and Luxation**. Bv J. P. DeMulL Edited by Xav.
Birhat, and trannlalod by Charles Caldwell, M.D. Philadelphin, 1806, p. 9!
» The Art of Surgery,'by Daniel Turner, vol. ii, p. 266. London ed., 1742.
FRACTURES OF THE CLAVICLE. 195
istro po6teriiiSy dum simul suo genu locato ad spinam dorsi, dorsum
Bustentet minister, nam tunc chirurgus folis digitis claviculam fraetam
reponere potest. DiffieUius autem in reposita sede reiinetur, sed loca
cava snpra et infra claviculam spleniis implenda/'*
Says Heister, writing only a little later : " The reduction of a broken
clavicle is not very hard to be effected, especially when the fracture is
transverse; nor is it unusual for the humerus, with the fragment of the
clavicle, to be so far distorted as not to be easily replaced with the
fingers ; but the difficulty is much greater to keep the bone in its place
when ihefroxiure is once reduced^ especially if the. bone was broken ob^
HqudyJ'^
Amesbury, after having exposed the inefficacy of all previous modes
of dressing, and especial Ij of the figure-of-8 bandage, Desault's, Boy-
eis, and an apparatus recommended by Sir Astley Cooper, proceeds to
describe his own apparatus and to affirm its excellence. It is, how-
ever, not much unlike a multitude of others, and is liable to the same
objections.*
M. Mayor, of Lausanne, thinks that up to. this day no successful
mode of treatment has been devised. " Here everything appears as
vet so little determined, that each day sees some new propositions and
different procedures,'* etc. He believes, however, that in his simple
handkerchief bandage, with straps across each shoulder, the indica-
tions are most fully accomplished and the most successful results are
obtained. If, however, it were to be treated without apparatus, the
horizontal position, lying upon the back, would, in the end, make the
most perfect unions.^
Says M. Malgaigne: "The prognosis, considering the trivial charac-
ter of this fracture, is sufficiently difficult. For, little as may be the
displacement, the surgeon ought not to promise a reunion without de-
formity; and certain successful results, proclaimed from time to time,
betray, on the part of those who relate them, the most extravagant
exaggerations.'**
M. N61aton having spoken of the various plans which have been
suggested to retain this bone in place, and of their inefficiency, comes
at last to speak of the handkerchief bandage of M. Mayor, and re-
marks:
"This apparel is very simple; but neither will it remedy the over-
lapping." .... "Of all the apparels which we have passed in review,
there is, then, not one which fills completely the three indications usu-
ally present in the fracture of a clavicle. None of them oppose the
displacement; they have no effect, with whatever care they may be
applied, but to maintain immobility in the limb. We think, then,
that it is useless to fatigue the patient with an apparatus annoying.
^ Jnbannift de Gorter; Chirursria Repurc:Hta, p. 79. Lugduni Batavorum, 1742.
• Heigtpr's Sureery, vol i, p. 184. London ed., 1768.
• Tpc»tm«»nt of Fra'^tiireg. by Jof^eph Amesbury, vol. ii, p 627. London ed., 1831.
• Xouveau Svpt^mp de D^li^ation Chirurgicale, par MHthias Mayor, do Lausanne,
p 2(84, f^tiv ralso Atlas, plati) 8, fiirnre 28). Paris ed., 1838.
• Traits des Fractures et des Luxations, par J. F. Malgaigne, tomo premier, p.
473. Paris ed., 1847.
196 FRACTURES OF THE CLAVICLE.
and, perhaps, even painful ; a simple sling, secured upon the sound
shoulder, will be sufficiently severe. Nevertheless, as this does not
assure so complete immobility as the bandage of M. Mayor, it is to
this that we think the preference ought to be given in all eases of frao-
tures of the clavicle, whether accompanied with displacement or not,
whether they occupy the middle or the external part of the clavicle.
If the fracture presents no displacement, we shall obtain a cure which
will leave nothing to be desired. If there is a tendency to displace-
ment, the consolidation will be effected with a deformity more or less
markeil ; but since this deformity is inevitable, at least with adults,
whatever may be the apparel which we employ, it is evident that the
apparatus which causes the least constraint ought to have the prefer-
ence. We may remark, farther, that this union with deformity in no
wise impairs the free exercise of all the movements of the members."*
"The venerable gentleman who stands at the head of American
surgery, and whose manipulations with the roller approach very nearly
to the limits of perfection, informed us, in 1824, that he had never
seen a case of fractured clavicle cured by any apparatus, witliout ob-
vious deformity."^
I need not say that the " venerable gentleman " to whom Dr. Coates
refers in this passage was the late Dr. Physick, of Philadelphia.
Dr. Gross says that, according to his ex|)erience, " fractures of the
clavicle are seldom cured without more or less deformity, whatever
pains may be taken to prevent it."''
Among the late German authors Roser speaks as follows: "The
treatment of fractures of the clavicle is, after all that ha.s been said,
very imperfect; and it is very often the case that, after a ni08t careful
treatment, some deformity will remain, such as protrusion of the inner
fragment, crossing of the fragments, and consequent shortening."*
Says Bryant, in his excellent Treatise on Surgery : " Deformity
almost always exists in spite of treatment."*
TraitmenL — If evidence were neeiled l)eyond that which has been
furnished, of the difficulty of bringing to a successful issue the tn»at-
ment of this fracture, it might be supplie<l, one would think, by a
reference merely to the immense number of contrivances which have
been at one time and another recommended.
A catalogue of the names only of the men who have, upon this
single |>oint, exercised their ingenuity, would be formidable, nor would
it present any mean array of talent and of practiwd skill.
AH thc»so surgeons, however, have admitteil the same indications of
treatment, viz., that in order to a complete restoration of the tiuter
fragment, which alone is supposed to be nnicli displacetl, we arc to
' Kicinpnt>* (1«? PHtbologie Cliirur«;ifal«», pur A. Nolali»n, tome |»n*mior, p. 720.
PariH .'(i., 1844.
* Uoyni'll CoHti»s, Amor. M**d. Journ., vol. xviii, p. r>2, old #ori»^. Il i* prohnhlft
that Dr. Ph»itk lu»r*» n'ft'rrtMl to compicli* ami ol>li<|uo frHcliirw of the nutiJI*
third, or that Dr. CorK^s ha-* forgotten llio pri*cis«» laiiguago pinployed on lhi» (kvm-
ftion.
> (iroM, Sy«t<'rn of Surpory, vol. i, p. 954, 1872.
* W. KoHor, Handbuch dor AnntoniUchori Chirurgie, 6 Aufl., Tiibingen, 1872.
» BryHQt, Praclico of Surgery, 1872, p 927.
FRACTURES OF THE CLAVICLE. 197
cany the shoulder upwards, outwards, and backwards. But as to the
means by which these indications can be most easily, if at all, accom-
plished, the widest differences of opinion have prevailed ; and, in the
debate, it may be seen that while, on the one hand, no invention has
wanted for both advocates and admirers, on the other hand, no method
has escaped its equivalent of censure.
Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and
other?, directed the patients to lie upon their backs, with little or no
tpparatus. S. Cooper and Dorsey also recommend that the patients
should be confined in this position during most of the treatment; and
from the account given by Dr. Lente, it will be understood that a
similar plan was at one time adopted in the New York City Hospital.
"But this result (deformity) rarely happens when the patient has
strictly followed the directions of the surgeon, as to position especially,
for it is by position, more than by any other remedial means, that a
good result is to be eflfected."
Nearly the same method we find recommended hf Alfred Post, in
1840, then one of the surgeons of that hospital ; the arm being merely
kept in a sling and bound to the side, with the patient lying upon his
hack. Dr. Post mentions a case treated in this manner, which termi-
nated with very little deformity ;* and I have myself treated many
causes by this plan, with more than average success.
Receutly, Dr. Edward Hartshorne, of Philadelphia, has published,
in the second volume of the Pennsylvania Hospital Reports, 1869, a
very ingenious argument in favor of the supine position, in which he
seems to have demonstrated that the special efficacy of this plan de-
pends upon the pressure made upon the angle of the scapula. In
order to accomplish this, and to place the scapula in the position most
&vorable for the rcdu(?tion of the clavicle, the back should rest upon
a broad, firm, and unyielding mattress, and not upon a pillow between
the shoulders, which latter has the effect rather to defeat than to pro-
mote the indication; the head should be slightly raised so as to relax
the stemo-cleido-mastoid muscles and somewhat extend the trapezius;
the arm and forearm of the injured side should be flexed, resting across
the chest, with the hand reaching over the sound shoulder, as recom-
mended by Veli>eau in the use of his dextrin apparatus, or it should
be placed at right angles with the body, as recommended by Dupuy-
tren. Bryant, of London, recommends essentially the same method.
It IS scarcely necessar}' to say that the absolute immobility required
by the posture treatment must always limit its application, and render
its general employment impossible. Dr. J. A. Packard, of Philadel-
phia, regards tne scapula, also, as the bone upon which the restoration
of the clavicle chiefly depends ; and he finds in the serratus magnus the
especial otetacle to this restoration.^
Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County,
N. Y., have also employed this method successfully;' while Malgaigne
declares it to be the most reliable means of obtaining an exact union.
1 N. Y. Journ. of Med , vol. ii, p. 226.
■ Packard, New York Journ. of Med., 1867.
* Bott. Med. and Surg. Journ , vol. Ivi, p. 468.
198
PBACTURE8 OF THE CLAVICLE.
Albiicasis, Lanfraiic, Guy de Cliouliac, Petit, Parr, Syme, Sker,
Brunningliuusen, and very many others, especially among tne Enfrlidli,
have preferred, in order t<i carry the
Fio. M. shoulders l>acl(, a fij(ure-of-8 ; while
Deaaiilt, Colles, South, Bryant, and
Samuel Cooper have represented ihia
bandage as useless, annoying, and
mischievous.
Helsler, CheliuH, Miller, BreiSeM,
Keckerly,' Colt-man,' Hunton,^ prefer,
for this purpose, m>mc form of liack-
splint, extemling from acntmion to
acn>mion, against which the shoulders
may be properly secured. Parker says
that splints of this kind, with a fignre-
of-8 bandage, arc *' better than all the
apparatus ever invented," while Mr.
South gives his testimony in relation
to all dressings of this sort as follows:
ngure-oM. " I do not like aiiv of the apgiaratua
in which the shoulders are drawn back
by bandtigea, ns these invariably annoy the patient, often cause excori-
ation, and are never kept long in place, the person <x>DtinuaIly wrig-
gling them off to relieve himself of the jtressurc."
Fox/ Brown," Dcsault, ajid others bring the elbow a little forwards,
and then lift the shoulder upwanls and backwards. Wattmau and
Lonsdale carry the elbow stilt fikrther fbrwanis, so as to lay the hand
across the op)M>site shoulder ; while Guillou carries the hand and fore-
arm twiiind the (uitient, and then proceeds to lifl the shoulder to its
place. Moore, al-^, recommends that the elbow shall be «irrie<l bark.
Thus Dc^ult, Fox, and Wuttinan accomplish the indication to carry
the shoulder buck, by lifliiig the humerus, with the ellniw in /rot)/ of
the body; while Guillou and M<K)re accomplish the same iutlii:alioo
by lifting the humerus when the cllww is a little brhiiul the ImxIv.
Chclius al.w .says : " The elbow, as far as [tosiAible, is to be laid back-
wards on the iKhly."
Sargent, who Jjulievcs that with Fox's ap)>aratils "the ocxrurrenoe <if
deformity is the exception," and not the rule, and prefers it to ail
others, bos treated three vases by Guillou's method, and ts pcrtivtiy
satisfied with its oi>er!itii)n. I lol lings worth, of Philadelphia, lias also
treated one ca.se successfully by (iuillou's nietluK), and adds his tt-sti-
mony in its favor. Several surgeons think they have obtained e«{ual
success with Moore's apparatus.
' Kuok.Tlv,
ili.-nrt.T'K
.urn. Mfd. M., vol. iv, p. ll.>; .l-o, mv Keporl on IVf-.r-
in TrnrM. ul Am^r. M.-d. A^m-v , vol vii'i, p. 440.
rk Jmirn. McU., second kitum, vul. <ij, p. 274, fivm Nvw
J.-r»y iU-il. U-p.
> lliinion. >L.i<l. ; >Uo, N^w J?r*<-j- Mt>.<. Itop., i.<l. v. p. 140.
* K..1, LM..1,'. I'r,.,lii..l SHrgcrv, Anir-r, vi., j. 47.
' Bruwn, SBrgint'i Minur Surgurv, p. 132.
FRACTURES OF THE CLAVICLE. 199
But how shall we explain these equal results from opposite modes
of treatment? Is the indication to carry the shoulders back, which
Fox sought lo accomplish by pressing the elbow upwards and back-
wanls, as easily attained by pressing the elbow upwards and forwards?
Or are we not compelled to infer that there has been some mistake as
to the precise amount of good accomplished by the apparatus in either
case? Moreover, Coates,^ Keal, and others instruct us that the only
fiife and proper position for the humerus is in a line with the side
of the body^ and that it must neither be carried forwards nor back-
wards.
Paulus -ZEgineta, Boyer, Desault, Pecceti, Liston, Fergusson, Samuel
Cooper, Erichsen, Miller, Skey, Levis, Dorsey,^ Gibson,^ Fox, H.
H. Smith,* Norris,* Sargent, Eastman,** recommend an axillary pad ;
while Richerand, Velpeau, Dupuytren, Benjamin Bell, Syme, Moore,
deny its utility, or affirm its danger. Dr. Parker has seen one patient
io whom paralysis of the arm resulted from the pressure upon the
brachial nerves, in the attempt "to pry the shoulder out;^' and 1 have
myself recorded another.
Oil)ot, of Boston, Massacusetts, has recommended a mould of gatta
penrha laid over the front and top of the chest.^
Desault's plan, which took its origin as Velpeau thinks, in the spica
of Glaucius, under various modifications, is recommended by Delpech,
Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson, Liston,
Cutler, Physick, Doi-sey^ Coates, and Gibson ; while by Velpeau,
Syme, CoUes, Chelius, Samuel Cooper, and Parker it is regarded as
inefficient and troublesome. Says Mr. Cooper: "In this country,
many surgeons prefer Desault's bandages ; but I do not regard them
as meeting the indi^-ations, and consider them worse than useless.'^
The dextrin bandages, or appaixUvs immobile^ of Blandin, Velpeau,
and others, constitute only another form of the bandage clrcssiug of
Default. In this connection it ought to Ix? noticed that Velpeau does
Dot regunl the employment of this apparatus, or of any other demand-
ing great restraint, as imperative. In his great work on anatomy,
referring t4i the fact that when the bone is broken and overlapped, the
patient is still able^in many cases, to move the arm freely, he remarks :
"Do nut these cases give support to the opinion of those who admit
that fractures of the clavicle do not actually require any other appa-
ratus than the simple supporting bandage?'^ " It is necessary to ob-
ser\'e,'' he adds, " that by thus acting we do not prevent an overlap-
ping,''* etc.
According to Flower and Hulke, authors of the article on " Injuries
* O'Jitoji, Am«'r. Journ. Med. Sci., vol. xviii, p. 62.
' Th'Ti-ey, ElenionU* of Surgery, toI i, p. 133.
* GiKf^m, Ins»tituto8 and Prnctice of Surjcery, vol. i, p. 271.
* H. H. Smith, Pnicliee of Surgery, p 864.
* Norri.-, Li.«t<>n*8 Practical Surg., Ainer cd., p. 46.
* £ii>tni:in, Apparatus for Fractured Clnviclo, by Paul Eastman, Aurora, 111. ;
Bo»t<in Med. and Surg. Journ., ro\. xxiii, p. 179.
' Cal>«»t, Boj*t M**d. and Surg. Journ., vol. lii, p. 232.
* Velpeau, Anatomy, Amer. ed., vol. i, p. 2i±
FRACTURES OF THE CLAVICLE.
of the Upper Extremities" in the lost o<)ition of Holmes's Surgery, in
most of the hospitals in Lod<1oii the siii^eons employ a moderate^ized
pad in the axilla, and then secure the arm to the body with a broad
calico roller, some of the turns of which are made to pass beneath the
elbow and over the opposite shoulder. Some of the surgeons advance
the elbow, others carry it back, but a majority permit it to hang per-
pendicularly beside the body. Ae will be hereafter seen, this plan is
essentially the same as that adopted by myself.
Professor E. M. Moore, of Rochester, in a paper read before the
New Yortf State Medical
Society, in 1871, has called
attention to what he terms
the " Figure-of-8 from the
elbow," ty which he pro-
poses to render tense the
clavicular fibres of the peo-
toralis major, and at the
siime time draw the twap-
ula backwards toward va.t
"pine He is thus able, be
afhrm^, to overcome the
notion of the sterno-cleido-
mastoid which lifts the
sternal fragment; and to
draw the acminiat frag-
ment outwards and up-
ward«
These ends arc accom-
|>liahed by placing the ex-
tremitj ofthemiddlefinger
of the broken arm upon
the ensiform cartilage, with the forearm and cliww piuned back and
against the bwly. In onlcrto secure the arm in this jMisition, " I use,"
says Dr. Moore, "a shawl or piece of cotton cloth, which, when folded
like a cravat, ei[!lit inches in breadth at the centre, should be about two
vanls long. Placing this at the centre across the palm of the surgeon,
lie seizes with this liiind the elbow of the ])aticnt, which corresponda
with the briikcii clnvi<'lc. The two ends of the bandage hang to the
floor. The one fsiiliiig inwani toward the jiaticnt is carried upward, in
fntnt of the shmililer and over the Uick, making a spiral movement in
fnmt of the shoulder. This is intrusted to an assistant. The outer
end is then carried across tlie forciirm, l>chind the Itack, over the oppo-
site shoulder, and around the axilla. This meets the other end, willed
may be <nrricd under the axilla ami over the shoulder of the op)Kwite
side, thus making the figure eight (S) turn, around the tiound shoulder.
This twist, it will l)e seen, niakc^ also the figure eight (8) turn, around
the ell>i>w of the afftH-tcd side. I therefore style the bandage, ' The
elbow figure eight (8).'"
"The forearm should be sustained by a sling which raises >t toao
PBACTURES OF THE CLAVICLE.
moving the whole arm
r SIX caaes in
tcate anele in order that, gravity may assist ii
bickwai^. This is best
dooe by a simple strip
Ibee or foar inciies wide,
vhidi may be pianecl to
Ai shawl at the shoulder,
or by a sling across the
cfipoGite shoulder and be-
kind the back. The for-
ner moch to be preferred.
Any tenden(7 od the part
of the »bawl to slide from
the shonlder may be ar-
Rsted by a pin thrust at
ibe crossing. The shawl
tt the elbow is kept in
place by folding the upper
part that fits the arm and
securing it by a pin. This
makes a sort of cup for
the elbow."
The principle upon
which this dressing is con-
structed, appears to me sound ; but hitherto, in the five o
which it has been employed under my observation it has failed to ac-
complish any more than is accom- „ „
plisbed by many other forms of dress-
mg. It 13 especially liable to become
di»minged, and to cause excoriations
in the sound axilla; in this respect
beti^ quite as obnoxious to criticism
as the ordinary figure of eight.
Dr. Lewis A. Sayre, of this city,
has for some time employed an appa-
ratus for dressing broken clavicles, by
whiiA he proposes, also, to render tense
the clavicular attachments of the pec-
toralls major, and thus secure more
cSectoally the depression of the sternal
fr^ment, while at the same time the
ahmilder is lifted and carried back.
Two strips of adhesive plaster are
■tnMred, each about three and a half
iMDea wide, for an adult; one long
cnoogh to encircle, first the arm, and
then Ae body completely; the other e.T«-. .pp.«.u^
of nifficient length to reach from the
■ootid shoulder, over the point of the elbow of the broken limb, and
■CTcn the back obliquely to the point of starting. Maw's moleskin
^■stetjor some plaster equally strong, is to be preferred.
202
FBACTURE8 OF THE CLAVICLE.
Tlie first strip is looped around the arm just below the aiillsty
margin, and pinned, or stitehcd, with the loop sufficiently open to avora
strangulation. The arm is then drawn downwards and backwards tintU
the clavicular portion of the pectoralia major is put sufficiently on the
Stretch to overcome the sterno-clcido-mastoid, and thus draw the stenwl
fragment of the clavicle down to its place. The strip of plaster is then
carried completely around the hody, and pinned or stitched to itself on
the back.
The second strip is then applied, commencing on the front of tbe i
shoulder of the sound side, thence it is carried over the top of the ,
shoulder, diagonally across the back, under the elbow, diagonally a/ocom ■
the front of the chent to the point of starting, where it is secured hf
pini or thread A long tudmal slit is made in the plaster, to receive
tin ]K n>t f the elbow
Ikf re lavnig the plaster across the elbow, an assistant must pnm
the I 1Ih>w well ioruards and inwardt and it must be held firmly in this
position until the dressing is com[ kted It will be now seen that tbc
arm ha'i bc<.n converted into a kver whose fulcrum is the loopof sdbe^
ivc plj.1(r at tlu loner margin of the axilla; and upon this it is b^
licvc^l that lu a gnat measure the efhcieiicy of the apparatus depuDds,
Certainlj it no longer depend U|>on the position of the elbow, which
wa" at first earned l^k in order to render tense the clavicular fibm
of the pectoralts major sum f r the purpose of converting the hutae>
rtH into a lever the elbow is subsequently <lrawn forwards, and tiw
claM ular hbri-s f the ;.reat pectoral are again relaxed. If, therefore^
the n|i|>uratiis has any advantages over other modes of treatment, it k
solelv hv its action njMni the humerus as a lever; but the fulcrum is
too remote from the u])per end of the humerus to act very eSicientlj.
Great force has to he applied to secure this end, or at least so mnoh
FRACTURES OP THE CLAVICLE. 203
tone (hat, if steadily maintained, it is pretty sure to cause excoriatioDS
of the arm where the fulcrum acts ; or, as more ofteu happens, it will
^eedily loosen, under the expansion and contraction of tlie chest in
KtpiratioD, aod thus cease to be efficient. Several cases of fractured
eliTicles, treated in Bellevue and St. Francis hospitals by this method,
bve come uitder my notice, and the results have been no better than
when my apparatus has been used, while they have in most cases caused
nore discomfort.
The sling, in some of its forms, is employed by Richerand, Huber-
dul, Colles, Miller, Fox, Stephen Smith,' H. H. Smith, Bartlett,*
Levis,' Dtigas,* Benjamin Bell, Bransby Cooper, Earle, Chapman,
Eeal, and Dy a large majority of the t^gHsh surgeons.
So apparatus, perhap, has been so generally employed, among
Aroerican sutseons, as that form of the sling introduced by Dr. George
Fux into the Peonsylvania Hospital in
1828. *■"■ "»■
Sargent says of it : " Fractures of the
clavicles, treated by this apparatus, are
daily dismiaaed from the Pennsylvania
Hospital, and by suigcons in private
practice, cured without perceptible de-
formity."
Norris, in a note to Liaton's Practical
Surgery, affirms that "the chief indica-
tioDs in the treatment of fracture of the
daviclc are perfectly fulfilled by the
lue of this apparatus."
H. H, Smith, in his Jfinor Surgery,
deelarcs that Fox's apparatus accom-
plishes " perfect cures in very many
cases, and that it is "a very rare thing
for a simple case to go out of the house
(Pennsylvania Hospital) with any other
deformity save that which time cures,
vix,, the deposition of the provisional
alius." He has also repeated substan-
tially the Bamc opinion in his larger
work, entitlttd Practice of Surgery.
Soch testimony in favor uf any dress-
ing demands respectful attention; and
I dtall not be regarded as detracting
fiwD the respect due to these authorities, when I express my belief
that it is in deference to the distinguished reputation of the surgeons
«bo had daring the preceding thirty years had charge of the services
9 that boBpital, and who have been so loud in its praise, that the use
< Stephrn Smilh, New York Journ. Med., vol. il, 3d eerieg, p, 384 (May, IS57}.
* Rutlett, mj " B«port on Defor.," etc., Appendix; also, Boat. Ued. and Surg.
J«im., Tol. li. p. 404.
> LcTit. H. B. Smith'! Practice of Surg., p. SS6. Am. Journ. Med Sri., April,
1M0. p. 128.
* I>us*i, Bqrart on Snrgerf.
itrlp of <•
c Aj.e nqiilrnl. The
lied for diher Jide bj
imcDtor Ibeallnc."—
• r- ■
Ul-T -
_ *
:ui.
I'f'-rmj
t ■ '
■ 1 * -
LIV'
, 1
:;:••
•f.-n. »»
.'mT'
•— !!
:.- -'If
1.
-V. .:
«a VtJ
.". . , .• !
.n •:■
•r.i 1 ■»
'.. ^-1. Wilt .i:i.: '.'r .
■ - t
1- ;*';:iii.f ■ ,«ji:. i.^jii t'>r th:U rvas
..•.• ..>.:/ fi. 'li, Fiarni. It L:* p
'ifli ii- fhif l<r<4f f-rid iipwanis. in rli
Jl'i Miii« ■•.|i«iiifJiii;; tn tli«* hn»k<.>n <'!a'
•Milt .:#■ iiM-il in |ila(v l»v rajM*^ irci
f>> il-! ii|i|nt riiil, ami iiutilt' 'ii^r 'r
hilli il lolliir ii)Htn tlu' i»|in«i*{t' -«■•»!
> •
^ 9
"l?i
> ■!*
FBACTUBES OP THE CLAVICLE. 205
of the surface of the integument, the deformity will be less apparent
than if one fragment lies in front of the other.
Finally, while I deprecate incautious assumptions in regard to the
capabilities of any form of dressing for broken collar-bones, a disposi-
tion to which is manifested by more than one advocate of special plans,
I am ready to declare my preference for an apparatus consisting essen-
tially of a sling, axillary pad, and bandages to secure the arm to the
chest. Among the considerable variety of dressings which I have used,
this has seemed to me most simple in its construction, the most com-
fortable to the patient, the least liable to derangement (if I except
Velpeau^s dextrin bandage, and certain other forms of "immovable"
dressings), and as capable as any other of answering the several indi-
cations proposed, while the patient is permitteil to walk about.
No apparatus is better able to answer the first indication, namely,
to "carry the shoulder up,'' than the sling. Indeed, in nearly all the
forms of dressing hitherto deviseil, the sling is employed for this pur-
pose. The bandage carried beneath the elbow is, in effect, a sling. In
a few instances, men of no practical exi)erience have sought to substi-
tate an upward pressure in the axilla for the sling; but it is scarcely
necessary to declare the absurdity of this practice, inasmuch as no pa-
tient will be found willing to submit to it beyond a few hours.
It is proper to say, however, that some surgeons, whose opinions are
entitled to respect, believe that it is quite as important to depress the
sternal fragment as it is to elevate the acromial, the outer end of the
sti^mal fragment being lifted, more or less, by the action of the sterno-
deido-mastoid muscle. No doubt this is one of the difficulties with
which we have to contend in our efforts to restore the two fragments
to the original line of the axis of the bone.
Inclination of the head to the side of the fractured limb will allow
the sternal fragment to fall ; but it is impossible for the patient to
maintain this position for any length of time. A compress laid over
the sternal fragment, and held in place by adhesive straps or bandages,
will be found totally inefficient. Dr. Moore has adopted a more
ingenious and philosophical method, by calling into requisition the
clavicular fibres of the pectoral is major to antagonize the sterno-cleido-
Bttstoid. Indeed, this is one of the essential principles upon which he
"KtB the superior claims of his dressing; and I have myself observed
^ when, in the case of a recent fracture, the elbow is thrust behind
tke body, the outer end of the sternal fragment is depressed. Never-
4el«B, I have certain theoretical and practical objections to the doc-
trine as taught so ingeniously by Dr. Moore. My theoretical objection
ithat the clavicular fibres of the sterno-cleido- mastoid will soon, under
^continual strain, become relaxed, and after a little time cease to
^oeooiplish w^hat they did at first. This is a law in regard to the action
^ muscles put upon the strain, as every surgeon knows. It may be
^opposed that if the pectoral muscle is thus rendered less competent to
depress the fragment, the sterno-cleido-mastoid will be rendered, also,
len competent to elevate the fragment ; but this is not strictly true :
the latter operates at right angles with the axis of the bone, and to
206 FRACTURES OF THE CLAVICLE.
great advantage, while the former acts very obliquely, and to a corre-
sponding disadvantage.
The practical objection which I have to offer is, that the dressings
required to maintain this position are exceedingly liable to cause exco-
riations and to become disarranged, and that in fact this bas happened
in all, or nearly all, of the cases which have been observed by me.
Moreover, whatever cause may be assigned for the failure, the results
have been no better, so far as overlapping and deformity are concernedi
than when my own dressings have been used.
The second indication, namely, '' to carry the shoulder back,'* is
certainly more difficult of accomplishment tnan the first, and it is only
imperfectly met by my own method, or by any other form of sling
dressing. Desault taught that when the arm was lifted by the sling,
or by any mode of pressure beneath the elbow perpendicularly, the
shoulder was necessarily carried back. This is probably true, but its
effect is not very marked. The ordinary figure of 8, which might at
first be supposed to be the most rational mode of effecting this purpose,
has long since been proven to be a failure. None of the contrivances
to hold the shoulders back by bands which traverse the axilla, made
fast to back splints, have done any better. They all cause excoriations,
and soon become intolerable. Dr. Sayres's adhesive plaster band,
attiiched to the up|)er part of the humerus, below the axillary margin,
either loosens or excoriates, also, and in the end proves inefficient.
After all it must be said, that the indication " to carry the shoulder
back," except in so far as it incidentally accomplishes the indication "to
carry the shoulders out," and thus obviate the overlapping of the frag-
ments, is relatively unimportant. It is seldom that the falling forward
of the shoulders is very marked, or in itself a source of defomiitv; Imt
carrying the shoulder back does diminish or overcome the riding of
the fragments, and in this view alone is it important, and for this
rciuson, surgery will be indebted to any one who devises a method by
which this position of the shoulder can be maintained until the union
of the fnigments is consummate<l.
The third indication is "tocarrv the shoulder out," by which means
it is proposo<l to overcome, directly, the riding of the fragments. *\Ve
have siH^n that this may be accomplished, indirectly, by carrying the
shoulder back ; but, unfortunately, no means has yet lieen found by
which this can Ik? done and permanently maintained.
The thick axillary pad, and all other devices by which it is proposed
to act ujK)n the humerus as a lever, and thus force the shoulder out,
have totally faiknl or proved eminently mischievous. In short, I may
say that this indication can, in my opinion, be effectually a(XH)mplished
in only one way, and that is, by laying the patient upon his Iwick on
a flat, firm mattress, and thus pressing the base and inferior angle
of the scapula strongly and steadily against the back. The rct|uisite
pressure u|M)n the scapula cannot be maintained by any plan yet con*
trived while the patient is in the sitting or standing (K)8ture, and espe-
cially when permitted to walk about. Its application musty there*
fore, be limiteil to rare and exceptional cases. If a slight overlappioff
and deformity were to cause any appreciable diminution of the strength
TCofter to be deecribetl.
The mode of dressing a fractured clavicle which, while the patient
tt liberty to walk about, will secure the beet results with the least
iSering and annoyauce, is &8 fnlJows :
The arm hnnging perpendicularly hesitle the body, a sling is placed
ider the elbow and forearm, and tied over the opposite shoulder. An
208 FRACTURES OF THE CLAVICLE.
and nerves, when tlie axillary pad is iised, and the arm is, at the saroa
time, carried forwards npon the body. In bringing the elbow for^
wards, so as to lay the forearm across the body, the humerus is macia
t« rotate inwards, and the brachial artery and nerves are brought into
more direct apposition with the pad;' while in the position which 1
have recommended and practiced hitherto, these nerves and vessels arfr
removed in a great measure, but not entirely, Irom pressure.
The pad should be no thicker than is necessary to fill completely,
the axillary space, its puri>oae being to steady the arm, and, in somt
slight degree, to counteraet the action of those muscles which tend to
displace the sbi>ul(icr inwards. It should be long enough in ita antero-
posterior diameter to project distinctly in front and behind, otherwisa
it will not keep its place. In the adult it needs to be six or seven
inches long. Id the direction of the axia of the limb, its length should
be less, perhaps four inches. Being now well pressed up into tba
axilla, and Eccured with a needle and thread to the upper edge of (h>
roller which encircles the lower part of the arm and the body, it will
keep its position and serve some useful purpose.
The sling may be made of cotton or flannel cloth, and susnended
from the opposite shoulder by the aid of four tapes, a broad aud thick
pad of folded cloth being laid upon the shoulder to support the ktiotiL
A considerable experience has satisfied me that the stuffed collar, u.sej
in the Fox dressing, possesses no advantage as a means of suspcusion.
The leather sling, also, in use at some hospitals, is liable to the objeo-
tion that it cannot be stitched to the roller, which encirclra the body
and lower part of the arm, in the manner 1 shall hereafter dcticribe.
The roller should be made to encircle the lower fourth of the arm,
and a few turns should pass beneath the forearm as far forwanLs as lh«
hand, in this manner securely fixing the elbow and forearm against
the side and front of the body.
If thought nece>«:<ar}', the hand may be supported by a loop of band*
age passed under the wrist aud tied over the neck.
Finally, in oi-der that this dressing may retain its plaoe and serve'
its purpose most efFectually, its several parts should besliti'li»l lugvthvr'
thoroughly wherever the dressings cross or approach cui.-h other, la
no other way can anything like pcrmuneucy Ite insured in a [Ktrtiim uf
the body so movable as the shoulder and chest; but even with ihiR
precaution, daily attention and frequent readjustment are generally
required.
JVfa/m«i( of JncompMe Fractures of the CYariWf. — In eaae of uattta]
fracture of the clavicle, accompanie<l with a peraislent Iwnd in the lia*
of the axis of the bone, it is proper to attempt the rcplaeemeDt of tba
fragments by direct pressure. The ends of the bone being fixed, wB
cannot, as in the case of a partial fracture of olher long Wncs, cmploir;
leverage; and with direct pressure alone, applied in a dc^^v wliiim
might be r^urded as incurring no danger of musing a coniplrtr fn^
ttirc or of a dislocation, our ehanecs of success are very small. I i
not say thot I have ever succeeded in aeeont{>lishing anytiiiug in
I CoaLct, Am. Juurn Mi^. Sd , t
i|P C2.
FBACTUBES OP THE BODY OP THE SCAPULA. 209
way, although I have oflen made the attempt, and would always advise
others to do the same. A failure, however, to restore completely the
line of the axis of the bone is not, I imagine, a matter of great conse-
quenoe, since, as has already been fully explained when speaking of
partial fractures ii^ general, the natural form will be in most, if not in
all cases, completely restored after the lapse of a few months or years.
This observation applies especially to partial fractures occurring in
childhood and in&ncy. I have no experience as to what is the result
of a similar deformity left after a partial fracture in the adult.
As to the method of dressing these fractures, it need not differ from
that recommended for complete fractures ; but in a majority of these
cases I have thought it sufficient to place the arm in a sling, with a
bandage around the elbow and body to keep the arm at rest, or I have
direct^ the mother to make the sleeve fast to the front of the dress
with tapes. The axillary pad can seldom, if ever, serve any useful
parpose.
Uuion occurs with great rapidity, sometimes as early as the seventh
or tenth day ; but the arm ought to be kept quiet, as a matter of safety,
two or three weeks.
For a more full consideration of the subject of partial fractures of
the clavicle, the reader is referred to the chapter on " Incomplete
Fractures."
CHAPTEK XIX.
FRACTURES OP THE SCAPULA.
Fractures of the scapula may be divided into those which occur
through the body, the neck, the acromion process, and the coracoid.
2 1. Fractures of the Body of the Scapula.
Under this title I propose to consider not only fractures of the
**body," properly speaking, but also fractures of the angles and of the
spioe.
GaH9€8, — The scapula is usually broken by the fall of some heavy
body directly upon the bone, or by some severe crushing accident, by
^ kick of a horse, by a fall upon the back ; in short, by direct causes
•lone, and by such causes as operate with great violence.
Malgaigne says that a Doctor Heylen has recently published a case
rf this fracture which he believes to have been the result of muscular
fctioD, occurring in a man forty-nine years old. The case, however,
tt Dot stated so clearly as to relieve us entirely of a doubt as to the
ottare and cause of the accident.
I have myself recorded six cases which have been under my treat-
**>€nt; and I have lately seen two other examples of fractures of the
body of the scapula not caused by firearms. There are two cabinet
spoomens of fracture of the body of the scapula below the spine in
208 FRACTURES OP THE CLAVICLE,
and nerves, when the axillary pad is used, and the arm is, at the same
time, carried forwards npon the body. In bringing the elbow for^
wards, so as to lay the forearm across the body, the humerus is made
to rotate inwards, and the brachial artery and nerves are brought into
more direct apposition with the pad ; * while in the i)08itioD which I
have recommended and practiced hitherto, these nerves and vessels are
removed in a great measure, but not entirely, from pressure.
The pad should be no thicker than is necessary to fill completely
the axillary space, its purpose being to steady the arm, and, in some
slight degree, to counteract the action of those muscles which tend to
displace the shoulder inwards. It should be long enough in its antero-
posterior diameter to project distinctly in front and behind, otherwise
it will not keep its place. In the adult it needs to be six or seven
inches long. In the direction of the axis of the limb, its length should
be less, perhaps four inches. Being now well pressed up into the
axilla, and secured with a needle and thread to the upper oJge of the
roller which encircles the lower part of the arm and tne body, it will
keep its position and serve some useful purpose.
The sling may be made of cotton or flannel cloth, and suspended
from the opposite shoulder by the aid of four tapes, a broad and thick
pad of folded cloth being laid upon the shoulder to support the kuotflL
A considerable exiHjriencc has satisfied me that the stuffed collar, used
in the Fox dressing, possesses no advantage as a means of susiK'nsion.
The leather sling, also, in use at some hospitals, is liable to the objec-
tion that it cannot be stitched to the roller, which encircles the Unly
and lower part of the arm, in the manner 1 shall hereafter describe.
The roller should be made to encircle the lower fourth of the arm,
and a few turns should pass benenth the forearm as far forwards as the
hand, in this manner securely fixing tlie elbow and forearm against
the side and front of the body.
If thought nwcssar}', the hand may be supported by a loop of band-
age passed under the wrist and tied over the neck.
Finally, in order that this dressing may retain its place and serve
its purpose most effectually, its several parts should be stitched together
thoroughly wherever the dressings cross or approach ejich other. In
no other way c^ui anything like permanency be insured in a portion of
the body so movable as the shoulder and chest ; but even with this
precaution, daily attention and frequent readjustment are generally
required.
D'eafmnit of Incomplete Fractures of the Clavicle, — In case of partial
fracture of the clavicle, accompanied with a persistent bend in the line
of the axis of the bone, it is proper to attempt the replacement of the
fragments by dirci't prt»8sure. The ends of the bone being fixed, we
cannot, as in the ca'^e of a partial fracture of other long lx)nes, employ
leverage; and with direct pressure alone, applied in a degree which
might Ik* regardinl as incurring no danger of causing a complete frac-
ture or of a diskn'ation, our chances of success are very small. I can-
not say that I have ever sucx.*eeileil in aecomi>lishing anything in tliis
> CoHle^, Am. Juurn Med. Sci , vol. xviii, p ti2.
ft
FBACTUBES OP THE BODY OF THE SCAPULA. 209
waj, although I have oflen made the attempt, and would always advise
odierB to do the same. A failure, however, to restore completely the
lioe of the axis of the bone is not, I imagine, a matter of great conse-
qoence, since, as has already been fully explained when speaking of
partial fractures in general, the natural form will be in most, if not in
all cases, completely restored after the lapse of a few months or years.
This observation applies especially to partial fractures occurring in
childhood and infancy. I have no experience as to what is the result
of a similar deformity left after a partial fracture in the adult.
As to the method of dressing these fractures, it need not differ from
that recommended for complete fractures ; but in a majority of these
cases I have thought it sufficient to place the arm in a sling, with a
bandage around the elbow and body to keep the arm at rest, or I have
direct^ the mother to make the sleeve fast to the front of the dress
with tapes. The axillary pad can seldom, if ever, serve any useful
purpose.
Union occurs with great rapidity, sometimes as early as the seventh
or teeth day ; but the arm ought to be kept quiet, as a matter of safety,
two or three weeks.
For a more full consideration of the subject of partial fractures of
the clavicle, the reader is referred to the chapter on " Incomplete
Fractures."
CHAPTEK XIX.
FBACTUBES OF THE SCAPULA.
Fractubes of the scapula may be divided into those which occur
through the body, the neck, the acromion process, and the coracoid.
2 1. Fractures of the Body of the Scapula.
Under this title I propose to consider not only fractures of the
** body,*' properly speaking, but also fractures of the angles and of the
spine.
Causes. — ^The scapula is usually broken by the fall of some heavy
body directly upon the bone, or by some severe crushing accident, by
the kick of a horse, by a fall upon the back ; in short, by direct causes
alone, and by such causes as operate with great violence.
Malgaigne says that a Doctor Heylen has recently published a case
of this fracture which he believes to have been the result of muscular
action, occurring in a man forty-nine years old. The case, however,
is not stated so clearly as to relieve us entirely of a doubt as to the
nature and cause of the accident.
1 have myself recorded six cases which have been under my treat-
ment; and I have lately seen two other examples of fractures of the
body of the scapula not caused by firearms. There are two cabinet
specimens of fracture of the body of the scapula below the spine in
210
PEACTURES OP THE SCAPULA.
the Pennsylvania Medical Collie, and two involving the spine. Dr.
Mutter had in his collection a fracture of the posterior angle, and Dr.
March had a s]jecinien of fracture of the body. I Ijelieve also that in
the collection of the late Dr. Charles Gibson, of Richmond, there were
one or two specimens of this fracture. I know of no other museum
Specimens in this country except my own of partial fracture, ilescribed
in the chapter on Partial Fractures.
Eavaton, after a practice of fifty years, declared that he had never
seen a fracture of the scapula except as it had iieen produced by fire-
arms. Among 2358 fractures reported from H6tel Dieu during a
period of twelve years, only four examples of fracture of the scapula -
are recorded; and at Middlesex Hospital, Ix>nsdnlc has noticed, among
1901 fractures, only eight of .the bo<iy of the Bcaputa.
The infrequency of this fracture is no donbt due in a great measure
to the elasticity of the ribs, to the mobility of the scapula, and to the
softness of the muscular cushion upon which it reposes.
Si/mpfonui. — Since this bone is seldom broken except by great force
directly applied, the usual signs of fractures are likely to be con-
cealed by the specily occurrence of swelling. It is for this reason that
it becomes neces.sary, generally, that the examination shotiM be made
with great care before we can
safely determine npon the
diagnosis. I have more than
once had occasion to €»rrect
the diagnosis of other prac-
titioners, who believed they
had discovered a fracture of
the scapula.
When, however, the line
of the fracture has traversed
the spine, and any consider-
able displacement has occur-
red, one may rocognixe the
fracture easily by merely car-
rying the finger along the
crest.
If ihe fracture has occur-
red through the body, below
or above the spine, or through
either of the angles, the dis-
placement may not be bo
easily recognized. The sur-
geon ought then to trace
carefully with his finger the
outlines of the scapula ; and
thishewillbeabletodomore
satisfactorily if he places the
scapula in such positions as
elevate its margins and render them more prominent. In examining
Uie posterior angle, the hand of the injured limb may be placed upon
PBACTURE8 OP THE BODY OF THE SCAPULA. 211
the opposite shoulder, the foFearm being carried across the front of the
cbest; but in searching for a fnu^iire below the spine, the forearm
Might to be laid across the back.
Crepitus, which is not always present, owing t© the fact that the
Infmeats overlap completely, or because they have been widely sepa-
Mted by the action of the muscles, may generally be detected by placmg
the palm of the hand upon some portion of the scapula, bo as f« steady
the fragment upon which it rests, while the arm is moved backwards
wd forwards, and in various other directions, until their broken surfaces
ire brought into contact.
Some degree of embarrassnKot in the motions of the shoulder and
trm must always result from this fracture ; sometimes this embarrass-
nieat is very great, but it ought not to be considered ever as diagnostic
of a fracture, since it may be produced eqmally by a severe contusion ;
mi even when it is accompanied with a fractare, it is doe rather to
the contusion than to the fracture.
Pathologtf, Seal, Direction, etc. — Of incomplete fractures of the
Kspula, I have already mentioned that I have seen one example.
Ualgaigne thinks that he has seen one case of incomplete fracture,
which occurred in a man who was injured by the tall of a heavy block
of stone upon his back; but as tJie patient recovered, his dit^osis
must remain doubtful. I know of no other recorded examples.
Complete fractures occnr most often below the spine, and they are
generally oblique or transverse, sometimes nearly kingitudinaL
Fractures involving the spine are noticed oocasiojially ; but I am
Dot aware that any one has ever seen a specimen of a fracture of the
spine alone, although many surgeons have
spoken of them. ^'°- ***■
I have mentioned one example «f a frac-
ture of the posterior angle as being in the
cabinet; of I>r. Mutter, of Fhila<lclphia.
Malgaigne seems to doubt its existence,
bat upeaks of it as a fracture which sur-
geons have " imagined."
Occasionally the bone is broken into
more than two fragments.
As a result of the fracture there is usu-
ally more or less displacement ; generally,
if the fracture is below the spine and trans-
wise, and especially if its diret^tion is ob-
lique from before backwards and down-
wtrds, the inferior fragment is displaced
fwwards, or forwards and upwards, by the ^ ,,^,„,„ „, ^„ ,„ .„„ „,„„.„„
Ktioa of the serratus major anticus, or of pioci'oiif tbs aupuii,
the teres major, while the superior frag-
ment is inclined to fall backwards, and sometimes it is carried upwards
Mjd backwanls, following the action of the rhoraboideos major.
In cases of comminuted fractures, and occasionally in simple frao-
•nres, the direction of the displacement is reversed, or altogether
that the lower fragment, instead of being in front, is be-
212 FRACTURES OP THE SCAPULA.
hind the upper fragmeDt ; and instead of overlapping, the two fragments
are more or less drawn asunder. These are deviations which are not
easily explained, but which depend, perhaps, rather upon the directioo
of the blow than upon the action of the muscles.
In a few cases there is no displacement in any direction, although
the crepitus with mobility sufficiently demonstrate the existence of a
fracture.
Prognosis, — If displacement actually has taken place, it will be found
very difficult, as we shall see when we come to consider the treatment,
to hold the fragments in apposition until a cure is completed ; so that
they are pretty certain to unite with a d^ree of overlappiug, or othtf
irregularity.
Lonsdale, Lizars, Chclius, N6laton, Gibson, Malgaigne, and othen
have spoken of the difficulty or impossibility generally of keeping
these fragments in place. N6laton and Malgaigne, indeed, confeBS that
they have never succeeded; Gibson declares that it is scarcely possible;
while Chelius affirms that if the fracture is near the angle, the cure is
always effi^cted with some deformity.
But then it is not probable that the patient will ever suffer any seri-
ous iuconvcnience from this irregular union of the fragments, since the
perfection of its function depends less upon any given form or size than
in the case of almost any other large bone; and if, as has been observed
by IxHisdale, the free use of the arm is not recovered for some time, or
if, as has been noticed by B. Bell, a permanent stiffness results, these
should be regarded as due to the injury which those muscles have
8uffore<l which envelop the scapula, or to some injury of the ligaments
and masclcs which surround the shoulder-joint.
In some few examples upon record, the bone has been so commino-
ted, and the sod parts adjacent so much injured, that suppuration and
necrosis have ensued. And in one case of gunshot fracture of the scap-
ula, attended with much comminution, and resulting in necrosis, I
have had occasion to remove the entire scapula.
Treatment — In the treatment of this fracture, the first object with all
8ur^(H)ns has been to restore the fragments to place, and this they liave
chiefly sought to acc»ompIish by jx)sition ; after which they have endeav-
onnl to immobilize the fragments by bandages, etc.
In seeking to accomplish the first indication, they have placed the
shoulder and arm in a great variety of j)ostures. Nearly all seem to
have regarded it as of some importance that the shoulder should be
elevated, so as to relax the muscles attached to the up]KT and back [lart
of the sc\ipu]a, and thus {)ermit the upper fragment to fall downwards
and forwards.
If we confine our remarks first to fractures through the body, and do
not include fractures of the inferior angle, this indication is the only
one which N6laton and Mayor have sought to accomplish, and iur this
Sur|)ose they employ a simple sling; while Amesbury, Listen, Lon»-
alo, S. Cooj>er, South, Skey, Miller, Pirrie, have added to the sling m
bandage or roller, which is made to inclose snugly the body and arm.
Erichsen uses the body bandage alone, as in fractures of the rihs,
while B. Cooper, Lizars, and Tavernier employ a bandage which io-
FRACTURES OF THE BODY OF THE SCAPULA. 213
doses not only the body, but also the arm ; neither of these last-men-
tiooed surgeons recommends a sling, or any other means to elevate the
inn.
Johannes de Gorter advises that a sling shall be used, but that the
elbow shall be lifted away from the side of the body, so as to relax the
deltoid. Cbelios and Desault recommend the same position, but with
the addition of an axillary pad, whose apex shall be directed upwards,
secured in place with appropriate bandages.
Pierre d Argelata usea also an axillary pad, but instead of a wedge
ke recommended a simple roll; and instead of lifting the elbow away
from the body, he directed that the elbow should be secured against the
ride, making use of the axillary roll as a fulcrum.
Petit and Heister advised that the elbow and forearm should be car-
ried forwards upon the front of the chest, and secured in this position.
In the treatment of no other fracture perhaps have surgeons differed
more widely as to the indications than in this, since, as we have seen,
some recommend the elbow to be carried from the body, and some that
it shall be made to approach the body ; one directs that the elbow shall
Ml perpendicularly beside the chest, a second prefers that it shall be
carried a little back, and a third that it shall be brought well forwards.
Id one thing alone have they nearly all agreed, namely, that the elbow
shall be lifted; and generally also it has been recommended that the arm,
forearm, and body shall be confined by sufficient bandages to insure
Zoietude. It might be proper to conclude, therefore, that the sling and
andage constitute all of the apparatus which is necessary or useful ;
Slid that it is relatively unimportant whether the elbow is near or re-
mote from the body, or whether it is in front of, or behind, or beside
the chest.
Such, indeed, is the conclusion to which we have ourselves arrived;
ret if, in relation to the position of the elbow, a choice were to be ex-
pressed, we would give the preference to that in which the arm is laid
vertically beside the body, or, perhaps, with the elbow a little inclined
baekwaHs, so as to relax as completely as possible the teres major.
It is quite probable, however, that no single position will be found
of universal application; and perhaps it would be more safe to advise
the surgeon in any given case first to reduce the fragments as com-
pletely as possible by manipulation, and then to place the arm in such
a position as, upon careful experiment in this particular instance, he
shall find enables him to best retain them in place.
If, however, the fracture is such as to have separated the inferior
angle from the body, it will be w^ell to follow the advice of Boyer and
of others, and to place a compress in front of the inferior angle, to resist
the greater tendency to displacement in this direction. This compress
will more effectually accomplish this indication if the roller with which
it 18 secured to the body, and with which we seek to immobilize the
Boipnla and chest, is turned fix)m before backwanls, or in a direction
of antagonism to the action of the muscles which produce the dis-
placement.
Deeanlt, with Chelius and Bransby Cooper, has recommended also,
in the case of a fracture through the angle, that the forearm should be
214
FRACTURES OF THE SCAPULA.
acutely flesed upon the arm, and that the hand should be placed ta
front of the cheat, upon the sound shoulder, a position which is always
irksome, and sometimes insupportable, and which does not offer in any
case sufficient advantii^es to render it wwthy of a trial.
i 2. Fractores of the Neck of the Scapula.
If by the " neck " of the scapula surgeons mean that slightly con-
Btricled portion of this bone which is situated at the base of the glenoid
cavity — and it is to this portion, we believe, that anatomists have gen-
erally applied the term "neck'' (we will take the liberty of calling this
the "anatomical" neck) — then its fracture is certainly very rare. In-
deed, the existence of this fracture, uncomplicated with a comminuted
fracture of the glenoid cavity, is denied by Sir Aatley Cooper, South,
Erichsen, and others. Mr. South says there is no such specimeo in
any of the museums in London; and I have not been able to find one
in any of the American cabinets. Dr. Valentine Mott has said to me
that he had never seen a specimen, and that in the natnral cooditioD of
the bone he regards its occurrence as impossible. Such, I confess, also,
18 my own conviction.
If, however, it is intended, in speaking of fractures of the neck of
the scapula, to refer, as Sir Astley Cooper has done, only to fractures
extending through the semilunar notch, behind the root of the coracoid
process (" surgical " neck), then its existence is certain ; yet the frac-
ture is not common. Duverocy has reported one example, the exist-
ence of which he established by a dissection. The coracoid procea*
was broken at the same time, but the fracture through the surgicftt
neck was distinct from this; and Sir Astley has recorded three ex-
amples in which the diagnosis was very clearly made out, yet not actu-
»lly proven by an autopsy.
FHACTUBES OF THE ACROMION PROCESS. 215
In Holmes's Surgery it is stated that there is one specimen in the
moseam of Guy's Hospital ; another, in which repair has taken place,
in the museum of the Royal College of Surgeons; and the writer re-
fes, ako, to the case reported by Duverney in 1751.*
Perhaps some of the cases, diagnosed during the life of the patient
as frafftures of the neck of the scapula, were fractures of the lower or
anterior lip of the glenoid cavity ; but I have never found such a
specimen in any collection of bones which I have yet examined, and
it most be admitted to be exceedingly rare.
Symptoms, — Sir Astley Cooper justly remarks that " the degree of
deformity produced by a fracture of the surgical neck of the scapula
depends upon the extent of laceration of a ligament which passes from
the under part of the spine of the scapula to the glenoid cavity. If this
be torn " (and to this we ought to add the ligaments passing from the
ooracoid process to the clavicle and acromion process — coraco-clavicu-
lar and coraco-acromial), " the glenoid cavity and the head of the 08
homeri fall deeply into the axilla, but the displacement is much less if
thfe remains whole."
The usual signs are, a depression under the acromion process, the
same as in dislocation of the head of the humerus downwards, but not
80 deep ; the head of the humerus felt, perhaps, in the axilla ; crepitus,
and the immediate recurrence of the displacement whenever, after the
reduction has been fairly accomplished, the arm is left unsupported.
The crepitus is best discovered by resting one hand upon the top of
the shoulder in such a manner as that a finger shall touch the point of
the process, while the arm is rotated and moved up and down by the
opposite hand. It may also be easily ascertained that the coracoid
process moves with the humerus instead of the scapula. Occasionally
the accident is accompanied with paralysis of the arm, from pressure
upon the axillary nerves ; and a rupture of the axillary artery is also
mentioned by Dugas.'
Treatment, — The indications of treatment are three, namely, to carry
the head of the humerus, with the glenoid cavity, etc., up, to carry it
out, and to confine the body of the scapula. The first is accomplished
by a sling, the second by a pad in the axilla, and the third by a broad
roller carried repeatedly around the arm and chest and across the
shoulder. In short, the treatment is essentially the same as that which
we have recommended for a broken clavicle.
2 3. Fractures of the Acromion Process.
Examples of fracture of the acromion process have been reported
by Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, N^laton,
Halgaigne, West,* Brainard,* Stephen Smith, and others. I have
' Holmes 'b Surgery, vol. ii, p. 776, Amer. ed., 1870.
' R«fnark« on Frac. of Scapula, by L. A. Dugas, Georgia. Amer. Journ. Med.
Sei.Jan. 1858
• W«it, Penin. Journ. of Med., vol. v, p. 254.
* Braioard, Bo«t. Med. and Surg. Journ., vol. xxxi, p. 501.
216 FRACTURES OF THE SCAPULA.
myself reported three examples ;* and one more example has cx)me
under my notice since the date of that report.
In the case seen by Cooper it entered the articulation of the clavicle^
and produced at the same moment a dislocation. Malgaigne says it
occurs generally farther up, and posterior to the attachments of th€
clavicle, " near the junction of the diaphysis with the epiphysis/' and
that the fracture is in most cases transverse and vertical ; but N6lato&
saw a case in which the fracture was oblique. In the case reported by
C. West, of Hagerstown, Md., the fracture was through the base of
the process. In two of the examples seen by me the fracture was in
front of the clavicle ; in the third, occasioned by the fall of a barrel of
flour upon the shoulder, the fracture occurred at the acromio-clavicalar
articulation, and was accompanied with an upward dislocation of the
outer end of the clavicle ; and in the fourth the fracture occurred at the •
same point, but there was neither displacement of the clavicle or of the
process, the fracture being only recognized by the crepitus and motion.
There is some reason to believe, I think, that a true fracture of the
acromion process is much more rare than surgeons have supposed,
and that in a considerable number of the cases reported there was
merely a separation of the epiphysis; the bony union having never
been completed. If such fractures or separations occurred only in
children very little doubt might remain as to the general character of
the accident ; but the specimens which I have found in the museums,
and the cases reported in the books, have been mostly from adults. It
is more difficult, therefore, to suppose these to be examples of separa-
tion of epiphyses, but I am inclined to think that in a majority of
instances such has been the fact. It is very probable, also, that in the
case of many of the specimens found in the museums, called fractures,
the histories of which are unknown, they were united originally by
cartilage, and that in the process of boiling, or of maceration, the dis-
junction has been completed. The narrow crest of elevated bone
which frequently surrounds the process at the point of sc{)aration, and
which Malgaigne may have mistaken for callus, is found upon very
many examples of undoubt<?d epiphyseal separations which 1 have ex-
amined ; and this circumstance, no doubt, has tended to strengthen the
suspicion that these were cases of fracture.
This opinion is confirmed by the remark of Mr. Fergusson, that a
fracture of this process is an accident "of rare occurrence." "I have
dissected," he adds, "a number of examples of apparent fracture of the
end of this process; but in such instances it is doubtful if the movable
portion had ever been fixed to the rest of the bone." Dr. Jacks<m says
there arc four specimens in the museum of the Massachusetts Mediod
College, and in the museum of the Boston Society for Medical Im-
provement, which might easily be mistaken for fractures, but which
only illustrate to how late a jieriod the bony union is sometimes de-
layed. In one specimen the patient could not have been less than forty
years of age ; " the acromial process of each scapula was fully formed,
out having no bony union whatever witli the bone itself. The union
vras ligamentous, but strong and close."
^ Report on Deformities.
FBACTDBE8 OF THE ACROMION PROCESS.
217
To the same class belong several specimens in my own collection;
fpedmens 163 and 997 in Dr. March's collection ; 707 in the Albany
College collection ; two specimens in the Mutter, and one in the Jeffer-
(m Medical College museums.
I wish to mention, also, that in the case of my own specimens of
(piphyseal separation, as well as most of the specimens which I have
examined, the ends of the fragments were closed with a compact bony
tisene.
The mode of development of the scapula will explain these cases.
The scapula is formed from seven centres ; namely, one for the body,
(MM fop its posterior border, one for its inferior Ixirder, two for the
acromion process, and two for the coracoid. Ossification of the body
oiMs to a certain extent at or near the period of birth. It commences
inwie of the centres of the coracoid process, about one year after birth,
ud anites to the body at about the fifteenth year. All t)ie other
mtres remain cartilaginous until from the fifteenth fo the seventeenth
nu, when ossification commences, and is completed by a common
mion among ail parts, usually between the twenty-second and twenty-
fifth years.
Nq donbt, however, a fracture of this process does occasionally take
16
218 FRACTURES OF THE SCAPULA.
place. In addition to ray own, I have already mentioned several other
examples, some of which have been confirmed by dissection, and in the
case mentioned by Stephen Smith, an autopsy, made three weeks after
the ac(;ident, showed a fracture without displacement, the periosteum
covering its upper surface not being torn ; the fragment could be turned
back as upon a hinge.
Prognosis. — The process generally unites with a slight downward
displacement. This occurred in at least two of the examples seen by
me ; but in such cases the motions of the arm are not in consequeooe
much, if at all, impaire<l ; unless, indeed, it is so much depressed as to
interfere with the upward movements of the arm ; a result which
Heister erroneously supposed was inevitable.
Sir Astley Cooper says that a true bony union is rare in these frac-
tures, and that there generally results a false joint, the fragments
uniting by a fibrous tissue; but sometimes the surfaces, instead of
uniting either by bone or ligament, become polished, and even ebar-
nated.
Malgaigne has noticed, also, in a specimen contained in the Dupuy-
tren museum, a hypertrophy of the lower fragment, this portion having
a diameter nearly twice as great as that of the portion from which it
was detached.
Symptoms, — Where no displacement exists, the diagnosis must always
be difficult, if not impossible. In such a case we could only be in-
structed by the manner in which the injury had been received, by the
contusion, and by the presence of mobility or crepitus.
In examples attended with displacement, if no swelling is present,
the finger carried along the spine of the scapula to its extremity, will
easily detect the fracture by the abrupt termination of the proc^ess, or
by the presence of a fissure, or a depression ; but a.s to the other syrap-
toiny, they must deixjnd very much upon the |K)int at which tjie frac-
ture has taken place. If in front of the acromio-clavicular articulation^
the |)<)sition of the arm in its relations to the body will not be changed;
but if the fracture is through the articulation, and a dislocation of the
clavicle results, or if it is l)ehind the acromio-clavicular articulation,
the arm, having in either case lost the supjHjrt of the clavicle, will
assume the same position that it does in a fracture of the clavicle; that
is, the shoulder will fall downwards, inwards, and forwanls.
Treatment. — If the fracture has taken place in front of the acroniio*
clavicular articulation, no doubt the most rational plan of treatment^
if one aims at the accomplishment of a perfwt Ixmy union, is that
recommended by I)el|>ech ; that is, placing the patient in btnl, u|>on his
back, and carrying the arm out from the binly nearly to a right angle;
sinc^t* by this method the fragment is not imly lifteil, but the deltoid
muscle is relaxe<l, and, consequently, the fragment is no longer forcibly
drawn away from the spine of the scapula. If, therefore, the patient
will submit to this treatment for a sufficient length of time, the union
must 1k» a(?complished with the least passible amount of displacement.
But in the case of a fracture of the acromion process at the |>oint indi-
cate<l, only a few fibres of the deltoid muscle are attached to the fipajf-
ment which has been broken off, and consequently, even in case no union
FRACTURES OP THE ACROMION PROCESS. 219
took plaoe^ the muscular power of the arm could not be appreciably
impaired. Nor would a slight falling or depression of the fragment
cause any embarrassment to the motions of the shoulder-joint.
For these reasons it is scarcely worth while to do anything more, in a
great majority of cases, than to place in the axilla a pretty heavy wedge-
shaped pad, with its apex upwards, and then secure the arm to the
side with a sling and roller, the same as in the case of a fracture of the
davicle.
If, however, the fracture has taken place at or behind the junction
of the clavicle with the process, the indications of treatment will be, in
all respects, the same as in the case of a fracture of the clavicle.
{ 4. Fractures of the Goracoid Process.
•
"The coracoid process," says Mr. Lizars, " is said to be broken off,
but this I question very much ; it must be along with the glenoid
cavity, or there must be a fracture of the neek of the scapula."
Dr. Neill, of Philadelphia, has in his cabinet a specimen of separa-
tion of this process at about one inch from its extremity. The line of
separation is somewhat irregular; there is no callus, but it is united
to the upper portion by a dried tissue, half an inch in length, and con-
tinuous with the periosteum. This has been regarded as an example
of fracture ; but although the scapula is large, and evidently belongs to
an adult, the fact that the acromion process is not yet united l)y bone
renders it probable that this, also, is an epiphyseal separation. Prof.
Charles Gibson, of Richmond, Va., has informed me also that he has
in his cabinet a dried specimen, from an adult, which has been broken
obliquely near the end, but which is now united by a ligamentous or
fibrous tissue of one line and a half in length. The fragment is dis-
placed a little forwards as well as downwards. Reuben D. Mussey,
of Cincinnati, possessed a very remarkable and conclusive example of
this fracture. The humerus is dislocated forwards, the head and neck
being finnly united to the neck and venter of the scapula, while at the
flune time the coracoid process is broken and displaced. Dr. Jackson,
of Boston, says that specimen No. 453 in the museum of the Massa-
chosetts Medical College seems clearly to have been a fracture involv-
ing the \yase of the coracoid process, and which, having taken place
inmewhere within a year of the death of the person, had become united
by bone, and that just before death the process had broken off, and so
completely, as to involve a portion of the glenoid cavity.*
Bransby Cooper relates a case of fracture through the base, which
•fter eight weeks, when the patient died, was found to be united by a
ligament. The acromion process was broken at the same time, and
bad anited in the same manner. The head of the humerus was also
broken and partly united.* One example is said to have occurred in
tbe practice of Dr. Amott, at the Middlesex Hospital, London, in
eoosequence of which the patient died, when a dissection disclosed the
* The author'A Report on Dpf«>rmitios, op. cit.
* B. Cooper, editi(»n of Sir Astlcy on Frac. and Disloc , Amer. ed., p. 380.
ES OF THE SCAPULA.
true nature of the accident.' Mr. South has also reported a case resem-
'bling somewhat Mussev's, but much more complicated. The humenia
was partially dislocatod forwards, the clavicle, acromion procefls, and
the olecranon were broken as well as the coraooid process. Neither
the fracture of the clavicle nor of the coracoid process was made out •
until after the patient died, which was on the fourth day ; the &ct of
the existence of these fractures being then ascertained by diseectioiL'
Holmes has reported a case,' Erichsen says there is in the muGcam rf
the University College a preparation showing a fracture at the base ei
this process, the line of fracture extending across the glenoid cavity.'
Buverney, Beyer, and Malgaigne have also reported four additional
examples, confirmed by dissections.'
The existence of this form of fracture, established by at least oiiw
or ten dissections, can no longer be denied; yet it is usually accom-
panied with serious complications, such as must in meet cases prove
fatal. In the only two cases, how-
FiQ, M. ever, in which I have had reason to
believe that I had to deal with a
fracture of this kind, the symptonw
and termination were less grave, al-
though they were l;>oth complicated
. /•^^^^^^^^■lUrl' ^'^'^ ''^ upward dislocation of the
_Ij" ^^^39^H|H||nAT'' outer end of the clavicle. A gentle-
man residing in the country w«
struck by a board \vhich fell edge-
wise upon his shoulder. The frac-
ture of the coracoid process does not
seem to have been recognized by his
surgeon. An apparatus was applied
to retain the clavicle in its placr,
but after three months, when he
called upon me, it still remained ,
displaced as at first. During all of this time the apparatus had been
steadily kept on. On laying ofi" the dressing, I discovered that the
coracoid process was detache<l, obeying constantly the movements of
the bead of the humerus, but being not at all subject to the movements
of the scapula. Some months later I examinc^l the arm again, and
found the parts in the same condition as before, but the functions of
the arm were not impairo<l. A girl was admitted to Bellevue Hnapital
in Novcml>cr, 18G8, having fallen upon her loft shoulder, and havii^
sustained a complete luxation of the acromial end of the clavicle, up-
wards and outwards. Upon careful examination, a fracture of the
coracoid process was also diagnosticated, indicated by both mobilitr
and crepitus.
' Arnotl, FerijuMon's Siiit:., n MIS,
" S."iih, L"ncl. Mnd.-Chir. R«v., 181'
■ HoImM, Mnd..Chir. TrHna., vol. il
' KrirlLi-n, Surg.Ty, p. 207.
* Mal|;aigne, op, cit., p. CAi.
FRACTURES OF THE HUMERUS. 221
It has been generally stated that when this process is broken off, it
will be carried downwards by the united action of the pectoralis minor,
the short head of the biceps, and the coraco-brachialis muscles; but
this will depend upon whether the coraco-clavicular ligaments are rup-
tured also; a circumstance which is not very likely to occur, at least
to any great extent; and in fact not one of the well-attested examples
cS this fracture has ever been accompanied with any considerable dis-
placement in this direction.
Treatment. — In a case of simple fracture of the process, unattended
with any other lesions, it has been recommended to place the arm in a
sling, with the elbow advanced as much as possible upon the front of
the chesty as by this position we relax somewhat all of the three mus-
cles having attachments to this process, and then to confine the scapula
by a few turns of a roller. It is not probable, however, that by these
measures we should accomplish enough to justify their continuance if
they were found to be painful, or even exceedingly irksome. Patients
onder my observation have generally complained very much of the pain
and discomfort attending this position of extreme flexion of the arm
and forearm, first employed by Velpeau for fractures of the clavicle.
Moreover, I do not think the fragments are generally displaced; and if
they were, and the final union were to be accomplished solely by liga-
ment, I think the usefulness of the arm would not be at all impaired.
Such, at least, has been my experience in the two cases above recorded,
and in both of which no bony union occurred.
In the graver forms of the accident, where other bones about the
sboalder are broken or dislocated, which, as we have seen, constitute
the larger proportion of the whole number, the treatment must gener-
illj have little or no r^ard to this particular injury.
CHAPTER XX.
FRACTURES OF THE HUMERUS.
It is not sufficient to consider fractures of this bone as occurring
thfoogh the shaft and its two extremities, as some systematic writers
have done ; since upon this simple arrangement it is impossible to base
a natural division of their causes, symptoms, prognosis, and treatment.
We shall find it necessary to consider —
1. Fractures of the head and anatomical neck. (Intra-capsular ;
non-impacted and impacted.)
2. Fractures through the tubercles. (Extra-capsular ; non-impacted
and impacted.)
3. Longitudinal fractures of the head and neck, or splitting ofi* of
the greater tubercle.
4. Fractures of the surgical neck. (Including separations at the upper
epiphysis.)
222 FRACTURES OF THE HUMERUS.
5. Fractures through the body of the shaft. (Shaft below the surgi-
cal neck and above the base of the condyles.)
6. Fractures at the base of the condyles. (Including separation at
the lower epiphysis.)
7. Fractures at the base, complicated with fractures between the con-
dyles, extending into the joint.
8. Fractures or separations of the internal epicondyle.
9. Fractures or separations of the external epicondyle.
10. Fractures of the internal condyle.
11. Fractures of the external condyle.
Of 153 fractures of the humerus examined and recorded by me, 42
occurred through the upper third, 31 through the middle third, and 80
through the lower third. An observation which is in contrast with the
statement made by Amesbury, and which has been repeated by LizarSy
B. Cooper, Fergusson, Gibson, and others, that this bone is most oft«i
broken in its middle third.
Of the fractures belonging to the upper third, 5 were suppose<l to be
epiphyseal separations, one was probably a fracture at or near the ana-
tomical neck, with impaction and splitting of the tubercles, one was a
fracture of the greater tubercle alone, and 35 were fractures at or near
the surgical neck.
Of the fractures belonging to the lower third, 15 were through the
internal condyle and epicondyle, 19 through the external condyle, 17
were at the base of the condyles, 6 through the condyles and across the
base at the same time. One at the epiphysis, the remaining 22 being
through the shaft, but above the base.
Unfortunately, surgical writers have not been agreed in the !ise and
application of the terms "head," "neck," "anatomical neck," and "sur-
gical neck" of the humerus; and, as a consequence, their meaning k
often obscure, and their teachings are sometimes contradictory and
absurd.* It is necessary, therefore, that we should define them more
precisely.
The " head " ©f the humerus is that smooth, elliptical surface, covered
by cartilage and synovial membrane, which articulates with, and is re-
ceived into, the glenoid cavity of the scapula.
The "anatomicid" neck is the narrow line immediately encircling
the head, and which receives the insertion of the capsular ligament.
The "surgical " neck is that portion which commences at the lowei
margin of the tubercles, or at the |)oint of junction between the epiphy-
sis and the diaphysis, and which terminates at the insertion of the jwe-
toralis major and latissimus dorsi.
The " neck " is all of that portion included between the head, and
the insertions of the |)ectoralis major and latissimus dorsi ; coinprisina
not only the anatomiuil and surgical necks, but also the tubercles ; whicn
latter occupy the triangular space between these two.
^ Boston Med. and Surg, .lourn., June 24, 185S, p. 410.
FBACTDHES OP HEAD AKD ANATOMICAL NECK. 223
1 1 FraetUM of the Head and Anatomical Neck. (IstracapBvIar ;
Non-impacted and Impacted.)
(bfua. — The causes which have been found competent to produce
friclnres of the head and anatomical neck are, the penetration of balls
Of of other mistiiles dircctl)' into the joint, producing thusn compound,
ind generally comminuted, fracture of the head ; and falls, or direct
bW^ upon the shoulder, without penetration.
Pathoiagy, Reguita, etc. — When the fracture results from the direct
pfoetratioD of some foreign body into the joint, it is not only a com-
poaad ftactupe, but the head of the bone is almost necessarily broken
into fragments. If the patients recover, sooner or later the fragments
have generally to be removed.
Fractures of the anatomical neck, produced by falls upon the
shoulder, without penetration, arc, however, usually neither compound
DOT comininuted ; and they sometimeH follow, with a remarkable d^ree
of accuracy, the line of the insertion of the capsular ligament, being
alwa\'8, according to Robert Smith, within the inferior or outer margin
lathis insertion. He calls them, therefore, intracapsular. It is nroba-
hle, however — since, as we sliall presently see, bony union is not denied
tft this fracture — that the line of separation is not always, or generally,
perhap, completely within the insertion of the ligament, hut that it is
in Mme degree extra-arlicular, if not extracapsular. If it is entirely
iDtra-articulnr, no doubt union of the fragments
can never take place; and necrosis, with suppura- fiq. ss.
tioD mu^t enRue, demanding, at a j>criod not very
remote, an operation for the removal of the frag-
ments, the same as in (impound fractures,
Gibson, however, thinks that the fragment occa-
sionally remains, being gradually at^orbed and
changed in figure. He says that his museum con-
tains three or four well-marked cases of this kind,
io all of M'hich the head has lost its spherical form,
ind is very much diminishe^l, and rough and flat-
tened next to the scapula.' Other cabinets are said
to contain similar specimens.
The displai«nients to which the upper fragment,
or the head of the bone, is subject, are remarkable,
ud some of them do not seem to be satisfactorily
Mplained. Frequently, indeed, its position is not
tfoaibly disturbed, but at other times it is found
impacted, or driven into the cancellous structure
of the inferior figment, in consequence of which "' ""''
one or both of the tubercles are frequently broken off.
Robert Smith relates the following case as having afforded him his
Gm opportunity of ascertaining by post-mortem examination the exact
nature of this form of displacement :
> Oibaon, BleniFnU of Surgery, vol. i, p. 279,
224 FRACTURES OF THE HUMERUS.
" A female, set 47, was admitted into the Richmond Hospital, under
the care of the late Dr. McDowell, for an injury to the humerus, the
result of a fall upon the shoulder. Five years afterwards, the woman
was again admitted, under the care of Mr. Adams, with an extracap-
sular fracture of the neck of the femur, one month after the occurrenoe
of which she died, in consequence of an attack of diarrhoea,
" The shoulder was of course carefully examined ; the arm was
slightly shortened, the contour of the shoulder was not as full or round
as that of its fellow, and the acromion process was more prominent
than natural. Upon opening the capsular ligament, the head of the
humerus was found to have been driven into the cancellated tissue of
the shaft, between the tuberosities, so deeply as to be below the level
of the summit of the greater tubercle; this process had been split off,
and displaced outward ; it formed an obtuse angle with the outer sur^
face of the shaft of the bone."*
The description is accompanied with two excellent drawings of the
specimen, showing the distance to which the suj)erior fragment bad
penetrated the inferior, and showing also complete union by bone.
I believe, also, that in the foll(»wing example there was a fracture at
or near the anatomical neck, with impaction, and splitting of the tu-
bercles :
January 12, 1858, a young man, aged about sixteen years, fell from
a height in a gymnasium, severely injuring his left shoulder. I saw
him, with Dr. Boardman, soon atler the accident, and found him com*
plaining very much of the shoulder, which was some swollen and
tender. He could not tell us how he fell, nor could we discover any
contusions by which to determine the point where the blow was re-
ceived. iVir motions of the shoulder-joint were painful; and there
was a remarkable fulness in front of the joint, feeling like the head of
the bone, yet not such as is usually present in a forward luxation. To
determine this more positively, however, the limb was manipulated as
for the reduction of a disl(K*ation. Once during the manipulation a
feeble but distinct crepitus was detected ; yet the position of the booe
remained unchang(Ml. The head was found to be in the socket, but
the prt*cise nature of the injury was not made out.
Fifteen days later, when the swelling had completely subsided, a
careful examination was again made by Dr. Boardman and myself,
when we arriveil at the conclusion that it was a fracture through the
bicipital groove, and that the lesser tubercle was carried forwards half
an inch or more from its fellow, while the head and the greater tuber-
cle occupied their natural positions opposite the socket. The fragment
projecting in front presented a sliarj) point, and could not be con-
founded with any swelling of the soft parts. There was a distinct
space between the tul>ercles, into which the finger could be laid. No
depression existed under the acromion process behind, but, on meas-
urement, the h(^d of this humerus was found to be half an inch wider
in its antero-posterior diameter than the opposite.
That this fracture was accomimnied with impaction was rendered
^ South, Fracture* in Vicinity of Joints, pp. 191-3.
FRACTURES OF HEAD AND ANATOMICAL NECK. 225
certain by the repeated and careful measurements of the length of the
humeruSy which constantly showed a shortening of half an inch.
Under these circumstances union generally takes place; but it is
osoally accompanied with the formation of an irregular mass of osteo-
phytes, which encircle the head like a coronet; presenting in this
respect again a remarkable resemblance to extraaipsular fractures of
the neck of the femur. This ensheathing callus, as it may be called,
is an outgrowth from the inferior fragment, and it sometimes incloses
the upper fragment as the case of a watch incloses the crystal, only in
t manner much more irregular, thus retaining it steadily in its place,
although very little direct union has occurred. The cancellous tissue,
nevertheless, is occasionally found united completely by a new and
intermediate bony tissue, and at other, times by a fibrous tissue, or by
both fibrous and bony tissue.
In some cases a jjerfect false joint has been formed between the
opposing surfaces ; while in a few unfortunate examples the head not
only refuses to unite, but by its presence, as we have already remarked,
produces inflammation and suppuration, resulting in its final extrusion
from the joint.
At other times the upper fragment turns upon its own axis, and is
foond more or less tilted or completely rotated in the socket ; so that
its cartilaginous or articulating surface rests upon the broken surface
of the lower fragment, and its own broken surface presents toward the
glenoid cavity.
Bobert Smith has described a specimen of this kind which he re-
moved from the body of a woman, aged forty, who many years pre-
vious to her death fell down a flight of stairs, and struck her shoulder
with great violence against the edge of one of the steps. Whether
she applied to a surgeon or not at the time of the accident, Mr. Smith
was not able to ascertain. After death the shoulder looked somewhat
as if there was a dislocation of the humerus into the axilla, there being
t marked depression under the acromion process, but the shaft of the
hamerus was drawn upwards and inwards toward the coracoid process.
When the cajisular ligament was opened, the head of the bone was
found to have been broken from the shaft through the line of the ana-
tomical neck, and to have completely turned upon itself; and the car-
dlagioous surface was actually driven one inch into the cancellated
structure of the shafl, so as to split off the lesser tubercle with a por-
tion of the greater. Only one-half of the upper fragment was thus
impacted, the other half projecting beyond the margin of the lower
fragment. Between the cartilaginous surface and the shaft no union
hid occurred ; but there was complete bony union between the upper
and lower fragments, beyond the limits of the cartilage.
The upper surface of the superior fragment rested in part against
the inner half of the glenoid cavity and upon its inner margin, and in
part it rested against the neck of the scapula in the direction of the
ooracoid process.'
» R. Smith, op. cit., pp. 193-6.
226
FRACTURES OF THE HUMERUS.
X6laton saw a similar specimen in the possession of M. Dubled, the
revolution of the upper fragment being complete; but there was no
lateral displacement, and the union
Fio. 66.
Fio. 67.
k
M
V5
\
k
i.
li
!^}
had been accomplished in a manner
similar to that which is seen after
intracapsular, impacted fractures,
without reversion.^
I have also been permitted to
examine a specimen belonging to
the late Dr. Charles A. Pope, of
St. Louis, Mo., which seems to
have been broken not only through
the line of the anatomical neck,
but also through the surgical neck.
Both fragments are united by bone,
the lower fragment being carried
in the direction of the coracoid
process, while the upper fragment
appears to be reversed, so that its
articular surface is directed toward
the shaft, and its broken surface
articulates with the glenoid cavity.
The history of this specimen is
unknown.
Reverting to the histories of the
several cases above referred to, in
which these extraordinarj- changes
of position have taken place, it
would seem to admit of a doubt
whether they were the direct result
of the accidents which broke the
bones, or whether thev ensued
indirectly, in consequence of a
chronic arthritis following the accident, and the constant l>ut long-
continued u«'e of the arm.
There is another theory which, in my opinion, is capable of explain-
ing most of the phenomena usually present in these cases, and which,
if admitted, renders the sup|><x**ition of a fracture unnecessarj'. It is,
that in consecpienoe of an injury, |wrhaps, but not of a fracture, a
chronic inflammation, softening and al^sorption has taken place, ami
that the changed |)osition of the head is due to pressure alone, being
acted upon by the muscles which surround the joint, and which act all
the more vigorously l)ecause they partake also of the inflammation
which has invaded the bone. This view of these specimens, which
had already mort» than once suggested its<»lf to me, was very stn.>ngly
confirmed by its having occupitMJ the mind also of Dr. Neill, of Phil-
adelphia, and who at his own instance stated to me that he believed
this was their true explanation. We were, at the time, examining Dr.
Dr. Pope's Specimen.
Front Tiew. Side viet
* N^Uton, Elements de Pathol Chirur., torn, preni., p. 307.
LONGITUDINAL FRACTURES OF HEAD AND NECK. 227
Pope's specimen, already alluded to, and, on comparing it with a speci-
men of dislocation and partial absorption of the head of the humerus
contained in Dr. Neill's museum, the points of resemblance were so
numerous and striking that we felt compelled to doubt whether Dr.
Pope's specimen, together with those seen by Smith and N^laton, did
not belong to the same claas with this of Neill's.
In a case of fracture of the "cervix humeri within the capsular liga-
ment," examined by Sir Astley Cooper, there was also a complete for-
ward luxation of the head ; but ligaraentotts union had occurred between
the fragments.^ I think it certain that in this case the fracture was
not entirely within the capsule.
i 2. Fractures through the Tubercles. (Extracapsular; Non-impacted
and Impacted.)
Under this division we intend to speak of all fractures traversing the
upper end of the humerus, and involving the tubercles; or of all those
which occur between the anatomical neck on the one hand, and the
epiphyseal junction, or surgical neck, on the other hand, and which
may be more or less oblique as well as transverse. Fractures of the
greater or lesser tubercles are of course excepted, since they are more
properly longitudinal fractures, and do not completely traverse the
diameter of the bone. Nor do we intend to include those fractures
which occur at the epiphyseal junction; since being below the principal
insertion of those muscles which are attached to the tubercles, they pre-
sent very peculiar and distinctive features, which will demand for them
a sejwrate classification and consideration.
CmiseSy Pathology^ and Results. — Fractures through the tubercles,
like fractures through the anatomical neck, are the results generally of
direct blows received upon the shoulder. They are not usually accom-
panied with much lateral displacement at the point of fracture; a cir-
cumstance which finds a partial explanation in the fact that the line of
fracture is through the insertions of the muscles converging upon the
tubercles, and not entirely above or below them, so that they continue
to act nearly equally upon both fragments ; but it is also sometimes due
in a measure to impaction : the head being forced downwards toward
the axilla, and upon the shafl, until it is made to ride upon its inner or
axillary wall like a cap; the compact bony tissue of the shaft penetrat-
ing the reticular structure of the head. These fractures generally unite
by bone; yet more or less impairment of the motions of the limb
results from the inflammation which occurs in and about the joint, or
from the irregular deposits of callus in the vicinity of the fracture.
i 3. Longitudinal Fractures of the H^ad and Neck ; or Splitting off of the
Greater Tubercle.
fhuses. Pathology, Symptoms, and Results. — Mr. Guthrie seems to
have been the first io call attention to this peculiar injury of the
shoulder. In a lecture delivered in November, 1833, he described four
* Sir A. Cooper on DielocalioriJ*, etc., p. 872.
228 FRACTURES OF THE HUMERUS.
oases which had come under his observation, and which he r^arded as
examples of separation of the small tuberosity, accompanied with more
or less of the head, the fracture extending along a portion of the bicipi-
tal groove.^
Robert Smith, however, believes that it was the greater and not the
lesser tuberosity which was thus detached in the cases mentioned by
Mr. Guthrie, since the external signs were so nearly like those which
were present in a woman seen by himself, and in whom an autopsy en-
abled him to verify his diagnosis. The following is the case as related
by Mr. Smith :
" In July, 1844, 1 was requested to examine the body of Julia Darby,
8Bt. 80, who had died of chronic pulmonary disease. Upon entering
the room, the appearances of the left shoulder-joint at once attracted my
attention, and struck me as being diflferent from those which attend the
more common injuries of this articulation.
^^ The shoulder had lost^ to a certain extent, its natural rounded
form ; the acromion process, although unusually prominent, did not
project as much as in c^es of dislocation of the head of the humerus.
The breadth of the articulation was greatly increased, and, upon press-
ing beneath the acromion, an osseous tumor could be distinctly felt,
occupying the greater part of the glenoid cavity; it formed a promi-
nence which was perceptible through the soft parts ; it moved along
with the shaft of the humerus, but was manifestly not the head of the
bone.
" A second and larger tumor, presenting the rounded form of the
head of the humerus, lay beneath the base of, and internal to, the com-
coid process, and between the two the finger could be sunk into a deep
sulcus, placed immediately below the coracoid process. The elbow
could be brought inta contact with the side, and there was no appreci-
able alteration in the length of the arm.
" Upon removing the soft parts, the head of the bone presented itself,
lying partly beneath and partly internal to the coracoid process. The
greattT tuberosity, together with a very small portion of the outer part
of the lirad of the bone, liad been completely separated from the snaft
of the humerus. This portion of the bone occupied the glenoid cavity,
the head, of the humerus liaving been drawn inwards so as to project
upon the iiincr side of the coracoid process ; it was still, however, con-
tained within the capsular ligament.
" The fracture traversed the upper jxirt of the bicipital groove, which,
in consequence of the displacement which the head of the bone had
suffered, was situated exactly below the summit of the coracoid pnK'i^^.
A new and sliallow socket had been formed ujMjn the costal surface of
the neck of the scapula, below the root of the coracoid process, and the
inner etlge of the glenoid cavity corresponded to the posterior jiart of
the sulcus, which separated the head of the bone from the detachetl tu-
berosity. The latter was united to the shaft only by ligament,
'^ The capsule had not been injured, but was thickened and enlarged,
and the bone had been deposited in its tissue. The injury had evi-
^ Robert Smith, p. 181, from Lond. Med and Pbyt. Journal.
FRACTURES THROUGH THE SURGICAL NECK. 229
dently occurred many years before the death of the patient, but the
history connected with it could not be precisely ascertained/'*
Mr. Smith relates one other case, in the living subject, which he
saw in connection with Mr. Adams, at the Richmond Hospital, and he
adds that " numerous " other living examples have fallen under his
observation.
Sir Astley Cooper has also published the particulars of a case of
fracture of the greater tubercle, which was communicated to him by
Mr. Herbert Mayo.*
The following I believe also to have been an example of this rare
accident :
John Hill, 8Bt. 78, fell upon the sidewalk, striking upon his right
shoulder. The physician to whom he was sent thought the humerus
was dislocated, and directed him to the Buffalo Hospital of the Sisters
of Charity, but he did not apply for admission until eight da}'8 after,
Oct. 14, 1857, when Dr. Boardman and myself examined the limb
carefully.
Although we placed him under the influence of chloroform, the
diagnosis was not satisfactorily made out. We inclined, however, to
the opinion that it was a fracture of the greater tubercle. The antero-
posterior diameter of the upper end of the bone was greatly increased ;
there was occasional distinct crepitus, but the limb was not shortened.
Subsequently, the examinations were repeated many times, and the
depression between the fragments becoming more palpable, the diag-
nosis was at length confirmed.
Xo treatment was adopted, except confinement in bed, and stimu-
lating embrocations. Two months after the accident he still remained
an inmate of the hospital, his shoulder being quite stiff, and the pro-
jection continuing in front.
Dr. J. J. C'harles, demonstrator of anatomy. Queen's College, Belfast,
has reported a case with great care, which he believes to have been an
example of this rare accident, and in which opinion I am disposed to
concur. The man was 30 years old, and it is supposed that the middle
of the head of the humerus was struck by the pole of a tram car. Dr.
Charles examined the patient fourteen months after the receipt of the
injury; the breadth of the head of the humerus was greatly increased,
there was a broad sulcus in the situation of the bicipital groove, and
the humerus was shortened half an inch. The motions of his arm were
very much limited, espec^ially in abduction.*
ilr. Robert Smith thinks that when the displacement is considerable,
the fragments generally unite by ligament, rather than by bone.
i 4. Fractnrei through the Surgical Neck. (Including Separations
at the Upper Epiphysis.)
I have already defined the " surgical neck " as all of that narrow
portion commencing at the upper epiphysis and terminating at the
' Robert Smith, op. cit., p. 178.
' Sir A. Cooper, on Dislocations and Fractures of the Joints. Edited by B.
OM>p<«r American edition, p. 884.
* J. J. Charles, British Med. Journ., Sept. 26, 1874.
230
FRACTURES OF THE HUMERUS.
Fio. 68,
insertion of the pectomlis major and latissimus dorsi. It seems proper,
therefore, that we should inchide under this division both fractuivs
and separations occurring at the epiphysis, especially since, owing to
their anatomical relations, tl>ey are subject to the same displacements
as fractures occurring half an inch or one inch lower down ; the
capsular muscles, with the exception of the teres minor, having no
more influence over the lower fragment when a separation occurs at
the epiphysis, than when a separation occurs at any other point of the
surgical neck.
Separation cf the Upper Epipli^si^, — A brief description of the plan
of development of the humerus will enable the reader better to under-
stand the occasional separation of the epiphyses, both at the upper and
lower ends of the bone.
The humerus is originally formed from seven cartilaginous centres,
namely, one for the shaft, one for the head, one for the greater tuberosity,
one for each epicondyle,and two for the lower, artic-
ulating end of the bone. At birth the shaft is ossi-
fied in nearly its whole length. Between the first
and fourth years ossification commences in the
several centres composing the up|)er end of the
bone, and they coalesce by the end of the fifth year,
so as to form a single epiphysis, which finally
unites with the shaft at about the twentieth year.
At the lower end of the bone, ossification com-
mences in the radial portion of the articular sur&ce
at the end of two years, in the trochlear {)ortion at
twelve years, in the internal epicondyle at the fifth
year, and in the external epicondyle at the thirti*enth
or fourteenth. At the sixteenth or seventeenth year
all the centres are joined to each other, and to the
shaft, except the inner epicondyle, which docs not
unite by bone until about the eighteenth year. It
will be observed, therefore, that although ossifica-
tion commences in the upper epiphysis first, it is the
last to form bony union with the shafts
The following is a brief account of all the cases
of separation at the upper epiphysis which liave
come under my notice.
Case 1. — In 1855, Mike Bovin, aet. 13 montli^
fell siileways from his cradle, causing some injury
to his arm iK»ar the shoulder. He was taken to an
empiric, who calleil it a sprain, and applioil iini-
nient.<. Three weeks after the accident lie was
brought to me, and I found the arm hanging beside the body, with
little or no jwwer on the part of the child to move it. There ynis a
slight depression below the acromion process, and considerable tender-
ness about the joint; but the shoulder was not swollen, nor had it been
at any time. The line of the axis of the bone, as it hung by the side,
was directiHl a little in front of the socket.
On moving the elbow backwards and forwards, the upper end of the
MffSSL
Uuinerus, irith epiphyses
(From Gray.)
FRACTURES THROUGH THE SURGICAL NECK. 231
shaft moved in the opposite directions with great freedom, and could
be distinctly felt under the skin and muscles. This motion was accom-
paoied with a slight sound, or sensation, a sensation not like the grating
of broken bone, but much less rough. There was no shortening of the
limb. When the elbow was carried a little forwards upon the chest,
the fragments seemed to be restored to complete coaptation ; and of
this I judged by the restoration of the line of the axis of the shaft to
the centre of the socket, and by the complete disappearance of the de-
pression under the point of the acromion process.
I applied suitable dressings to retain the arm in this position ; but
five months after the injury was received the fragments had not united,
and the child was still unable to lift the arm, although the forearm and
hand retained their usual strength and freedom of motion. The same
crepitus could occasionally be felt in the shoulder, and the same preter-
natural mobility. The shoulder was at this time neither swollen nor
tender.
Case 2. — Samuel Robuck, set. 13, fell through a hatchway, July
9th, 1868, striking on his shoulder. He saw a regular physician
vitbin five hours after the injury was received, who said that the arm
was dislocated ; and on the following day, under the influence of chlo-
roform, he tried to reduce it. The doctor thought he had succeeded,
and he then applied bandages to keep it in place. At the end of two
weeks the doctor declined, for reasons which are not known, to have
anv further care of the case, and the patient consulted Dr. Voss, at the
Dispensary. Dr. Voss detected the nature of the case, and sent him to
me to confirm his diagnosis. I found the upper end of the lower frag-
ment projecting in front, and not united. The arm was shortened half an
inch. I have not seen the patient since, and do not know the result.
Case 3. — Joseph Snellbach, set. 16, fell backwards down a flight of
steps, striking upon his back and arm near the shoulder, May 10th,
1868, causing a separation of the upper epiphysis of the left humerus.
Dr. , of this city, now deceased, saw the patient within half an
boor, and supposing that he had suffered a dislocation of the head of the
bomerus, he attempted to effect reduction with his heel in the axilla,
and without anaesthetics. On the following day I found him in Ward
J6 at Bellevue. The house-surgeons were divided in opinion as to its
character, some at first believing it to be a dislocation ; others, with
myself, recognized it to be an epiphyseal separation.
All eflforts at replacement proving ineffectual, splints were applied
by ray direction, and on the 15th of July the patient left the hospital
with the fragments united, but overlapped at the point of fracture, the
opper end of the lower fragment being in front of the upper fragment.
TTie limb was shortened one inch, but its motions were free, and there
was DO reason to suppose that its utility was in any degree impaired.
Case 4. — C. H., set. 19, living in a neighboring town, in the de-
lirium caused by fever, fell from a third-story window. May 12th, 1868.
Two very intelligent and experienced physicians, who were called,
thought the boy had received a fracture of the acromion process, ac-
companied with a dislocation of the head of the humerus, and they
attempted to reduce it, but without success.
232 FRACTURES OF THE HUMERUS.
On the 2d of June following, three weeks after the receipt of the in-
jury, I saw the patient in consultation with his physicians, and found
a separation of the upper epiphysis of the humerus. The upper end
of the lower fragment projected in front of the acromion process, ap-
pearing a little above the level of the process, and covered only by the
skin. No union had occurred between the two fragments.
Case 5. — John Davis, at. 18, fell about eight feet, September 2d,
1873. Of the three surgeons first called, Drs. H. and S. thought the
boy had received a fracture; the third believed it to be a dislocationi
and having placed the patient under the influence of ether, attempts
were made to reduce it. The deformity not being relieved, I was added
to the consultation. I found the shoulder a good deal swollen. The
upper end of the lower fragment could be felt distinctly in front of the
acromion process. At first, the surgeons informed me, the broken end
seemed just under the skin and almost ready to be thrust through, but
the extension had made it retire somewhat. The end felt rough and
serrated. While making extension I was able to detect a slight crep-
itus or click. Employing Dugas's test, I found the elbow would r&t
upon the front of the chest. In short, the diagnosis was complete, and
Dr. S., having taken charge of the case, applied one long splint, and a
sling under the wrist, but not under the elbow. The fragments have
united with very little deformity.*
This case was subsequently seen by Dr. Moore at one of my Beilevne
clinics, by whom my diagnosis was fully confirmed.
Robert Smith and Sir Astley Cooper both speak of it as a frequent
accident in early life, but the recorded cases are very few. The case
mentioned by Mr. Smith has been given very much at length, and, as
a characteristic example, deserves to be repeated :
"During the early part of last year, a boy, eight years of Me, was
admitted to the Richmond Hospital, under the care of Dr. McDowelL
About a week previous to his admission he had fallen upon the shoul-
der, and at once lost the power of using his arm.
"It was at first sight evident that there did not exist any laxaCion
of the head of the humerus, and it was equally obvious that the case
was not an example of any of the ordinary fractures to which the neck
of the bone is liable. There was no diminution of the natural rotun-
dity of the shoulder, nor any unusual prominence of the acromion
process; the head of the lH)ne could be clistinctly felt in the glenoid
cavity, and it remained motionless when the arm was rotated ; there
was very little separation of the elbow from the side, but it Mras di-
rected slightly backwards.
"About three-quarters of an inch l>elow the coracoid priK'ess there
existed a remarkable and abrupt projection, manifestly formed by the
upper extremity of the shaft of the humerus, every motion imparted
to which it followed. Its suf)erior surface, which could be distinctly
felt, was slightly convex, and its margin had nothing of the sharpnoits
which the edge of a recently broken l)one presents in ordinarj' fractures.
"When this proje<*ting |K)rtion of the bone was pushed outwards, so
> Tho Medical Kocord, May 1, 1874.
FRACTUHES THROUGH THE BUROICAL NECK.
233
» to bring it in contact with the under surface of tlie hea<l of the
bufflerus (previously fixe<) as far as it waa possible to do so), a crepitus
ne produced by rotating the shaft of the bone. It did not, however,
nsemkle the oi^inary crepitus of fracture, but it would be extremely
difficult, by any description, to convey a clear idea of what the dilfer-
eoce consisted in.
"From a careful consideration of the symptoms and appearances
abovementioned (taking into account also the age of tlie patient), the
diagnosis was formed, that the injury oonslsted in a separation of the
nperior epiphysis of the humerus from the shaft, of the bune. Va-
rious mechanical contrivances were employed in this case, but all
proved ineffectual in maintaining the fragments in their proper rela-
tive position." •
Sir Astley Cooper has also briefly described one example, which oc-
curred in a child ten years of age.'
Prof. E. M. Moore, of Rochester, in a paper read before the Ameri-
OD Medical Association, in 1874, and published in the Transactions
Cv that year, has called attention to what he considers the true condi-
tirni of the separated fragments in most of these cases, and to the proper
remedy. He observes tliat the displacement is not usually complete ;
bat that the upper end of the lower fragment is carried inwards to the
distance of about one-fourth of Its diameter, where it is arrested, by a
tonvexity of the lower fragment becoming lodged in a natural concavity
b the upper fragment. The upper fragment now becomes tilted by the
ictionof the muscles, its internal mai^in ascending in the glenoid cavity,
ud its outer margin descending until It is arrested by the capsule.
TtfRttillihjiIiDrbnBitnu. (From Uoore,) Eplpb;Kii1 lepsnUon, (Ptou Moore.)
If, under these circumstanoee, the arm is carried forwards and upwards
lo the po^ndicular line, the upper fragment or epiphysis will remain
' Robert Smith, op. cit., p. 201. ' Sit A. Cooper, op. cil., p. 382.
234
FBACTUKES OP THE HUUEBU8.
fixed, being held fast by the capsule inserted into the outer and pn»-
terior margin of the head, while the lower fragment or diaphjsis, aided
by the natural action of the muscles, will move outwards and resnme
ite original jiosition.
The correctness of this opinion he has verified by having in this
manner eSeeted the rcductioD with great ease, in three cases which have
cume under bis observation. The patients were respectively six, four-
teen, and sixteen years of age.
In the first case the reduction was effected on the fourteenth day ; in
the second case, on the second day ; and in the third, on the seventeenth
day. In both of the latter, ineffectual attempts had been already
made to reduce what was supposed to be a dislocation.
In order to maintain the reduction, it was only found necessary to
bring the arm down while in a state of moderate extension, and to
secure it beside the body with a Swinburne extension splint Any of
the forms of dressing applicable to a fracture of the surgical nec:k would
probably prove equally efficient.
The observations made by Professor Moore seem to me exceedingly
valuable ; yet I do not think it always happens that the aeparatiob 'a
incomplete, nor <loes Professor Moore say that it b, but only that wm
the condition in all tlie cases seen by him.
In Cases 4 and 5, reported by myself, the upper end of the lower
fragment ntts above the level of the coracoid process, and aeemed to be
directly beneath the skin. These were probably examples of complete
separation ; hut the remaining three presented the symptoms described
as characteristic of the partial separation in Professor Moore's paper;
the projection was 1e^ marked, ana on a
*'"'■"■ level with the coracoid process, or a little
below it.
In all of my coses the Qppcr end of the
lower fragment could be felt, not shftrp or
pointed, as in most ezsmples of fracture t^
the surgical neck, but soinewhat imsularly
transverse, and when covered with the skim
and muscle, might be easily mistaken, hf
the inexponeiiced, for the h«td of the hoot.
True Fracture at the Surgicai Xect. — It
' seems ncces<<ury, in order to a full under-
standing of the varying aspects under whidi
this accident occurs, and in order to the
establishment of the diagnosis, prognosii,
and treatment, to relate a few i[lu8trati\-e
examples.
CAHt; 1. Simplf fracture, never ditpiaeed ;
buineiui. (Frum Orar.) Union Without df/ormUt/. — Alex. Balentioe,
let. 62 ; admitted to the Bu^lo Hospital of
the S!st«rs of Charity, December 19, 1851. He had fallen upon the
aidewalk, striking upon his ri^ht arm. Dr. Johnson, of fiuffiilo, had
reduced the fracture, and applic<l appropriate dressings. No unioa of
the fragments had yet occurred ; but as tJie sur&ces were in appasitioa.
FRACTURES THROUGH THE SURGICAL NECK. 236
«
it was only after considerable manipulation, and not until we bent the
forearm upon the arm, and rotated the humerus by means of the fore-
arm, that the crepitus became distinct, and gave unequivocal evidence
of the existence of a fracture, and of its situation.
The treatment, after admission, consisted in the application of one
gntta percha splint, accurately moulded, and extending from above the
uioulder to below the elbow, and encircling one-half the circumference
of the arm ; the splint being secured with the usual bandages, etc
The result is a perfect limb.
Case 2. Simple fraxsture ; union, with displacement and deformity, —
White, of Buffalo, set. 12, fell fourteen feet, striking on the front and
ootside of the left shoulder. Dr. P., of Erie County, saw the lad within
three hoars (July 19, 1S53). He was brought to me on the fourth day
after the accident. The upper part of the arm was then very much
swollen. I found the arm dressed as for a fracture of the middle or
lower third of the humerus. It was shortened one inch. The elbow
was inclined backwards, and there was a remarkable projection in front
of the joint, feeling like the head of the bone. The hand and arm
were powerless. I suspected a dislocation of the head of the humerus
forwards; and, having administered chloroform, I attempted its redwo-
tioD with my heel in the axilla. While making extension, I felt a
sodden sensation like the slipping of the bone into its socket, but on
examination I found the projection continued as before. I then re-
peated the effort, with precisely the same result.
I now applied an arm-sling, and directed leeches and cold evapora-
tiofr lotions.
On the 25th, five days after the accident, it was examined by Drs.
Mixer, McGr^or, Joseph Smith, with myself. We still believed it
was a dislocation, and, having administered chloroform, we again at-
tempted its reduction. The same slipping sensation was produced as
b^re, and the deformity was repeatedly made to disappear; but, on
mspending the extension, it as often reappeared.
The character of the accident was now made apparent, and we pro-
eeeded at once to apply the splint and bandages suitable for a fracture
of the soi^cal neck of the humerus, namely, a gutta percha splint, ex-
teoding, on the outside, from the top of the shoulder to below the elbow,
with an arm and body roller secured with flour paste.
On the 3l8t, twelve days after the accident, Dr. Wilcox, Marine Sur-
geon at Buffalo, saw the arm with me. The fragments were displaced
die aame as when I first saw it, and the same as when no apparatus was
applied. We examined it again carefully, and attempted to make the
mgments remain in place, but we were unable to do so, except while
boldii^ them and making extension.
August 9 (twenty-first day). I removed all the dressings. Motion
between the fragments had ceased, but the projection and shortening
lemaiiied as before; now, also, the irregular projections of the fractured
boncB were more distinctly felt The dressings were never reapplied.
Thiee months later no change had occurred. He could carry the elbow
fcrwards freely, as well as teckwards, the motions of the shoulder-joint
being unimpaired.
236 FRACTURES OF THE HUMERUS.
Case 3. Simpk fracture, wiUi displacement; resulting in deformity aiid
non-union, — L. B., of Lockport, 8et. 43, was thrown from his horse in
February, 1854, striking upon his right elbow.
Dr. Maxwell, an experienced surgeon of Lockport, examined and
dressed the fracture. Dr. Fassett, was present and assisteil at a subse-
quent dressing. Three surgeons who examined the arm before Dr. M.,
called it a dislocation.
Twelve weeks after the accident, Mr. B. called upon me. The right
arm was shortened one inch ; the elbow hung off slightly from the body ;
the upper end of the lower fragment was distinctly felt in front of the
shoulder-joint, under the clavicle, feeling very much like the head of
the bone. The fragments were not united, but they could be seized
easily, and made to move separately and freely. He stated to me that
be was subject to rheumatism, and especially in the shoulder and arm
of the side injured. He wished to know whether it could not be " reset."
Two years after, I found the bone still ununited. He was, however,
able to write with that hand, having first lifted his arm with the other
hand and laid it upon the table.
Case 4. Simple fracture, probably imjHicted; resulting in deformity. —
Wm. A., of Buffalo, tet. 15, fell backwards, June 4, 1855, striking on
his back and left shoulder. Dr. L. saw it immediately, and, regarding
it as a dislocation, attempted its reduction. He subsequently repeated
the attempt. I saw the patient with Dr. L. on the tenth day. The
Arm was shortened one inch and a half. The fragments were displaced
forwards, projecting in front of and a little below the joint. As in
Case 3, it might easily be mistaken for the head of the bone ; but the
difficulty of diagnosis had been very nmch lessened by the subsidence
of the swelling. There was no motion between the fragments; nor
could the deformity, by any manipulation or extension, be made to dis-
appear. It was probably impacted.
March 23, 185G, nearly ten months after the aciudent, I found the
fragments remaining as when I first examined the limb, and the arm
shortened one inch and a half. The elbow hung a very little back from
the line of the bo<ly. The upper end of the lower fragment was lifted
to within one inch of the head of the humerus ; the up|)or fragment
having its he;id in the socket, with its lower end downwards and for-
wards. The arm was, however, in every res|>ect as useful as befoiv it
was broken. It was equally strong, and he could raise his arm as high
and move it in every direi»tion as fTw\y as he could the other.
Causes. — Epiphyseal separations belong almost exclusively to the
periods of youth and childho<Kl, but true fractures at the surti:ical neck
occur most often in adult life ; with the exception of one girl and two
lads, ageil, ns|KH»tiveIy, eleven, twelve, and fifteen years, all of the ex-
amples of this latter ac^^dent nn^orded by me (35) occurred in adults,
and the averagt* age is about forty-three years ; yet Sir A. Cooper de-
clares these fractures to be most common in infiincy, while Malgaigne
has never s<vn a case in a person under fifty-three years.
Both epiphyseal se|)arations and fractures at this {)oint are occasioned,
in most cases, by dirt^ct blows or falls upon the shoulder. Of thirty-
one examples in which I find the cause recorded, twenty-two were from
FRACTURES THROUGH THE RURGICAL NECK. 237
direct blows, eight from indirect blows, and one from muscular action^
as in throwing a ball. Of the eight resulting from indirect blows, one
was from a fall upon the hand, seen by Desault, and seven were from
&IIs upon the elbow, of which two were seen by Desault, and five by
myself.
Pathology, — I have found the fragments sensibly displaced in twelve
ca^es out of seventeen ; a proportion much greater than has been ob-
served by Malgaigne, who has only seen a displacement twice in more
than twenty eases. It is certain, however, that complete or sensible
displacement is less common in this fracture than in most other frac-
tures, the broken ends being retained in place, probably, by the long
tendon of the biceps, and the long head of the triceps.
As to the direction of the displacement, I have generally found the
upper end of' the lower fragment drawn forwards and upwards toward
the coracoid process; in one of which examples the upper fragment
plainly followed in the same direction. Sir Astley Cooper declares that
with infants this direction is constant, and in museum specimens I have
seen but one exception. In the specimens of fracture of the surgical
neck, with also displacement of the head, belonging to Dr. Pope, this
direction of the fragments is plainly seen, as also in a specimen belong-
ing to Dr. Neill, or the Pennsylvania Medical College, where the lower
fragment almost reaches the coracoid process, and in a specimen con-
tained in one of the cabinets of the University of Pennsylvania, where
the upper end of the lower fragment has become united by bone to the
coracoid process.
The only exception which I have met with is in the possession of
Dr. Neill. In this example the two ends are tilted toward the axilla.
I am compelled, therefore, to doubt the accuracy of Malgaigne's obser-
vations, who thinks he has seen the lower fragment most often drawn
toward the axilla, as well as the observations of those who think that
the upper fragment is generally displaced outwards; yet, no doubt,
they do sometimes assume this position. Desault has seen them both
thrown backwards; while Dupuytren, Paletta, and others have seen
them pushed outwards; and I have in my cabinet the copy of a sj)eci-
inen in which both fragments are drawn outwards, but the lower frag-
ment is to the inner side of the upper.
When the fracture occurs at or near the epiphysis, it is «)metimes
accompanied with impaction, of the same character as we have already
described when speaking of fractures through the tubercles. Robert
Smith has given, in his treatise, an engraving intended to illustrate
the relative position of the fragments in extracapsular impacted frac-
tares, and the line of separation very nearly corresponds to the line of
janetioD of the epiphysis with the shaft.
But in a majority of cases no impaction occurs. Dr. Charles A.
Pope, of St. Louis, Mo., has two specimens of this kind, in which no
nnion has taken place, nor is there any evidence that impaction had
ever cK5curre«J. Jn one case the line of fracture commences at the junc-
tion of the head with the shaft, and extends thence irregularly across
to a point half an inch below the greater tuberosity. In the second
238 FRACTURES OF THE HUMERUS.
specimen the fracture commences at the same point, and terminates
three-quarters of an inch below the greater tuberosity. In relation to
these bones, Dr. Pope remarks : " These are not cases of detachment
of the epiphyses, as the bones are evidently those of adults, and there
is, at their lower extremities above the condyles, no trace of an epiphy-
seal line.''
Results. — Eight of the examples of fracture of the surgical neck
recorded by jne are known to have resulted in perfect limbs, and three
are more or less deformed. In one o( these no bony union has taken
place after the lapse of two years or more. It is satisfactory, however,
to know that, with the exception of this last (Case 3), all the patients
have recovered the free and complete use of -their arms.
Syny)tam8f or IMffereiUial Diagnosis of Accidents about the Shoulder^
joint, — No place could be more appropriate than this to call attention
tothedifiicalty of diagnosis in the case of accidents about the shoulder-
joint, a difficulty which surgeons have constantly recognized, and which
has sometimes rendered diagnosis impossible.
Let us first study the ordinary signs of a dislocation at the shoulder-
joint, regarding this as the type with which the other accidents are to
be compared.
a. Signs of a Dislocation. (Chuae, generally a fall u|)od the elbow or
hand, yet not very unfrequently a direct Wow.)
1. Preternatural immobility.
2. Absence of cre{>itus.
3. When the bone is brought to its place, it will usually remain
without the employment of force.
These three are commpn signs, which apply to any other joint as
well as to the slioulder.
4. Inability to place the hand upon the opposite shoulder, or to
have it placed there by an assistant, while at the same time the elbow
touches the breast. This is a sign common to all of the dislocations
of the shoulder.^
The following are special signs, or such as belong only to particular
dislocations of the shoulder.
& Depression under the acromion process; always greatest under-
neath the outer extremity, but more or less in front or behind, accord-
ing as the dislocation may be into the axilla, forwards or backwards.
6. Round, smooth head of the bone sometimes felt in its new situa-
tion, and very plainly removed from its socket ; moving with the shaft.
Absence of the head of the bone from the socket.
7. Elbow carried outwards, and in certain cases forwards or back-
wards, and not easily pressed to the side of the body.
8. Arm shortene<l in the dislocation forwards, and slightly length-
ened or its length not changed, when in the axilla.
b. Signs of a Fracture of the Neck of the Sc<ipula. (Oause^ generally
a direct blow ; exceedingly rare.)
* Report on a New Principle of Diagno^i^ in Di^locntiont of the Sboulder-joint,
bv L. A. Dug^at, Prof, of Surgery in the MudicMl College uf Georgia. Trans. Amer.
Med. Amoc.| vol. x, p. 175.
DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 239
1. Preternatural mobility.
2. Crepitus, generally detected by placing the finger on the coracoid
process, and the opposite hand upon the back of the scapula, while the
iiead of the humerus is pushed outwards and rotated.
3. When reduced, it will not remain in place.
4. The hand may generally, but with diflBculty, be placed upon the
opposite shoulder, with the elbow resting upon the front of the chest.
5. Depression under the acromion process, but not so marked as in
dislocation.
6. Head of the bone may be felt in the axilla, but less distinctly than
iu dislocation. Never much forwards or backwards. Head of the bone
moves with the shaft. Head of the bone not to be felt under the acro-
mion process, although it has not left its socket.
7. Elbow carried a little outwards, but not so much as in dislocation.
Easily brought against the side of the body,
8. Arm lengthened.
9. The coracoid process carried a little toward the sternum, and
downwards.
10. Pressing upon the coracoid process, it is found to be movable,
and it is also observed that it obeys the motions of the arm.
c. Signs of a Fracture of the Lower or Anterior Lip of the Glenoid
(hvity. Not yet fully determined.
d. Signs of Fracture of the Anatomical Neck of the Humerus. Intra-
capgular. (Cause, a direct blow; generally opening to the joint, but
not always.)
1. Mobility not increased, nor diminished.
2. Crepitus, generally discovered by pressing up the head of the
bone into its socket and rotating; or, when the tubercles are also
broken, by grasping the tubercles and rotating the arm.
3. Fragments not generally displaced.
4. The hand can be placet! easily upon the opposite shoulder, with
the elbow against the front of the chest.
5. Very slight, if any, depression under the acromion process.
6. Head of the bone generally in its socket, but not felt so distinctly
88 before the fracture.
7. Elbow fill Is easily against the side of the body, or is easily placed
there,
8. Arm not lengthened, nor appreciably shortened, unless the head
be driven so much into the body as to separate the tubercles.
9. In this latter case there are present also the signs of fracture of
the tubercles.
e. Signs of Fracture of the Humerus through the Tubercles, Extra-
capsular. {CkmsCy direct blows.)
1. Generally, there is neither marked mobility nor immobility,
except what immobility may be due to a contusion of the muscles.
2. Crepitus, discovered, but not so easily as in intracapsular frac-
tures, by rotating the arm while the tubercles are grasped firmly.
3. If displacement exists, the fr^ments are not always easily kept
in place when once reduced.
240 FRACTURES OP THE HUMERU8.
4. The hand can be placed upon the opposite shoulder, with the
elbow against the front of the chest.
5. No depression under the acromion process.
6. Head of the bone in its socket, and moving with the shaft, when,
as is usually the case, it is impacted.
7. Elbow hangs against the side of the body.
8. Arm shortened when impacted, but not much.
The signs which characterize this accident are more obscure than
in either of the other shoulder accidents. They are mostly nega-
tive, and will not generally be determined positively except in tha
autopsy.
f. Signs of a Longitudinal Frachire of the Head and Neck, or splitting
off of the Greater Tubercle. [Cause, direct blow upon the front of the
snoulder.)
1. Mobility of the limb natural.
2. Crepitus ; elicited especially by grasping the tubercles and rotat-
ing the arm, or by carrying it up and back and then rotating.
3. When reduced, the fragments will not remain in place.
4. The hand can be placed upon the opposite shoulder, while the
elbow rests against the front of the chest.
5. Some depression under the acromion process.
6. A smooth bony projection directly underneath the coracoid pro-
cess, or close upon its inner or outer side, moving with the shaft. The
head of the bone cannot be felt in the socket, yet the space under the
acromion is not entirely unoccupied.
7. Generally, but not always, the elbow hangs against the side.
Sometimes it inclines a little backwards. It can always be easily
brought to the side.
8. Arm generally neither lengthened nor shortened.
9. A remarkable increase in the antero-posterior diameter of the
up|>er end of the bone.
10. A dei»p vertiojil sulcus between the tubercles, corresponding with
the upper part of the bicipital groove.
g. Signs of a Fracture through the Surgical Neck, [Cause, generally
direct blows, but in old people frequently caused by a fall upon the
elbow.)
1. Preternatural mobility often, but not constantly, present.
2. Crepitus, produced easily when there is no im|)action, or when
the displacement is not complete, but with difficulty when impaction
exists or the displacement is complete.
3. When once the fragments have l)een disi)laced, it is exceetlingly
difficult ever afterward to maintain them in place.
4. The hand can be easily plactnl u|K)n the opposite shoulder, while
the ellK)w rests against the front of the chest.
♦ 5. A slight depression below the acromion, not immediately under-
neath its oxtn»mity, but an inch or more below.
6. Head of the l>one in the s(x»ket, and moving with the shaft when
impacted, but not moving with the shaft when not impacted. The
upper end of the lower fragment l>eing often felt distinctly preeeing
FRACTURES OP THE ANATOMICAL NECK. 241
upwards toward the coracoid process; its broken extremity being
easily distinguished by its irregularity from the head of the bone.
7. Elbow hanging against the side when the fragments are not dis-
placed, but away from the side when displacement exists.
8. Length of arm unchanged unless the fragments are impacted or
overlapped ; or both fragments are much tilted inwards. If the frag-
ments are completely displaced, the arm is shortened.
h. Sifffis of a Separation at the Epiphysis. {Causey direct blows.)
1. Preternatural immobility.
2. Feeble crepitus; less rough thdn the crepitus proiluced when
broken bones are rubbeil against each other.
3. Fragments replaced are not easily maintained in place, unless the
reduction has been effected by Moore's method.
4. Same as in preceding variety of fracture.
5. The depression is not immediately under the acromion, yet higher
than in most fractures of the surgical neck, perhaps one inch below
the acromion process.
*6. Head of the bone in its socket, and not moving with the shaft.
Upper end of lower fragment projecting in front, when displacement
exists, and feeling less sharp and angular than in case of a broken
bone; indeed, being slightly convex and rather smooth, it may easily
be mistaken for the head of the bone.
7. Same as preceding variety.
8. Length of arm not changed unless the fragments are overlapped,
or b<ith fragments are tilted upon each other. When the fragments
are overlapped, the arm is shortened.
9. This accident is peculiar to the young. It can seldom occur after
the twentieth year.
There are other accidents about the shoulder-joint, such as a patho-
logical partial luxation of the humerus, dislocation of the tendon of the
biceps, etc., which might possibly be confounded with fractures, but the
consideration of which I shall reserve for another time.
Treatment. — I have already spoken of the treatment of fractures of
the neck of the scapula, and my remarks will now be confined to frac-
tures of the upper end of the humerus.
Fractures of the Anatomical Neck; Intracapsular. — As has already
been stated, these are generally compound fractures, and, from the ex-
tent of the injur}', often demand resection, or amputation of the entire
arm. If an effort is made to save the arm, splints will not be applied,
and the treatment will have little or no reference to the existence of a
fracture; it will be directed only to the reduction or prevention of the
inflammation, etc.
Simple fracture of the anatomical neck, if not entirely within the
capsule, without any external wound communicating with the joint, and^
accompanied, as it is sometimes, with impaction, may unite, or the
npper fragment may become incased in the lower.
it is not proper in such cases to employ great violence for the purpose
of detecting crepitus, lest the fragments should become displaced; and
if the arm should be found to be a little shortened, it must not be ex-
242 FRACTURES OF THE HUMERUS.
tended, with a view to overcoming the shortening, since upon the im-
paction probably depend, in a great measure, the chances of union.
The elbow and forearm may be suspended in a sling, while the arm
is gently supported against the side, merely to insure quietude. No
splints are necessary or useful.
Treatment of Fractures through the Tubercles {Extracapsular) ; Norn*
impaxUed and Impacted, — In these cases, also, the fragments being sel-
dom displaced, very little if any mechanical treatment is demanded.
A sling is all that is usually required. If, however, on aocouut of dis-
placement of the fragment, a splint is thought necessary, it most be
applied in the manner hereafter to be directed in cases of fractures of
the surgical neck.
If impaction, with shortening, exists, the same remarks are applica-
ble here as in intracapsular impacted fractures, namely, that we ought
not to rotate the limb much, nor violently, in order to discover crepi-
tus, nor make extension with the view of overcoming the shortening,
since the fragments unite more promptly and certainly when the im-
paction remains, and its continuance in no way damages the usefulnfiSB
of the limb.
Treatment of Longitudinal Fracture of the Head and Necky or of a
Separation of the Greaier Tubercle. — In the only instance which I havo
recognized as a fracture of the greater tubercle, and already referred to,
the displacament was moderate, and could not he overcome either by
change of position or by pressure with extension. The patient was
therefore merely laid upon his back in bed. No dressings of any kind
were employed, and the fragments seemed to unite promptly, and with
no increase in the displacement.
If the displacement is originally more considerable, attempts ought
still to be made to reduce the fragments, by extension and abduction
of the arm, with dii^ect pressure; yet they will not generally prove
completely successful, nor will it be found easy to retain them wheo
reduced.
Mr. Mayo treated a fracture of this character, which occurred in a
man of sixty years of age, with a figure-of-8 bandage, and a sling, with
a lathe splint on the other side of the humerus, the upper part of whidi
was made to bear on the fragments, by uniting the upper part of the
circular arm roller to the figure-of-8 bandage. "The fracture united
favorably,'' he says, but we presume that he does not mean to affirm
that it united without any degree of <lisplacenient; a result which pn>b-
ably ought never to be expected. Mr. Mayo adds, however, tlmt '*for
a long time the patient had some difficulty iu carrying the arm back-
wards."*
Treatment of Fractures of the Surgical Necky including Separtitions ai
the Epiphysis. — We have already considered the value of Moore*8
method of reduction in cases of incomplete epiphyseal separations of
the upper end of the humerus; but the reduction having \iecn accom-
plished, I see no reason to suppose that the indications of treatment can
* B. Cooper'8 edition of Sir A. Cooper on Ditlocaiion8| eto., American edition, p.
S86.
TBEATMENT OP FRACTURES OF SURGICAL NECK. 243
essentially vary in separations at the epiphysis from those in true frac-
tores through any part of the surgical neck, since the relative action of
the muscles remains the same, and the direction of the displacement is
generally the same. My remarks, therefore, upon this point may be
considered as equally applicable to fractures and cpiphysary separa-
tions.
In a considerable proportion of these cases not much displacement of
cither fragment takes place, and consequently we have only to apply
such moderate retentive means as will insure quiet. Indeed, under
sQch cireumstances we might not hesitate to adopt the posture treat-
ment practiced by Dupuytren in two cases, both of which terminated
£ivorably. The treatment consisted in placing the arm, semi-flexed,
ona pillow, the pillow being arranged so as to form a pyramid, the
samniit of which was lodged in the axilla, while the elbow was secured
to the side of the body by a bandage.^
Unhappily, however, as we have seen, this condition is not always
present; the most frequent form of displacement being that in which
the lower fragment is drawn upwards and inwards, or toward the cora-
ooid process.
Id such cases it will require, often, no little perseverance and skill
to eflect reduction, if it is not found to be actually impossible, and still
more to retain the bones in place when once reduced. Indeed, it is
proper to say that a complete reduction is seldom accomplished and
permanently maintained, owing, probably, to the advantsigeous action
of the muscles which tend to prcxluce the displacement, and in part
also to the difficulty of applying any apparatus or dressing which shall
act efficiently upon the fragments.
Sir Astley Cooper recommends for this accident a couple of splints,
to be placed one in front of and one behind the shoulder, an axillary
pitd, a clavicular bandage, and a sling; the sling being made to sus-
pend only the wrist and not the elbow, since he had observed that
when the elbow was lifted the upper end of the shaft was inclined to
fiiU forwards.
Mr. Tyrrell informed Mr. Cooper that in a similar case he had found
the bone best maintained in its natural position by its l>eing raised and
supported at right angles with the side, by a rectangular splint, a part
of which rested against the side, while the arm reposeil upon the other
part; ancf until he had made use of this plan, he could not succeed in
removing the deformity, or in keeping the bone in its place.
The following is the plan which I have myself generally pre-
ferred:
Two splints are prepared, made of felt, gutta percha or leather. The
Utter is the most economical, generally most easily obtained, and an-
swers its purpose as well as either of the others. The leather to be
employed, should be sole leather, of medium thickness and hemlock
tanoMed. (See General Treatment of Fractures, Chapter V.)
1 Dapuytren on Bones, Sydenhnm edition, p. 99.
FRACTDBE8 OF THE HDHERITS.
The "long" splint must be long enough to extend from the tip <^
the acromion prooen
to a point jiist above
the external condyle.
The form of 'the
splint, before it k
moulded, is repra-
Bentcd in the accom-
panying woodoot,
Fig. 72. It is dwB
to be bevelled or
thinned along its edges by shaving
a thin ribbon from the margins <mi
the side wliich i» to be laid agaiiiat
the arm ; a few holes are to be
made with a brad-awl on the mar-
gins of the V-shaped section at
i^»,i«Mi..r.pii« j,,^ ^ ^^j iiaymg soaked
the splint in water, until it is ren-
dered slightly flexible, it is rolled
np from its two sides until it has the natural curve of the circumfer-
ence of the arm. If it is wet too much it will yield under the pressure
of the bandages, and this is not dcsiral>le. It ought to be straight, or
nearly so, iu lis longitudinal axis, except nt the top, where it embrsccd
the end uf the shoulder; and it shoilld be inflexible when applied, the
splint touching the arm firmly only over the head and tuberosities, and
along the lower portion of the humerus. The V-shnped section at the
top of the splint is then closed with strong linen, or shoemaker's thread;
and in order to give it a more regular curve, and to render it smooth,
it may be hammered.
Some of the splints which surgeons prepare, in imitation uf this gen-
eral plan, extend too fur upon the shoulder, and are liable to be dit-
tnrbi'<l in motions of the neck or of the arm. It is only necessary thMt
the splint should embrace the shoulder .sufficiently to prevent its slid-
ing down. The splint will now be eoniplele<l hy inclosing it in a lo<ise
flannel sack, stitched on the outside. If the arm is swollen and tender,
or the skin very ddieaie, a thin sheet of cotton wadding should be laid
between the cover and splint.
The "short" splint madoof h'ather, also— binder's board will answer
e<)ually well — oarefully trimmed, and c-overed with flannel cloth, must
have sufticient length to extend fnmi the free margin of the nxilln to
the internal condyle, taking Mire ihiit it shall not touch either. The
ptir|)oseof this splint is nut to sup|Mirt the fragments, for it is apparent
that it cannot extend so high, even, iis the point of fracture; but it is
solely to protect the delicate skin Iwneath the arm from the bandages,
which are apt to form «inls and cause excoriations. In this point of view
it is of great im|Mirtanee, and cnnuot projM-rly t>e omitted.
The splints Iveing laid upon the arm, and while extension and cnun-
tcr-exlciision arc mainlainetl by assistants, for the purpose of restoring
the fragments to position if |>ossihle, the surgeon will apply a roller.
TBEATMENT OP FRACTURES OF SURGICAL NECK. 245
inclosing the splints, from the elbow to the axillary margin. This
roller must be carefully stitched to the covers of both splints. A second
roller is then carried from the top of the long splint to the opposite
axilla, and by several successive turns the upper end of the splint and
tbe shoulder are completely covered in. This is also to he made fast to
the cover of the long splint, by stitches. Finally, a third roller is
made to idcIosc both the body and the lower portion of the arm ; and
tbe forearm is secured at a right angle with the arm by a sling, looped
ooder the forearm. It is important that the sling shall not embrace
the elbow, since it will, if thus applied, tend to displace the fragments
aod drive them past each other.
The bandage or roller hitherto applied by surgeons to the hand and
ibrearm, when dressing a broken humerus, is wholly unnecessary and
often a source of annoyance. The roller inclosing the arm and splints
will seldom give rise to serious congestion or swelling of the forearm
iiid hand unless it is applied too tightly; and when swelling does occur
it will be promptly relieved by a few hours' or days' confinement to
the horizontal position. The most serious objection, however, to the
roller applied to the hand and forearm, is not that it is unnecessary, but
that it is, in most cases, injurious. It is exceeding liable to become
disarniDged, especially if the patient is permitted to move the arm at
the elbow-joint; and in most cases it will be soon found, by its unequal
pressure, to cause those congestions and swellings which it was designed
Co prevent. Perhaps it will be sufficient for me to say that for many
years I have rejected this bandage altogether in all fractures of the hu-
merus, and that no harm has ever come of the practice.
It will be readily seen that the first roller performs the most impor-
tant function in this dressing. The long outer splint being firm and
unyielding, and being supported above by the projection of the head
of the humerus, the first roller draws the upper end of the lower frag-
ment outwards, and thus, as far as possible, accomplishes its readjust-
ment. The upper fragment is always beyond our control. The second
roller is not of much use, inasmuch as it soon becomes loose ; and in
any event it can only hold the top of the splint a little more firmly
against the head of the humenis. I occasionally omit it. The third
niller insures quietude to the arm, in the best position, namely, beside
the body.
When the patient is standing or sitting, the forearm needs to be sus-
pended in the sling; but when reclining, the forearm may, if the patient
chooses, be extended. If the entire dressing is well stitched it is not
much liable to disarrangement, and may be worn two or three weeks
at a time without removal; but from time to time, as the swelling sub-
sides or the muscles atrophy, the bandages may need to be tightened
by overstitehing, or by supplementary rollers.
I have been thus minute in my description of this dressing, because
its value depends upon the care with which the details are carried out;
and because, essentially, the same dressing is ased by me in all fractures
of the humerus occurring through its upper or middle thirds; more-
over, I do not wish to be held responsible, in any case, for bad results
^hen dressings are applied in an imperfect or slovenly manner.
246 FRACTURES OF THE HUMERCB.
If union taken place without overlappiDg, of course the arm is not
nmimed by the fracture ; but even when the union occurs with consid-
erable overlapping, the usefulness of the arm is seldom impairc<l.
i 6. Shaft, below the Surgical Reck and above the Base of the
Condyle!.
Cktueee. — In a record of 22 cases in which the cause of the iracturt
is stated, I find this portion of the shaft broken from direct violer
13 times ; from indirect blows, the concussion being received upon tlw
elbow. 4 times; once it was a consequence of tertiary hies, once it oo>
curred during birth, and three times in the same patient it lias bceo
broken from inuscular action alone, each consecutive fracture oocurniq
at a diETerent point. The records of sui^ry furnish many example o
fractnre of the shaft of the humerus from must^'ular action, as in thrown
ing a stone or snowball ; but the most singular examples are thoee ii
which the bone has been broken in a trial of strength between twi
persons, by grasping the hands palm to palm, with the elbows resting
upon a table, and twisting, when the humerus has suddenly given war
a little above the condyles. This practice ia called by the Frenm
" foumer poignet," the game of turning wrists. I have seen one c
of this kind, which was under the care of Dr. Winne, and MalgiugiM:
has collected five other similar cases, two of which wer« reiwrtetl li_
Lonsdale. In L' Union Midicale is reported an example in whicJi tbil
fracture occurred on a level with the insertion of the deltoid, a Httl«
below the insertion of the pcctoralis major and latissimus dorsi. Th»
fracture seemed to be nearly transverse.'
The example of fracture during birth, to which I have rcfonwl^
occurred in a heaUhy female child, whose parents wore also hi-fllthjr^
The mother was in labor six or eight hours, but the tuI>or was not
severe. She was attended by a midwife, and does not know whethi _
violence was employed or not. Dr. Lockwood, of Buffalo, waa called
on the third day, and found the arm broken a little below its niiddl^
and moving as freely as it did at the elbow-joint; be applied lateral
splints with bandages, etc. I saw the child with Dr. Ijockwood oi
the seventeenth day after its birth. There was then a |>erfcct femile o
cnshcathiug callus surrounding the fragments, and which, owing to ih
softness of'the flesh, could be easily detected and defined. The tn^
ments liad been tirm at least three or four days. Nearly a year after,)
I again examined the arm, and co\i\d not discover any traces of tbi
act^ident.
Dr. Lowenhardt has also reported a tiase in which the cvidi-ni'c mt
conclusive that the fracture was caused solely by the contrartions of Um
uterus, which forced the arm against the pubes ; the arm being hrord
distinctly to snap when it was passing this point and while thf lianA
of the accoucheur were not aiding in the delivery. In (his cow ihl
humerus was broken in its upper thinl.'
^p. IfiS.
I Amw. Mud Tim , ., _
• mwrnh*rdt, AnicriciiD Jnurnnl of the H«dica1 Sci*ncM, JanMry,IMl,B. •
from Medidn. Zeli., Mai S, 1840.
SHAFT BELOW THE SURGICAL NECK. 247
Dr. N. Fanning, of Catskill, N. Y., has reported to me the follow-
ing as having occurred in his own practice :
"Mrs. H., of Catskill, was delivered June 8, 1865, after a short and
not severe labor, of a full-grown and healthy male child. The mother
was well formed, with ample pelvis. The labor was natural, and the
presentation the most favorable, the occiput (jorresponding to the loft
soetabahim ; but immediately after the delivery of the head, a hand
tnd a portion of the forearm of the child were felt above the pubes.
The shoulders and body were delivered very quickly after the head,
ind during a single |>ain. Just as the right shoulder of the child was
pMing under the arch of the pubes, I heard a snap, not unlike that
CMsed by the breaking of a pipe-stem, which I soon found, as I sus-
pected, to be caused by the fracture of the right os humeri of the child
m its upper third." The bone united with some deformity.
Dr. Fanning is of the opinion that, in this case, the contraction of
the uterus, occurring while the arm of the child occupied some unusual
pontion, was the cause of the fracture. It was certainly not due to
«ny force applied by Dr. Fanning himself
Snrf and Direction of the Fradure, — The seat of the fracture is more
often below than above the middle of the bone; thus, I have found the
nicture fourteen times near the middle, and the same number of times
helt»w the middle third, but only seven times above the middle third.
The observations of Norris, who found four fractures of the shaft
ibove the middle, and nine below, correspond with my own ;* but M.
Gn^retin, in the same number of fractures, found nine above the mid-
dle and four below.*
The line of fracture is generally oblique, but more often transverse
than in fractures of the clavicle, femur, or tibia.
wplacemenL — ^The direction of the displacement depends, no doubt,
innetimes upon the precise point of the fracture and ujwn the action
rf the muscles operating upon the two fragments ; thus, if the fracture
^kes place just above the insertion of the deltoid, the lower fragment
B liable to be drawn upwards and outwards, in the direction of its
Ibres, while the upper fragment is carried toward the origin of the
pworalis major, etc. ; but, in a great majority of ea^^es, the influenc-e
of these muscles L« more than counterbalanced' by the direction of the
fcttc, and by the direction of the fracture. Practically, therefore, it is
«Uom of much importance to determine the exact point of fracture,
« to whether it is just above or below the insertion of a particular
■WHcle ; nor, indeed, is it generally very easy to ascertain this point
with much precision.
The amount of displacement varies considerably in different persons
■»d in fractures mt difR^rent point*, but it will average abr»ut three-
qoartera of an inch. When the fracture is produced by muscular
•rtioo alone, it is genermllr transverse, and displacement seldom oermrs.
Soch was the fiict in everr instance where my own patient brr^ke the
«ni three times conscmtively at different prants: and union was
* KoTTW, Am. Jr^src. ''f Jf-id .v.: . Jtr-fcrr, l^tJ, v:!. x:x. p. 2S.
248 FRACTURES OF THE HUMERUS.
speedily accomplished, and with no deformity. Dupuytren, however,
saw a case which constituted an exception to this general rule. The
fragments became completely separated, and were so movable thai
union could not be effected, and he was compelled, after three months,
to resort to resection.
Results. — In twenty-three examples, the average shortening is aboat
one-quarter of an incli ; but of these, thirteen are not shortened at all,
so that the average of shortening in the remaining ten is three-quarten
of an inch ; the amount of overlapping varying from one-quarter of
an inch to one inch and a quarter.
In forty-five examples, not including gunshot fractures, I have three
times seen the humerus refuse to unite by bone ; once when the fracture
was in the lower third of the shaft. This was an oblique, eompoand
fracture, and no union had taken place at the end of five months. The
man was intemperate, but in pretty good health.^ In the second case,
the fracture had occurred a little below the middle of the bone, and it
was simple. Five months after the accident this patient consulted me,
when I found the elbow anchylosed, the forearm being fixed at right
angles with the arm.' Neither of these patients had been under my
care previously, but I learned that an intelligent Canadian surgeon
had treated one of them, and the other had been seen and treated hj
several surgeons.
In the third case, a lad, five years of age, received a fracture aboat
three or four inches above the elbow-joint, by the passage across the
limb of a heavy army wagon. The arm was dressed with splints, and
in about five weeks several fragments of necrosed bone were removed
by Dr. Pope, of St. Louis, and the splints were again applied. Ten
months from the date of the injury. Dr. Brinton, of Philadelphia,
operated by i>erfi)ration, and reapplied splints. When the splints were
removed, the limb was straight and apparently firm, but the bond of
union gradually gave way, and when he came under my charge in No-
vember, 1864, more than two years after the accident, the arm was benl
at an angle of 45°, and the union was fibrous only. Under my advice
all restraint and dressings were removed, and he was sent into tbe
country to improve his general health, with the understanding that I
would o|>erate at some future day. Subsequently, on the 14th of April^
1867, 1 resected the bone at the seat of fracture, securing the fragments
with wire, and supporting the arm with a gutta percha splint. The
result was a perfect bony union, and a very useful arm.
In two other cases the elbow remained somewhat stiff a long time
after the splints were removed ; in one case complete freedom of motion
was not restored at the end of fifteen years.
Generally, however, the motions of the elbow-joint have been verjr
soon restored after the rt»moval of the splints and sling.
I ought to mention that, not unfrequently, fractures of the shaft of
the humerus, and especially where they are occasioned by direct blow8»
SLTv followed by great swelling, and sometimes by abscesses. In one
instance, the fracture having taken place within the insertion of the
> Report on Deformiliet, etc., Case 83. ' Ibid., Cam 21.
SHAFT BELOW THE SURGICAL NECK.
249
Fl(». 75.
Lonsdale's extension appa-
deltoid muscle, the sharp extremity of the lower fragment was made to
penetrate the fleshy causing an abscess, and finally tetanus^ of which my
pitient soon died.
The following remarks of Malgaigne are too pertinent to be omitted
ID this connection : "When there is great obliquity, with overlapping,
or a fracture with splintering, or a multiple frac-
tnre, a certain amount of deformity is inevitable,
and the formation of callus demands one or two
weeks more. With the inflammation comes also
the danger of suppuration, and later, a rigidity of
tlie articulations difficult to dissipate. In short,
we most not forget that of all fractures, those of
tbe humems are most liable to fail of consolida-
tion."
On the other hand, we shall find, in the case
of this bone, as in aJl others, some remarkable
exceptions, where, although the fracture may be
eompoand, and badly comminuted, yet the limb
has been saved and made useful.
TrettimenL — In the treatment of fractures of
that portion of the shaft of the humerus now
Dnder consideration, we shall do best to adopt
esKDtially the same plan which I have rec-
ommended for fractures of the surgical neck.
In proportion as the fracture occurs at a lower ratus-A. crutch, b. siiaa.
point of the humerus, however, will it be neces- ^' ^^"^ ^^^- ^- ^^^ ^^^
• . A J a1_ 1 T X J 1 • attachment of bandage, op-
saiy to extend the long splint downwards, in poito whkh i« a crossbar for
the direction of the elbow; so that, while in the same purpose.
fractures of the surgical neck and upper half of
the shaft it may not be necessary to extend the splint quite as low
■8 the external condyle, in the case of fractures in the lower half of
the shaft it will be necessary to include the condyles with the splints,
and sometimes it may be necessary to employ the gutta percha angular
3Jint, which will be recommended hereafter in fractures involving the
bow-joint. It is in these latter cases, also, that we shall find, sonie-
timeR, the plaster of Paris dressing, including the forearm, arm, and
shoulder, giving the most satisfactory results. Whenever the splints
iw made to touch or include the condyles, very great care must be
taken to protect them from pressure.
Other surgeons have sought to make permanent extension in these
ind certain other fractures of the humerus, by various contrivances.
Mr. Lonsdale constructed an instrument which might be lengthened
or shortened to suit the case ; it was made of steel, and was worked
with a screw operating upon cogs in a sliding bar; resembling, in some
vespects, the arm portion of Jarvis's adjuster. In the second London
edition of a series of plates illustrating the action of the muscles in
producing displacement in fractures, by S. W. Hind, is a drawing of
Ml apparatus invented by the author for the same purpose, which is
very gimple, and in some respects more complete than Lonsdale s, and
whidi may be easily adapts to almost any form of arm-splint. In-
17
I.
260
FRACTURES OF THE HUMERUS.
deed, nothing more is necessary than to attach to the ordina
splint a movable crutch.
Dr. Henry A. Martin, of Boston, has invented a splint, also
purpose of making extension in fractures of the humerus, the c
extension being made, by adhesive plasters, from the side of th<
A. Martin') txttnitnn Id ftiutui
The apparatus is elongated by u ratchet operating upon two ale
which are thus made to move uiMn ca<^h other.
In my opinion, and in the opinion of nearly all practical ai
who have written ujMJn this subject, it is ini[>osBiblG by these
other uimilar contrivances to make extension in fractures of I
mcrus. The axilla can never be made a proper point of supj:
permanent counter-extonsion ; and Dr. Martin's method, while it
the dangers of axillary pressure, cannot prove cflicicnt. The m
plasters must inevitably fail to retain their places when even i
erate amount of traction is continuously made upon them.
Dr. E. A. Clark, of the St. Louis City Hospital, has prop<
accomplish the extension, in frouturcs of the head and surgici
by suspending a weight from the elbow. He reports one case i
fully treated by this method. When the patient is in the reci
posture, the weight must he suspended over a pulley. No dou
IS the only method by which really eOectivo exteusiua oau f
SHAFT BELOW THE SURGICAL NECK. 251
made in fractures of the humerus ; and there may be, perhaps, ex-
amples of fractures of the neck of the humerus in which the fragments
overlap persistently, where it will be proper to resort to this novel ex-
pedient. When fractures occur above the deltoid, the overlapping is
often excessive, and there is not much danger of their being forcibly
separated by the extension ; but in fractures below this. Dr. Clark s
method would expose to the danger of separation and non-union of
the fragments. In the case of fractures of the neck, no splints are
nsed by Dr. Clark ; yet as a means of holding the lower fragment out,
a single ontside splint might be useful.
In reference to those forms of apparatus which are intended to press
upon the axillary margins, it ought to be stated here, since we have
omitted to speak of it in connection with fractures of the surgical neck,
tbat in all fractures of the upper half or third of the humerus, includ-
ing fractures of the surgical neck, they must prove not only useless,
but they must actually tend to defeat their own purpose. They are
intended to replace the fragments ; but by their pressure upon the pec-
toralis major and latissimus dorsi, which compose the free margins of
the axillary space, they must inevitably cause the separation of the
fragments.
Malgaigne, when speaking of the apparatus of Lonsdale, remarks :
" But the surgeon should never lose sight of the fact that permanent
extension is a resource always dangerous, often useless, and which
demands in its application much caution and watchfulness."
The following example will illustrate the practical difficulty of em-
ploying permanent extension in fractures of the humerus :
A laborer, aged thirty, was admitted into the Buffalo Hospital of
4e Sisters of Charity, on the second day of October, 1853, with a
^nple oblique fracture of the humerus, which had occurred three days
Irfore. The fracture was situated within the insertion of the deltoid,
•Bd, having been produced by the rolling of a log upon the arm, the
^hok limb was much swollen. The night following his admission,
'^ a fit of delirium tremens, he removed all of the dressings. When I
*^iled the wards in the morning, I found the fragments displaced and
fte muscles contracting violently. The ordinary dressings were applied,
^d continued until the fifth day, when, as the delirium had not ceased,
*^d the muscles continued to contract with great \^olence, it was de-
^'^tmined to attempt permanent extension. For this purpose we lifted
^ elbow upwards and outwards, to relax the deltoid, and then, having
"^Ude extension with the forearm placed at a right angle with the arm,
^ fitted carefiilly a large gutta-|>ercha splint to the forearm, arm,
^illa, and side, in such a manner that when the splint was secured to
^fcese several parts, the arm could not fall to the side of the body
^^'topletely, and in proportion as it did fall downwards, it would make
^^tttttion upon the arm. This splint was well padded, and secured in
place bjr rollers.
Od the sixth day the delirium had ceased, and never returned. The
^^casiiigs were well in place, and seemed to accomplish the indication
** ^ had in view ; but, on the seventh day, although he had kept very
'■ <l^, everything was disarranged, and the whole had to be readjusted.
I
252 FRACTURES OF THE HUMERUS.
On the eighth and ninth the same thing occurred. During this time
we had varicnl the dressings, position, etc., each day, to meet, if possible,
the difficulties; but it was at length deemed unwise to pursue the
attempt any farther, and we returned to the use of the ordinar}" splintSy
laying the arm against the side of the body. The union was finally
completed without either overlapping or angular displacement.
Something may always be accomplished, when the patient is walking
about, by allowing the elbow to escape from the sling, so that its weight
sliall make constant traction upon the lower fragment; and the plan
which I suggested some years since, of treating certain cases of delayed
union of the humerus, namely, extending the arm at full length by the
side of the body, so that the lower fragment shall receive the whok
weight of the forearm and hand, might occasionally prove valuable in
rec^ent fractures where the tendency to override was very great. In
three instances, I have already put this plan sufficiently to the test to
determine its safety and utility.
The precise plan, and my reasons for its adoption in certain cases of
delayed union, were set forth in the following paper, read before the
Buffalo City Medical Association, and published in the Buffalo Medical
Jouimal for August, 1854.
" I have observed that non-union results more frequently after frac-
tures of the shaft of the humerus, than after fractures of the shaft of
any other bone.
*' Comparing the humerus with the femur, between which, above all
others, the circumstances of form, situation, etc., are most nearly par-
allel, and in both of which non-union is said to Ixi relatively frequent,
I find that of forty-nine fractures of the humerus, four occurred through
the surgical neck, twelve through the condyles, and twenty-nine through
the shaft. In one of the twenty-nine the patient survived the accident
only a few days. In four of the remaining twenty-eight union had not
occurred after the lapse of six months, and in many more it was delayed
beyond the usual time. Two of the four were simple fi*actures, and
occurred near the middle of the humerus ; the third was cora|X)und|
and occurred near the middle also; the fourth was compound, and
occurred near the condyles.
"This analysis supplies us, therefore, with four cases of non-union,
from a table of twenty-eight casc»s of fractures through the shaft.
"Of eighty -seven fractures of the femur, twenty occurred through
the neck, one through the trochanter major, and one thntugh the con-
dyles. The remaining sixty-five occurred through the shaft, and gen-
erally near the middle, and not in one case was the union delayed U^*
yond six months.
"To make the comparison more complete, I must add that of the
twenty-eight fractures of the shaft of the humerus, six were com{K>und;
and of the sixty-five fractures of the shaft of the femur, six were either
com|)ound, comminuted, or l)oth compound and comminuted. The six
compound fractures of the shaft of the humerus furnished two cases of
non-union. The six cases of either compound or comminuted or com-
pound and comminuted fractures of the femur, furnished no case of
non-union.
SHAFT BELOW THE SURGICAL XECK. 253
"I b^ to suggest to the Society what seems to me to be the true ex-
planation of these facts.
"It is the universal practice, so far as I know, in dressing fractures
of the humerus, to place the forearm at a right angle with the arm.
Within a few days, and generally, I think, within a few hours, after
tbearm afid forearm are placed in this position, a rigidity of the mus-
cks and other structures has ensued, and to such a degree that if the
sph'nts and sling are completely removed, the elbow will remain flexed
aod firm ; nor will it be easy to straighten it. A temporary false an-
chylosis has occurred, and instead of motion at the elbow-joint, when
the forearm is attempted to be straightened upon the arm, there is only
motion at the seat of fracture. It will thus happen that every upward
and downward movement of the forearm will inflict motion upon the
fracture ; and inasmuch as the elbow has become t\\e pivot, the motion
at the upper end of the lower fragment will be the greater in propor-
tion to the distance of the fracture from the ellx)w-joint.
" Xo doubt it is intended that the dressings shall prevent all motion
of the forearm upon the arm ; but I fear that they cannot always be
made to do this. I believe it is never done when the dressing is made
without angular splints, nor is it by any means certain that it will be
accomplished when such splints are used. The weight of the forearm
is such, when placed at a right angle with the arm, and incumbered
with splints and bandages, that even when supjwrted by a sling, it
settles henvily forwards, and compels the arm-dressings to loosen them-
selves from the arm in front of the point of fracture, and to indent
themselves in the skin and flesh behind. By these means the upper
Old of the lower fragment is tilted forwards. If the forearm should
continue to drag upon the sling, nothing btit a permanent forward dis-
placement would probably result. The bones might unite, yet with a
deformity.
" But the weight of the forearm under these circumstances is not uni-
form, nor do I see how it can be made so. It is to the sling that we
most trust mainly to accomplish this important indication. But you
have all noticed that the tension or relaxation of the sling depends upon
the attitude of the body, whether standing or sitting ; upon the erec-
tion or inclination of the head; upon the motions of the shoulders;
and in no inconsiderable degree upon the actions of respiration. Nor
doe?* the patient himself cease to add to these (X)nditions by lifting the
forearm with his opposite hand whenever provoked to it by a sense of
&tigue.
"This difficulty of maintaining quiet apposition of the fragments
while the arm is in this position, at whatever point it may be broken,
hccomes more and more serious as we depart from the elbow-joint, and
wimld be at its maximum at the upper end of the humerus, were it not
that here a mass of muscles, investing and adhering to the bone, in
some measure obviates the difficulty. Its true maximum is, therefore,
Mar the middle, where there is less muscular investment, and where,
wi the one hand, the fracture is sufficiently remote from the pivot or
fulenim to have the motion of the upper end of the lower fragment
o&altjplied through a Jong arm, while on the other hand, it is sufficiently
254 FRACTURES OF THE HUMERUS.
near the armpit and shoulder to prevent the upper portion of the splint
and arm -dressings from obtaining a secure grasp upon the lower end of
the upper fragment.
" It must not be overlooked that the motion of which we speak be-
longs exclusively to the lower fragment^ and that it is always in the
same plane forwards and backwards, but especially that it is not a
motion upon the fracture as upon a pivot, but a motion of one fragment
to and from its fellow. This circumstance I regard as important to a
right appreciation of the difficulty. Motion alone, I am fully con-
vinced, does not so often prevent union as surgeons have generally be-
lieved. It is exceedingly rare to see a case of non-union of the clavicle.
Of forty-seven cases of fracture of the clavicle which have come under
my observation, and in by far the greater proportion of which consid-
erable overlapping and consequent deformity ensued, only one has re-
sulted in non-union, and in this instance no treatment whatever was
f>racticed, but from the time of the accident the patient continued to
abor in the fields, and hold the plough as if nothing had occurred. I
have, therefore, seen no case of non-union of the clavicle where a sur-
geon has treated the accident. Indeed, what is most pertinent and re-
markable, its union is more s{)eedy, usually, than that of any other
bone in the body of the same size. Yet to prevent motion of the frag-
ments in a case of fractured clavicle with complete separation and dis-
placement, except where the fracture is near one of the extremities of
the bone, I have always found wholly impracticable. Whatever band-
age or apparatus has been applied, I have still seen always that the
fragments would move freely upon each other at each act of inspiration
and expiration, and at almost every motion of the head, body, or upper
extremities. It is probable, gentlemen, that you have made the same
observation.
" From this and many similar facts I have been led to suspect, for a
long time, that motion has had less to do with non-union than was
generally believed.
" I find, however, no difficulty in reconciling this suspicion with my
doctrine in reference to the case in question ; and it is precisely because,
as I have already explained, the motion, in case of a fractured humerus,
dressed in the usual manner, is peculiar.
" In a fracture of the clavicle through its middle third (its usual
situation), the motion is upon the point of the fracture as upon a pivot;
although, therefore, the motion is almost incessant, it does not essen-
tially, if at all, disturb the adhesive process. The same is true in
nearly all other fractures. The fragments move only upon themselves,
and not to and from each other. I know of no complete exception
but in the case now under consideration.
" Aside from any speculation, the facts are easily verified by a per-
sonal examination of the patients during the first or second week of
treatment, or at any time before union has occurred, both in fractures
of the humerus and clavicle. The latter is always sufficiently exposed
to nermit you to see what occurs ; and as soon as the swelling nas a
little subsided in the former case, you will have no difficulty in feeling
the motion outside of the dressings, or, perhaps, in introducing the
SHAFT BELOW THE SURGICAL NECK. 255
finger under the dressings sufficiently far to reach the point of fracture.
I believe you will not fail to recognize the difference in the motion
between the two cases. Such, gentlemen, is the explanation which I
wish to offer for the relative frequency of this very serious accident —
DOD-anioQ of the humerus.
''I know of no other circumstance or condition in which this bone
IB peculiar, and which, therefore, might be invoked as an explanation.
Overlapping of the bones, the cause assigned by some writers, is not
laffident, since it is not peculiar. The same occurs much oflener, and
to a much greater extent, in fractures of the femur, and equally as
often in fractures of the clavicle, yet in neither case are these results so
frequent Nor can it be due to the action of the deltoid muscle, or of
lov other particular muscles about the arm, whether the fracture be
beiow or above their insertions, since similar muscles, with similar at-
tachments, on the femur and on the clavicle, tending always powerfully
to the separation of the fragments, occasion deformity, but they seldom
prevent union.
" If I am correct in my views, we shall be able sometimes to con-
summate union of a fractured humerus where it is delayed, by straight-
ening the forearm upon the arm, and confining them to this position.
A straight splint, extending from the top of the shoulder to the hand,
constructed from some firm material, and made fast with rollers, will
secure the requisite immobility to the fracture. The weight of the
ibrearro and hand will only tend to keep the fragments in place, and
if the splint and bandages are sufficiently tight, the motion occasioned
bv swinging the hand and forearm will be conveyed almost entirely to
the shoulder-joint. Very little motion, indeed, can in this posture be
oommunicated to the fragments, and what little is thus communicated
is a motion, as experience has elsewhere shown, not disturbing or per-
nicious, but a motion only upon the ends of the fragments, as upon a
pivot.
" I do not fail to notice that this position has serious objections, and
that it is liable to inconveniences which must always, probably, pre-
vent its being adopted as the usual plan of treatment for fractured arms.
It is more inconvenient to get up and lie down, or even to sit down,
in this position of the arm, and the hand is liable to swell. But I
shall not be surprised to learn that experience will prove these objec-
tions to have less weight than we are now disposed to give them.
Remember, the practice is yet untried — if I except the c^ase which I
im about to relate, and in which case, I am free to say, these objections
scarcely existed. The swelling of the hand was trivial, and only con-
tinued through the first fortnight, and the patient never spoke of the
inconvenience of getting up or sitting down, or even of lying down.
"The following is the case to which I have just referred : ' Michael
Mahar, laborer, set. 35, broke his left humerus just l)elow its middle,.
Dec 14, 1853. The arm was dressed by a surgeon in Canada West,,
and who is well known to me as exceedingly "clever." After a few
days from the time of the accident, " the starch bandage was put on as
tigbt as it could be borne, and brought down on the forearm, so as to
wnfinc the motions of the elbow-joint." Six weeks after the injury.
256 FRACTURES OP THE HUMERUS.
January 29, 1854, Mahar applied to rae at the hospital. No union had
occurred. The motion between the fragments was very free, so that
they passed each other with an audible click. There was little or no
swelling or soreness. In short, everything indicated that union waa
not likely to occur without operative interference. The elbow waa
completely anchylosed. I explained to my students what seemed to
me to be the cause of the delayed union, and declared to them that I
did not intend to attempt to establish adhesive action until I had
straightened the arm. They had just witnessed the failure of a pre-
cisely similar case, in which I had made the attempt to bring about
union without previously straif^htening the arm.
" * On the 6th of February, 1 854, we had succeeded in making the ann
nearly straight. I now punctured the upper end of the lower frag-
ment with a small steel instrument, and, as well as I was able, thrust
it between the fragments. Assisted by Dr. Board man, I then applied
a gutta percha splint from the top of the shoulder to the fingers, mould-
ing it carefully to the whole of the back and sides of the limb, and
securing it firmly with a paste roller. March 4th (not quite four weeks
after the application of the splint) we opened the dressings for the
second time, and carefully renewed them. A slight motion was yet
perceptible between the fragments. March 18th, we opened the dress-
ings for the third time, and found the union complete. This was within
less than forty days. The patient wa)5 now dismissed. On the 29th
of April following, the bone was refraetured. Mahar had been assist-
ing to load the "tender" to a locomotive. As the train was juj^t get-
ting in motion, he was hanging to the tender by his sound arm, while
another laborer seized upon his broken arm to keep himself upon the
car, and with a violent and sudden pull wrenched him from the tender
and reproduced the fracture. The next morning I applied the dress-
ings as before, and did not remove them during three weeks; at the
end of which time the union was again complete. The splint was,
however, reapplied, and has been continued to this time — a i>eriod of
about six weeks.'"'
Since the date of the above paper, I have four times had oppor-
tunities to test the value of this mode of treatment in cases of delayed
union of the humerus, and in each case with the same favorable result.
Meamircment — It may be well to indicate in this place by what
method we shall best insure an accurate measurement of the arm, or
forearm.
In either case, the point from which the measurement can be most
satisfactorily made above, is the posterior and inferior e<lge of the
acromion process, at the most salient point of this margin, about oppo-
site the scapulo-clavicular articulation. If the ami can be straightened,
the extremity of either of the fingers can be used as the lower fixed
point. If the arm cannot be straightened, we may use as the lower
point either condyle, or the point of the elbow. In order to get the
point of the elbow accurately, the hands should be clas|)ed in fWmt of
* BufTHlo Med. Jiurn., vul. z, pp. 14-147.
BASE OF THE CONDYLES. 267 *
tlie body ; and as the elbows are pressed back, a rule may be laid be-
Mth, aad the measurements made from the upper surface of the rule.
i 9. Bus of the Condyle!. Syn. Sapracondyloid Fracture of the
Ham erst.— Ualgaigne.
Qtuea. — Of 1 7 fractures at this point, 1 1 oecurral in children under
loi years of a^, the youngest being two years old,
la 11 taaes the fracture had been produced by a fall, and it is pre-
nined that the blow was received upon the elbow; in the remainiDg
ax cases the cause is nut staled. I believe, therefure, that this fracture
i> generally the result of an indirect blow, inflicted upon the extremity
of the elbow; in a few examples it has 'been pnMlnced by a blow
t«ei%'ed directly upon the point of fracture, as by the kick of a horse,
etc., but I have never, save in a single instance, been able to trace it to
B &11 upon the hand. Dr. Shearer, U. S. A., has reported a case also,
which seems to have occurred in the name manner.'
bue or lh« coadrlEg. (From nnT>)
IHrtelion of ihe Fraciitre, Displacement, and Symptorns. — I think
Uiis fracture is generally oblique, and its line of direction upwards and
btckwards; in nine of the eleven cases where this point was determined,
inch has been its apparent direction, and the lower fragment has been
feund drawn up behind the upper. Once I have found the lower
frvment in front, and once on the outside of the up|tcr.
Three of the 17 were compound comminuted fractures, this being
• larger proportion of serions complications than \a usually found in
WDnedioD with fractures of long bones.
I have never met with what I supposed to be a separation of the
b«w ejitphytia; but sui^ical writers have occasionally spoken of this
Ktdent, and the late Dr. Watson, of New York, Itelieved that he had
«eeo one example in an infant not quite two years old. The limb had
been violently wrenched by the mother, in attempting to lift her. She
I Journ. of Chemistry,
FltACTUBES OF THE HUUEBUS.
was not seen by Dr. Watson until the fourth day, at which time the
swelling was such that the diagnosis could not be easily made out ; hot
on the ninth day " it was apparent that the shall of the humerus had
been separated from its cartilaginous expansion at the condyles, near
the elbow," By the use of angular pasteboard splints the reduction
was maintained, and the fragments became united after about four or
six weeks.'
Dr. J. C Reeve, of Dayton, Ohio, has recently sent me a specimen
of epiphyseal separation, which occurred in his practice in the year
1864. Agirl, Kt. 10, fell a few
^o.n. Fio. w. fggj^ striking, probably, upon her
elbow. The fracture was com-
pound, and union not having oc-
curred at the end of three weeks,
the condition of the arm reudered
amputation necessary. In this
case a small fragment of the shaft
came away witfi the epiphysis.
Dps. Little, Voss, and Buck, of
this city, have each reported &
similar case.'
The diagnosis of a fracture *t
the base of the condyles is at-
tended with peculiar difficulties,
and it has occasionally been mis-
Dr. "'■"*'' fueof MP- taken for a dislocation of the
piirib"or the'humlrut.^ radius and ulnal>ackwards. Du-
puytrcnsays: " There is nothing
so common as to see a fracture of the lower end of the
humerus, immediately almve the elbow-joint, mistaken
for a dislocation backward ;" and he mentions three cases
lo^T^'phjiL. which have come under his own observation, I Lave
found an opposite error, however, by far the most fre-
quent, namely, a dislocutiou of both bones backwards has bceD sup-
poee<l to be a fracture.
The sources of this embarrassment are found in the proximity of
the fracture to the joint, in the rapidity with which swelliDg occurs^
and in the striking similarity of the symptoms which characterize tba
two accidents.
It will be necessary, therefore, to establish with care the differentia]
diagnosis. The following are the signs of fracture :
1 . Preternatural mobility, which, owing to the rapidity of the swell-
ing and the contraction of the muscles whose tendons are stretched over
the projecting ends of the bones, is often soon lost, being sucoeeded.
sometimes after a few hours, by a rigidity equal to that which is usually
present in dislocations, or even greater. It Is especially difficult to flex
„ Not.
BASE OF THE CONDYLES. 259
tlie ariDy owing to the pressure by the upper fragment into the bend of
the elbow.
2. Crepitus. This can usually be detected at any period if tjie arm
is sufficiently extended, so as to bring the broken surfaces again into
apposition.
3. When the extension is sufficient, reduction is easily effected, and
the natural length of the arm is restored; but the limb immediately
shortens when the extension is discontinued — esi)ecially if at the same
moment the elbow is bent. This is a very important means of diagnosis.
4. A careful measurement, made from the point of the internal
condyle to the acromion process, declares a positive shortening of the
hamenis.
5. By flexing and extending the forearm upon the arm, while the
fingers are placed upon the lower portion of the humerus, the project-
ing fragments can be felt. Generally, the upper fragment being in
front of the lower, and pressing down into the bend of the elbow, its
end cannot be so easily recognized; but the upper end of the lower
fragment can easily be made out, posteriorly, when the forearm is con-
siderably flexed. The lower ena of the upper fragment feels more
rough, and is less wide, than in dislocations.
6. The whole of the lower fragment is carried backwards, and with
it the radius and ulna, producing a striking prominence of the elbow
and olecranon process. Efforts to straighten the forearm upon the arm,
when no extension is used, increase rather than diminish this projection.
7. The forearm is slightly flexed upon the arm, the angle made at
the elbow being about 25 or 30 degrees.
8. The hand and forearm are pronated.
9. The relations of the olecranon process with the two condyles
remain unchanged.
In a case of epiphyseal separation, the lower end of the upper frag-
ment has greater br^dth than in the case of a fracture at the base of
the condyle, and the line of separation is nearer the end of the bone.
Signs of a Dislocation of the Radius and Ulna Backwards. — 1. Pre-
ternatural immobility. That is to say, extension and flexion are limited,
bat there is almost always present a prete^^natural lateral mobility.
2. Absence of crepitus. It is in this joint especially that surgeons
have been deceived by the chafing of the dislocated bones upon the in-
flamed joint surfaces, and have supposed that they discovered crepitus
when no fracture existed. The rapidity with which inflammation de-
velops itself after dislocations of the elbow-joint, and the consequent
ibandant effusion of lymph, afford the probable explanation of this
fircquent error.
3. When reduced, the bones are not generally disposed to become
again displaced, even though the elbow should be flexed.
4. The humerus is not shortened, but the olecranon process approaches
the acromion process.
5. There are no sharp projecting points of bone. The lower end of
the humems may not always be felt in the bend of the elbow ; but
when it is felt, it is found to be relatively smooth, broad, and round.
260 FRACTURES OF THE HUMERUS.
6. A remarkable prominence of the elbow and olecranon prooesBy
which prominence is sensibly diminished when an eiTort is made to
straighten the forearm on the arm.
7. Forearm flexed upon the arm to about the same degree as in frac-
ture.
8. Hand and forearm pronated, precisely as in fracture.
9. Relations of the olecranon process to the condyles changed very
greatly.
The most constant diagnostic signs are, then, in the case of a frac-
ture, crepitus, shortening of the humerus, projection of the sharp ends
of the fragments, and an increase of the projection of the elbow when
an attempt is made to straighten the arm ; and in the case of a dislo-
cation, the absence of crepitus, humerus not shortened, while the olec-
ranon approaches the acromion process; the smooth, round head of the
humerus lost, or indistinctly felt in the bend of the elbow, and the pro-
jection of the point of the elbow diminished when an attempt is made
to straighten the forearm on the arm.
It is proper, also, to repeat here what we have already said in rela-
tion to the causes of this fracture. A fracture at this point is produced
almost always by a fall upon the elbow, but a dislocation of the radius
and ulna backwards can never be. On the other hand, a dishication is
[produced, in most cases, by a fall upon the palm of the hand, while I
lave never known but one fracture above the condyles to be thus pro-
duced.
BesulOi, — Nine times have I found the arm shortened from half an
inch to one inch, or a little more.
Muscular anchylosis is almost always present when the apparatus is
first removed, and it is seldom completely dissipated until after several
months ; but I have found more or less anchvlosis at seven and nine
months; and twice after the lapse of three years the motions of the joint
have been very limited. A few years since, I examined the arm of a
gentleman who was then twenty -seven years old, and who informed me
that when he was four years old he broke the humerus just alx>ve the
condyles. There still remained a sensible deformity at the point of
fracture — he cx)uld not com|)letely supine the forearm. Thp whole arm
was weak, and the ulnar nerve remarkably sensitive. The ulnar sitle
of the forearm, and also the ring and little fingers, were numb, and have
l)een in this condition ever since the accident. I know the surgeon
very well who had charge of this case, and I have no doubt that tlie
treatment was carefully and skilfully applieil.
In June of 18o0, I ojXTated u|)on a lad, nine years old, by sawing
off the projecting end of the up|MT fragment, whose arm had been
broken nine months before. This fragment was lying in front of tlie
lower, and the skin covering its sharp |>oint was very thin and tender.
There was no anchylosis at the elbow-joint, but the hand was flexed
forcibly uiK)n the wrist, the first phalanges of all the fingers extended,
and the se(X)nd and third flexed. Supination and pnmation of the fore-
arm were lost. The forearm and hand were almost completely imra*
lyzeil, but very painful at times. The ulnar nerve could ne felt lying
acro88 the end of tiie bone.
BASE OF THE CONDYLES. 261
Jo the hope that some favorable change might result to the hand by
reJieving the pressure upon the nerve, yet with not much expectation
of success, I exposed the bone and removed the projecting fragment.
The nerve had to be lifted and laid aside. About one year from this
time I found the arm in the same condition as before the operation.
Xon-union is a result not so frequent in fractures at this point as
Ugber up; but Stephen Smith, of the Bellevue Hospital, New York,
reports a case of non-union in a young man of twenty-three years. He
was admitted to the hospital on the seventh day after the accident.
The fracture was simple and transverse, yet at the end of four months
ke was dismissed "with perfectly free motion at the point of fracture."*
The failure to unite was attributed to a syphilitic taint.
A case was tried a few years since in the Supreme Court at Brook-
lyn, N.Y., in which, after a simple fracture at this point, the arm
being dressed with splints and bandages, the little finger sloughed off
in a condition of dry gangrene, and the adjacent parts of the hand
were attacked with moist gangrene. Drs. Parker and Prince believed
that this serious accident was the result of bandages applie<l too tightly
and suffered to remain too long, while Drs. Valentine Mott, Rogers,
Wood, Ay res, Dixon, and others, believed the gangrene might have
been due to other causes over which the surgeon had no control.^
A few years ago, a similar case occurred in the town of Spencer,
Tioga Co., N. Y. ; a boy, six years old, having broken his humerus
jnst above the condyles. The fracture was oblique. The surgeon
who was called to treat the case was an old and highly respectable
practitioner. I am not informed of the plan of treatment any farther
than that a roller was applied. On the eighth day, a second surgeon
was employed, who, finding the hand cold and insensible, removed all
of the dressings; after which the thumb and forefinger sloughed, with
other portions of the skin and flesh of the hand and arm. The sur-
geon who was first in attendance was prosecuted, and the case was
tried in the Supreme Court of that county, but the jury found no cause
of action. Dr. Hawley, of Ithaca, and the late Dr. Webster, of Geneva
Medical College, testified that, in their opinion, the death of the fingers
was owing to the pressure of the fragment upon the brachial artery,
and not to the tightness of the bandages.
Dr. Gross has also informed us of still another case of the same
character, which occurred in Warren Co., Ky. A boy, ten years old,
had broken his arm above the condyles, and his parents having em-
ployed a surgeon residing at some distance, the dressings were applied,
and directions given to send for the surgeon whenever it became neces-
aary. The parents saw the arm swell excessively, and knew that the
bny was sufiering very much, but did not notify the surgeon until the
tenth day, when the hand was found to be in a condition of mortifica-
tioD, and at length amputation became necessary.
Long afterward, in the year 1851, when the boy became of age, he
' Smith, New York Journal of Medicine, May, 1S57, p. 3S6, third series, vol. 11.
' Kew York Medical Gazette, vol. xii, pp. 46, 80, 111.
262
FRACTURES OF THE HUMERUS.
prosecuted his snrgeon, but with no result to either party beyond
payment of their respective costs.
While I would not deny that in all of these cases the sloagi
might have been solely due to the tightness of the bandages, aga
which cruel and mischievous practice we cannot too loudly declaii
knowledge of the anatomy of these parts, and the opinions of the '
distinguished gentlemen who testified in defence of these surg€
must compel us to admit the possibility of such accidents wliere
treatment has been skilful and faultless.
Treatment. — The splints generally employed in this country, in 1
tures about the elbow-joint, are simple angular side splints, will
Fio. 81.
Fio. 82.
Welch's tpHnt. The hinget mftj he tnamXm
8|>llota of difl^rent liaes.
joints, such as those recommended by Physick:^ angular pasteb
splints, felt, leather, gutta percha, etc., or angular splints with a hi
such as Kirkbridc's,' Thomas Hewson's, Day's, Rose's, Welch^i
Bond's.
Kirkbride's splint, which has been used in the Pennsylvanim 1
pital in several mstances, is composed of two pieces of board, coniM
together by a circular joint, and having eyes on the inner edge,
inches apart, and holes through the splint at graduated distanoa
tween them. There is also a swivel eye, passing through the a
part of the splint, and riveted below. A wire is fisistened to the aw
and bent at right angles at its other extremity, of a sice to fit the
and holes in the splint. This splint, properly supported by pads,
> ElemenU of Surgery, bv John Syng I>ortey, PhiladelphU edition, toI. 1. p
* American Journal of the Medical Sciences, vol. xvi, p. 816.
he placed either upon the outside or inside of the arm, and secured by
rollers. When the angle is to be changed, the wire is unhooked and
removed to another eye, or to some of the intermediate holes U[>on the
side of the splint. Dr. Kirkbride reports two cases of fracture of tlie
lower part of the humerus treated by this plan, one of which resulted
in auehylosis, but the other was much more successful.
H. Boud, of Philadelphia, has contrived a very ingenious splint for
the elbow-joint, and which is designed also to afford a complete support
to the forearm.
For myself, I generally prefer gutta percha, nionided aud applied
tnrately to the limb. It should be extended beyond the elbow to
' lie wrist, so as to support the whole length of the arm, elbow, and
fiifwin. Some experience in the use of wooden angular splints has
wivinced me that they cannot be very well fitted to the many iuequal-
iliaof the limb; and neither pasteboard nor binder's board has sufG-
oai firmness, especially in that portion which covers the joint. Angu-
™ splints, furnished with a movable joint, possess the advantage of
«ahling na to change the angle of the limb at pleasure, and of keeping
"pMme degree of motion in the articulation without disturbing the
fneian or removing the dressings; but the crossbars of Day's and
»^'e iplints render them complicated, and are in the way of a nice
»P]iliiation of the rollers; while they are all equally liable to the ob-
i^on stated against angular wooden splints without joints, viz., that
"■^ «el<|um can be made to fit aecurately the many irregularities of
tliearni, elbow, and forearm. In applying the author's splint, care
""St be taken that the humeral portion is not too short, or the result
^ill be an unnecessary degree of overlapping of the fn^ments. This
""y generally lie avoided if the surgeon will first shape his material
^themutid urra, while the whole length is underlaid with three or
, nw lliicknesses of woollen cloth. Welch's splints, made of a material
«ing a slight amount of flexibility, approach more nearly the ac-
L •Wnplishment of all the indications thau any other manufactured splint
PBACTUnBS OF THE HUMEBDB.
w!th which I am acquainted, but the niiraber of cases in p
which they are applicable will be found to be limited, while gut
has no limit in its appli
F*^ «*■ Whatever material ise
the splint should be f
with one thickness of
cloth, or some pro[>er B
A pretty large pledgt
cotton batting ought a
laid in front of the ell
to prevent the roller fn
iating the delicate and
skin; and great care e
taken to protect the I
nences al>out the joint, <
to relieve them from pr
increasing the thickoe
pads above and below t
nences.
At a very early day,
indeed, as the seventh
day, the splint should be
and, while the fraen
steadied, gentle, pasaiv
should be inflicted upon
This practice shoula be
as often as every second or third day, in order to prevent,
pw^iiiblc, anchyloeis. If much swelling follows the injury,
custom to open the dressings, withont removing the splitlt
second or third duy after the accident, or at any time when 1
toms admonish of its necessity. Occasionally it is well to cl
angle of the splint before reapplying it. If the angular spli
movable joint is used, slight changes may be made while tW
on the arm ; but if the angle is much changed without remi
rollers, they become unequally tightened over the arm, aD<
mischief.
When anchylosis has actually taken place, we may mot
overcome the contraction of the muscles and of the ligaments
passive motion, or by directing the patient to swing a dun
some other heavy weight, as first recommended by Hildanui
must boar in mind the danger of causing a refracture by toi
immoderate force.
n* authoi'i elbow (pUnt.
t 7. Fraotan at the Bate of the Condyle), eompUoated with 1
btttwssn the Condylaa, axtending into the Jcdot
This fracture, which is but a variety or complication of tl
tng, is even more difficult of diagnosis ; and its signs, ret
proper treatment differ sufficiently to demand a separate cone
Li have recx^nized the accident eix times. CoDfined to no period
_|tlife> it seems to be the result of a severe blow iuflicted directly
npoii the lower and back part of the Immeriis,
or upon the olecranon process. Dr. Parker, of Fm, m.
New York, was inclined to regard an obscure
accident about the elbow-joint, which ho &iw in
a lad sixteen years old, as a longitudinal fmc-
turc of the humerus, with separation of one
condyle, hut which had been occasioned by a
foil ii]K>n the band.' For myself, I should re-
ganl this latter circumstance as presumplive
evidence that it wa^ not a fracture of thit< char-
■, yet I do not mean to deny the possibility
its occurrence in this way.
Its characteristic symptoms are, increases^
1th of the lower end of the humerus, oc-
led by a separation of the condyles; dis-
ment upwards and bnckwanis of the radius
ulna; shortening of the humerus; crepitus and mobility at the
of the condyles, with crepitus also between the condyles, developed
)>re«sing them together; or in case the radius and ulna are drawn
i>iid back, the crepitus may be detected, after restoring these bones
plaw, by prewing upon the opposite condyles.
Its coosequencea are, generally great inflammation about the joint,
laneut deformity and bony anchylosis. An opposite result must
rt^uded as fortunate, and an an exception to the rule.
Of the treatment we can only say that it must be chiefly directed to
lire prevention and reduction of'innaniuiation ; at least during the first
fcw days. Nor is this inconsistent with an early reduction of the
fragments, and nitKlcrate etibrts, by splints and bandages, such as we
^it directed in case of a simple fracture at the base of the condyles,
•"kcpj) the fragment-* in place. No surgeon would lie justified in re-
fnsiiig altogether to make suitable attempts to accomplish these im|)or-
••WtmlicationH; but he must always r^ard them as secondary when
""ntarcd with the importance of w>ntroliing the inflammation.
Whfn splints arc employed, the same rules will be applicable, both
M to their form and mode of application, as in cases of t^imple fracture
•'"ive tlic condyles. Plaster of Paris, or some of the immovable forms
"f ilrHsing, furnished with ample fenestrte, will sometimes be preferred.
The fallowing examples will more <«mpletely illustrate the character
mm, and proper treatment of these cases than any remarks or rules,
■hicb we can at present make.
A WDRian, a!t> 44, fell ujion the sidewalk in January, 1850, striking
'("m her right elbow, I saw her a few minutes after the accident, but
•* purts alxrut the joint were already considerably swollen, and it was
■w' without difficulty that the diiignoais was made ont. The forearm
J^digbtly flexed ujmn the arm, and pronated. On seizing the elbow
""ily, a distinct motion was perceived above the condyles, and a
' Mtr, Ke* Turk Journnl of Medidne, Nov. 1856, p. 391, Sd si
J, vol. i.
266 FRACTURES OF THE HUMERUS.
crepitus. I could also feel, indistintly, the point of the upper frag-
ment. While moderate extension was made upon the arm, the con-
dyles were pressed together, when it was apparent that they had been
se[)arated. On removing the extension, they again separated, and the
ole<Tanon drew up. She was in a condition of extreme exhaustion,
and the bones were easily placed in }>osition.
An angular splint was secured to the limb, and every care used to
support the fragments completely, but gently.
From this date until the conclusion of the treatment the dressings
were removed often, and the elbow moved as much as it was possible
to move it.
Seven months after the accident, the elbow was almost completely
an(»hylosed at a right angle. The fingers and wrist also, were quite
rigid. Six years later, the anchylosis had nearly disappeared ; she
could now flex and extend the arm almost as much as the other; the
wrist-joint was free, and the fingers could be flexed, but not sufticiently
to touch the palm of the hand. The line of fracture through the base
could 1h^ traced easily, but the humerus wjis not shortene<l. There
was, moreover, much tenderness over the point of fracture through the
base, and at other points. Occiisionally, a slight grating was noticed
in the nidio-humeral articulation. She experienced fretjuent ftainsin
the arm, and especially along the l)ack and radial border of the ring
finger. During the first year or two after the accident, the arm per
ishcil very much, but although the hand remained weak, the musclei
were now well devclopcnl.
A gentleman was struck with the tongue of a carriage with whid
a couple of horses were runninjr. The blow was rect»ived directly upoi
the back of the left elbow. Dr. Sprague and myself n»movetl s^mui
small fragments of bone, and while o}M?ning the wound for this par
pose, we could see distinctly the line of fracture extending into th
joint as well as a<Toss the lM)ne. The condyles were not sc*}isinUed.
The sulx**efjuent trwitment consisted only in the use of such nwmn
as would l)est support the lind), and most succx'ssfully comliat inflam
mation. The arm and forearm wen» laid u}M)n a broad and well
cushiontHl angular splint, covered with oil-cloth, to which they wei^
fastcn<»d bv a few lisxht turns of a roller.
Twelve years after, I found the humerus shortened one inch and i
half During the first yrar, he sjiys, then* was n4) motion in the elliow
joint, l)ut he can now flex and extend the fort^arm through about -15®
when flexed to a right angle, it s(»ems to strike a solid body like bom
R4)tati<m of the f()r4^irm is completely lost, the hand Iwing in a pan
tion midway lx»twwMi supination an4l pronation. lie suffers no imin
and his arm is quite stn)ng and useful. No nutans have Ix'en employei
to ri»store the functions of the limb but passive motion at fin*t, am
8ul)se<|uently (»onstnnt, active use of the hand and arm.
The late Dr. Thomas S|H»ncer, of (Jeneva, used to relate a case ii
M'hich a surgeon was calleil to what he suppose<l to be a fracture of tb
lower end of the humerus, and which he treated accordingly, witl
«plii}t*», etc. On the second or third day, another surgeon was called
FRACTURE AT THE BASE OF THE CONDYLES. 267
who removed the splints and bandages, and pronounced it a dislocation
of the radius and ulna backwards ; but he was unable to reduce it.
After some time, the first surgeon was prosecuted for having treated
as a fracture what proved to be a dislocation. Dr. Spencer, who had
examined the arm carefully, gave his testimony last, and at a time
when, from the evidence, it seemed almost certain that the surgeon
must be mulcted in heavy damages; but he declared his belief that
both surgeons were right, since, on measuring the breadth of the
humerus through its two condyles, he found that the humerus of the
iDJured arm was three-quarters of an inch wider than the opposite.
His conclusion, therefore, was that the condyles had been split asunder
and were now separated ; that the first surgeon proj)erly reduced this
fracture, but that when, on the second or third day, the second surgeon
removed the splints and the dressings, a contraction of the muscles had
taken place and the dislocation occurred, the bones of the forearm being
drawn up between the fragments. Dr. Spencer believed this was an
example of the variety of fractures now under consideration, but it is
not quite certain that there was anything more than an oblique fracture
extending into the joint, followed by a dislocation. In either case, the
first surgeon was entitled to an acquittal, and so the jury promptly
declared by their verdict.
In a case of comjwund comminuted fracture of the character now
ooder consideration, Dr. Stone, of the Bellevue Hospital, New York,
removed the condyles and sawed off the sharp end of the humerus.
The woman was twenty-six years old and intemperate. The operation
was made as a substitute for amputation. No serious complications
followeil. On the ninety-sixth day the wounds were completely healed,
and she could bend the forearm to a right angle with the arm, the
action of the muscles having drawn up the radius and ulna against
the lower end of the shaft of the humerus, so that the motions were
natural and free.^ The practice, as the result sufficiently shows, was
wniaently judicious; and its practicability ought always to be well
WDsidered before resorting to the serious mutilation of amputation.
The great principle upon which the success of resection is here based
K the fthortening of the bone, whereby the reduction may be accom-
plished without painful tension to the muscles ; a principle which will
demand of us hereafter a more careful consideration and a wider appli-
cation.
Fractures of the Condyles.
Chaiissier describeil that portion of the lower end of the humerus
^kieh articulates with the ulna as the trochlea, and that portion which
Articulates with the radius as the condyle ; naming the two lateral
P^^ectious, respectively, epi trochlea aud epicondyle. Some of the
French writers have adopted this nomenclature, but I prefer, as being
""■^orc familiar to my own countrymen, the terms external and internal
^ndyle, to which it will be convenient to add the terms external epi-
^odyle and internal epicondyle, as indicating the extreme lateral pro-
* Stone, New York Journ. of Med., May, 1851, p. 802, vol. vi, 2d series.
268 FBACTUBES OF THE HUMERUS.
jections, which are formed from separate points of ossification, and
which do not become united to the condyles hy bone until about the
sixteenth or eighteenth year of life.
When, tlierefore, we speak of a fracture of the epicondyle, we rcf«
only to a separation of the epiphysis, such as it is in early life; or to
its true fracture, when, at a later period, it has become united by bcHie.
1 8. Fractnrei of the Internal Epicondyle. (Epitrochlea, ChanBiier.)
Thia is the fracture which Granger first described in the Edinhur^
Medical and Surgical Journal,^ and which he ascribed solely to niuscti-
lar action. "A distinguishing circumstance attending this fracture is
that of its being occasioned by sudden and vio-
lent mnsrularexcrtion; and it will I>e rccol Iccted
that from the inner condyle those powerful mus-
cles which constitute the hulk of the flci<hy sub-
stance of the ulnar aspect of the forearm have
their principal origin. The way in which the
muscles of the inner comlyle are involuntarilr
thrown into such sudden and es<'es8ive action I
take to \k this: the endeavor to prevent a fall
by stretching out the arm, and thus receiving
jpy JUl^^^^ '''^ jiercusston from the weight of the bo<iy on
WfliJStmm^^^ '''^ hand."*
Au/JA^Qajj^H It is a fact, perhaps of some significance ia
^■^^^^^^^W this c<mnection, that most of these frarturei nrciir
in children, before the union of the e|>iphysiii »
Fracw™ oMntcrpii completed, when muscular oontractiun mi^t
rpi«>iid;i«. more often prove adet^iinte to its sejuiration, and
when the epicondyle ia less prominent, and,
therefore, less exposed to direct blows than in adult life ; thus, of fiw
fractures which 1 have distinctly recognize*! as fnictures of the epicon-
dyle,all, except one,occurred Itetween the agt^of twoand fifteen yenn.
But then it is equally true that a large muiority of all the frnctures of
the internal condyle, including those which enter the articulation, u
well as those which do not, belong to chihlhtvNl and youth. I hax**
seen but two exceptions in fifteen ca«es. Since, then, direct blows
generally prtxluce those fractures which penetrate the joint, no good
reason can be shown why they should not prtKlucc fnicturts of the
epictmilyle. One of the exee|>tions to which I have referred as not
having occurred in early life, is sutliciently rare to entitle it to especial
notice.
On the 16th of May, 1856, a laborer, thirty-four years of age, fell
from an awning uiK)n the si<lewalk, di^loenting the radiu.i and ulna
backwards; the dislm-jition was immctltatcly reduced by a woman who
FRACTURES OF THE INTERNAL EPICONDYLE. 269
came to his assistance, but when he called on me soon after, I found a
small fragment of the inner condyle, probably the epicondyle alone,
broken off and quite movable under the finger. It was slightly dis-
placed in the direction of the hand.
I could not learn positively whether in falling he struck the elbow
or the hand, but there was presumptive evidence that he struck the
hand; if so, then probably the fracture was the result of muscular
action, which is the more extraordinary as having taken place in a
man of his age.
It is pretty certain, however, that the theory of causation adopted by
Granger is too exclusive. A lad was brought to me in October, 1848,
aged eleven, who had just fallen upon his elbow, the blow having been
received, as he affirmed, and as the ecchvmosis showed pretty conclu-
sively, directly upon the inner condyle. The fragment was quite loose,
and crepitus was distinct. He could flex and extend the arm, and ro-
tate the forearm, without pain or inconvenience. I am quite sure the
fracture did not extend into the joint; the result seemed also to confirm
this opinion, for in three months from the time of the accident the
motions of the elbow-joint were almost completely restored.
Indeed, Mr. granger has failed to establish, by any particular proofs,
that in more than one or two of his cases the fracture was the result of
muscular action ; but, on the contrary, I am disposed to infer, from the
violent inflammation which generally ensued in his cases, from the fre-
quency of ecchymosis, and especially from the injury done to the ulnar
nerve in at least three instances, that most of them were produced by
direct blow« inflicted from below in the fall upon the ground. Frac-
tures produced by muscular action are seldom accompanied with much
infiammation or effiision of blood, and it is much more probable that
the ulnar nerve should have been maimed by the direct blow which
caused the fracture, than by the displacement of the epiphysis, which
is, as we shall presently show, almost always carried downwards, and
^rfUner slightly forwards than backwards. It is only when the frag-
Bwnt is forced directly backwards that the ulnar nerve could be made
to suffer; a direction which, it does not seem to me, it could ever take
^m muscular action alone.
IHrection of Di^lacement, SymptomSy etc. — I have seen this fragment
^lisplaced in the direction of the hand, or downwards, very manifestly,
^^, and in two other examples a careful measurement showed a
flight displacement in the same direction. The greatest displacement
^iccurred in a boy fifteen years old, who was brought to me from St.
Catharine, Canada West. He had fallen upon his arm is wrestling,
*nd his surgeon found a dislocation of the bones of the elbow-joint,
^hich he immediately reduced. The fracture was not at that time de-
^«cted, the arm being greatly sw^ollen. No splints were applied. It
^as three months after the accident when I saw him, at which time I
^ttud the internal epicondyle broken off and removed downwards
^^rdthe hand one inch and a quarter; and at this point it had be-
I come immovably fixed. Partial anchylosis existed at the elbow-joint,
I out pronation and supination were perfect.
270 FRACTURES OF THE HUMERUS.
Hues upwards aud two backwards toward the olecranon; in each of the
other examples the fragment has not seemed to suffer any sensible dis-
placement.
Granp:er found, also, in the five examples which came under his
notice, the epicondyle carried toward the hand, with more or leas vari-
ation in its lateral |)osition, so that while in some instances it touched
the olecranon, in others it was removed an inch or more in the oppo-
site direction.
It is probable that, except where controlled by the force and direc-
tion of the blow, or by some complications in the accident, the frag- \
ment, if displaced at all, always moves downwards toward the hand,
or downwards and a little forwards, in the direction of the action of the
principal muscles which arise from this epiphysis; and w^hen the frac-
ture or separation is the result of muscular action alone, this form of
displacement seems to me to be inevitable. In addition to the mobility,
crepitus, and generally slight displacement of the fragment, which are
the principal signs of this fracture, it may be noticed that there is usu-
ally some embarrassment in the motions of the elbow-joint, which may
be due in part to the swelling, and in part to the detachment of the
point of bone from and around which most of the pronsytors and flexors
of the forearm have their rise. In one instamx}, already quoted, that
of the lad aged eleven years, who broke the epicondyle from u direct
blow, the motions of pronation, with flexion, were not at all impaired,
neither immediately nor at any subsequent |)eriod, but the fragment
was never sensibly, or only very slightly, displace<l.
Granger has recorded another class of symptoms, to which I liave
already alkuled, his explanation of which, however, I am not pre(iared
to admit. One of these cases he describes as follows: A boy, eight
years old, fell with violence, and broke off completely the whole of the
inner epicomlyle of the right humerus. The lad said he had fallen oa
his hand. The fragment was displaced toward the hand. Severe in-
flammation followed, but he recovered the free and entire use of the
elbow-joint in less than three months after the accident. No spliuta or
bandages were ever emj)loyi»d.
From the moment of the accident, the little finger, the inner side of
the ring finger, and the skin on the ulnar side of the hand, lost all sen-
siition. The alxluctor minimi digiti and two amtiguous muscles of tlie
little finger were also paralyze*!. This condition lasted eight or tea
years, after which sensation and motion were gradually restored to
these parts. As a consequence of this paralyzed condition of the ulnar
nerve, also, successive cro|>s of vesications, al)out the size of a split
horse-bean, commenceil to form on the little finger and ulnar e*lge of
the hand some weeks after the accident, leaving troublesome ex(*oria-
tions. This eruption did not entirely cease for two or three months.
In two other wises, Mr. Granger remarks that he has found *'the
same paralysis of the small muscles of the little finger, the same lorn
of feeling in the integuments, and the same succession of cro|)s of vesi-
cles on the affected parts of the hand, as is describetl to have occurred
in the prece<ling trase."
Without intending to intimate a doubt of the accuracy of Mr. Gran-
FRACTURES OF THE INTERNAL EPICONDYLE. 271
ger^s statement, that such phenomena have followed in three cavSes out
of the five which he has seen, I must express my belief that it was
only a remarkable concurrents of circumstances, since the same phe-
nomena have never been seen by myself, nor do I know that they have
been observed by any other surgeon.
Results. — As in all other accidents about the elbow-joint, a temporary
rigidity is almost inevitable. The mere confinement of the arm in a
flexed position is sufficient to determine this result without the inter-
position of a fracture; but when inflammation occurs, more or less con-
traction of the tendons, muscles, etc., about the joint must ensue. To
this circumstance, therefore, added to the confinement, rather than to
the fracture, will be due the anchyhxsis. If the fragment is not dis-
placed, the fracture cannot certainly be responsible for the loss of
motion, since it does not in any way involve the joint; and if displace-
ment exists, its ultimate effect in diminishing the power of the muscles
which arise from the epiphysis must be only trivial and scarcely ap-
preciable. We might, therefore, reasonably conclude that where the
accident has been properly treated, permanent anchylosis would be the
exception, and not the rule. This view of the matter seems also to be
Bostained by the recorded results. In Granger's cases, the full range
of flexion and extension of the forearm has been finally restored, or
with so trifling an exception as not to be observable without close
attention, in every instance; except in the one already mentioned, which
was originally complicated with dislocation; and even in this case the
ullimate maiming was inconsiderable. Malgaigne, who says " it ought
to be understood that in this accident articular rigidity is almost inevi-
table," seems nevertheless to admit the justness of Granger's observa-
tions as to the final result, if the proper means are employed to prevent
it. I have myself found only once any considerable impairment of
the motions of the joint after the lapse of a few years.
TreatmenL — This accident does not constitute an exception to the rule
which experience has established, that small epiphyseal projections,
when once displaced, can seldom be restored completely to, or main-
toed in position. Granger remarks: '*I have purposely avoided
ftying one word about replacing the detached condyle (epicondyle),
wd for these reasons: during the state of tumefaction of the limb, no
Dieans could be adopted for confining the retracted condyle in its place,
heyond that of the relaxation of the muscles; and both before the tume-
&ction has commenced, and after it has subsided, all endeavors to re-
E'ace the condyle, or even to change the position of it, have failed."
eeven proceieds so far as to declare that while attention ought to be
given to the reduction of the inflammation by appropriate means, we
OQght, nevertheless, to instruct the patient to flex and extend the arm
^lyfrom the moment the accident occurs until the cure is completed,
tod without any regard to the consolidation of the fragment; "the ex-
^fdseof the joint in this manner must constitute the principal occupa-
^onof the patient for several weeks; and should it be remitted during
the formation and consolidation of the callus, much of the benefit which
^Y have been derived from this practice will be lost, and will with
difficulty be regained."
272 FRACTURES OF THE HUUERUB.
With only slight qualifications I woitlil adopt the advice of Mr.
Granger, The limb ouf;ht, at first, to be plaee<! in a position of nemi-
flexioii, so thiit if ancliylosis should unfortunately ensue, it would be
ill the condition which would render it most serviceable, and also be-
eansf! in this position the muscles which tend to displace the fragment
would l>e most completely relaxed. While thus placed, an attempt
oii^ht to bo made, by seizing the epiphysis, to restore it to j)o«ition;
and if the elTort siicfeecU, as it certainly is not very likely to do, a com-
press and niller ought to be so applied as to maintain it iu |>osition;
provide<1, always, that it shall not bo found necessary to apply the
roller so tight as to endanger the limb, or increase the in flam mat ion.
An angulni' splint woul<l be an almoHt iiidis)>ensable part of the apparel,
at least with children, where this indication is in view. In no case,
however, ought more than seven or fourteen days to elapse before all
bandaging and splinting shiuild be abandoned, and careful but fretjuent
flexion and extension be sulistitutcd.
In three eases seen by me, a displacement of the fragment, either for-
wards or backwanls, lias occurred whenever tbe
arm was flexed, and it has l)een necessary, there-
fore, to tix'at the ea.se with the arm in a straight
l>osition. Those are plainly only exceptions to
the rule.
i 9. Fractures of the External Eplcondyle. (Epi-
coodyle, Chauasier.)
I have only mentioned this sup[>ose<I frni'ture,
of which some writers have Sjwken as a tact, in
onk'r that I may declare my conviction tlial its
existeiieo has never been made out. If wo admit
the jiossibility, that, while in a slate of opipliysiii
it might, like the corresponding internal opiphy-
Fra iiirv.,fi- I I'll '''■'*' ^"^ sepanite<l hy muscular action, we mu!>t
duu.iji*. yet deny its probiibility, since it is !»> excvetlingly
small ; and wo must, for the sumo reawm, lie jter-
mitte<] to doubt whether the fact of its .separation c<mld bo rec<)gnizc«l
in the living subject. SIor<-over, if a true fracture occurs at this gmint
as the nsull of external violence, it is suflioiently plain, fnno an ex-
amination of the anatomical striK'tiirc, that it must more or Ictfs extend
into the joint and involve the condyle itsi-lf.
i 10- Fractnrea of tbe Internal Condrle. (Trochlea, Chaauier.)
R. ('iMi[)cr, South, Sir Astley (■<«)iKr, and others, spcnk of fracture
of the inlornal oiiidyle us very oiinmon, and more so than fracture of
the iwiernal i'<iiidylo; while Malgaigiie, who admits its existence, has
never met willi a single living example, and regards its occum'nco ai
exceedingly rare. In a recon) of li)lc<'n fnu-tures,] have fouiwl nodiffi-
culty in rwiignizing five asfnicturcs of tile iiiiior condyle; five, I have
nln-ady said, were fracturett of the epicondyic, and the remainder were
FRACTURES OP THE INTERNAL CONDYLE.
273
^ letermined, while my recortU furnish niDeteen examples of uDfloubteii
ftictures of tlie external condyle. It is probable that Sir Astlcy did
Bot intend to make any distinction lietween frac-
tures of the condyle and epicondyle, and this
might explain somewhat his opinion of the rotu-
tivcfre(|uency of tliese accidents;, but even reject-
ing this important distiuetion, it has happened to
me to see more examples of fracture of the outer
condyle than of the inner.
L- Cni«r«. — It has already been stated that frac-
BIdks of the internal (Njiidyle, as well as fractures
^^ihfr e|iicoQdyle, belong almost exclusively to
in&ucy and childhood, only two instances having
tome under mv notice after the eighteenth vcar
nflife.
1 havfl seen no instance which could be traced
In any other cause than a direct blow, such as a
fall upon the elhow, the force of the concussion jji,,.
being received directly u|»on the condyle.
Unr of Fraeture, DiHplncenient, Symptame. — The direction of the line
of fracture is tolerably uniform, namely, commencing about one-quarter
or hnlf an inch above the epicondyle, it extends obliquely outwards
thrimgh the olecranon and coronoid fossje, and enters the joint through
tieeeiiire of the trochlea.
Displacement of the lower fragment can take place only in a direc-
tion upwards, backwards, forwards, and inwards (to the ulnar side).
Tlie fVogmcnt cannot be carried downwards, in the direction of the hand,
niir outwards, in the direction of the radius, unless the radius also is
Wen or dislocated.
The moat common form of displacement is upwards and backwards,
'111 perhaps at the same time a little inwards; the ulna remainint; at-
t*4eii to the lower fragment, and following its movements. I have
Wfl one instance in which the fragment was carried directly down-
Wnls toward the hand, but this accident was originally complicated
*itli a dislocation of the radius backn'ards. The dislocation was im-
"laiiately reduced. Five years after, when the young man was twcnty-
rs old, I fitund the condyle displaced downwards and forwanls
'ut half an inch, ao that when the forearm was extended it became
ikiugly deflected to the radial side.
The symptoms which characterize this fracture are crepitus, almost
easily delected; mobility of the fragment, diaeoverijd especially
J'eiiing upon the epicondyle, or hy (iexing and e.xtending the arm ;
tfement of the smaller fragment and a projection of the olecranon
S8, this latter being very marked when the forearm is extended
the arm. but almost completely disappearing when the elbow is
'1; projection of the lower end of the hnmeriLs in front when the
_ lii extended; the humerus shortened when mea.sured along its ulnar
^', &om the internal epicondyle ; the breadth of the humerus through
"««n(lylea gonei-ally increiLsed slightly, sometimes half an inch or more;
^ 'he lesser fragment is carried upwards^ it will also be found that
274 FRACTURES OP THE HUMERUS.
when the limb is extended, the forearm will be deflected to the ulnar
side.
Sir Astley Cooper remarks that it is frequently mistaken for a dis-
location ; and Thomas M. Markoe, of New York, has shown that it is,
in fact, frequently complicated with a dislocation of the head of the
radius backwards ; indeed, he expresses a belief that this dislocation
of tiie radius seldom or never occurs without a fracture of the internal
condyle.* I shall refer to his views again wh'^n considering disloca-
tions of the head of the radius.
Results, — It is probable that in a majority of cases no permanent
displacement exists; although the irregularity of the bony deposits
around the base of the condyle,' which generally may be easily felt,
would lead to a contrary opinion. The fact that the lower fragment
usually follows the motions of the olecranon, renders its replacement
and retention com})aratively easy, unless some complication exists. It
is not from displacement, therefore, so much as from permanent mus-
cular, and especially bony anchylosis, that serious maiming so often
results. Under any treatment bony anchylosis will very oflen ensue,
and under improper treatment it is almost inevitable.
Treatment — The arm must be immediately flexed to nearly or quite
a right angle, when, without much manipulation, the fragments will
be made to resume their place. A gutta percha, or felt, right-angled
splint, such as I have already directed for fractures occurring just above
the condyles, well and carefully cushioned, may now be applied, and
secured by rollers. Suitable pads must also aid the splint and roller,
in keeping the fragments in place. Markoe prefers keeping the fore-
arm in a position about ten degrees short of a right angle, believing
that in this position the ulna itself will act as a splint, and, by its sup-
port on the uninjured portion of the trochlea, hold in its plaoe the
broken condyle. Very properly, also, he prefers to lay the angular
splint, made of tin, and fltted to the arm and forearm, upon the back
of the limb, instead of upon the front or sides. If it is upon the inside,
it covers the broken condyle, and we are unable to know so well its
position ; if upon either side, it is apt to press injuriously upon th«
epicondyles; and if it is in front, the fragments cannot be so well ad-
justed or supporte<l. Upon this point, however, surgeons are not very
well agreed, and no doubt more will depend uj>on the care with whidb
the splint is applied than upon the surface against which it is laid.
Considerable swelling is almost certain to follow, and no surgeon
ought to hazard the chances of vesications, ulcerations, etc., by neglect-
ing to o|)en or completely remove the dressings every day. Within
seven days, and perhaps earlier, passive motion must be commenced,
and |)erseveringly employed from day to day until the cure is ac*coni-
plished ; in(lee<], in a majority of cases it is better not to resume the
use of splints after this {)eriod ; for, although at this time no bony
union has taken place, yet the efl'usions have somewhat steadied the
* Markoe, New York Journal of Medicine, May, 1S5S, p. 882, second series, roL
ziv.
FRACTURES OF THE EXTERNAL CONDYLE. 275
fragments, and the danger of displacement is lessened, while the pre-
vention of anchylosis demands very early and continued motion.
When the fracture is compound, or otherwise complicated, these
simple rules will seldom be found applicable; indeed, fractures at-
tended with no such complications will occasionally be found difficult
to reduce, or to maintain in position after reduction.
2 11. Fractures of the External Condyle.
Chuses. — All the fractures (19) of the external condyle, of which I
have a record, occurred in children under fourteen years of age, except
one; in which instance a woman, eighty-eight years of age, fell upon
her elbow while intoxicated, breaking off the outer condyle. Two
months after the accident I found the fragment displaced half an inch
upwards, and firmly united.
In a large majority of these cases the patients themselves have
iffirmed, and the surface of the skin has furnished conclusive evidence,
that the fracture was produced by a direct blow, generally by a fall
open the elbow.
Une of Fracture f Displacement, and Symptoms, — The direction of
the fracture is generally such that, commencing always above and
without the capsule, it descends obliquely and enters the joint either
just within or through the " small head '' or articulating surface upon
vhich the radius is received ; or else it penetrates more deeply in its
progress, and passing through the olecranon fossa, it enters the joint
through the middle of the trochlea.
In the first of these classes of examples, which I think also is the
most common, the condyle alone is broken off, and it is liable only to
become displaced backwards, forwards, or outwards ; generally, I have
fcund it displaced a little outwards sufficiently to increase manifestly
the breadth of the condyles, or it has been carried backwards ; once
slightly forwards ; it Ls also, in some cases, carried upwards in a small
degree, although the action of the supinators and extensors would seem
to render a downward displat^ement more common. These displace-
oeats are usually not considerable, and in a few cases there is none at
all. Whatever may be the direction or degree in which the fragment
is moved, however, the head of the radius is found almost always to
accompany it ; but in the case which I am about to relate, the head of
the radius became completely separated from the condyle.
Frederick Keaffer, set. 11, fell from a load of hay, and he is confi-
dent that he struck the ground with the back of his elbow. Six hours
tftw the accident he was brought to me by the physician who was first
«lled to him. The arm was much swollen, and the external condyle
cooM not be distinctly felt, but when pressure was made directly upon
it, crepitus and motion became manifest. The head of the radius was
It the same time dislocated backwards, and separated entirely froni the
«»dvle, its smooth button-like head being very prominent. It is
diffiiU to conceive how a blow from behind should leave the head of
the radius dislocated backwards, or how the radius could have sepa-
ited from the broken condyle ; but as the examination was repeated
276
FBACTUBES OF THE HDHERUS.
ondjle.
several times, and while the patient was under the influence of e
I have no doubt of the fact. Several other surgeons who were ptt
concurred with me in opinion fully.
Kta H While prosecuting the esanii nation, I red
the dislocation of the radiur, but it would no
main in place a moment wh^n pressure or suf
was removed. The lad reeovcred with a
useful arm, the motions of flexion and exten
with pronation and supination, after the lap
a year, being nearly as complete as before thi
eident, the radius remaining unreduced.
Sometimes it will be noticed that while the
tion of the condyle which is attached to the n
falls backwards, its upper and broken extrei
pilches forwards; and this attitude it isespec
prone to assume when the forearm is exlende
It is even possible, when the fracture tran
the trochlea, for the ulna also to bet-ome displ
backwards along with the radius and the I
fragment.
Crepitus, which is usually very distinct, is most easily obtaine
rotating the radius, or by seizing upon the condyle with tlic th
and fingcn, and moving it backwards and forwanls.
HrsulU. — Or<linarily, this fragment unites promptly, and by
interposition of a bony callus; but in four ea^es, I have noticed
either no union has oix-urrcd, or the union has been accomplished
through the medium of fibrous structures, and the fragment contii
afterward to move with the radius.
As a consequence, probably, of the displacement of the lesser I
ment upwards, the forearm, when straightened, is occasionally fi
deflected to the radial side. The surgeon must not, however, confi
the deflection which is natural and which is greater in some pei
than in others, with the unnatural radial inclination whicli is <
sionnl sometimes by this accident. I have met with tliis phcnomi
three times in children under three years of age, in one of whi
eould not tliscovcr that the condyle was mrrietl toward the shou
but only outwards ; in each of the other cases the fragment had ai
by ligament. The following is one of the examples referral to:
A girlfict. 3, fell and broke the external condyle of the lefl humi
the fracture extending freely into the joint ; orcpitns distinct ; fon
sligiitly flexe<l ; prone, Irfswr fragment displaced outwards u
little backwards, carrying with it the radius. On the second d
was dismissed on account of the unfavorable prognosis which I f
or rather l>ecnnse I refused to guarantee a perfect limb, and an cm
was employetl.
July 2, 1857, several months after the accident, the father bro
her to me for examination. There was no anchylosis, but the l
fragment had never united, unless by ligament, moving fn<e1y
the head of the radius. When the forearm was straightened upot
FRACTURES OP THE EXTERNAL CONDYLE. 277
ann it fell strongly to the radial side, but resumed its natural relation
>gain when the elbow was flexed.
Two other examples are reported at length, in the second part of my
Rfpoii on DcfotifiiUiea after Fractures, as Cases 57 and 59 of fractures
of the humerus.
In one other example, however, mentioned also in ray report as
Case 56, the deflection was to the opposite side. I examined the lad
one year after the accident, he being then five years old, and I ibund
the external condyle very prominent and firmly united, but not appar-
ently displaced iii any direction except outwards. The radius and
ulna had evidently suffered a diastasis at their upper ends, but all of
the motions of the joint were free and perfect.
DoRey^ s))eaks of this lateral inclination as being always to the
ulnar side, but does not indicate to what particular fracture of the
elbow it belongs. He has also descril)ed a splint, contrived by Dr.
Phvsick, intended to remedy the deformity in question.
Chelius also j&peaks of the same deformity as occurring after fractures
of the intenial, but does not mention it in connection with fractures of
the external condyle, that is, an inclination of the forearm to the ulnar
side.
Id more than half of the cases of fracture of this condyle some
«gw of anchylosis has resulted, lasting at least several months. I
have seen it remaining after a lapse of from one to twenty years, but
generally ii gradually diminishes, and, in a majority of cases, com-
pletely di?ap|»ears after a few years.
Trttiimnit. — I do not know that I need add much to what has already
heen said in relation to the treatment of fractures of the op|X)sitc cr>n-
avle, and at the base of the condyles, since the measures applicable to
the fMie are, in general, applicable to the other.
wnerally, the forearm ought to be flexed upon the arm, es[K»cially
™i a \Tew to overcf»me the usual tendency in the upf>cr end of the
wer fragment to pitch forwards, and which form of displacement is
F«»tly incr(^<!€d by straightening the arm. A remarkable cx^-eption
to this rule, and one of two which I have seen, must be mentioiK'il.
Jaia«« Cn»nyn. aged 6, wa< broujrht to me in March, 1807, having,
» few minnu* before, fallen from a height of four or five feet to the
P»imL HLs fiiiber^id the elbrjw had Ix^n brr>ken at the same i>oint
tvoycar^ Vipfcire, and fnnn that time had remained stiff and rrfxtktt\.
1 foa»J the exiernal or.wlyle bn.ken off, and, with the head of the
Miuf, earned hackwani^. This wa-. the |K/sition which it ^x-cupied
ooiMtaiiy, thocgb It was easily n-ioreri and maintain<r<l in |>.r.iiion
«« the mim w^ straitrhr Knt nr.t 1.,- «« :i u ,n*.an. ^Iien the
•lUw* ji ^ straight, but not bv anv jK^sible
ttoow n» fl^Mi I dp^sred the arm,' then-fore. in an extend^^ fK...i-
noa, wnh m lo^z felt splint, and the fragments remain^r^l well in plarje
Witd a COT* wifc* aorvjmpiwherj.
I ui *a**^^^ *=«^-irig of notic-e that, in the four r:af^ in which
iJ«uJ^r" - -^ -°''^"° ^'' ^^"- and the fratrments to ry.ntinue
r^u!^ J'^' ^a^]' ^"*^ ^'*^- fniguK^nts to ry^nti
•f the e:l>..w-j#/irj: have, in a ver\- shon ti
me,
i46.
278 FRACTURES OF THE HUMERUS.
been completely restored. If it does not prove that Granger was
correct in his views as applied to fractures of the internal epicondyle,
namely, that it was of little or no consequence whether the fragment
united or not, and that the elbow-joint ought to be submitted to free
motion from the beginning to the end of the treatment — if it does not
absolutely prove, I say, the correctness of his views, it at least must
abate our apprehensions of the supposed evil results of non-union in
the case of the fracture now under consideration.
I shall take the liberty of quoting also, with a qualified approval,
the opinion of Dr. John C.Warren, of Boston, as stated bv Dr. Norris
in his Report on Surgery, made to the American Me<lical Association
in 1848.
" In the treatment of fractures of the condyles of the os humeri, a
course is usually recommended which he believes to be hurtful, inas-
much as it favors the worst consequences of the injury, namely. Ices
of motion in the joint. By this m(Kle of treatment, the fractured piece
becomes sufficiently fixed to create partial anchylosis; and there is so
much pain afterwards in the proposed passive movements as to cause
the omission of these measures until permanent stiffness takes place.
The proper course in the management of these accidents, he conceives
to be — 1st. To apply no splints, but in the earlier days to make use
of the proj)er means to prevent inflammation. 2d. To accustom the
patient to early and daily movements of flexion and extension. ZA.
When the action of the joint becomes limited, to overcome the resist-
ance by force, and repeat it daily until the tendency of the joint to
stiffen ceiuses.
" The accomplishment of this process, he adds, is so very painful
that few patients have courage to submit to it, ancl few surgeons firm-
ness to prosecute it. The consequence has been that in a great num-
ber of cases the use of the articulation to a greater or less extent has
been lost. The introiluction of etherization, by pr(»venting the paiu,
gives us, in the opinion of Dr. Warren, the means of overcoming the
resistanw. Bv its aid he has restored the motion of a considerable
number of anchylosed elbows, and has sucxx?ssfully applied the same
measures to other joints, particularly to the shoulder and knc^e. This
has now become his settled practice, with the results of which he is
entirely satisfied. The inflammation consequent upon the forced
movements of an anchylosed joint is not to be lost sight of. By t
reasonable abstniction of blood, and other anti-inflammatory treatment^
he has never found it alarming.''^
My respect for the distinguished surgeon whose opinion is here
given does not |RTmit me to question the correctness of his practice;
but I rannot avoid a l)elief that his language does not convey a precise
idea of his views. If he intends to say that he would move the joint
freely when it is suffering from acute inflammation, and when motioD
occasions great pain, I must protest against the prairtice as likely to
do vastly more harm than good in any case ; but if he would move the
> TrHTiftaclions of the American Modical Association, vol. i, p. 174.
I
FRACTURES OF THE NECK OF THE RADIUS. 279
joint from the first, when the inflammation and swelling are trivial,
and when it occasions only an endurable amount of pain, then his views
are just and his practice worthy of imitation.
CHAPTER XXI.
FRACTURES OF THE RADIUS.
Op one hundred and nine fractures of the radius which have been
recorded by me, not including gunshot fractures, or fractures demand-
ing immediate amputation, three belonged to the upper third, eight to
the middle third, and ninety-eight to the lower third. Four were
compound, and one hundred and five simple. Sixty-two are reported
18 occurring in males, and forty-seven in females; forty-nine as having
occurred in the left arm, and thirty-five in the right.
Fracture of the neck of the radius, as a simple accident, uncompli-
cated with any other fracture or dislocation, is exceedingly rare; yet,
owing to the depth of the superincumbent mass of muscles, and the
difficulty of determining, where so many bones and processes approach
each other, precisely from what point the crepitus, if any is found,
proceeds, surgeons have often been deceived, and they have believed
that they were the fortunate possessors of this rare pathological treas-
ore, when the autopsy has too soon disclosed their error. Both B.
Cooper and Robert Smith have alluded to this difficulty, and the case
repc>rted by Dr. Markoe to the New York Pathological Society, and
published in the American Medical Monthly, will serve to illustrate
the same point; in which case tiic signs of a fracture of the radius at
it8 netrk were such as to deceive that experienced surgeon, yet the
iuto|isy disclosed the fact that it was a dislocation of the head of the
lidius forwards, with a fracture of the ulna. Indeed, its existence as
a form of fracture was doiibted by Sir Astlcy Cooper, and by others
luLs l)een actually denied. I have seen no specimen obtained from the
cadaver, except the doubtful one contained in Dr. Watts's cabinet, and
of which I have furnished an account, accompanie<i with a drawing, in
mj report to the American Medical Association,* and the specimen
owned by the late Dr. Mutter, of Philadelphia, of which he has kindly
fiimi«hed me the following description: "History unknown. The
line of fracture seems to have passed through the neck of the left
ndius, just at the upper extremity of the bicipital protuberance.
Union with deformity has resulted. Owing to the fracture having
taken place within the insertion of the biceps, that muscle appears to
have drawn forward and upward the lower end of the short upper
fragment. In consequence of this movement, the articulating facet of
> Transactions, vol. ix, pp. 157 and 229.
FRACTUBEa OP THE BADIU&.
the hf«d of the radius is tilted backwards, so as no longer to be Id con-
tact with the humerus. As a secondary consequence, the anterior edge
of the htad of the radius rests permanently against the articuiatiif
surface of the humerus. At this new point
^'°- '*• of contact a new surfiice of articulatioa !■
seen to havel>een formed, while the original
articulating facet is directed baukuirds,
and lies at right angles lu the one of man
recent formation. At the inner edge of the
new articulation of the head of the radiut
with the humerus, contact with the ulni haa
developed another surface of articulation.
The upper and lower fragments are united
at an angle, and the radium does not ap|>eir
to have lost in length."
Velpeau has once demonstrated the eiirt-
ence of this fracture in a dissection, but tba
fracture was acconii)anied with a fractun .
also of the coronoia procciis ; and B(nid
olttaiiied possession of a similar ppccimen.
I do not remember to have ntxn a nolinof ',
any others. Malgaignc alBrnis, with his
usual frankness, that although he has o^
casionally believed that he had met with
it, the autopsy, whenever it has been ot^
tained, has shown that it was rather a wlh
lu.\ution than a fracture. On the oth^
hand, Mr. South calls it a "not unfrcquent
Fr>riiirc-"f neck of radius (Mm- accidcnt," but in Confirmation of this dw
tatiniihcet! b.b. alwuiic'iuABg 'aniiion he cites no csamplcs.
ruviL r. rrr.j.T.im«f..Bu>i!nu. While, therefore, the presence of »'*'
ap]>enr to be the rational diagnostic «ig^
has com)>elltMl nie lo record one case as an uncompIioattHl fracture (K
the neck of the radius, and two others as fractun-s at this point ati^**
panied either with a fracture of the humerus or a dislocation of l""
ulna, I am prepared to admit that some doubt remains in mv o"
mind iw to wnetlier in either case the fact was clearly uscertuineii ; "<*
do I think, s)>eak!ng only of the simple fracture, that it will ever "•
safe to dwiare (xwitivcly that wc have before us this accident, Ictt **
bus hap|K>ncd many times before,' in the final ap|>eal to that cO*>**
who><e judgment waits until aAer death, our decisions should be '^
vcrsi-d. ,
\othing, [wrhaps, could more fully illustrate the diPGoulty of •*'**
iiosis in the case of injuries rect-ivwl in the neigh In irho«Ml of the l'*^
of the nidiurf than the testimony given in the case of Noyes i-». A^ ■-
trietl in the ijupreme Court at Cambridge, January, 18&6, licfore J^^S
Itigelow. Mr. N'oves injure<l his eIl>ow, January 7, 1854, anJ ^
Allen, who was called imine<liatcly, believed that the ligaments of ^
joint had been lorn, but that no bones were broken or dispWtxl.
FRACTURES OP THE NECK OF THE RADIUS. 281
the following morning he was dismissed, and Mr. Noyes went home.
Three weeks later it was seen by Dr. Dow, who also thought there
was no fracture. About eight weeks after the accident a physician ex-
amined the arm, and declared the neck of the radius broken, and the
fragments displaced; and when the case was finally brought to trial he
testified still that such was certainly the fact; and five other physicians,
not one of whom, however, we are told, was a member of the State
Medical Society, testified positively that the radius was broken at its
neck, producing a bony protuberance; that such an injury only could
account for the symptoms manifested at the time of the accident, and
that no other fractures or injuries of the joint could explain so well the
present appearances of the arm. While, on the part of the defence,
six of the most intelligent medical gentlemen of the State, Dr8. Kinibal
and Huntington, of Lowell, and Drs. Townsend, Lewis, Clark, and
Gay, of Boston, testified that the head and neck of the radius were
not displaced, nor was there any evidence that this bone had ever been
broken. There is every reason to believe that these latter gentlemen
were correct; yet it is to be presumed that the gentlemen who first tes-
tified were not without some grounds for their opinions so confidently
expressed.
The case was given to the jury after a trial of five days, who promptly
returned a verdict for the defendant.^
When this fracture occurs, the upper end of the lower fragment will
probably be carried forwards by the action of that portion of the biceps
which has its insertion into the tubercle; and the displacement in this
direction must necessarily be increased in proportion as the arm is
straightened. In the cabinet specimens belonging to Dr. Mutter, the
line of fracture, commencing in the neck, has terminated in the tuber-
cle; consequently the biceps, having still some attachment to the upper
fiagment as well as the lower, has drawn them botli forwards.
The same anterior displacement I have noticed in all of the supposed
living examples, but whether both fragments or only one had suffered
displacement I am unable to say.
A girl, »t. 11, living in Ontario Co., N. Y., fell from a tree, and
^Djured her right arm. Her surgeon, who regarded it as a fracture of
tte neck of the radius, reduced the fragments, and placed the forearm
^t a right angle with the arm. On the twenty-eighth day all dressings
'^we removed, and the patient was dismissed; the fragments seemed to
t* in place. The parents, finding the elbow stiff, now made violent
^nd snccessful efforts to straighten the arm.
Fifteen months after the accident, the child was brought to me.
There was at this time a bony projection in front, opposite the neck of
*he radius, which I believed to be the point of fracture. The hand
'^^ forcibly pronated, and she had only a limited amount of motion at
the elbow-joint. The anchylosis was probably due to inflammation
^wctly resulting from the severe contusion ; but it is quite probable
* Amer. Med. Gazette, vol. vii, p. 299.
19
FRACTURES OF THE RADIUS.
that the forward displncement of the fragments was alone due to tin
too early and too violent attempte to straighten the arm ; at least, (bit
was the explanation which 1 ventured to give to
^"- *'■ the parents at the time.
/Tne second case occurred in a lad eight yean
old, living in Wyoming Co., N. Y. His piraito
hrought him to me ten weeks after the iniuiy
was received, and I then found the forearm bent
to a right angle with the arm, and anchvloied
at the elbow-joint. The hand was also forcibly
pronated, and could not be supinated. In (ntit,
and opposite the neok of the radius, there m
/I ijia a distinct bony projection, which I bclipi'cdto
I jK be the point of union of the l»ny fragment
I m The external condyle seemed also to have Ijtfli
broken.
The third example, treated originally byDf.
Nott, of Buflulo, was seen by me six montiK
after the accident. The upper end of the Iomi
fragment seemed to be <lisplaccd forwarffc
There was very little motion at theclhow-joinli
and both pronation and supinatiim wore cxn-
pletelv lost.
1 nave seen, in Dr. Mutter's cabinet, t**
spetrimcns of fracture of the outer half of ™
head of the radius. In one cnxo, the small ft^^
ment is slightly displaced downwanis in llieo*"
rection of the axis of the Iwne ; an<l, in the oth^i
the fragment is thrown outwanls, or to the red*
side, iloth are firmly unite<l in their new po^
tions.
Dr. Hodges presented to the " Boston Socie*!
for Medical Improvement" a specimen ve^
much resembling those of Dr. Mutter's, in whi^
case the patient eorvived his injuries only»*
hours; and in the examination after death •*
(M^"u'"'T«n'''ito'''^'''i- ^'^'•■^''"""'1 t*^ have also an oblique fractured
BCD A. No. iM) the shaft of the ultia, the line of fracture con*
mcncing nl>ovc thecoronoid process, and extcov
ing obliquely downwards and Iwfkwnrds. He remarks, moreover
that he has three times found a longitudinal fracture of the head of lb<
radius ;i»4oeiatcd with a fracture of the conmoid process of the nliM.
I have already ohser\-ed that Vetpenn had onw noticc^l tlic same coi»
cidence.
In the treatment of fractures of the neck of (he radius, we must no
neglect to flex the forearm n|K>n the arm, so as to ndax, as coinpletch
as possible, the hiec[)s, whose advantageous insertion into lhi> tultcircl
of the radius would be certain to pnxluce displacement, unlcm tin
■ UudgM, Botton Med. and Surg. Journ., Dm. B, ISttB.
FRACTURES OF THE HEAD OF THE RADIUS. 283
position wa? adopted. A single dorsal splint^ properly padded, should
support the forearm, while the surgeon, having placed a compress over
the upper end of the lower fragment, proceeds to secure the whole with
a roller.
&|)ecial care must also be taken to prevent the forearm from being
tttended before the bony union is fairly consummated, lest the biceps,
iww firmly contracted, should draw the lower fragment forwards, as
it must inevitably do while the bony union is imperfect ; an accident
^ioh, there is some reason to believe, occurred in (me of the examples
^kich I have alreadv cited.
u the patient be a child, or if there is any reason to suppose that
^ifse rule? will not be faithfully complied with, it would be well to •
secure the arm in this j)osition with a right-angled splint.
When the fracture occurs in any portion of the radius below the
Wsertion of the biceps, and above the insertion of the pronator radii
•tt^, Mr. Lionsdale suggests the propriety of placing the forearm in a
«>iidition of supination, at least so far as is practicable, for the purpose
of securing a proper ap})osition of the fragments. His argument in
&vor of this practice is ingenious, and deserves consideration.
When the bone is broken anywhere in this portion, the action of
Ae pronators upon the upper fragment ceases ; while that of the biceps,
which is a powerful supinator, continues ; consequently the up|)er frag-
nient becomes at once, and completely, rotated outwards or supinate<l.
Now, if the hand, to which the lower end of the radius alone remains
attached, should be forrribly pronated, the radius will also 1x3 rotated
inward* upon its own axis; and although it might Ik? j)ossible in this
condili<m to bring the broken ends into contact, and a bony union,
without defi)rmity, might be consummated, yet the |)ower of supination
most l)e forever Ioe?t; since the union has been eifectefl while the head
*im1 ap|)er fragment are already in a state of complete supination ; and
if such is the facrt, it is evident that the whole bone, together with the
^nd, will be inca|iable of any further supination.
It Ls not, in<lee<l, the practice with any surgecms, so far as I know,
^ tnut thii? fracture with the hand placed in a |K^ition of extn-me
l»tmation ; but the ta.'re has been suppose<l for the purjK»se of rcinhT-
^the argument more intelligible. The usual practice is to place
w* forearm and hand in a position midway l)ctween supination and
Pronation, and then to lav it across the \kh\v at a rij^ht nii;r^' with the
*nn; but it is plain that the same obji*ction, ditfcring only in degree,
*ill apply to this position as to that of pronation. The ii\*^ of the
t'fo fragments are n'»t made to corresi^md, since, while the lower trag-
*nJt is only half n»tate<l outwards, the up|)er fragment is completely,
*wl ilie rcsalt of ihe union must lx» the hiss of one-half the p«nver of
KpinatiuD in the hand.
his only, then, by tr)mplete supination of the hand durin;: tre:it-
■>*nt that this difficulty c-an Ije avuide<-l. and I have no drMibt that we
'^ght to adopt this plan, whenever it U practicable to do so, or when-
ever we are not hindered by serious ol>*tach.-s: and the only o!>-Ta'!e
^ich occQr^ to me as likely to interjKise ib^elf. is the praetieal one
▼hich UKist •argeoD!? roust have experienced in treating all injuries of
284 FRACTURES OF THE RADIUS.
the forearm, whether fractures, or only severe contusions of the i
cles, etc., namely, the constant and almost uncontrollable tend
of the hand to assume the prone or semi-prone position. This is
no doubt, to the great preponderance of power in the pronators;
such is the resistance which they afford to supination that it is c
quite impossible to lay the hand upon its back while the forcari
across the body, and, if accomplished, the position generally beoc
in a few hours so painful as to be intolerable. By extending the i
however, and laying it upon a pillow, the hand Avill be found agai
rest easily upon its back, because in this way we avail ourselves of
outward rotation of the humerus at the shoulder-joint.
Dr. X. C. Scott, formerly Resident Surgeon to the Brooklyn <
Hospital, in his inaugural thesis, submitted in March, 1869, has
cussed very fully the advantages of this position in many fractun
the forearm, and he has devised a very ingenious mode of securing
limb after supination is cifected, adding also a moderate amount oi
tension by adhesive plasters and elastic bands.
Fia.92.
Scott's apparatus for fractures of the forearm.
Dr. Scott informs me that he has treated twenty-five cases
8U(x.*cssfully at the Brooklyn City Hospital and elsewhere, by
method.
It has already been stated that of the whole number of fractui
this l>one recorded by me, amounting in all to one hundred and
only eight Ixilongcd to the niiddle third ; an ol)^rvation which
striking contrast with the remark of Chelius, that it is broken
frequently in its middle.
If the fragments are completely separated in the middle third
lower end of the upper half is drawn forwards by the action of the h
aided by the pi*onator radii teres, in case the fracture is below its i
tion; while the lower fragment is tilted toward the ulna by the
joined action of the supinator radii longus and pronator quadi
But as to the direction of the displacement much will depend upo)
direction of the force by which the fracture has been oocasioned.
TBACTCBES OP THE HEAD OF THE ItADIUS. 285
A laboring man, eet. 35, broke the mdius near the lower en<l i)f tlio
niiMle third. On the same day I replaced the fragmeiitM mt well iw I
(ooU in the midst of the swelling which had already oec'urre<l, and
Fnetan of tbi
■P^iei] two broad and well-padded splints, one to the palmar and one
» rW dfiraal fur&ce of the forearm-
Do the twentT -eighth day I first dipcovere*! that the frajrmentH were
Nwrinz in front, and I at once propow<i to thrust them Iwk by
mw.lni the patient declined allowing me to do m. I then appli") a
wnpres; near the summit of the projection, but not exa'.-tly u|khi it,
wii'^boald t-axi^ ulcerstioa.aud et-«'ur«] overthU a firm fiplint. At
«^ iV» ttentfd to prr Jo** a change in the fragment^;, but aft^-r a
wople irfvpekf I (oand there was no improvement, and it was diiw^fm-
■wkA Atnat six fnootbs after the frarture wcurrMl, thi'! man had
waiM arm t€TT7l>!y Iwxnted in a railrriad aoi;id<^nt, and I wait
°tili^ H) iiDpiita:;^ Dear the ^hoalder-jolnt ; and I thit% Mbuine«I the
*"*« ndiK. n*!- lr.«»e was firmly unitfjd, bnt with an angle, wilient
""•nt. of aboai un df«i»*s, Tb^re wa.^ no inclination towanl th*
iIb.
^y inpns4on fe thai iI»b«* frajment^ w^re utver <y/mpl'?tely fr-
P'wLapMiK wLk^ I rr.i3>] »'*; w*" dfi^rmin* at first on a'^-'^jnt "f
*< lapid «?S4rc If '.buy lad }i**z]. I think th»^- <*/'j!'I hav^ v*n
"fiwd b pcir« whL ti«* apY-^ao'** n'*^, .\JmoT^ ever%- '!ay 'L*: IiJ-ib
•« eiaciiwri. i^ £> '..**a ^ ^-.-try f'ysrh or fiftt. day th<- 'ir'~:.'i^
W* n«wr»d ic»i •as^f^V.T rf^y^'.U^. And '^nly »■:.'*: -J'-J :.■.*;.' *«^
"■e » Ikkk » «r< v- *5-H -.if* r^-.-ilv-fr -Titj^r:. ar»d ::,I.-^ i* a j>r.->»i
■oohte % hxT> '^ya^:e^ 'm •Z'^^.m.'".
Te«^ MC v.- b> i>-*rr-^, ri/'OrT''.-:. sfjd :-::;i.:-r -r. "■-.' JT-'y
•?■ .'^■*- Twt «C3ii^_ >oj t.-,: t- a
c l.e-ri.-i. lai: v.-wiH
286 FRACTURES OF THE RADIUS.
the ulna through the action of both the biceps and the pronator radii
teres; a tendency which may in some measure be provided against by
flexion of the arm, but which must be overcome chiefly by steady and
well-adjusted pressure, near, but not upon, the ends of tlie fragments.
Fractures of the lower third, occurring above the line of Colies's
fracture, are almost as rare as fractures of the middle or upper thirds.
I have recorded five ; one of which it will be proper to relate as a rep-
resentative example.
George Vogel, a?t. 30, was admitted to the Buffalo Haspital of the
Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius
about three and a half inches above its lower end. The hand was
prone, and inclined to the radial side; while the broken ends of the
radius fell against the ulna, from which it was found difficult to sepa-
rate them. The lower end of the ulna was prominent, and projecting
upon the ulnar margin of the hand.
I was unable completely to separate the fnigments of the radius fro^
the ulna, by either pressure w^th my fingers between the bones, or l^'
seizing upon them with my thumb and fingers. Having, howev^^
adjusted them as well as possible, I flexed the arm, and applied a broJ^
and well-padded splint to the palmar surface of the forearm, securit^
it in place with a paste bandage. These dressings were finally remov^
at the end of four weeks, when I found scarcely any displacement c^
deformity remaining.
Most of these fractures, when properly treated, result in perfect limbfi
In a certain proportion, however, it \\\l\ be found impossible effectuallj
tx) resist the action of the pronator radii teres and of the quadratus, anc
the fragments will unite at an angle resting against the ulna, and some
times, by the interposition of intermediate callus, they will l)eooiii
firmly united to the ulna. Occasionally, also, especially where tb
fracture has been produced by a fall upon the hand, and the radio-ulna
ligaments of the wrist have been torn or stretched, the lower end of tk
ulna will be found to project permanently, and the hand to fall more i
less to the radial side.
Of the ninety-eight fractures belonging to the lower third of tl
radius, ninety-three were near the lower end, or within from half a
inch to one inch and a half from the articular surface, all being ii
eluded in those fractures called "Colles's fractures," most of which wej
no doubt true fractures, and probably a small pro{>ortion sepuratioos <
the epiphyses.
In every instance, except one, which has come under ray notk
where the ciuise of a Colles's fnicture has l)een ascertained, it has bei
occasionetl by a fall upon the palm of the hand. The exceptional oa
was in the person of Mrs. D. B., who fell in getting out of a street o
in the city of New York, May 20th, 186'), striking upon the hack <
her hand while the hand was shut. The displacement was in the aaji
direction as in erases caused by a fall upon the palm. Ilobert Smil
has seen a similar accident cause a displacement of the fragmeut (6
wards.
Colics described this fracture as occurring always about one im
and a half above the carpal end of the bone; but Uobert Smith, wl
COLLES'S FRACTURE. 287
kw carefully examined all of the cabinet Bpeciniens he could find,
■Imt twenty-three in number, has never seen the line of fracture
RBoved iarther than one inch from the lower end of the bone, and
in several specimens it was within one-quarter of an inch of this
olremity. Dupnjtren has also described the fracture as occurring
fivn three to twelve lines above the joint. I think I have found the
factiire generally as low as these latter surgeons have placed it, but
ocwionally as high as it was placed by CoUes.
Case. A woman, set. 40, fell upon the sidewalk, striking upon the
fklm of her left hand. She was brought immediately to my ofBce,
»nd I found the radius was broken about one inch and a half above
the wrist. The lower fragment was tilted back considerably. Hand
fnme.
Placing my thumb against the back of the lower fragment, it was
ttilr restorml to position, and with only a slight crepitus. When
By thumb was removed it manifested no tendency to displacement.
The arm was dressed with a curved palmar splint, secured in place
*ith a roller applied moderately tight. On the seventh day a straight
flint was substituted for the curved. The arm was examined almost
f«7 day, and the dressings occasionally renewed until the twenty-
Nith day, when the splint was finally removed. The wrist was at
I lliis time only slightly anchylosed, and there seemed to be no deformity
(t imperfection remaining. Passive motion, which had been practiced
' Unca removal of the dressings, was directed to be continued.
Case. A boy, ret. 11, was brought to me, having just fallen from a
purof stilts. His right radius was broken transversely, three-quarters
of in inch above the wrist, and the lower fragment was much tilted
bwl^; the lower end of the ulna was prominent, and the hand fell to
^ riidial side.
Poshing from behind, the lower fragment was made to resume its
we, and the deformity immediately disappeared. It was noticed,
Mrerer, that it required unusual force to accomplish this, but it was
Mt (dubA necessary to use extension. There was also, accompanying
the teductioD, a slight crepitus.
The treatment was the same as in the first case, except that the
enrved splint was employed throughout. Little or no deformity ex-
•ted wh«i the dressings were removed.
Case, George Lofiuch, ret. 42, fell upon an icy sidewalk, striking
"pon the palm of his left hand. Fracture three-quarters of an inch
288 FRACTURES OP THE RADIUS.
above the lower end. Fragment displaced backwards. A friend
partially replaced the fragment by pushing upon it, before he cam
me. Within half an hour after the accident ne was at my office,
I restored the lower end of the bone very easily to place by pwl
from behind with my thumb. No extension was necessary. It wc
not, however, remain in place unless the forearm was pronated so I
the weight of the hand could aid in the retention.
I applied my own palmar splint. The recovery was rapid i
complete.
Cask. Margaret Reed, set. 48, fell, September 23, 1855, strikinfi
the palm of the left hand, and breaking the radius about one inch ii
its lower end. One week after, she came under my care at the 1
pital. The arm had been previously dressed carefully by one of
colleagues, with curved dorsal and palmar splints ; but, on exami
tion, we found the fragments a good deal displaced. It was fo
necessary now to use both extension and pressure from behind to
store the lower fragment to position. This we finally sucoeedec
doing, and immediately splints were again snugly applied. Twoc
after, on opening the dressings, the lower fragment was a second t
found displaced backwards. It was again reduced, but only by u
great force. Fifteen days later, we were pleased to find the bone
and without deformity.
Margaret left the hospital on the 4th of November, with her 1
and wrist still swollen, and with a good deal of stiffness at the c!
and wrist-joints.
Case. Charles Stratton, a healthy and temperate laborer, set
fell forwards from a wagon, November 22, 1854, striking upor
palm of his hand, and breaking the radius a little more than one
above the joint. I found the lower fragment displaced backwards
it was easily reduced by pressure in the opposite direction. The
part of the wrist being quite tender to pressure, the splint was ap
to the dorsal surface of the forearm. The splint was curved (p
shaped), and the surface which was applied to the arm was pa
with wire; it was secured in place by a few light turns of a roller
laid across the body in a sling.
The arm was seen by me on each of the succeeding seven days,
on the third, fifth, and seventh days the splint was removed comple
but on this last day an erysi])elat()us inflammation had commence
the neighborhood of the wrist. The splint and roller were ther
not reapplieil, but the limb was laid upon a broad board, cash!
and covered with oiled silk, and cool water irrigations were dire
The inflammation soon subsided, but the splint was never resume
the fragments were found to stay in place perfwtly without its
At the end of five weeks, union seemed to be consummated ; am
year later the l)one was found to he |>erfectly straight, yet the f
joint and the finger-joints remained stiff, so much so that ho wm
able to |>erform any lal)or. The stiffness wa**, however, grad
disappearing, while all swelling and tenderness had long ceased.
Tne observations of M. Voillemier also have shown that, inste
being oblique, as has generally been supposed, the fracture is al
COLLES'S FRACTURE. 289
umrormlv transverse from the palmar to the dorsal surfaces of the bone,
aodonly occasionally slightly oblique in its other diameter, or from the
nrfid to the ulnar side. I have seen, however, in the museum of the
0)IIege of Physicians of Philadelphia, a specimen of this fracture in
wAich the line of fracture is transverse, from side to side, but very
oblique from before backwards, and from below upwards. There is
ibo a line of incomplete fracture extending into the joint. It is united
bv bone, with the usual displacement backwards.
The observations of both R. Smith and Voillemier have shown,
moreover, that the displacement of the lower fragment is seldom suffi-
cient to enable it to escape completely from the upper; and that where,
in extremely rare instances, and in consequence of extraordinary vio-
lence, such complete separation does occur, a disruption of those liga-
ments which attach the lower fragment to the ulna occurs also, and the
deformity becomes at once very great, so that it no longer presents the
peculiar features of CoUes's fracture, but resembles a dislocation.
In the so-called Colles's fracture, the lower and outer border of the
radius, or its styloid apophysis, is swung around or tilted, as it were,
upon the ulna; the lower and inner border of the same fragment being
retained in place by the radio-ulnar ligaments, which do not usually
suffer a complete disruption, but only a stretching or partial laceration.
The upper or broken margin of the lower fragment, and also the ulnar
margin, undergo very little displacement; while the lower or articular
Wifface, and the radial margin, are carried backwards, upwards, and
wtwards.
Surgeons have spoken of a falling in of the upper end of the lower
hgment toward the ulna, as an almost inevitable result of the action
of the pronator quadratus, and against which tendency they have sought
ttrefully to provide; but there is much reason to believe that any con-
aierable degree of displacement in this direction is a rare event, and
tktt, when it does exist, it is in consequence mostly of the direction of
tke force which has produced the fracture rather than of the action of
tkis muscle, only a few of the fibres of which are usually attached to
the lower fragment, and, in some instances, when the fracture is within
» half or quarter of an inch of the articulation, not any. Besides, there
8 actoally in these latter cases no interosseous space into which the
ftagracnt may fell, and its displacement toward the ulna becomes,
tbeirrfore, impossible.
Still, however, if one were dis[)osed to speculate upon the condition
rf these parts after the fracture, it might jxTluips be easy to persuade
wnelves that the action of the pronator quadratus uj)on the upper
Pigment, whose broken extremity was not completely, or at all, dis-
engaged from the lower, would carry both fragments together toward
4e ulna. But whatever might be the result of our spcKJulations, still
tbefcct, as proved by specimens, is not generally so; and this is not
the first time that fects and theories have disagreed.
The troth is, that it is unusual to find any of the museum specimens
of this fracture thus united. But they may be found constantly tilted
h»ck in the manner I have described, occasionally tilted forwards, and.
290 FRACTURES OF THE RADIUS.
still more rarely, slightly displaced upon their broken surfaces antero-
l)osteriorly.
The general absence of this internal displacement may find its ex-
planation in the direction of the force which generally produces this
fracture, in the occurrence of the fracture sometimes at a |)oint so low
as to render its displacement in this direction impossible, and in the
breadth of the bone, at the seat of the fracture, which does not permit
it to fall laterally without actually increasing its length ; a circumstance
which its secure ligamentous attachment to the ulna at its opposite ex-
tremities, and its complete apposition to the wrist and elbow-joint, do
not allow.
The mistake of those surgeons who have attempted to describe tliis
fracture has originated in the appearance presented in nearly all recent
fractures occurring at this point. The hand falls to the radial side, and
seems to carry the lower end of the lower fragment with it, while the
lower end of the ulna l>ecomes unnaturally prominent in fro;itandto
the ulnar side; a condition of things which has naturally enough bectt
ascribed to the displacement of the upper end of the lower fragment \^
the direction of the interosseous space.
But this same radial inclination of the hand, and prominence of tl^
ulna, are present frequently when the radius is broken at its lower etB^
and no displacement in any direction lias taken place; and I have ev^
observed it in simple sprains of the wrist, and in the hands of old '
feeble persons where all the ligaments have become relaxed.
It is seen, however, in a more marked degrc»e when the bone is act^
ally both broken and displaced backwards in its usual direction. W
short, the deformity in question is due, in a large majority of instance
to the relaxation, stretching, or more or less disruption of the radi^^
ulnar ligaments, which jiermits the hand to fall to the radial side by
simple rotatory movement over its articular surface. For this reason
also, because these ligaments onc*e lengthened or broken can never, C
only after a lapse of many years, be completely restoretl, this defornii^
may be exjK?cted, in a c^Ttaiu number of cases, to continue, howevc
exact and perfect may be the bony union.
It must be added, however, that so long as the tilting of the fragmen
remains, the articular surface is actually presenting somewhat to th
radial side. While in the normal condition it presents downwards, foi
wards, and inwards, it now presents, when the displacement is coiisid
erable, downwards, backwards, and outwards.
Diday niiiintaineil that there existed usually in this fracture an ovei
lapping or shortening of the bone in its entire diameter, and Voillcmk
thought that the s(>ecimens which he had examined proved that a
impaction was almost universal.
lioth of these opinions have been combate<l by Rolwrt Smith; tl
shortening observed by Diday l)eing found only on that side of the boi
to which the hand inclin«<, and being, acc<:>rding to Rolx»rt Smith, tl
result of the motion of the lower fragment aln*ady desorilxHl ; am\ tl
appearance of impaction being due to the ensheathing callus, which
deposited usually, if the displacement is allowed to continue, in the n
tiring angle op{KXsite the seat of fracture.
COLLE8 8 FBACTUBB.
291
Ilwse are questions, however, requiring fur their decision a very
(V^) study of epecimens, and in relation to which furtlier observa-
ticos maj be neeefeary. Indeed, some recent observationa made by
ifr. Cal lender, of Saint Bartholomew's Hospital, London, go far to
nsttin the opinion of Diday, that some impaction generally existe,
tat rather upon the posterior margin than upon eitlier the radial or
ilnar side.*
In the accompanying woodtnit (Fig. 95) is seen an impacted and
omniiDuted fracture of the lower end of the radius. Dr. James Went-
forth, of Troy, N. Y,, who sent me the specimen, says that the patient,
man, tet, 50, in a fit of delirium jumped from a third-story window,
lighting upoD the stone pavement. He survived the accident leas
bin one hour.
Tlie next illustration (Fig. 96) is from a specimen prcsonlcd to me by
)r. William Van Burcn, and was found in an autopsy at the New York
"iHtj Hospital. In this specimen thore is comminution, without im-
pttioQ or displacement. The line of separation between the upper
^ lower fragments is transverse, and the lower fragment is divided
into live distinct pieces, each line of fracture involving the joint.
One curious example of this form of fracture is rc[>ortcd by Dr.
Kgelow, of Boston (Fig. 97). The patient had iallen, and being other-
"^•eriousiy injured, ultimately dit^ in the Massachw^tts Hospital.
Atfiret he had only complained of lameness at the wrist, as if it had
"wi severely sprained ; but at the end of several days the joint be-
WM swollen, and from the persistence of the swelling Dr. Bigelow
*»ledto diagnosticate a stellate crack in the articulating extremity
rfthe radiuB, he having met with a similar case two years before, when
> Callender, Bt. Biirtb. Hoip. Bep,, p. 381, 1865.
292 FRACTURES OF THE RADIUS.
a patient with the same symptoms had died of other injuries, and ex-
hibited a crack in the same place, but less extensive than in this case.
There was found, in this last example, a star-shaped fissure on the
articulating surface, without displacement. These fissures penetrated
the shaft for an inch or more. Dr. Bigelow thought that the bones of
the wrist acted as a wedge to spread the corresponding hollow of the
articulating extremity, and that this specimen would explain the per-
sistence of some cases of sprained wrist.*
There is no doubt that occasional examples may be found illustrat-
ing one or more of all these varieties of displacement, and that to the
impaction is sometimes added a comminution of the lower fragment,
the lines of the fracture extending freely into the joint.
Robert Smith has described a fracture occurring at the same point,
and probably j)Ossessing nearly the same characters as Colles's fracture,
in which the lower fragment is thrown forwards instead of backwards,
and which has generally been the result of a fall upon the back of the
hand. There is no such specimen, however, in any of the pathological
collections in Dublin, nor has Mr. Smith ever seen a specimen obtained
from the cadaver, although he reports a case which fell under his ob-
servation in practice.
I have myself seen one such case,* but I regret to say that my ex-
amination of the condition of the arm was not such as to enable me to
add anything to the information already possessed upon this subject;
indeed, until we have an opportunity of studying it in the cadaver, we
cannot s{)eak very definitely of its anatomical characters.
N6laton observes that all the varieties of this fracture which he has
seen are often acx»ompanied with fracture of the styloid apophysis of
the ulna, and with a tearing of the triangular ligament. I am not
aware that any other writer has made the same observation in relation
to the frequent occurrence of a fracture of the styloid apophysis of th^
ulna, and I think the accident is not so common as the remark ^
N(»laton would lead us to suppose.
Dr. Butler, House Surgeon to the Brooklyn Hospital, rei>orts a
of fracture of the right radius at the junction of the middle and lov^?
thirds, accompanied with a fnicture also of the styloid a|)ophysis **
the same bone. The accident occurred in a lad fourteen years o^^
who had fallen from a height of thirty feet upon the pavement. T*^
lower fradure commenced at the base of the styloid process of t^
radius, and extended down obliquely into the wrist-joint, bri^aking €^
about one-fifth of the articular surface. The process was drawn up C^
the posterior surface of the radius, about one inch and a half, by xt^
supinator radii longus muscle. It was movable, but, in conscxjuen^
of the contusion and swelling, could not Ik? returne<l to its place. T\0
hand occupied the same position that it <1(k^ in Colles's fracture.
On the eighth day an attempt was made to force down the prooe^
with a compress secure<l by adhesive plaster straps; but it ctmld n(P
be done. The hand and arm were confined also to a ]>istol -shaped
* Boston Med. and Surg. Journ., vol. Iviii, p. 99.
* Trans. Am. Med. Assoc., vol. ix, p. 145.
COLLES S FRACTURE.
293
I
ulc«rflti<>tiB enxued from the pressure of the compress, and the
was laid bare, but it fiually became iinittHi in its abnormal
ition ; tbo motions of the wrist, however, were not impaired, and
power of pronation and supination soon returned.'
believe I have seen two examples of a fracture commencing on
iial side of the bone and terminating in the joint, the Be|)arated
ut inchiding considerable more than the apophysis ; but neither
e eases has been verified by an autoi)sj'. They were described
il in the third e<]ition of this book.
Eecently Dr. E, Moore, of Rochester, N. Y., has demonstrated by
iminalions upon the cadaver and by experiment, that in a certain
jporiion of tases the internal lateral ligament, and the triangular
iibro-(»nilage having given way under the ibrce which has occasioned
thefmcini'e, the styloid proet»s is thrust under the annular ligament
tnd imprisoned ; in ^t, the ulna becomes dislocated, and is retained
bvth« annular ligament in its new position. Nor can the reduction
of tk' fracture be aocompUshed until the ulna is released from its im-
ptiaoLnient- Reduction is to be accomplished by extension and partial
dRumduction ; the hand being grasped firmly and extended iirst to
thf radial side, then backwards to tiie ulnar side, and finally forwards,
w inllie position of flexion. During the entire nianieuvre the wrist is
Wd lirrafy by the opposite hand of the surgeon. The test of reiluc-
liiMi is to be found in the presence of the head of the ulna on the radial
*iili' iif the ulnar extensor.
In order to retain the ulna in place when re<luction ia effected, Dr.
MmitE places a thick, firm compress over its lower end, on the palmar
»xl ainar margins of the forearm, and secures this in place with a
**l band of adhesive plaster drawn firmly around the wrist. The
warm ia tlien placed in a narrow sling passing under the wrist and
•wniiress. This completes the dressing,*
In the first volume of the Philadifphla Medical Examiner (1838)
»ii! W found a description, by J. Rhea Barton, of Philadelphia, of a
[WB (jf fracture occurring through the lower end of the radius, which
*iirolfflbly much less conunon than CoUes's fracture, and which had
"lithtrto csca[>ed the notice of surgeons. Its peculiarity consists in
tlw line of fracture extending very obliquely from the articulation,
opu'ards and backwards, separating and displacing the whole or only
■ piirtioii, as the case may be, of the po.'Jterior mai^in of the articu-
latine surface. 1 have not recognized this fracture in any instance
thicii has come under my own observation, nor have I been able to
JoJa cabinet specimen in any pathological collection. Dr. Barton
' »M not able to prove the correctness of his diagnosis by an autopsy,
tixi ilic only well-authenticated example which I can find upon record
that to which Malgaigne has alluded, as having been seen by M.
ir, and of which an account was published in the Archives Qhii-
dt MHtcinr, in 1839. M. Lenoir believed it to bo a simple
lion of the band backwards, but the patient having died, he was
294 FRACTURES OF THE RADIUS.
able to correct his diagnosis by an autopsy. A considerable fragmenfc
had been broken from the posterior lip of the articular surface, the
line of fracture being from below upwards, and from before back-
wards. This fragment had become displaced upwards and backwards,
carrying with it the carpal bones, and producing thus the appearance
of a simple dislocation.* I believe that the accident so carefully de-
scribed by Barton was either a Colles's fracture, or a fracture sirapjr
of the radial margin, of which I have given two supposed examplea,
with the usual signs of which his account so exactly coincides, and that
it was not a fracture of the posterior lip of the articulating surface, as
he believed.
Ninety-eight examples of fracture of the lower third of the radios
have furnished no cases of non-union, nor indeed do I remember ever
to have seen the union delayed ; yet only twenty-six are jxwitively
known to have left no perceptible deformity or stiffness alwut the
joint: it is probable, however, that the number of perfect results might
be somewhat extended, inasmuch as in very many of the cases the final
results have not been noted. In one example, the case of a man whose
arm was broken in Germany, when he was only ten years old, the
fragments of the radius were driven into each other, or overlapped one
inch, and the ulna had been displaced downwards toward the fingers
the same distance. This was examined twelve years after the accident,
and he had then a very useful arm. Twice I have found the wrist and
finger- joints quite stiff after a lapse of one year; in one case I have
found the same condition after two years, in one case after three years,
and in two cases after five years.
If we confine our remarks to Colles's fracture, the deformity which
has been observed most often consists in a projection of the lower end
of the ulna inwards. In a large majority of cases this is accompanied
with a |KTceptible falling of the hand to the radial side, while in a few
it is not. After this, in jx)int of frequency, I have met with the back-
ward inclination of the lower fragment. Robert Smith found tbii
displacement almost constant in the cabinet specimens examined by
him ; and it is ver}' probable that nearly all of the examples examined
by myself would present more or less of the same deviation upon the
nakeil bone ; but in the living examples a slight deviation would be
concealcMl by the numerous tendons which cover this part of thesmif
and perhaps by some permanent effusions, of which I shall speak ni<>**
particularly presently.
There remains for a long time, in a majority of cases, a broad, fi^
uniform swelling on the palmar surface of the forearm, commencM^
near the upper margin of the anmilar ligament and extending upwawii
two inch(*s or more. This swelling continues much longer in old •>»
feeble |)ersons than in the young and vigorous. It is pretty geuerallf
pro|M)rtioned to the amount of anchylosis existing at the wrist 9X^
finger-joints, and it disappears usually pari jxi^ with these coodi^
tions. There (ran be no doubt that this |)henomenon is due to effu«K**
along the sheaths of the tendons, and in the areolar tissue external to
• Miilgaigne, Tmit^ des Frao., etc., torn, ii, p. 700,
the sheatlis, and it is as often prcspnt after sprains and other severe
injurit^ iibont this part, as in iractiirM. In many cases, however, its
[imlonged continuance and its firmness have led to a suspicion that
llic bones were displaced, a suspicion which only a moderate degree of
rare in the eTamination ought easily to disi»el. A similar effusion, but
in less amount. Is fi-eqiientiy seen also on the back of the hand, below
the annular ligament. When both exi.=t simultaneonsly the appear-
snccs of deformity and' of displawmcnt are greatly increased. Here,
tlim, we shall find a partial explanation of the anchylosis in the wrist
uid finger-joints, which continues occasionally many months, or even
ymrs, if, indeed, it is not permanent; an anchylosis produced in a
few instances by extension of the inflammation to these joints, but
f^mch more often by the inflammatory effusion and consequent ad-
teions along the theop and serous sheaths, through which the tendons
9 in their course to the hands and fingers, and also by simple
' fmtraction of the articular ligaments, as a consequence of disuse, or,
I* it is usually termed, by passive contraction of these lifipiments. The
fingers are q«ite as often thus anchylosed af^r this fracture as the
writ^-joint itself; a circumstance which is wholly inexplicable on the
tlMtrinc that the anchylosis is due to an inflammation in the joints.
InW, I have seen the fingers rigid after many months, when, having
"Wrml the case throughout myself, I was certain tliat no inflamma-
iwr action had ever reached them.
The [)ecu1iar swellings of the wrist and hand which have been de-
"^fihal above, commence to show themselves very »f;irly after the
f^eipi of the injury; but I have noticed, also, a swelling which is a
litll* later in its accession, namely, an indnratiou and fulness upon the
I nAof the hand, which corresjwnds ac<!urately to the position of the
I fttpsi bones, and presents an appearance as if ail the carpal bones were
r"¥htly displaced backwards. This phenomenon is probably due to
■ "ming and induration of the numerous ligaments which bind
lliSBher their bones posteriorly. It usually disappears after a few
I Ntwis it any more difficult to show, I think, that the anchylosis of
I w wrist-joint is not often due to a malposition of its articular surfaces,
■ •Wimtnently been a.saerted in the written treatises.
w ma«t superficial examination of the mechanism of this joint
Wght to satisfy tis, that any moderate or even considerable malposition
I.*flhe lower fragment after a fracture of the radius, is not sufficient in
■ ""etrto occasion anchylosis. It Is true that in the fractnre now under
"^WMiileratton, the direction of the articular surface of the radius ia
•wnitHl, and that, while it was directed downwards, forwards, and to
"K ulnar fiido, it is now, perhaps, directed downwards, l>ackwards, and
IJ" the radial side. But of what consequence is this so long as the carpal
ftBOMB, with which alone this bone is articulated, preserve their relations
IbtlwiBdius unchanged?
I If any other evidence be demanded, it may be supplied by the ex-
Bpfriencc t»f most surgeons In examples of anchylosis without djsplace-
f^wit; in examples of displacement without anchylosis, but in which
Btw am'liylosis has yielded gradually to the lapse of time, while the dis-
ppW'cmenl lias continued, The folluwing case is in point : James Ryan,
4
296 FRACTURES OF THE RADIUS.
a private in the 15th N. Y. volunteers, fell from a height into a dito
during the battle of Fair Oaks, Va., May 31, 1862, striking upon tli
palm of his left hand, and causing a simple fracture near the lower ew
of the radius, accompanied probably with impaction. I do not kooi
what treatment was adopted, but when he came under my observatioo
in March, 1863, at the Central Park General Hospital, New York,]
found the most extraordinary deflection of the hand to the radial sidi
which I have ever seen after this fracture. The hand could be tunwc
laterally, to a right angle with the arm; yet the motions of flexion sjni
extension at the wrist-joint were nearly as perfect as in the oppositi
arm, and the hand was in all respects as useful as before the accident
To what I have said as to the prognosis in these accidents, I may bi
Permitted to add the opinion of our distinguished countrjman Dr
lott, given in a clinical lecture before his class in the University ol
New York.
" Fractures of the radius within two inches of the wrist, where treatd
by the most eminent surgeons, are of very difficult managemeutso tt
to avoid all deformity; indeed, more or less deformity ma^' occur undei
the treatment of the most eminent surgeons, and more or less iraper
fection in the motion of the wrist or radius is ver}' aj)t to follow for :
longer or shorter time. Even when the fracture is well cured, an an
terior prominence at the wrist, or near it, will sometimes result fit>'
swelling of the soft parts."
To which the reporter, himself a surgeon in the city of New Yor
adds:
"As the above opinion of Professor Mott coincides with my o^
observations, both in Europe and in this city, as well as with many
our most distinguished surgical authorities, I venture to hojie that
may assist in removing some of the groundless and ill-meritc<l asp^
sions which are occjisionally thrown on the members of our professi
by the ignorant or designing."*
In evidence that we have not yet attained all that we could dea
in the treatment of this fracture, I will quote farther:
" In young subjects, fractures of the lower end of the radius are ear
reduced, unite readily, and leave the use of the limb perfectly unii
paired; but in old persons, who, as l)efore stated, are t»s})ecially lial
to this injury, the result is often most unsatisfactory, even after t
greatest care has been used during the treatment. It is frequent
months before the hand is free from pain and regains its profier nuttioi
and too often an unsightly, crooked, and permanently stiff' wrist l
mains, to the great inconvenience and annoyance of the patient,"*
"Union occurs in about a month, but rarely without some displai
ment."'
"In a large number of cases it is impossible to loosen the impact
fragments."* Ashhurst and Gross exj)ress similar opinions. liCt I
add that several cases treated lately, under my observation, by t
* BoFton Mod. and Suri;. Journal, vol. xxv, p 289.
« Holm<*R'« System of Surjc»'ry, AmoricMii cd., 1870, vol. 2, p. 7W.
* Oant'ii 8y»t»*rn of 8uriji»ry, London, 1871, p 4f}H.
* Bryant's Surgery, London, 1872, p. U37. See aUo opinion of CAll(*ndcr on mo
COLLES'a FBACTUBE. 297
plaster of Paris and by Moore method, both of which have recently
been mach employed in this country, have given do better average re-
Milts than have been obtained by other methods.
Of gangrene as an occasional result of this fracture, I ehall speak
presently, in connection with tlie subject of treatment.
The peculiar character of the displacement which characterizes
CoUes's fracture, and the constant difBculty experienced by surgeons
in obviating deformity, have led to much speculation and ingenious
mvention ; and modern sui^eone, especially, have thought it necessary
to introduce here an essential modification of the usual apparel for
broken forearms. This modification consists in employing a pistol-
shaped splint, instead of a straight splint, by means of which the hand
nuj be thrown more or less strongly to the ulnar side.
UeisteH speaks of inclining the hand to\vard the ulna, while reduc-
ing a fracture of the radius, but when the reduction has been effected
he recommends a straight splint.
Among the first to advocate the permanent confinement of the hand
inthia position, were Mr. Cline," and M. Dupuytren.* Mr. Cline, and
(fter him Bransby Cooper,* and Mr. South,* recommend the ordinary
Einigbt splints for the forearm, hut the rollers by which the splints are
terared in place are not permitted to extend lower than the wrist; so
llut when the forearm is suspended in a sling, in a state of semi-pro-
utioo, the hand shall fall by its own weight to the ulnar side.
Dnpuytren, and after him, Chelius, adopt, in addition to the palmar
ud dorsal splinte, the "attellc cubitale," or ulnar splint; which is a
intta', composed of steel, iron, tin, or some other metal, and made to
'tlhe ulnar mai^in of the forearm and hand, when the hand is drawn
"^bly to the ulnar side. Blandin,* N^laton,' and Goyraud,' also,
■wler certain contingencies employ the same.
Most surgeons, however, employ either a palmar or a dorsal splint;
wboth palmar and dorsal splints constructed with a knee, or pistol-
**pal, and they thus avoid the necessity of the ulnar splint. Thus,
Wlaton,' Robert Smith,'" and Erichsen," recommend this peculiar form
wljin the dorsal splint; while Bond,'* Hays," E. P. Smith," G. F.
Shrady," and others, especially among the Americans, place the pistol-
^Tert splint against the palmar surface of the forearm and hand,
A few modem surgeons have not seen fit to adopt this peculiar prin-
^P^ of treatment, or this form of dressing under any of its modifica-
' ^IdTrentii Heigteri,In«titutioiieBCbirurgic», psrspriins,p. 203, Amsterdam
' M..li;,i,g,i... TraiW do Frac, etc., torn, i, p. 614, Paris cd.
; ^.[iiiiiri'ii on Bones, London ed., p, 140.
J li r.rjper, X,ecture« on Siir^., p. 232, American ed.
'-'^"iiu- '^ Sur^., vol. i, p. SIS. ' Malguignfl, op. cit. torn, i, p. 614.
; N.ilni,FL, Klfim. do Path. Chir., torn. I, p. 747.
l;>i;l.,I. 748,
II >f!j.i"ii,op cit.,p. 747. '* B. Smith, op. cit., p. 168.
tnchien, SuTtfevy, p. 216.
" "Id. Amer. Journ. Med 8ci , April, 1852. » Ibid., Jan. 1858.
»■ P. Smith, BiilTalo Mad. Journ., vol. ix, p. 225,
' %ndjF, Am. Had. Timei, 2 casea, Dec. 22, 1660.
FSACTDREB OF TH
BADinB.
tioRB. Colles* recoranaends a straight palmar and doisal split
does DOt incline the hand. Barton* advises the same, and Skey
in^ declared his preference for a couple of broad, straight spIiotSj
"Great care should be taken to prevent the hand felling, and tli
NtUUn'a apllDt for Aielunat
ject will be attained by inclosing the entire forearm and band in a
applied sling."*
Stephen Smith employs two broad, straight, palmar and <
Hplints, secured in position by adhesive strips, the hand Iwing tl
to the ulnar side by reversed turns of adhesive plaster.
Profemor Fauger, of Copenhagen, has undertaken to treat thii
ture in some sense without any splint, the forearm and han]
i. * Barton, PhiL M«d. Kzam ,
COLLES'S FBACTURE.
299
amply laid over a double-inclined plane, so as to bring the wrist into
a state of forced flexion. ''The hand having been brought intoaposi-
tkm of strong flexion, the forearm is placed, pronated, on an oblique
plaDe,with the carpus highest, the hand being permitted to hang freely
down the perpendicular end of the plane." ^ M. Velpeau, in a report
FlO. 101.
E. P. Snitb'i splint Sarlkce applied to forearm. A. Forearm piece, made of felt, with
incunrated margins.
of his surgical clinic at La Charity for the year ending September,
1846, says this plan has been tried during the year, and " the result
Fio. 102.
C —
E- P Snith'i iplint B. Opposite surfkce. D, the hand-block, it connected with the forearm piece
^tvvcimiUrbms plates, which move upon each other, in order that the hand-block may assume
ttf doired angle with the arm. In this way it may be adapted to either the right or left arm. It
>tu4 br a out, seen on the brass plate. Tlie letters C C indicate the extent of motion allowed to
«* not been very satisfactory. The experiment, however, has not
wen decisive upon this mode of treatment."^
Fio. 103.
Jj^rF.Bhnnly»g gpiint To be applied to the palmar surface of forearm and hand ; the hand
l^wMdcd towaxd the alna. A strip of adhesive plaster encircles the forearm and splint near
*j^- A loop it abo formed for the ulnar margin of the wrist by passing one end of a strip of
'■■||v.tkne faKhcs in width, between the palmar surface of the wrist and the splint, over on the
"^"'k* wrist; both ends being then brought around and made adherent to the under surface
")* V^ iM/Hjt Uie hand la secured to the hand-piece by a circle of plaster; the dorsal splint,
. "y^**» then be ^ipUed In the usual way. Passive motion is made every second or third
^''"rcaiilactlM apparatas at wriat and freeing the hand.
^ Faager, London Lancet, May 8, 1847.
> Yelpeaa, Boston Med. Journ., yd. xxxy, p. 218.
300 FRACTURES OF THE RADIU8.
Notwithstanding these exceptions, the practice seems to be pretty
well eslablished among the lading surgeons everywhere to empkf
iu the treatment of this fracture the principle of adduction of tK
hand, and always to the attainment of the same purpose, aamelf,
rotary ejitension, by which they hope to retain more securely the lower
frt^ment in place.
The late Henry 8. Hewit, of this city, devised a very ingeDiDaa
splint, by which the mobility of the wrist and lingers might be more
perfectly retained. The following is the description given by himeelf
of the apparatus: "The wooden mII grasped by the liand is connected
by & rud to a slender bar running longitudinally upon the face of the
splint, and capable of being Hexed at any desirable length. The roo
is attached to tlie travelling connection hy a universal joint, giving
play to the ball in limited movements of flexion, extension, pronstioUi
and supination. The natural tendency is for the patient to make the^
movements, and to perpetually relax and contract the fingors, '^K
splint ujwn the inner surface of the arm is antagonized bv a plain A <
splint on the outer surface, extending to the superior bonier of '
wrist-joint. This splint has been used for upwards of two yeare
myself and others, [wirticularly by Dr. W. T.White, at the Dec=3
Di.-pensary, and has given good results.'"
We come now to consider how far this peculiar treatment, ulnar
clination, is capable of answering the special indications of the casi — "■
are studying.
It is assumed, as I have already intimated, that, by bearing the h -=
strongly to the ulnar side, the fragments of the radius are broi^^
more exactly info apposition, and more easily and cfTectually retains*""
an assumption which supposes two things to have been determii^»^
first, that there exists an overlapping of the fragments, either thro- "•!
the whole extent of their broken surfaces or especially toward "
radial side, or that the upper end of the lower fragment is inclinei^>'
fall against the ulna, or that all of these several conditions coe^i^i
> Hewit, Medic*! Becord, April 1, 187S.
I
COLLES'S FRACTURE. 301
iody seoondly, that if such displacements do exist, they can be reme-
died by this manoeuvre.
The first of these suppositions seems to have been sufficiently con-
sidered by all those gentlemen who have particularly examine<l the
specimens contained in the various pathological collections, and to
whose careful investigations I have already frequently adverted. With
i»pe exceptions, none of these displacements have been found to exist,
ftlthou^h, as has been observed, a casual inspection of the arm when
recently broken would often lead to an opposite conclusion. I do not
here speak of impaction, which is usually upon the posterior margin,
if it exists at all.
In regard to the second supposition, namely, that where such dis-
placements do exist, a forced adduction will aid in the retention of
the fragments, I shall have to speak more cautiously, because, so far
as I know, my opinions have received as yet no public and author-
itative indorsement. In order that adduction may prove effective,
there must be some point upon which to act as a fulcrum. It is of
no use that we rotate the hand for the purpose of making extension
anless there can be found a resistance or fulcrum upon which the
rotary motion may be performed. Such a fulcrum exists, no doubt,
hut to determine its availability we must ascertain its character and
position.
It is not in the lower end of the ulna, for the ulna has no point of
Cf>ntact with the carpal bones, and when, in the natural state of these
iwrts, the hand is inclined to the ulnar side, the lower end of the ulna
«S<les freely downwards upon the wrist until arrested by the ligaments
"^hich unite it with the carpus, or by the capacity of the joint to admit
of motion in this direction. When the lower end of the radius is
broken, and the ligaments of the joint are more or less torn, the ulna,
^thou^h thrust downwards much farther perhaps than it could ever
Ascend in its normal state, still fails to find a support, and spreading
^rider and wider from the radius as it is thrust farther upon the hand,
IK) limit can be given to its progress in this direction. It was thus
tbit, in one example already mentioned, I found the ulna carried
downwards one inch or more.
The resii.stance will, then, in nearly all cases, be found to be in those
ligaments which bind the lower fragment to the lower end of the ulna,
wd the ulna to the carpal bones, viz., the radio-ulnar, and the internal
Wml ligaments, which in the normal state of the parts constitute the
«ntre upon which forced adduction expends its power, and which
<ill continue to be the point of resistance when the radius is broken.
B«t how feeble and uncertain must be a resistance which depends
»Wy on these injured ligaments ! And how ]>ainful to the |mtient
■08t be an extension sufficient to overcome the action of nearly all
4e mdfieles of the wrist, which is borne entirely by a few lacerated
vd inflamed fibres! even in health this position, when forced, cannot
^ endured beyond a few seconds, and it must be difficult to estiniate
4e soSerings which the same position must occasion when the liga-
^'^^ are torn and inflamed.
302
i OP THE RADIUS.
I am not to be told that surgeons have not inlended to advocate this
extreme practice ; that they have never recommended forced adduc-
tion, but only a moderate and easy lateral inclination, such as can
be comfortably borne. If they have not, then they shouJ<l not liava
spoken of making extension by thia means. An easy lateral incline
tion has no power to do good so far as extension is concerned, any
more than it has power to do harm. But the fact is, while a majori^
of surgeons have no doubt used less force than was hurtfnl, some have
used more than was useful or safe; indeed, the sharpness of the curvs
given to the splints figured and recommended by Dupuytren, N6latoD,'
and others, sufficiently indicates that their distinguisned inventors in-
tended to accomplish by these means a forced and violent adduction.
Malgaigne, speaking of other means of extension applied to the fure-'
arm, suggested by Godiu, Diday, and Velpeau, intended to operats'
only in a straight Uue, and, alluding especially to the modes devised
by Huguier and Velpeau, remarks: "Without discussing here ttw:
comparative value of the two forms of apparalns, I believe thai thoy-
could scarcely be endured by the patients; and M. Diday tells us xiiii-
in the trials which he has made, the pain produced by tlie extension
was so great that he was com[)elled to renounce it." Which obser\-a-
tioDS cannot but apply equally to this plan of extension by adduction
or to any other which might be adopted.
After all, it must not be inferred that I have concluded to reject
this mode of dressing in all of its modilications; tor although I am &r
from being persuaded of its utility as a means of extension and r«teiH
tion in any case, yet I am not prepared to deny to it some very ooiisid-^
erable value in another point of view ; and when judiciously emploved
it can certainly do no harm. It is, I repeat, fi»r another reason alti>>
gether than ihe one heretofore assigned, that I would recommend its
continuance, a reason which I cannot so well explain, or hope to r«ndrt
intelligible, except to the practical surgeon. This jtosition throw's thl
whole lower end of both radius and ulna outwards toward the radtd
margin of the splintSj and by keeping the radius more completely il
view, it enables the sui^jieon better to judjfe of the aocuniey of the n
duction, and to recognize more readily the condition and situation a
the compresses, etc. This alone I have always considered a siilficii-ni
ground for retaining the angular splint; although 1 have tn^atvd ft
great number of arms satisfactorily with the straight splints alone.
Finally, while surgeons have been seeking to accomplish an indica-
tion, the existence of which is at least rendered doubtful, aiid hy
means which appear to me totally inadequate, if it did exist, titer haw
probably too often overlooked or regarded indilfercntiy an iDdicalioi
which is almost uniforndy present, namely, to press forwards the tilw
fragment by a force applietl u{>on the wrist from l>ehind, and to retiii
it in place by suitable comprcs.s«!i. And 1 cininut help thinking titat
if they had rt^rded this us the sole indication in most rasv*, an ii
cation generally so easily accomplished, they would have made fe
crooked arms, und have saved their patients much suflering and thi
selves much trouble. Some of the cases which 1 have reported in
■l-
■«■'
F ■ -
COLLES'S FRACTURE. 303
early part of this chapter are intended to illustrate the value of this
principle.
In case the ulna is dislocated also, and is imprisoned by the annular
ligament, circumduction with extension, as practiced by Dr. Moore,
and heretofore described, will be required.
It only remains for us to determine the precise form of splint which
tt to be preferred, and to describe its mode of application.
le narrow "attelle cubitale" of Dupuytren is inconvenient; nor
CMi I give the preference to the curved dorsal splint recommended by
Ndaton, and employed by Robert Smith, Erichsen, and others. It is
not to me a matter of entire indifference, in case only one curved splint
is emplojedy whether this be applied to the palmar or dorsal surfaces
of the forearm. Foreign surgeons, so far as I know, have applied this
^Ijnt to the dorsal surface, and the straight splint to the palmar;
while American surgeons have adopted almost as uniformly the oppo-
site rule — to whose practice, in this respect, I acknowledge myself
abo [lartial. It is to the curved splint rather than to the straight that
We mainly trust ; not simply, or at all, prhaps, because of its form,
bat because the curved splint is also the long splint. This is the
splint, therefore, which ought to be the most steady and immovable
in its position. Now, the very irregularities of surface u|>on the
palmar aspect of the forearm and hand, instead of constituting an
embarrassment, enable us, when the splint is suitably prepared and
^justed, to fix it more securely. Moreover, upon it alone, after a
fcw days, the surgeon may see fit to rely, and in that case it ought to
be applied to that surface of the arm which is most tolerant of con-
tinued pressure. The palmar surface, as being more muscular, and
as having been more accustomeil to friction and to pressure, must nec-
«8iarily have the advantage in this raspect. The palmar splint termi-
nating also at the metacarpo-phalangeal articulations, instead of at the
*^pri*t, as the short straight splint must do when the hand is adducteil,
enable* the hand to be flexetl upon its extremity over a hand -block, or
pad of proper size. Soch are the not insignificant advantages which
^« claim for this mode over that pursued by our transatlantic brethren.
The block, suggested first by Bond, of Philadelphia, is a valuable
addition, siuce the flexed position is always more easy for the fingers,
Md in case of anchvlosis this position renders the whole hand more
usefnl.
For myself, I am in the habit of preparing extern |>orane<)Usly a
^int from a wooden shingle, which I first cut into the reipiirtite shape
*^ length; the length being obtained by measuring from the front of
^ dbow-joint. when the arm is flexed to a right angle, to the meta-
l^^iihalangeal articulations, the fingers being'first flexed. It ought,
"•Wto fall half an inch short of the bend of the ellxiw, to render it
'^ that it shall make no uncomfortable pressure at this point ; and
«*Jirection to measure with the arm flexed is of sufficient importance
^nnuki a repetition. The breadth of the splint should be in all its
2^jii9t «^DaI to the breadth of the forearm in its widest part, except
'n^e it is to receive the ball of the thumb, so that there shall be no
304 FRACTURES OF THE RADIUS. ,
lateral pressure upon the bones. If the splint is of unequal breadth, the ^
roller cannot be so neatly applied, and it is more likely to become ^
disarranged. Thus constructed, it is to be covered with a sack of cotton ;■
cloth, made to fit moderately tight, with the seam along its back, and afte^ >
wards stufled with cotton batting or with curled hair. These materials i-
may be passed in, and easily adjusted, wherever they are most needed, '.::
from the open extremities of the sack, ii
While preparing, the splint roast be w
occasionally applied to the arm until Ja
it fits accurately every part of the fore- j i
^^^^_^______^^_ arm and hand, only that the stuffing ^r
Author'8 palmar splint; right arm. must bc morc firm a little abovc tM j:
lower end of the upper fragment, and ;;
^'"- '^ in the hollow of the hand. Between .;
these two points there should be little '«
or no cotton. The open ends of the t
. .^ , , , ,. * sack are then to be neatly stitched
Authors dorsal Bp] int. . i /» i »• "k i • W
over the ends ot the spunt, aiter wnicn
the sph'nt may be laid directly upon the skin without any interooediate
compresses or rollers.
The advantages of this form of splint are easily comprehended. They
consist in facility and cheapness of construction, accuracy of adapta-
tion, neatness, permanency, and fitness to the ends proposed. There
is also no possibility of making painful or injurious pressure upon the
arteries or nerves which lie upon the front of the wrist.
The extemporaneous splint recommended by Dr. Isaac Haya, of
Philadelphia, is very similar, but it lacks the neatness and |)ermaDency
of that which I have now described.
In all cases it is better to employ, also, at least during the first fort-
night, a straight dorsal splint, of the same breadth as the palmar splinfi
and of sufficient length to extend from the elbow to the middle of the
carpus. This should bc covered and stuffed in the same manner as the
palmar splint, except that here the thickest and firmest part of the
splint must be oppasite the carpus and the lower fragment.
Having restored the fragment to place, in case of Colles's fracture,
by pressing forcibly u|)on the back of the lower fragment, the force
being applied near the styloid apophysis of the radius, the arm is to
l)c flexe<l upon the Ixxly, and placed in a position of somi-pronation,
when the splints are to be applie<l, and secured with a sufficient num-
licr of turns of the roller, taking e8j>ecial care not to include the
thumb, the forcible confinement of which is always painful and never
useful.
liCt me repeat that, in most cases, all of our success will depend npcNi
whether we employ sufficient force in the early stage of the a<*oideQl,
and in the right direction. When once reduced it is easily kept in
place.
I cannot too severely repn)bate the practice of violent extension of
the wrist in the efforts at reduction, when no overlapping or impniiicQ
of the fragments exists and the ulna is not dislocated; and tluit, whether
this extension be applied in a straight line, or with the liaiid adducted*
FRACTURE
; OP THE RADIUS.
tDthw'i drtHing compteM. Th« c
A bas been shown that in a great majority of cases no indication in
tfais direction is to be acconi-
pliilied; and to pull violently, . Fia.107.
oiMler these cimimstancefi, upon
tht wrigt, is not only useless but
hurtful. It is adding to the frac-
tnre, and to the other injurios
already received, the graver path-
ologiral lesion of a stret^iliing,
a sprain of all the ligaments con-
nected with the joint. I am per-
suaded that to this violence, add-
ed to the unequal and too firm
preeenre of the splints, are, in a
grreat measure, to be attributed
ihe subsequent inflammation and
anrhylosis in very many cases-
The first appli<>ation of the
Widages ought to be only moder-
ately tight, and as the iiiflamma-
ttonand swelling develop in these
Iitmccnres with rapidity the baud-
^shonld be attentively watched,
\ ind lorjeened as soon as they be-
' come painful. It must be con-
•<aDtly borne in mind that, to pre-
vent and control inflammation, in ^
tkiA fracture, is the most difficult
tnd by far the most important object to be accomplished, while to retain
the fragmeuls in place, when once reduce<l, is comparatively easy.
During the first seven or ten days, therefore, these casts demand the
most assiduous attention ; and we had much letter disiwnse with the
tplints entirely than to retain them at the risk of increasing the inflam-
matory action. Indeed, I have no doubt that verv many cnses would
eome to a successful termination without splints, if only the hand and
arm were kept perfectly still in a suitable {vosttion until bony union
was effected.
I most also enter my protest against many or all of tliosc carved
"plints which are manufacture<1, tinwked about the countr}', and sold
w mechanics, who are not suiiroons; with a fossa for each styloid pro-
MSia ridge Ut press between the bones, and various otlicr curious nro-
vijioBi for supposed necessities, but which never find in any arm their
eiact coanterparts, and only deceive the inexix^ricrK-wl surgeon into
neglect of the proper means for making a suitable adaptation. They
we the fruitful sources of excoriations, ulcerations, inflammations, and
deformities.
In reference to the treatment of these fractures, the following cases
■nd the accompanying remarks, by that great sui^eon, Diipuytren, are
too pertinent not to merit a place in every treatise of this character.
"The two succeeding cases are not only interesting as fractures of
tite radius, but they are farther deserving of attentive consideratioD, on
ftccoHDt of the serious complications whiph accompanied them, and
which were the consequence of forgetting an important precept. More
than mice, indeed, it has occurred that the surgeons have been bo Jutvnt
on preserviag fractures iu their propel- position that the extreme con-
striction employed has actttally caiued destruction of the sofl: parts, A.
piece of advice which I liave very frequently given, and which I can-
not t/>o often repeat, is to avoid tightening too much the apparatus for
fractures during the first few days of its being worn ; for the swelling
which supervenes is always ncooinpuuied by considerable pain, and may
be followed by gangrene. It cannot, therefore, be too urgently im-
pressed on young practitioners, to pay attention to the complaints whidi
patients make; aud to visit them twice daily, and relax tlic IwndagM
and straps as ueed may be, in order to obviatethe frightful i:«nsc<iiieDcca
which may spring from not heeding this necessary prvcautiou ; bv cars^
fully attending to this jxHut I have been saved tlte [tainful alternative'
of ever having to sacritice a limb fur complications whidi its nc^Mt
may entail.
" Antoinc Kilard, ret. 44, fractured his right radius whilst going down-
into a cellar, in Feb, 1828, and went at onCe t'> the Hospital of La
Charity. When the fracture wxis ro<luced (it was near the base of iba
bone) an apparatus was applied, b<it fastened too tshtly ; and, notwitti-
stauding the great swelling and the ikcute |min w-ltich the {wticnt
dured, it was not removed until the fourth day, when the hand
cold and ocdetnatous, aud the forearm red, painful, and c«vereil with'
vesications. Leeches, poultices, and fometttatious were applied,
followed by some alleviation of the loc»l symptoms, though there
much constitutional disturbance. At the close of a fortnight from lb*
accident, the jialmor surface of the forearm )>resent>:'(] ii ]M)i»t whew
fluctuation was supposed to exist; but when a bistoury was plungni
into it uo matter followed. Portions of the tiexw muscles suh6e<)ueutljr
sloughed, and the skin subsequently raortiliGd. The only resoume m
amputation, which was performed above the elbow six weeks »(ter hi
admission ; and he afterwards recovered without the ocrurrenoe of any
further untoward symptoms.
" R., at. 36, was at work boring an artesian well in 1832, when b*
was struck by part of the machinery on the right forearm ; he was in-
stantly knocked down and thrown violently on the right thigh. A
surgeon who was sent for detcjtetl a fracture of the rudiiis, and ap)ilieil
the usual apparatus, consisting of pads and splints, confined by a roller
extendti^ from the extremities of the fingers to the elbow, whidi ton-
pressed the arm so tightly as to give rise to very great suftiTinfr. V»
fingers, hand, and forearm were numbed almost to iiisensiliilily, u'
yet the surgeon in attendance did not think projter to loosen the api*-
ratus. 8uch was the condition of the patient until he came to tiv
Hotel Dieu, four days after the accident; the fiiigvre were then bUA,
oi>ld, and insensible, and when I removed the splints I found the hxii
likewise black, especially on its palmar surface. The lower [wrtof ik
forearm was a shade less livid, but eoually cold and insensible; W
several vesicles filled with pink-coloreu serum were appareut on Ivlh
FRACTURES OF THE RADIUS.
its surfaces where the epIiDts hud prvssed ; the uppc-r part of the fore-
arm was inflamecl, swollen, and very puinful. He was liled and lecclies
were applied to the inflamed part of the arm ; camphorated t^piric was
applietl to the fingers.
"On the following day heat was restored as low as the wriat, but
iht hand remained for the most part livid iind cold, and the radial
artery did not pulsate. Seventy leeches were applied to the forearm,
and the local EippHcaliou was continued." On tiie second day after
admission thirty more leeches were applied. On the fourth day the
* ind looked a little better, so as to "encourage some hope of its being
; but this was again blighted on the sixth day, by the eulire lose
t heat and sensibility in the part and incrcasetl pain and swelling in
'le forearm, to which the gangrene subsequently extended. On the
raltlh day amputation was performed at the elbow-joint; but the
Uieutdid not survive (he operation more than ten days, the imnie-
4mie cause of death being acute pleurisy. There was a considerable
quantity of purulent serosity poured out on the right side of the chest;
Bud aheeesees were found in the lungs and liver. On examining the
srm, there was found to be a simple fracture of the radius about its
(Mtre.
"The almve mae presents a painful illustration of the neglect to
wliifh I have alluded. In nearly every instance the swelling of the
limb rMjU ires that careful attention should be paid to the bandage or
anrs, by ivhieh the apparatus is confined. Similar accidents are
likely to result from the employment of an immovable apparatus, of
*liieh an example occurred in the practice of M. Thif-rry, one of my
pif\U. He was summoned to visit a young girl, on whom such an
apparatus had been applied for supposed fracture of the radius. After
siilleringexcruciatiug torment, the forearm mortified, and amputation
*w llie only resource; on examining the limb no trace of IractHre
wiiid be discovered. Had u simple apparatus been here employedf
^ixlpMperly watched, this patients limb would not have been sacri-
Swil."'
Koliept i^mith mentions, also, the case of a boy, ost, 18, who had a
I ™ture of the lower extremity of the radius, through the line of the
I JOoition of the epiphysis with the diapbysis, caused by being thrown
(B a horse. A surgeon appiied, within an hour, a narrow roller
htly around the wrist. On the following day the limb was intensely
NuCul, cold and discolored ; still the roller was not removed, nor even
Vktitied. On the fourth day be was admitted into the Richmond
Ijilal, when the gangrene hud reached the Ibrearm. Spontaneous
ntioD of the sou parts finally occurred, and the Ixmes were sawn
wgh twenty-four days after the fracture was produced, from which
W'everything proceeded favorably.'"
"iv, 21, 1851, a Ixiy, ten years old, living in the town of Andover,
I., had his left hand drawn into the picker of a woollen mill, pro-
308 FRACTURES OF THE RADIUS.
ducing several severe wounds of the hand and a fracture of the radios
near its middle. One of the wounds was situated directly over the
point of fracture, but whether it communicated with the bone or not
was not ascertained. A surgeon was called, who closed the woorMb,
covered the forearm with a bandage from the hand to above the elbow,
and applied compresses and splints. This lad made no complaint, his
appetite reinaining good and his sleep continuing undisturbed, until
the third day, when he began to speak of a pain in his shoulder; on
the same day also it was noticed that his hand was rather insensible to .
the prick of a pin. Early on the morning of the fourth day hissof- ?—
Cn being summoned, found him suffering more pain and quite rest- ]
i ; and on removing the dressings, the arm was discovered to be in- f-
sensible and actually mortified from the shoulder downwanls. *_
Opiates and cordials were immediately given to sustain the patient, ."=
and fomentations ordered. i_
On the sixth day a line of demarcation commenced across the shoulder, r
and on the twenty-first day the father himself removed the arm ftom -^
the body by merely separating the dead tissues with a feather. Subfie-
quently a surgeon found the head of the humerus remaining in the
socket, and remove<i it, the epiphysis having become separated from
the diaphysis. The boy now rapidly got well.
In the year 1853 this case became the subject of a legal investigi-
tion, in the course of which Dr. Pilsbury, of Lowell, Mass., declared
that in his opinion this unfortunate result had been caused by too
tight bandaging, and by neglecting to examine the arm during four
days.
On the other hand, Drs. Hayward, Bigelow, Townsend, and Ains^
worth, of Boston, with Kimball, of Lowell, Drs. Loring and Pierce,
of Salem, believed that the death of the limb was due to some injary
done to the artery near the shoulder-joint; and in no other wbv coald
they explain the total absence of pain during the first two days ; nor
could they regard this condition as consistent with the supposition thai
the l)andage occa^^ioned the dejith of the limb.*
I cannot but think, however, that these gentlemen were ml^^taken,
and that the giingrene was alone due to the bandages. In a similar
case which came under my own ol)si»rvation, and in which both the
radius and ulna were broken, the roller extended no higher than jusi
above the elbow, and the patient complained of no pain until the liand-
ages were unloaded, yet the arm separated at the shoulder-joint. I
shall ref<T agjiin to this example in the chapter on fractures of the
radius and ulna; and I shall take occiu<tion then also to s|)eak more
fully of the causes of these terrible awidents.
Norris nientions another case of compound fracture of the lower end
of the nidius which rafue under his notice at the Pennsylvania Hospitml
in August, 1837, the arm having been dressed by a surgeon within
half an hour after the accrident, M'ith bandages and splints. When
these l)andages were removed at the hospital, on the fit\h day, ** the
* Boat. Med. tnd Surg. Journ., vol. xlviil, p. 281.
FRACTURES OP THE RADIUS. 309
4iA parts around the fractare were found to have sloughed, an abscess
extended up to the eHK)w-joint, and sloughs existed over the condyle.
Severe constitutional symptoms arose, making amputation of the arm
necessary."*
A lady, »t. 50, was also seen by Thitoy, who, having broken the
radius near its lower end, lost her fingers by the sloughing consequent
upon a tight bandage.^
A woman was admitted into one of Dr. Wood's wards in the Belle-
vue Hospital about the 1st of February, 1863, who had fallen upon
her hand a few days before and broken the radius just above the wrist.
Bcr arm was dressed with splints and bandages at one of the dispensa-
ries in this city. (Jangrene ensued, and when I saw her on the 8th of
February, the death had extended to the middle of the forearm, the
dead tissues being dry and black. Dr. Wood amputated the arm, but
she died.
The remarks which have now been made in relation to the treatment
of Colles^s fracture, are applicable, with only such slight modifications
as would naturally be suggested, to fractures of the lower end of the
ndins commencing upon the radial side of the bone and extending
obliquely downwards into the joint; and it is to this form of fracture
especially, that the pistol-shaped splint must be found applicable. If
tne fracture actually extends into the joint, it must not be forgotten
that, in order to the prevention of anchylosis, the wrist should be early
rabjected to passive motion.
The following example of a compound comminuted fracture of the
ndius may serve to illustrate the value of a somewhat novel mode of
treatment under certain circumstances :
William Croak, of Buffalo, eet. 30. January 29, 1856, a large piece
of iron casting fell upon his arm, crushing and lacerating the wrist,
tod comminuting the lower part of the radius; he was immediately
taken to the Hospital of the Sisters of Charity. I found the whole of
the sod parts torn awny in front of the joint, and the fragments of the
radios projected into the flesh in every direction. The hoj)e of saving
the hand seemed to be scarcely sufficient to warrant the attempt; at
least by the ordinary mode of procedure. I, however, stated to the
gentlemen present, among whom were Dr. Rochester, my colleague,
and the house surgeon. Dr. Lemon, that I believed it could be saved
if, having removed the fragments of the radius, we practiced resection
of the lower end of the ulna, and allowed the muscles to become com-
pletely relaxed. Accordingly, after placing my patient under the in-
flooioe of chloroform, I enlarged the wounds so as to enable me to re-
move six or seven fragments of the radius, leaving others which were
broken off but not much displaced. I then removed with the saw one
indi and a half of the lower end of the ulna. The hand was immedi-
ately drawn up by the contraction of the remaining muscles, but their
tension was completely relieved.
* KorrU, note to Liston's Surgery, p. 64.
* Amer. Journ. Med. 8ci., vol. xxv, p. 461, from L'Exp^rience for 1S8S.
FRACTUKES IIF THE RADIUS.
The wounds were closed and dressed lichtly, and the whole limb ««
placed on a broad and well-padded splint oovered with oiled cloth.
The hand, whieh was very pale and exsanguine, was a
Fi'i. ii«, gr^] ^^.jt^^ warm cotton batting.
The subsequent treatment was changed from time
time to suit the indications; but his recovery was rapid and
complete, nor was there at any time excessive inflammation
in any part nf the limb.
I have seen this man frequently since he left the hospi-
tal, and while he has recovered only a little motion in the
wrist-joint, his hand and fingers are nearly as useful as be-
fore the accident. He is able to perform all ordinary kind*
of labor with almost as much ease as most other men ; aai,
what is always gratifying to the humane surgeon, he doM-
Dot fail to appreciate fully the service which has been ooa-
fcrred u|>on him by the preservation of his somewhat mu-
tilated hand. '
I have recently adopted the same treatment with equal^
success in a case of gunshot wound of the lower eud of the
radiuH.
Epiphygrnl SeparaHons. — This bone is formed from thre
centres, namely, one for the shaft and one for either ex-'
tremity. The shafl is ossified at birth. About the end of
the second year ossification commences in the lower ti»iphy-
Bis, and it becomes united to the shafl at about the tweif
'^'"'"^'' tieth ye»r. The same process commences in the i>pper
(iroiuunij.) epiphysis at about the fifUi yeiir, and is completed by con-
solidation with the shaft at the age of puberty.
I have met with no recorded examples of senaratiou iif the upp«r
epiphysis, and the examples of separation of the lower epiphysis \>»\f
widom been clearly made out. I have already mentioned one a*i
having been reported by Robert Smith. He speaks also of other cwai
oiwurring in conjunction with a separation of the lower end of the ulna,
and which is very liable to lie mistaken for a dislocation.'
The treatment of this accident will not require any sj>ecial considem-
tion, since it will not differ essentially from the treatment required ia
a fracture oocurring at the same point.
' Robert Smith, op. i
., p. 164.
n
FSACTDHE6 OP THE VLSJl.
CHAPTER XXIL
FRACTURES OP THE ULNA.
i 1. Shaft of the Vha.
«. — The shaft of the ulna, wlien it alane is flie seat of fractnre,
■ally broken by a direct blow. I have never seen an excep-
■his rule; but Voison ins related in the Gazette Midicale for
single exception, in which it was said to have been broken by
>on the palm of the hand. Malgaigne thinks it is most often
when one seeks to ward off a blow with the arm ; but it has
d most oAen to me to see it broken by a fall upon the side of
of Fradure, Direction of DispJateximf, etc. — In an analysis of
iree cases, I 6nd the shaft, has been broken eleven times in
r third, twelve times in its middle third, and ten
its lower third. All portions seem, therefore, Fia.'i<n.
mt equally liable to fracture. I think, also, the
< have generally been oblique,
iry to what ha« been observed by other writers,
oticed that DO law prevailed as to the direction
li the fragments have become displaced ; the
!nds being found directed forwards, backwards,
or outwards, according to the direction of the
ich has occasiooed the fracture ; and this is in
ce with the general rnle in other fractures
id by direct blows. No doubt, however, other
eing equal, the tendency of the lower fragment
: towara the interosseous space, in consequence
tion of the pronator quadratus in this direction;
i upper fragment, owing to Its broatl and firm
on at the elbow-joint, can only be displaced
or backwards, at feast to any great extent.
catiana. — In no case of the shaft of a long bone
lund serious complications more frequent than
•es of the shafl of the ulna. Four have been
I; eleven complicated with a forwanl, or for-
outward dislocation of the head of the radius; Fr«ciu»'>ftiK
a partial dislcxation of the lower end of the •'■»ftof hwoIm.
ekwardu; and one with a Hislocation of both
I ulna backwards at the elbow-joint. It will be seen, ibere-
sixteen, or nearly one-half of the whole number, have been
umplicated.
M. — Occasionally this fracture-is found to exist without sen-
312 FRACTURES OF THE ULNA.
sible displacement. In such cases the diagnosis is sometimes difficult,
and can only be determined by the crepitus and mobility. If, how-
ever, the ulna is firmly seized above and below the point which hu j^
suffered contusion, and pressed in opposite directions, these signs will ^
generally be sufficiently manifest, and will render the diagnosis certain. |—
But in cases where there is considerable displacement, the imier fS
surface of the bone is so superficial as to enable us to detect its devi- fe
ations with the eye alone, or, when swelling has already occurred, by
the fingers carried firmly and slowly along this margin.
If the head of the radius is dislocated also, the displacement of the
broken ends of the ulna must alwavs Ihj considerable, and the coo-
sequent deformity palpable. I have known one instance, however, lo ^
which a surgeon living in the neighboring province of Upper Cauadi ^
recognized and reduced a dislocation of the radius and ulna backwards, m
but did not detect a fracture of the ulna two inches above its lower m^
end. Six months after, in the month of March, 1856, the patient ^
called upon me with a marked deformity near the wrist, occasioned by ^
the backward projection of the broken ulna, and with a complete lfl» t
of the power of supination. It will not surprise us tliat this fracture jp
was overlooked when we learn that the man had fallen fifty-five feet Ik
Prognosis, — In simple firictures the prognosis is generally favorable, ^
since no overlapping can occur, and the lateral displacements are not
usually sufficient to produce a marked deformity, or to interfere materi-
ally with the functions of the arm ; yet it is not unfrequent to find the
fragments inclining slightly forwards or backwards, inwards or out-
wards. If the fragments fall toward the radius, I have noticed in
three or four instances a slight projection of the lower end or styloid
process of the ulna to the ulnar side; but not interfering in any degree
with the motions of the wrist-joint.
I have seen the radius left unreduced nine times after a fracture of
the ulna, and in each example the forearm was shortened. A boy, m!L
17, was struck by a h>comotive, and severely injured in various parti
of his body, June 5, 1855. I saw him, with two very intelligent ooan*
try practitioners, a few hours after the accident. The whole left arm
was then greatly swollen. Crepitus was distinct, and we easily rec<»*
nized the fracture of the ulna alx)ut three inches below its upper enid,
with which an o|)en wound was in direct communication, ne
pected, also, a dislocation of the hejid of the radius forwards, but i
could not make ourselves certain, and finding that the arm w*as in tmch
a condition as to preclude any further manipulation without greatly
diminishing the chance of saving the limb, we made no attempt at re-
duction, but laid the arm upon a pillow and directed cool water lotiona.
At no sul)sequent perion, in the opinion of the medical gentlemaa
who was left in charge, did a favorable opportunity occur to reduce
the radius ; and at the end of tw^o months I found the ulna unitedi
with the fragments bent forwards and outwards towanl the nuliai»
while the head of the radius lay in front of the humerus. The fbream
was shortenetl three-quarters of an inch. He could flex his arm freeljr
to a right angle and a little beyond ; and he could straighten it
SHAFT OF THE ULNA. 313
kedj. Hand slightly pronated, with partial loss of supination. Whole
trm nearly as strong and as useful as before the accident.
The second case occurred in the person of a man ret. 26, residing
about twenty miles from town, and was occasioned by the kick of a
horse. This was also a compound fracture. It does not appear that
his surgeon discovered the dislocation of the radius, but supposed that
it was a fracture of both bones. On the ninth day the patient became
dissatisfied and dismissed his surgeon, but employed no other.
Oct. 1, 1849, eleven weeks after the accident, he called upon me. I
found the ulna united, with a manifest displacement, but I could not
discover that there had been any fracture of the radius. The head of
the radius was in front of the external coudyle, and a depression ex-
feted where it formerly articulated. When the arm was flexed, the head
did not strike the humerus so as to arrest the flexion, but it glided up-
wards and outwards along the inclined base of the external condyle.
He had already begun to use his arm considerably in labor. The forearm
was shortened one inch.
Three times I have noticed after the lapse of several years that the
fcrearm could not be |>erfectly supinated; but pronation was never
permanently impaired. I think, also, that the motions of flexion and
exteDsion have always, except where the radius has remained dislo-
[ ttted, l>cen completely restored soon after the splints were removed ;
ind even in these latter cases it is only extreme flexion which has been
kiodered.
TrtaimenL — In simple fracture we must look carefully to the lateral
de\'iation of the fragments; and if they are found to be salient forwards
ortnekwards, pressure made directly upon or near their extremities
fesiores them to place, but it often requires considerable force to ac-
complish this. A gentleman fell and broke the right ulna near its
middle. He came immediately to me, and I found the fragments dis-
plared backwards. Pressing strongly with my fingers they sprung
fi)rwarJs with a distinct crepitus, and I thought they were now in
exact line. A broad and well-padded splint was applied to the fore-
trm, and I took especial pains with compresses nicely adjusted, from
day to day, to keep everything in place. The arm was placed in a
sling. Eight months after the accident this gentleman died of cholera,
and I was permitted to clissect the arm. I found the fragments well
united, but with a very palpable projection of the fragments backwards,
in the direction in which they were at first.
If the displacement is in the direction of the radius it is more difti-
cult to overcome, but its neires^ity is much more urgent, since, if the
ingroents fall completely against the radius, a bony union may take
place, occasioning a complete loss of the power of pronation and of
eopinatioD.
While moderate extension is being made, and the hand is well supi-
nated, the fingers of the surgeon should he pressed firmly, and in spite
sometinies of the complaints of the patient, between the radius and
oina, and the fragments of the broken ulna fairly pushe<l out from the-
railiue.
The forearm may now be laid in the usual pasition against the front
21
314 FRACTURES OF THE ULNA.
of the chest, midway between supination and pronation, and the same
splints applied and in the manner which we shall hereafter describe for
fractures of the shaft of both bones.
We ought, however, esjKJcially to bear in mind the danger of thrust-
ing the fragments against the radius, by allowing the sling or the
bandage to rest against the middle of the ulnar side of the bone. To
prevent this the sling ought to support the arm by passing only under
the hand and wTist, or the forearm may be laid in a firm gutter, which
will touch the forearm only at the elbow and wrist, or it may l)e laid
upon its back, as suggested and practiced by Scott, and also by Fleury,
the latter of whom, according to Malgaigne, had a case which had been
treated in the position of semi-pronation, and which remained not only
displaced, but refused to unite; but when the arm was supinated the
fragments came at once into contact, and bony union speedily took
place. This position may be adopted whenever it is found to be prac-
ticable ; but the position of semi-pronation is generally much more
comfortable to the patient, at least when the forearm is laid across the
chest, and I have found very few patients who would submit to apo*
sition of complete supination.
In fractures accompanied with dislocation of the head of the radius
forwanls or backwards, nothing should prevent the imme<liatc reduc-
tion of the dislocation but a demonstrati(m of its impossibility, or a
condition of the limb which would render manipulation hazardooa.
It can be reduced, generally, by pushing forcibly u|>on the head of the
bone in the direction of the socket, while the arm is moderately flexed
so as to relax the biceps, and while extension is being made at the
forearm by an assistant. In making the counter-extension, care should
be taken to seize the lower end of the humerus by the condyles, rather
than by its anterior aspect, by which precaution we shall avoid pre»-
ing u|)on and rendering tense the tendon of the bice|)s.
July 29, 1845, a lad, jet. 9, fell from his bed, breaking the ulna and
dislcK^ting the head of the radius. Dr. Austin Flint was called on
the following morning, and at his request I was invited to sec the Pi*
tient with him. We found the ulna bn)ken obliquely near its middle
and the head of the radius dislocateii forwards. While Dr. Flint seittd
tlie elbow in front of the (*ondyles, 1 made extension from the handf
the forearm being slightly flexed upon the arm, and at the same monieiit
I puslunl forcibly the head of the radius back to its socket. The r^
duction was accomplisheil easily and completely.
We then dressed the arm with an angular splint, constructed with
a joint opj)osite the elbow. This was laid upon the palmar surfacCV
and the whole wa^ nicely |>addeil, es|)ecially in front of the head Oi
the radius. In two weeks pasteboard was sul)stituted for the anguta^
splint. At the end of six wet^ks I was jHTmittetl to examine thcan0|^
and found the head of the ratlins perfectly in place, but the |K)int8<^
fracture slightly salient. All of the motions of the arm were full^
restored.
June 2, 1845. (\ C, let. 9, fell upon his arm, breaking the ala^
obliquely near its mid<lle, and dislocating the head of the radiua fiEM^
'wards. Dr. J. P. White being (»ttlled, requested me to vihit the
COBONOID PROCESS OF THE ULNA. 315
with him. We found one of the broken fragments protruding
nigh the skin, on the inside of the arm.
I^ith great ease, and by simply pressing with considerable force
D the head of the radius, it was made to slide into its socket. The
was left in charge of Dr. White.
ive weeks after, I found all of the motions of the forearm com-
dy restored, except that he could not extend it perfectly. The
1 of the radius was also a little more prominent in front than in
[opposite arm.
oar or five years later, the projection of the head of the radius had
ppeared, and the functions of tlie arm were perfect
2 2. Coronoid Frooess of the Ulna.
dissections have established the possibility of this fracture as a sim-
aocident in the living subject; but I have not myself seen any
nple of which I can speak positively. In the two following cases,
existence of such a fracture was at first suspected, but I have now
f little doubt but that my diagnosis was incorrect. I shall relate
n, however, as examples of those accidents which are likely to be
taken for fracture of this process.
I laboring man, aged about twenty-five years, had been seen and
ted by another surgeon, for what was supposed to be a simple dis-
tkm of the radius and ulna backwards. The surgeon thought he
reduced the dislocation very soon after the accident. On the fol-
ing day he found the dislocation reproduced, and he requested me
eethe patient with him. The arm was then much swollen, but the
meter of the dislocation was apparent. By moderate extension,
lied while the arm was slightly flexed, and continued for a few
inds, reduction was again effected, the bones returning to their
cei with a distinct sensation ; but on releasing the arm the disloca-
»wt8 immediately reproduced. Tlicsc attempts to reduce and re-
Bin place the dislocated bones were repeated several times during
(day, and on sul)sequent days, but to no purpose, and the patient
^disroissed after about two weeks with the bones unreduced.
Tlie impossibility of retaining the bones in place, and the existence
iDoenasiona] crepitus during the manipulation, inclined me to be-
'^ti the time that the dislocation was accompanied with a fracture
4e coronoid process.
Ai»ther similar case has since presented Itself in a child nine years
Ofiiid in which the subsequent examinations not only demonstrated
^ton-existence of a fracture, but also rendered doubtful the justness
tk conclusions which I had drawn in the case just related.
Tklslad fell, November 4, 1855, and his parents immediately brought
• tome; but as he lived many miles from town, I did not see him
•ffl eighteen hours after the injury was received. I found the arm
*k swollen, slightly flexed, and pronated. Flexion and extension
the arm were very painful, the pain being referred chiefly to the
jntof the joint, near the situation of the coronoid process; and at
V point afao there was a discoloration of the size of a twenty-five
316 FRACTURES OF THE ULNA.
cent piece. Flexing the forearm moderately upon the arm anc
extension, the bones came readily into place, but without sen
any kind, either a snap or a crepitus. That the bones had now
their position, however, I made certain by a very careful exa
Fio. 110.
Fracture of the corouuid proct-ss,
with the hand and hv measurement, vet thev would not remair
one moment when the extension was discontinued. The reduc
made several times, and constantly with the same result,
applied a right-angled splint to the arm, having first reduced tl
and thus were able to retain them in position. I believed
coronoid process was broken, and so informed the surgeon
care the boy was returned.
Five months after, he was brought again to me, and I th
that the radius and ulna had been kept in place; the motioi
joint were perfect, and if the coronoid process had ever been I
was now again in its natural i)osition, and with every structure
in a condition as com])lete as it was before the accident. Foi
I do not believe that so perfect a union of this process can ha
least in a case where, as must have been the fact in this example
aration and displacement of the pro<*ess are such that it no Ion]
an obstacle to tlie dislocation of tlie ulna backwards and upw
Malgaigne thinks that the fracture is more frt»quent than t
number of reported examples would lead us to sup|K)se, espei
cause he has notic(»d liow often the sun)mit of the pr<HX»ss is bi
when dislocation of the radius and ulna backwards is prixluo
cially on the dead subject. In threi* or four cases, also, of di?-
of these bones backwards and inwards, wiru^h had come under Ii
he was unable to feel this pr<H.*ess, an<t he therefore thought it
that it was broken off. Other surgeons have thought, also, th
a not infrequent awidcnt ; and they liave constantly made Ui
supposition to explain those cases in which the radius and uln
l)eeii dislocated backwards, would not afterward remain in pi
well reduced. Fergusson has indeed made the extnionlinan* s
in i*elation to dishn-jitions of the radius and ulna Iwckwanln g
that in these cases "the coronoid pnx^ess will prob:ibly be bru
But, in my opinion, these fnictures are ext^etnlingly rare ; am
these gentlemen nee<l to have funiishe<l some more ctinclusive
of the correctnessof their opinions than ran be found in their
or in the writings of any other surgeons which I have si'on.
Malgaigne mentions thre<» re|>orte<l examplt^s, namely : one |
by Comb^ Brassard, an Italian surgeon, in 1811, which Bras
only after a Iai>se of three months ; one seen by Pennock, and r
in the Ixinc^i in 1828, the patient then being sixty years olu
accident having ooeurnxl when he was a young man ; the t
CORONOID PROCESS OF THE ULNA. 317
seen by Sir Astley Cooper, several months after the accident, and is
reported by himself in his excellent treatise on Fractures and Disloca-
tions. Says Sir Astley: "It was thought, at the consultation which
was held about him in London, that the coronoid process was detached
from the ulna.'* This was the only living example seen by Sir Astley
in his long and immensely varied surgical practice; and even here we
cannot fail to notice the apparent reserve with which he expresses
his opinion — " It was thought at the consultation.*'
To these examples our own researches have added a few others.
Dorsey says that Dr. Physick once saw a fracture of the coronoid
process. The symptoms resembled a luxation of the forearm back-
wards, "except that when the reduction was effected, the dislocation
was repeated, and by careful examination, crepitation was discovered.
The forearm was kept flexed at a right angle with the humerus. The
tendency of the brachialis internus to draw up the superior fragment
was coanteracted in some measure by the pressure of the roller above
the elbow. A perfect cure was readily obtained."* In 1830, Dr. Wil-
liam M. Fahnestock reported a case occurring in a boy, who, having
fcllen from a haymow, received the whole weight of his body " on the
back part of the palm of the left hand," while the arm was extended
forwards. It seemed to be a dislocation of the forearm backwards,
but when reduced it was again immediately displaced, with an evident
crepitus. The arm was secured in the angular splint of Dr. Physick
ana "recovered very speedily.''* Dr. Couper, of the Glasgow Infirm-
My, also has reported a dislocation of the forearm backwards and out-
^Mtls, occurring in a young man aged seventeen, and which he thinks
^ accompanied with this fracture. The dislocation was easily re-
^•Jced, but returned again immediately on ceasing the extension. The
fragment was not felt, nor does he speak of crepitus ; the existence of
^ fracture being inferred from the fact that the bones would not re-
»Mun in place without help. The forearm was placed across the chest,
^th the fingers pointing toward the opposite shoulder, and secured in
4b position with splints and a bandage. At the end of four weeks
^ion had taken place, with only slight deformity, although with some
^Mhess of the joint.
In relation to this example, the editor remarks that the symptoms
Were not to his mind conclusive in determining the existence of a frac-
*nreof the coronoid process, and he inclines to the belief that it was
^er an oblique fracture of the lower extremity of the humerus.
In cases like these," he adds, " where very rare accidents are sus-
pected, we think that unless the diagnosis is clear, the leaning should
always be the other way : we mean that, ccderis paribus, the symptoms
Aoald rather be referred to the common than the extraordinary injury.
The contrary practice introduces a dangerous laxity in diagnosis."^
Dr. Duer, of Philadelphia, has reported a case which occurred in a
* Doney, Elements of Surgery, vol. i, p. 162. Philadelphia, 1818.
* Fahnestock, Amer. Journ. Med. Sci., vol. vi, p. 267.
* Couper, Lond. Med.-Chir Rev., new ser., vol. xi, p. 609.
318
FRACTURES OF THE ULNA.
hoy six years old, aud in which lie felt and moved the fragnieut witli
his fingen;. It was complicated with a diBlocation, which remains uo-
reduced. This case was last seen about seven weeks after the acvideul.'
If at a later period we coiild he permitted to examine the patient, it la
probable that the diagnosis might be i-endercd certain.
In the ATuci-ican Medioal MonUdy for October, 1855, also, I find the
report of a trial for malpractice, in which a lad nine years old received
some injury about the elbow-joint which resulted in a maiming. Tht
defendant claimed that there had been a dislocation of Ihf forearm
backwards, accompanied either with a fracture of the trochlea of llw
humerus, or of the corouoid process of the ulna.
Dr. Crosby, of Dartmouth College, tcutificd tliat he had never met
with a fracture of this process, yet he would not say that it did not
exist in this caiie. He was not able to decide positively. Dr. Peaslec^
of the same college, thought it altogether probable that it had been
broken, and Dr. Spaulding was of tne opinion fully that it had beeB
broken.
The jury did not agree, and a nonsuit was finally allowed by lit^
court.
The defendant, in his rcjiort of the trial, seems to me lo have justl/!
complained that Mr. Fer^sson has said, that in a dislocation of tb*
forearm backwards " the coronoid process will probably be broken."
This was ui^ed in the trial by the plaintifTs counsel us conlnulictioj
the medical testimony, and as evidence of a conspiracy on tltc part O-
the surgeons to defeat the ends of justice ; since they constantly affirmed
that the accident was so rare as not tu have been reasonablv expected,
and that a failure tu look for or to disoover it did not imply a lack of
ordinary skill or care.'
Says Mr. I^iston: "The coronoid process is occasionally pnllMl or
pushed off from the shaft, more especially in young subjects. I saw t<
case of it lately, in which the injury arose in coiiscqueucc of the p>*
tient, a boy of eight years, having hung for a lung time from the tof-
of a wall by one hand, afraid to drop down;"' after whom Milkr,
Eriehsen, Skey, Lonsdale, and most of the Scotch and English sur-
geons have repeated the assertion that this process may l>e broken ii
this manner by the action of the bmchialis aniicus alone, yet do mi
of them has to this day seen another example.
The explanation of the accident in the case of the boy, given ta
Liston, im|)lie9 two anatomical errors : first, that the corouoid priwoi
is an epiphysis during childhood ; and second, that the brachialu nnti-
cus is inserted upon its summit. The coronoid process is sever m
epiphyRi.s, but is formed from a common point of ossification with tin
shaft ; the olecranon process and the lower extremity of the ulna hivng
also separate points of ossification : the olecranon becoming nnitolW
the shaft at the sixteenth year, and the lower epiphysis at the twcntiftk.
Moreover, the brochialis anticus has its insertion at the base of ifcf
< Duer, Amer. Journ. MrA. BcL, Oct. IS'IS. p. S90.
< Op. cit., vol. iv, p. 33S. • LUlon, Pra
CORONOID PROCESS OF THE UI.NA.
319
e an(] partly upon the body of the ulna, but in no part upon its
it ; indeed, the pn>cess seems rather to he intended as a pulley
r which the hi-arhinlts anticiis may play ; resembling
> winewhat, iu ita function, the patella; serving to flu. iii,
rotMt the joint and peihaps the ranscJe itself from be-
nuing compressed in the motions of the joint. Cer-
Wnry it ixiuld never have boeu broken by ihe action of
pis muscle, and the ca^e mentioned l>y Mr. Littton
■ItKt &ad some other explanation. It may have been a
Inptiire of the bradiialia anticus itself, or of the bicepa,
V jMissihly a forward luxation of the bead of the radius.
Gther of these suppositions is more rational thau the
lenient niado by Mr. Listou, because either one of
a is possible, while his stippositiou is impossible.
I have already i]uoted Dr. Hodges as saying that he
■ Iwl found the coronoid process broken off three times
I Inconneclioti with longitudiual fractui-es of the head of
I tbtt rnilius.
These, if I exeept my own, constitute all of the sup-
peeil examples seen in the living subject, of which I
fwl any record ; twelve in all.
It is true, however, that at least two other cases have
two reported to me by letter, of which the writers speak
*ith great con6dence, and the authenticity of which I
am uiiable to dispute; but in neithercaseis the testimony
I to me satisfactory, and as they are not upon record, I
^^ ihtll be excused from discussing their merits. »■. (Fiom am.)
^H The two first of the twelve above enumerated, were
^F'M entirely sati.sfactory to Malgaigne; the third is spoken of cautiously
" ySirAstley Cooper, as if it needed, in addition to his own great name,
w* indorsement of the "London council." Dorsey reports hia case upon
I Wxay, and the result is quite too satisfactory to give it much claim to
I "Klihility. Falinestock's case is to our mind far from being fuUy
! pwven. Couper's case is doubted by Dr. Johnson ; and the New Hamp-
•aire tase was not made out satisfactorily toeitlier the jury or the medi-
■31 men. Ltaton's case was simply impossible. Duer s ciise could have
««i better verified at a later period. Having never seen areport of the
«!•» cases referred to by Dr. Hodges, I am unable to form any opinion
^'itlieir claims. His well-known reputation, however, disposes me
■Onocept of them as authentic,
1 Certainly it is not upon euch testimony as this that we can rely to
I 'Wain Mr. Ferguasoii's opinion that this fracture is likely to occur in
Ul iliglocatioDs of the forearm backwards, or of Malgaigne's conjecture
l™ it is of more frequent occurrence than the published cases would
*«ni to !ihow. Nor will it be regarded as conclusive, that the beak of
ttio process is often found broken atler luxations made upon the sub-
jwt; since between luxations thus produced and luxations occurring in
tiw living subject there exists this important difference, that in the case
of tile latter, muscular action is the principal agent in the production
320 FRACTURES OF THE ULXA.
of the dislocation, while in the former it is the external force aloi
which drives the bone from its socket.
The fact, therefore, that so few cases have ever been reported,
that most of these are far from having been clearly made out, remai .
presumptive evidence that the actual cases are exceedingly rare ; bat3
to this we add such negative evidence as is furnished by actual dias^
tions, and by examinations of the pathological cabinets of the worC
we think the testimony is almost conclusive.
Only four specimens have been mentioned by any of the surgii^-^
writers known to me. Sir Astley Cooper says that a person was bro
to the dissecting-room at St. Thomas's Hospital, who had been the g
ject of this accident. " The coronoid process, which had been brokai
off within the joint, had united by a ligament only, so as to mczs
readily upon the ulna, and thus alter the sigmoid cavity of the u"W,
so much as to allow in extension that bone to glide backwards upo
the condyles of the humerus."* Mr. Bransby Cooper adds in a no^
that the external condyle of the humerus was also broken and united
by ligament.
Samuel Cooper describes, rather obscurely, a specimen contained in
the University College Museum, "in which the ulna is broken at the
elbow, the posterior fragment being displaced backwards by the aetioa
of the trice jKS ; the coronoid process is broken off; the upper head o{
the radius is also dislocated from the lesser sigmoid cavity of the ulot,
and drawn upwards by the action of the biceps. In this complicated
accident, the ulna is broken in two places."
Malgaigne says that Vclpeau has also established by an autopsy thi
existence of a fracture of the coronoid apophysis, but without havioj
given any further particulars in relation to the case.
In addition to these examples, Dr. Charles Gibson, of Richmond, Va.
has stated to me, by letter, that he has in his possession a s|>ecimen o
this fracture, evidently belonging to an adult. The process wax brokei
transversely near its extremity, and has united again quite closely aiM
without any displacement, and without ensheathing callus.
We must subject these s|)ecimens to analysis also. The first tm
were complic^ated with other fractures, and the second, especially, seem
to have been a general crushing of all the bones concerncil in the fWr
mation of the elbow-joint ; neither of them could have been oecasionei
by contractions of the brachialis anticus, while only that one descTibei
by Sir Astley Cooper could have biM?n the result of a dislocation of tb
forearm backwards. Of the sj)ecinien said to have been seen by Vel
peau, I am unable to speak without more circumstantial knowletlge o
its condition. Nor can I speak very confidently of that belonginp^ t
my distinguishcil friend, Dr. Gibson, of Virginia. Xotwithstandtiq
the r&<^pect which I entertain for his opinion, I cannot avoid a suspioio)
that the bone was never broken at all, since I find it more easy to be
Heve that he is deceived by certain appearances, than that it shoah
have united by bone again, and so perfectly as not to leave any line c
separation or degree of displacement. Certainly the fracture was to
* Sir A. Cooper, Dislocations and Fracturef, p. 411. .
CORONOID PROCESS OP THE ULNA. 321
ii%li to have been produced by the action of the muscle, if such a thing
ever possible ; and if broken by a dis^location, which must have
it violently from its position, as the ulna was driven upwards, it
to me incredible that it should ever be made to unite again so per-
£%ctly.
We are therefore left as before, with no evidence that the coronoid
process was ever broken by the action of a muscle, and with only one
example in which it is probable that a fracture occurred as a conse-
ciuence of a dislocation of the radius and ulna backwards. If then it
Joes hap|>en that in this dislocation it is pretty often found difficult or
impossible to retain the bones in place without aid, it will be the part
«f pnidence to ascribe this troublesome circumstance to some more com-
mon accident than a fracture of the coronoid process ; perhaps to a frac-
ture of some portion of the lower end of the humerus, or to a disrup-
tion, more or less complete, of the tendons of the biceps and brachialis
tnticus, together with the ligaments which surround the joint.
(Since writing the above my attention has been called to a review by
Zeis of a paper on fractures of this apophysis, published by Lotzbeck,
of Munich, in 1865.* The original paper furnishes five cases, to which
the reviewer has added four more, one of which, Pennock's case, I have
already spoken of. After a careful reading of the review, I fail to
find conclusive evidence that the coronoid process w-as broken in cither
case. The evidence may be, indeed, in some of the cases probable,
but never conclusive, since other explanations of the phenomena pre-
sented than those which are here offered, would prove to me equally satis-
fiictory.)
GaitJies. — It is probable that this process will be sometimes broken
in a fall upon the palm of the hand ; the force of the blow being re-
crived directly upon the lower end of the radius, and, through its
numerous muscles and ligamentous attachments, being indirectly con-
veyed to the ulna, producing a violent concussion of the coronoid pro-
cess against the trochlea of the humerus, and resulting finally in a frac-
ture of this process and a dislocation of both bones of the forearm back-
wards. The gentleman seen by Sir Astley had fallen upon his extended
Hand while in the act of running. Brassard's patient had fallen also
upon his hand with his arm extended in front. Pennock's patient, an
old man of sixty years, had fallen upon the palm of his hand, and
Fahnestock's fell upon the " back of the palm. In no other case is
the point upon which the blow was received particularly mentioned.
In two of the examples mentioned by Malgaigne there was a luxation
of the forearm backwards ; such was also the fact in the case seen by
Fahnestock ; in Couper's case it was dislocated backwards and out-
wds, and in Sir Astley's case I infer that there was only a subluxa-
tion of the ulna backwards.
We know of no other causes, therefore, than such as equally tend to
produce dislocations at the elbow-joint, unless we except direct crush-
ing blo^-s, which of course may break the bones at any point upon
which the force happens to be applied.
* Schmidt's Jahrbuch for 1866, vol. 139, p. 134, et seq.
322 FRACTURES OP THE ULNA.
Si/^mjjtmis, — Partial or complete displacement of the ulna, or of *^
radius and ulna backwards, accompanied with the usual signs of th. -■
luxations; to which may be possibly added crepitus; and it is fair^
presume that in some examples the fracrment carried forwards by beSh
driven against the trochlea, may be felt displaced and movable in ^tH
bend of the elbow. Brassard affirms that it was so with the pati«»
whom he saw. If only the summit is broken off, the brachialis anti^H
could have no influence upon it; but if it were broken fairly thnnic
the base, it might be displaced slightly in the direction of the act -
of this muscle.
The symptoms, however, which have been regarded as moet di=^ —
nostic, are the disposition to re-luxation manifested in most of tl
examples when the extension has been discontinued; and es|)ccially
fact that the olecranon was particularly prominent when the arm ^
extended, but that it resumed its natural position when the arm '
flexed to a right angle. But I am unable to understand how eithei
these circumstances can be better explaine<l upon the supposition
fracture of this apophysis, than without sucli a supposition. If the we
duction of both bones is once effected, even though the support of the
coronoid process is completely lost, the head of the radius ought io
prevent a re-luxation unless the arm is disturbed again ; nor can I
undei'stand why, when the elbow is bent, the re-luxation is less likely
to occur; since, although in this position the humerus bears less di-
re(!tly upon the process, the difference in this respect must be veiy
little, for in whatever position the arm is place<l, so long as the radius
retiiins its |)osition the ulna cannot be drawn very forcibly against the
humerus; while, on the other hand, by flexing the arm the jwwerof
the biceps and of such fibres of the brachialis as remain attached to the
ulna, to aid in the maintenance of reduction, is completely lost; and
at the same moment the resistance, and consequent i>ower of the trioepfl
to produce the luxation, are greatly increased.
In short, we must confess that we are here, also, notwithstanding
the confidence with which writers have spoken of the signs of this acci-
dent, very much in doubt; nor do we see how these doubts axn be re-
moved until we have in detail the symptoms of at least one example
the indubitable existence of which has been subsequently verified bj
dissection.
Prw/nosis. — In the case of Cooper's patient, seen several moiitlu
after the accident, the ulna proje<*ted backwards while the arm was ex-
tended, but it was without much difliculty drawn forwartls and lient
and then the deformity disapix^ared. He thought that during exteii
sion the ulna slipped back behind the inner condyle of the hunienii
BrassanPs patient, seen after three months, retained the power of pro
nation and supination, with also extension, but flexion was completely
impossible, the forearm being arrwted in this direction by the small
slightly movable fragment of b(me in front of the elbow-joint, am
which was sup|K)sed to l)e the process itself. Pennock's old muD, wb
had met with the accident in boyhoo<I, had still the radius luxatei
forwanls and outwards, and the olecranon more salient backwards tluu
iu the sound arm. Extension and flexion were nearly but not quit
CORONOID PROCESS OP THE ULNA. 323
oomplete. Fahnestock informs us that his patient "recovered com-
pletely/' but whether without deformity or maiming' we are not told.
Cbuper says the bone was united in four wceks^ and that only a slight
deformity and a little stiffness remained. Physick's patient made a
perfect recovery.
Let us come again to the dissections. Rejecting the doubtful speci-
men belonging to Dr. Gibson, we have an exact account of only two,
and, indeed, Sir Astley Cooper alone has doscril)ed the mode of union.
Samuel Ck)oper says that in the case of the University College speci-
men the nidius is dislocated forwards and upwards, and the olecranon
is displaced backwards, but he does not say whether the coronoid pro-
cess has united, nor described its position ; but Sir Astley informs us
that in the example seen and dissected by him the process was united
bjr ligament, which was sufficiently long and flexible to allow the frag-
ment to move upwards and downwards in the motions of flexion and
extension.
In the absence of any other testimony, we may be allowed to express
an opinion that when the fracture has taken place across the summit or
above the insertion of the brachialis anticus, nothing but a ligamentous
onion can be regarded as possible, since the fragment can only derive
nourishment from a few untorn fibres of the capsule and perhaps of
the internal lateral ligaments; and although it may not l^ displaced,
it cannot have the advantage of impaction, upon which alone, I sus-
pect, a fracture of the neck of the femur within the capsule must rely
fcf a bonv union, if it ever does so unite. If, however the fracture has
taken place at the base, and fortunately it has not become much dis-
placed by the force of the concussion against the humerus, it does not
«etn to me so impossible that under favorable circumstances a bony
union might now and then occur. It will b<? remembered that a good
portion of the attachment of the brachialis anticus is still below the
fracture, and the remaining fibres are not therefore very likely to dis-
place the fragment, especially when the arm is sufficiently flexed, so as
to properly relax this muscle.
It will be of small importance, however, whether the union is bony
or ligamentous, provided only there is not great displacement.
Treatment, — Whatever view we take of the pathology of this acci-
dent, the rational mode of treatment would seem to consist in flexing
the arm at a right angle, and retaining it a sufficient length of time in
that position ; not forgetting, however, the danger of anchylosis from
wjng-oontinued confinement in one position.
An angular splint may be useful in preventing motion at first, but
I think it ought not to be continued beyond seven or ten days at the
®«t. After this, a simple sling is all that can be necessary, since
from this period some motion must be given to the joint if we would
t»ke the proper precautions to prevent stiffness. Sir Astley Cooper
thought the limb ought to be kept immovable three weeks, and Vel-
P^w preferred four; but I cannot agree with them, l)elieving that the
qoestionof the future mobility of the elbow-joint is vastly more impor-
tant than the question of a bony or ligamentous union between the
"•gments. Couper says that he adopted in the treatment of the case
324 FBACTUBES OF THE ULNA.
reported by him, extreme flexion; but both Pliysick and Fahne8t<^
placed the arm at right angles, and Sir Astley Cooper has recommend
the same position. The latter position has always the advantage
case permanent anchylosis occurs, and the former cannot add much
the chance of complete replacement of the fragment.
Bandages are only serviceable to retain the splint in place, and tti
may be thrown aside as soon as the splint is removed.
I 3. Fractares of the Olecranon Process.
Causes. — My records furnish me with accounts of only fifteen of tlra
fractures, and, so far as I have been able to ascertain, all were
sioned by falls upon the elbow, or by blows inflicted directly upon
part. Malgaigne has, however, been able to collect accounts of six
amples of fracture of the olecranon, produced, as is affirmed, by
violent action of the triceps; as in pushing with the arm slightly fit
in throwing a ball, in plunging into the water with the arms extenc
etc. ; but only four of these reported examples does he think are si
ciently authenticated to entitle them to be received as facts ; nor C
think it possible to affirm positively that in any instance, where
whole process is broken off, the triceps alone has occasioned the sc|
tion. For example, Capiomont reports the case of a cavalier,
being intoxicated, was thrown head foremost from his horse, and, st-r
ing probably upon his head, was found to have broken the olecra,«J
process. We do not, in this example, sec evidence alone of a forcriA
contraction of the triceps, but also of violent pressure against the Iwiiic
and in the direction of the axis of the forearm toward the elbow-joini,
by which the olecranon process might have been so thmwn forwards
against the fa<^sa of the humerus as to ctiuse its separation. The sanM
explanation might apply to several of the other examples.
Point and Direction of Fracture; Displacement y etc. — The process mtj
be broken at its summit, at its base, or intermediate between these twc
extremes, the last of which is the nu>st common.
It is probable that when the action of the triceps alone has produce!
the fracture, it will be found that only that portion which nKjeivfS th
insertion of the triceps has been broken oiF. Malgaigne, who has bee
able to find upon record only two cases of a fracture of the extrem
end of the process, declares that they were both occasioned by miiscala
action.
Fractures of the middle are generally transverse, or only slight!
oblique, occurring in the line of the junction of the epiphysis with tli
diaphysis.
Fractures through the base arc generally auite oblique, the line i
fracture extending from before downwards and backwards, so that im
only the whole of the process, but a portion of the back of the shaft
carrie<l away ; and this accident can scarcely han|)en, except by a bio
received u|)on the lower end of the humerus, directly in front of tl
process ; or, what would amount to the same thing, by a blow from h
FRACTURES OF THE OLECRANON PROCESS. 325
received upon the ulna just below the olecranon process, or by
thing the forearm violently back, while the humerus is fixed.
J only displacement to which
pper fragment seems to be ^ ^^°- "^•
is in the direction of the
i; and the degree of this dis-
lent does not depend so much
he point at which the fracture
en place as upon the violence
has occasioned it, the extent
disruption of the ligaments,
rosis of the triceps and of the
I, and upon whether, since
dent, the arm has been flexed Fractures at the base.
; extended.
bur instances I have found distinct crepitus immediately after
x^tnre had occurred, produced by only moving the fragment
y, showing plainly that little or no displacement had taken place.
Hewing example will show also that this displacement does not
happen even after the lapse of several days, and where no sur-
"catnient has been adopted.
oel Duckett, set. 14, fell upon the point of the elbow, and two
ifter was admitted to the Buflalo Hospital of the Sisters of
jr. The elbow was then much swollen, but no crepitus could be
d, and he could nearly straighten his arm by the action of the
. On the sixth day, the swelling having sufficiently subsided,
inct crepitus was discovered when the olecranon process was
between the fingers and moved laterally. We extended the arm
liately, and applied a long gutta-percha splint to the whole front
arm and forearm, securing it in place with a roller. On the
th day, five days after the first dressing, the splint was taken off*
5 angle at the elbow-joint slightly changed ; and this was repeated
(lay until the twenty -sei»ond from the time of the accident. The
was then finally removed, when the fragment was found to be
without any jxjrceptible displacement, and the motions of the
?ere unimpaired.
na«t not be inferred, however, that it is always prudent to leave
Bctare thus unsupporteil, since it has occasionally happened that
splacement, which did not exist at first, has taken place to the
; of half an inch or more, after the lapse of several days. Mr.
mentions a case in which the separation did not take place until
ith day, when it was occasioned by the patient's attempting to tie
ckclotn.
tpUmts. — The usual signs of a fracture of the olecranon process
hen the fragments are not separated, crepitus, discovered especi-
y seizing the process and moving it laterally ; or, when displace-
has actually taken place, the crepitus may be discovered some-
hj extending the forearm, and pressing the upper fragment
iwds until it is made to touch the lower fragment ; the existence
326 FRACTURES OF THE ULNA.
of a palpable depression between the fragments, partial flexion of tS
forearm, and total inability, on the part of the patient, to straighten
completely, or even to flex the arm in some cases. If the fragraenr-
do not separate, gentle flexion and extension of the arm, while t—
finger rests upon the process, may enable us to detect the fracture.
It will sometimes happen that, owing to the rapid occurrence
tumefaction, the evidences of a fracture \vi\\ be quite equivocal ; bw^
in all cases where a severe injury has been inflicted upon the pom
of the elbow, it will be well to saspend judgment until, by repeats
examinations, made on successive days, the question is determino^
Meanwhile, the arm ought to be kept constantly in an extended
tion, as if a fracture was known to exist.
Prognosis, — In a large majority of cases this process becomes
united to the shaft by ligament, which may vary in length from a 1
to an inch or more, and which is more or less perfect in different ca^
Sometimes it is composed of two separate bands, with an intermedial
space, or the ligament may have several holes in it; at other time» i
is composed in part of b<)nc and in part of fibrous tissue ; but most
frequently it is a single, firm, fibrous cord, whose breadth and thick-
ness are less than that of the process to which it is attached.
If the fragments are maintained in perfect ap|>osition, a bony union
may ocrcur, yet it is not invariably found to have taken place, even
under these circumstances. Malgaigne thinks, also, he has seen one
case in which there was neither bone nor fibrous tissue depositecl be-
tween the fragments. This was an ancient fracture at the base of the
olecranon ; the superior fragment remained immovable during the
flexion and extension of the arm, yet it could be moved easily from
side to side.
In my own cases I have five times found the fragments united
without any appreciable separation, and have presumed that the unim
was bony. One of these examples I have already mentionitl ; tlu
second was in the jwrson of a lady aged about forty years, who, havin|
fallen down a flight of steps on the 8th of September, 1857, sent foi
me immediately. 1 found a large bloody tumor covering the elbow
joint, but there was no difficulty in detecting a fracturt* of the olecra
non prowss. It was easily moved from side to side, and this inutioi
was accompanied with a distinct crepitus. During the first week th*
arm was only laid upon a pillow, but as it was found to bi«couie gmd
ually more flexed, and the swelling having in a great mt»asure sulisided
the arm was nearly, but not quite, straighteneil, and a long gutta
percha splint applieti to the palmar surface of the fore:irm and arm
The fragments uniteil in al)out twenty or twenty-five days, and withou
8ej)anition, so far as could be discoverwl in a very irareful examination
The third example to which I have refernnl, oct»urred in a bfi;
fourtetMi years old, and was treated by Dr. Benjamin Smith, of KcTk
shire, Massachusetts. Sixty-nine years after, he being then eighty
three years old, I found the olecranon process united apparently b
bone, but to that day he had been unable to straighten the arm com
pletely, or to supine it freely.
FBACTURES OF THE OLECRANON PROCESS. 327
In one instance I found the fragment, after the lapse of one year,
United by a ligament, which seemed to be about
€>»e-()uarter of an inch in length, and the arm ap- ^'°- ^^^*
red to be in all respects as perfect as the other,
e could flex and extend it freely.
In the two following examples, also, the bond of
nion was ligamentous:
John Carbony, set. 18, having broken the olec-
oon, it was treated with a straight splint. Nine
3?ears after, I found the process united by a ligament
Miait an inch in length, and he could nearly, but
not entirely, straighten the arm. In all other re-
spects the functions and motions of the arm were
Tferfect.
A lad, set. 15, was brought to me by Dr. Lau-
^ale, a very excellent surgeon in the town of
Genesee, Livingston Co., N. Y., whose olecranon
process had been broken by a fall six months before,
»nd at the same time the head of the radius had union by ugament
been dislocated forwards. I found the radius in
place, and the olecranon process united by a ligament about half an
inch in length. He was not able to straighten the arm completely,
the forearm remaining at an angle of 45° with the arm.
Treatment — It will surprise the student who is yet unacquainted
with the literature of our science, to learn that in relation to the treat-
ment of a fracture of the olecranon process, a wide difference of opinion
has been entertained as to what ought to be the position of the arm
and the forearm, in order to the accomplishment of the most favorable
results; and that, while some insist upon the straight position as essen-
tial to success, others prefer a slightly flexed position, and still others
have advocated the right-angled position. Thus Hippocrates, and
nearly all of the earlier surgeons, down to a period so late as the latter
part of the last century, directed that the arm should be placed in a
position of semiflexion ; Boyer, Desault, and, after them, most of the
French surgeons of our own day, prefer a position in which the fore-
ann is very slightly bent upon the arm ; while Sir Astley Coo|)er, and
a lai]ge majority of the English and American surgeons, employ com-
plete or extreme extension.
The arguments presented by the advocates and antagonists of these
various plans deserve a moment's consideration.
In favor of the position of semiflexion, requiring no splints, and, in
the opinion of some writers, not even a bandage, but only a sling to
support the forearm, it is claimed that it leaves the patient at liberty
at once to walk about and to move the elbow-joint freely, so soon at
least as the subsidence of the swelling and pain will permit, and that in
this way the danger of anchylosis is greatly dirainishe<l; that, more-
over, if anchylosis should unfortunately occur, the limb is in a much
better position for the proper performance of its most ordinary func-
tions than if it were extended. Some have also added to this argu-
ment a statement that a fibrous union, under any circumstances, is in-
328 FRACTURES OF THE ULNA.
evitable, and that it is a matter of little consequence whether the
ligament thus formed is long or short, since in either condition it will
be equally serviceable.
In reply to these statements, it may be said briefly that they m
nearly all based upon false premises, or that they have been proven is
themselves to be essentially erroneous.
Anchylosis is always a serious event, which by all possible meani
the surgeon will seek to prevent, but position has nothing to do with
determining this result; when it does occur, it may usually be ascribed
either to the severity and complications of the original injur)', to the
violence of the consequent inflammation, or to having neglected, at •
proper period and with sufficient perseverance, to move the joint
That a fibrous union is inevitable under any circumstances, has been
fully proven to be an error; and it has been equally proven that the
functions of the arm are generally impaired in proportion to the length
of the uniting medium.
The only argument which remains, and which really possesses any
weight, is, that, if permanent anchylosis does actually occ^ur, the arm,
when semiflexed, is in a better position for the performance of it•*o^
dinary functions; and this, considered as an argument in favor of the
univei'sal or even general adoption of the flexed position, is suc(*es"*f«lly
met by a statement of the infrcquency of permanent anchylosis after •
simple fracture, when the case has been properly treated, whether by
the flexed or straight position; while, if the limb is flexeil, a mainiinjS
as a result of the great length of the intermediate ligament, is alinot^
inevitable.
Yet if, in any case, from the great severity and complications of tlH
injury, c^specially in certain examples of compound and comminutet
fracture, it were to l)e reasonably anticipated that i)ermanent booj
anchylosis must result, or even where the probabilities were stronglj
that way, the surgeon might be justified in selecting for the limb, i
once, the position of semiflexion; or he might leave the arm witlioii
a splint, and at liberty to draw up spontaneously and gradually to thi
position, as it is always very prone to do.
In favor of moderate, but not complete extension, it is claimed thi
it is less fatiguing than the latter position, while it mrcomplishesa moi
exact apposition of the fragments, if they hap[Hin to be brought nctuall
into contact.
I am unable, however, to understand how the apposition can be rei
dere<l less exact by comj)lete exten«*ion, unless by tliis is meant a degr
of extension beyond that which is natunil, and which, I am well awar
is |)ermitted to the elbow-joint when this posterior brace is broken o:
It would certainly derange the fragments to place the arm in this e:
treme condition of extension — that is, in a conditicm of extension a|
proaching dorsal flexion, which is beyond what is natural. Indee
j)erliaps we may admit that, in order to jwrfect ap|)osition, the extfl
sion ought to l)e less by one or two degrees than what is natural, 8ufl
cient to compenstite for the trifling amount of eff\ision which may I
presunuHl to have occurred in the oleiTanon fossa, and wliich wou!
prevent the process from sinking again fairly into its fossa.
FBACTUEE8 OF THE OLECRANON PROCESS. 329
r is to its being leas fatigaing, it is well known to those accustomed
to tmt fiactures of the thigh by permanent extension that the muscles
xmfidly acquire a tolerance, which soon dissipates all feeling of fatigue,
mod that, after a few hours, or days at most, the patients express them-
selves as being more comfortable in this position than in the flexed.
Finally, the advocates of complete, natural extension claim that in
ttiiB position alone is the triceps most perfectly relaxed, and conse-
qneotly the most important indication, namely, the descent of the olec-
nooo, most fully accomplished. In this opinion we also concur; and
regarding all other considerations, in the early days of the treatment,
•B Mooodary to this one, we unhesitatingly declare our preference for
irittt has been called the " position of complete extension," as opposed
tolexioD, semiflexion, or extreme extension.
It only remains for us to determine by what means the limb can be
ixst maintained in the extended position, and the olecranon process
most easily and effectually secured in place.
For this purpose a variety of ingenious plans have been devised,
Pio. 114.
Sir Astlej Cooper's method.
■'^ch as the compress and " figure-of-8 " bandage of Duverney, without
*pViDt8; or a similar bandage employed by Dcsault, with the addition
^ along splint in front; the circular and transverse bandages of Sir
^ley O^oper, with lateral tapes to draw them together, to which also
^iplint was added; and many other modes not varying essentially
^ those already described, but nearly all of which are liable to one
Prions objection, namely, that if they are applied with sufficient firm-
ly to hold upon the fragment, and Boyer says they " ought to be
jiftwn very tight," they ligate the limb so completely as to interrupt
its circulation, and expose the limb greatly to the hazards of swelling,
oloenition, and even gangrene. How else is it possible to make the
iftodage effective upon a small fragment of bone, scarcely larger than
the tendon which envelops its upper end, and with no salient points
igaisst which the compress or the roller can make advantageous pres-
«ire? If, then, these accidents — swelling, ulceration, and gangrene —
are not of frequent occurrence, it is only because the bandage has not
been generally applied " very tight," and while it has done no harm,
it has as plainly done no godd.
The duigers to which I allude may be easily avoided, without relax-
ing the security afforded by the compress and bandage, by a method
which 18 very simple, and the value of which I have already suffi-
ciently determined by my own practice.
The sorgeon will prepare, extemporaneously always, for no single
pattern will fit two arms, a splint, from a long and sound wooden shin-
22
330
FRACTURES OF THE ULNA.
gle, or from any piece of thin, light board. This must be long enougk
to reach from near the wrist-joint to within three or four inches of tht
shoulder, and of a width equal to the widest part of the limb. Iti
width must be uniform throughout, except that, at a point correspond^
ing to a point three inches, or thereabouts, below the top of the olec-
ranon process, there shall be a notch on each side, or a slight narrow*
ing of the splint. One surface of the splint is now to be thickly padded
Fig. 115.
The author's method.
with hair or cotton-batting, so as to fit all of the inequalities of the
arm, forearm, and elbow, and the whole covered neatly with a piece of
cotton cloth, stitched together upon the back of the splint. Thus pre-
pared, it is to be laid upon the palmar surface of the limb, and a roller
is to be applied, commencing at the hand and covering the splint, bf
successive circular turns, until the notch is reached, from which point
the roller is to pass upwards and backwards behind the olecranon pro-
cess and down again to the same point on the opposite side of the
splint; after making a second oblique turn above the olecranon, to
render it more secure, the roller may begin gradually to descend, et»
turn being less oblique, and passing through the same notch, until th^
whole of the back of the elbow-joint is covered. This completes ^
adjustment of the fragments, and it only remains to carrj' the roH**
again upwards, by circular turns, until the whole arm is covered ^
high as the top of the splint.
The advantage of this mode of dressing must Ihj apparent J
leaves, on each side of the splint, a space upon which neither tlT
splint nor bandage can make pressure, and the circulation of the Hwi
i.«i, therefore, unembarrassed, while it is eipially effwtive in retainivb
the olecranon in place, and much less liable to become disarranged.
Before the bandage is applied al>out the elbow-joint, the oU^cnuiQ
must be drawn down, as well as it c»an be, by pressure with the finger
and a compress of folded linen, wetted to prevent its sliding, must I
placed partly alx)ve and partly u|)on the pnxH«s; at the same tim
also, care must be taken that the skin is not folded in between li
fragments.
When the fragments are not much, or at all separated, and ooiiMequent
no such force is requirt»d to dniw down the upper fragment^ a spit
may be employed, constructed like that recommended by Sir AM
Cooper, made of light wood, curved to fit the limb, or of gutta-perdi
felt, or sole-leather. This should be covered with a flannel or ootfei
FEACT0RES OF THE OLECRANON PROCESS.
331
, and then secured in place by a roller. The sack will enable the
eon to stitch the roller to the splint, and he cau thus employ eSect-
y the oblique and %ure-of-8 turns about the elbow-joint. The im-
ivablc dressings are, in these ca-ses, cumbrous, liable to become loose,
i they increase the danger of anchylnsis.
The dressing ought, no doubt, to be applied immediately, since, if
lewait, as Boyer seems to advise, until the swelling has subsided, it
rill be found much more difHeult to straigliten the arm completely
ban it would have been at first, and the olecranon proceas will be more
drawn up and fixed in its abnormal position. Something will be
gained by these means, adopted early, even if the bandage cannot be
»pplied tightly ; and moderate bandajring will not in any way interfere
with ihe proper and successful treatment of the inflammation. We
must always keep in mind, however, the fact that the fracture being
iBnally the result of a direct blow, considerable inflammation ana
^wiling around the joint are about to follow rapidly ; and on each suc-
twsive day, or oftener if necessary, the bandages must be examined
rarefully, and promptly loosened whenever it sccma to be necessarj".
fir lliis purpose it is better not to unroll tlie bandages, but to cut
lliem with a pair of scissors, along the face of the splint, cutting only
s small portion at a time, and as they draw back, stitch them together
sgnio lightly; and thus proceed until the whole has been rendered
sufficiently loose.
B As soon as the inflammation has subsided, and as early sometimes
1 the fifth or seventh day, the dressings ought to be removed onm-
Itely ; and while the fingers of the surgeon sustain the process, the
toir ouKht to he gently and slightly flexed and extended two or three
es. From this time forward, until the union is consummated, this
utire should be continued daily, only increasing the flexion each
e,as the inflammation and pain may permit. If it is thought best,
>t length, to change the angle of the arm, and to flex it more and more,
it may be done easily by substituting a very thick slieet of gutta-percha
fcr either of the other forms of dressing.
Dieffenbach has scvenil times, in old fractures of both the olecranon
»od patella, where the fragments were dragged far apart, divided the
Iwiiions, so as to be able to bring the two portions together, and, by
^ion of them one upon the other, has endeavored to exi-ite such
L Ktion as might end in the formation of a shorter and a tinner bond of
1 Bnioo. In some instances, it is said, consideralde benefit was obtained,
l*Iler all other means had failed ; in others, the result was negative.
^Kexamploof auold ununited fracture of the olecranon is mentioned,
■■which he divided the tendon of the triceps, secured the upjK-r fn^-
B**nt in place, and every fourteen days rubbed it well against the lower
*f; in three months " the union was firm.'"
. Thi! practice, not witliout its hazards, needs further observations to
\ Wenninc itfl value,
Reeently a gentleman called upon me with his son, aged seven years,
332
CTUBBS OF THE RADIUS AND Ul.NA.
who had an unreduced dislocation of the radius and ulna backwards
of nine weeks' standing. While reducing this dislocation, it being
neceseary to fles the arm forcibly, the epiphysis constituting the olec-
ranon process gave way, and bei^me separated from one-half to threts
quarters of an inch. This is the only example of separation of this
epiphysis which has come to my knowledge. I have, however, twice
since broken the olecranon in attempts to reduce old dislocations of the
radius and ulna backwards, and I ha%'e not regretted the occurrence,
since it enabled me to reduce the dislocations without cutting the triceps.
CHAPTER XXIir.
FRACTURES OF THE RADIOS AND ULNA.
Causes. — In a large majority of the examples of this fracture seen
by me, which have been of such a character as to warrant an attemnt
to save the limb, the accident has been occasioned by a fall npon tne^^
palm of the hand while the arm was extended in front of the body
Yet this cause is not so ctmstant as in fractures of the radius atoDo ^
since a considerable number have been occasioned by direct blows
and if we were to add to this estimate all of those bad compound frm
tures which have demanded immediate amputation, the proportion <
fractures occasioned by direct and indirect blows might be found to t
pretty nearly balanced.
Point of Fraciure^ Character, Direction of DispfacetMmt, dc. — In
record of sixty- three fractures of botli bones, not including guiiiJa
fractures, or those demanding immediate amputation, I have fcxtitdfl
broken in the upper third, twenty-live in the middle third, and tkd'^
two in the lower third.
In one case the radius was broken three-qimrtefs of an inch «lw»
its lower end, and the ulna about one inch below the ooronoid i>rw»-
Four of the fractures belonging to the lower third were probably fff-
phvseail scf Mirations.
Forty-nine were simple, eight comp<iund, one wascomminnWl.^iw
both wmpound and comminut^-d, one complicntcd with a fraitii'C"'
the humems, aad one with > partial iuMtioo of tht hwwr Md cf tl»
K1.0TUBES OF THE BADIUS AND DLKA.
ith three exceptions, all of these more serious accidents
^ among fractures of the lower third, and generally the
wen broken near the wrist.
ractures have been frequently observed, but having treated
idents fully in the general chapter on Incomplete Fractures,
tlunk it necessary to make any further allusion to them in
$, — Generally these bones unite in from twenty to thirty
I have seen the' union occasionally delayed considerably
3 time, and this delay has occurred especially in the case of
Thus, in three cases of compound and comminuted frac-
Ina united within four or five weeks, while the radius did
intil the ninth or tenth week. Twice in simple fractures
las united in the usual time, but the radius not until the
reek. Once the ulna has united promptly and the radius
nunited at the end of two years, at which time I practiced
f the broken ends of the radius, and union was speedily
ther hand, I have once seen the union delayed four months
of the ulna, when the radius had united in the usual time;
i example of com-
turc both bones re- fio. ii7. fio. iis.
nite until after the
hree of the whole
ive united without
iable deformity, and
known to have left
ed defect, while two
ed finally in the loss
Of the remainder
>eak positively.
seen the fragments
;htly in almost every
tut most often it has
id that the deviation
radial or ulnar sides.
:hree examples, two
lad been (impound
be bones have united
Kwition as that from
of fracture down-
forearm has been FnctunlDlba Vnton with illght
> the ulnar side, and lower ihw. uuni diipiuemeDt.
projection has been
Beat of fracture on the radial side ; while in two examples,
lich were simple fractures, exactly the opposite condition has
he lower part of the forearm being deflected to the radial
jorily of cases the hand has been left with some tendency to
334 FRACTURES OF THE RADIUS AND ULNA.
pronation; in many instances this tendency was very slight and scarcely
appreciable, hut in others it has been quite marked, so that the patients
have been wholly unable to supine the forearm except by a motion of
the humerus in its socket.
From what has been said, it must be seen that the prognosis in thew
accidents takes the widest range ; for while a larger proportion than in
the case of almost any other of the long bones, unite without anj
appreciable deformity, a considerable number delay to unite, or do not
unite at all, and some, even where the fracture is most simple, result
in the complete loss of the limb. I am not now speaking of those
more severe accidents in which the limb is at once condemned to am*
futation, and which, in the case of the arm, are numerous; but, as
have already mentioned, our observations here apply only to cases
which (mme under treatment with a view especially to the fracture.
I shall state the facts more fully, and then i>ernaj)8 we shall think
it proper to inquire why, when, as a rule, the treatment is found to be
so simple and successful, occasionally, and pretty often indeed, it re-
sults so disastrously.
A boy, aged about ten years, fell from a tree, April 22, 1856, frac-
turing the right forearm near the lower end of the middle third. 1^
was evident that he had fallen upon the palm of his hand, as tlielo«'CT
fragments were inclined backwards, and one of the bones had be«^
thrust through the skin on the front of the arm.
It was at first dressed carefully by Dr. Wilcox, but the father oft
lad, on the following day, placeci him under the care of an eoipiric.
Six davs afler the fracture occurred I was called to see him, wi
several other gentlemen. He was then suffering under a severe att
of tetanus which had commenced the night before. His arm wasmu
swollen and very painful. He died the same evening.
I was unable to learn very particularly what haci bei»n the trea^^
ment since the patient wa.s seen by Dr. Wilcox, except that the band^^
ages had l)een most of the time very tight, and that the empiric bar
applied stimulating liniments, the boy constantly complaining greati
of the pain. I found the arm done up in a most slovenly manner witl^^
several narrow splints, underlaid with loose and knotty fragments u^
cotton-batting.
We removed all of these immediately, and laid the arm upm a-^
cushion supported by a board, to l)oth of which the arm was lightly
secHircil by a few turns of a bandage ; cool water lotions were diligently
applie<l, and chloroform administered by inhalation ; but the fatal event
was delaved only a few hours.
' I shall not stop to inquire the cause of a result so unfortunate, where
the treatment has been so palpably unskilful.
I have already mentioned one case of gangrene of the hand, after
a fracture of the lower part of the humerus. Norris, in a note to the
Americjin eclition of Lhton^if ^^^^9^^^^ mentions a case which came
under his observation in the Pennsylvania Haspital, the fracture liav-
ing taken place just above the condyles; and still another has been
related to me lately. I have bn)ught together also no less than six
cases of sloughing of the arm, after fracture of the radius, and one of
PKACTURES OF THE RADIUS AND ULNA.
[
sloughing from tight bandaging, where the radius was supposed to be
broken, ulthoiigb the disseutioD proves that it was nut.
Robert Smith says that similar cases have been rec-ordeil in the Ga-
e Miflicah. To these I shall now add eijjht examples of sloughing
r fracture of both radius and ulna; making a total of eighteen cases
I the upper extremities, in addition to those reported iu the Gaidte
'Hicate, an exact account of which I have not seen.
^ John McGrath, xt. 9, fell, July 2, 1847, from a ladder, about thirtv
!t tu the ground, breaking the right radius and ulna in their middle
'rdfi. A surgeon was in attendance about four or five hours after
le accident otn;urred. He then reduced the fraclures and applied two
*4road splints, one on the palmar and one on the dorsal snriiiee of the
Whether a roller was first applied to the arm or not, I am
unable to say. The splints were secured in place by a roller and the
arm laid in a sling.
The third day was onr national holiday, and the patient was not
visiiwl. Nor was he seen on the fourth day, nfit being found at home.
On ilie fifth day the surgeon removed the bandages and found the arm
gangrenous; and within an hour aflerwards I W3.s requested to see it
I found him lying in a miserable apartment, with his right arm
rarting upon a pillow. The arm, forearm, and hand were gangrenous
through their whole extent; and the skin of the right side, on the
•fivnl «f the chest, had assumed a dusky color, the extreme inargfn of
i*liich was indicated by an abrupt crescentic line. The thumb and
■Bgere were black. Hie countenanee was bright and cheerful, and his
hltiid intelligent ; pulse 75, and soft ; tongue clean. He had slept un-
dtslurlied the night before, and he had all along felt perfectly well,
'Except that he had a 8li";lit diarrhcea. I was assured by the sui^eon,
by all of the family, that the bandages had not been applied
[htly; hut we were told that on the third day of tlie accident, having
I locked into the house by his mother, who was a peddler, he
ibed out of the window, and that during all of that and most of
fbllowiog day he wa^ running about the streets firing crackers,
ing most of which time his arm was removed from his sliug and
ing by his side. On the morning of the fourth day his mother
' that his fingers were black, but she thought they were stained
ih powder.
We ordered him to take one-quarter of a grain of opium every four
mrs, aud applied a yeast poultice to the arm. On the seventh day
*he gangrene was still extending, and the pulse was 124 ; yet he con-
'inued to feel well and to eat as usual. On the tenth day the line of
demarcation had commenced opposite the shoulder-joint; and the cres-
centic discoloration on the breast, which had at first spread rapidly
intil it covered nearly the whole upper half of the chest, was quite
faint, in some parts almost lost.
In a. few days more he was removed to the connty almshouse, the
(^ixmiion continuing rapidly to take place until the arm fell off at the
ilimlder-joint ; after which he made a good recovery.
A dbiU, two yean and three months old, had iallen from a ohair
336 FRACTURES OF THE RADIUS AND ULNA.
upon the floor, a distance of about two feet. A German pbysidiii
being called, found, as he believes, a fracture of both bones of the left
arm. The fracture was near the middle. He immediately applied!
roller from the fingers to the elbow, and over this three narrow splinti
made of the wood of a cigar-box. One of these was laid upon tlie
palmar, one upon the dorsal, and one upon the radial side of thefore>
arm, and the whole were bound together by another roller. From
this time until the tenth day the child continued to play about on the
floor. Ten days after the accident occurred the doctor noticed thil
the ulnar side of the little finger was blue. The bandages were im-
mediately removed, and were never again applied tightly.
Three or four days after, I was requested to see the arm with the
attending physician. The gangrene had continued to extend, involv-
ing now the whole of the little finger and most of the thumb. There
were also gangrenous sj)ots over the hand and forearm, extending to
within one inch from the ellx)w-joint ; these spots were more nuraerooi
in front and on the back of the forearm, and seemed to correspond to
the pressure of the splints. The hand was much swollen, and akoth*
arm above the line of the gangrene. The sloughs had already cofli*
menced to be thrown ofl*, and the gangrene was only extending in ^
few points. The child api)eared well and rather playful, except whe*
the arm was being dressed. I ordered a yeast poultice, and a uourisb
ing diet.
I have since learned that the arm and a large portion of the haM
were finally saved.
About the year 1865, as near as I can remember, a lad aged aboa
nine years was brought to the Ix)ng Island College Hospital Dispen
sary, with a fracture of the radius and ulna. It was dressed by tb
visiting surgeon with splints and bandages. He did not return to tb
Dispensary as directed to do, and on the third or fourth day portion
of the arm and hand were found in a gangrenous condition.
In March, 1867, I was consulted by the parents of D. C, of Catla
raugus Co., N. Y., on account of a serious distortion of the hand aw
forearm, caused by sloughing, splints and bandages having been tp
plied by her surgeon for a supposed fracture; but when examined b
me about ten weeks after the accident, there was no evidence that tb
bones had ever been broken. She complained to her surgeon that tb
bandages were too tight, but he thought otherwise, and they were nc
removed until the thinl day, when the gangrene had already oocurrec
The child was five years old at the time of the accident.
A young man, »t. 20, suffered a simple fracture of the fight radio
and ulna March 14, 1874. On the same day it was dressed with
roller next to the skin and over this the splints. On the followin
day the fingers were black, but the same dressings were iH>ntinuep
and they were not remove<l completely until the next <Iay. He w«
admitte<l to Bellevue on the 16th, and by ct>urtesy of Dr. Goulet
was {)ermitteil to examine the arm on the 7th of April. He had iha
last all of his fingers, extvpt a |K>rtion of the thumb, and there wr
extensive sloughing and suppuration along the forearm. His c*ondicic]
was very critical. Ilis death took place a few days later. It in wortk:
FRACTURES OF THE RADIUS AND I'LNA
of remark that, after the first few hom-s, there was no pain in the arm
allhougl) the dressings had not been removed,'
Alice Thompson, let. 50, fell upon her left hand in March, 1870,
raufiing a compound fracture of the radius and ulna, about three inchts
above the wrist-joint. She went at once to one of the New York City
Difipenaaries, and the surgt-ou dressed the arm with splints, applying
tlie bandages "snugly." Two days later she was brought to one of
my (vnrds at Bellevue, with the back of the hand and most of the (bre-
tirm in a state of gangrene, evidently t^uaed by the bandages. Seven
tr eight days later she died before the house surgeon could reach her,
t'min II secondary liKmorrhagt'.
In the following case there was probably no fracture; no doubt
cuulil be entertains, iherefore, as to the cause of the gangrene.
A girl, fet. 5, fell upon the palm of her hand in 1866. A surgeon
ssw her within one hour, put on two wooden splints, with cotton
lolling laid loosely underneath, securing them with a roller. Half an
liiiur after it was drestted the tingers were blue, and the pain was so
grvat that the sui^con was recalled. On his arrival he said it was not
loo tight. On the tbllowing day the oouditiou was the same, but the
surgeon refused to loosen the dressings. Two days later he removed
Ihr hundage, and found a slongh extending nearly the whole length of
the palmar snrlace of the forearm. Some months later I found the arm
Hrajght, but the hand much distorted by the cicatrix.
I have now to relate a case in which sloughing and death occurred
Vi tlie coniiequence of a tight bandage, the patieut being under my
Own charge,
James Bracheu, tet. 22, was admitted to ward 12, Bellevue Hos-
pital, April 1, 1871, with a fracture of the left forearm, near ita
"liddle, eauseil by the kick of a horse on the day before. On the
^u»e day I dressed the fracture before the class of medical students in
»he hospital, nsing a palmar and dorsal board splint, covered and
^uflfx] with cotton batting, according to my usual method; securing
tk« splints with a roller, including the hand and forearm. The arm
Ethen placed in a sling and he was sent to his ward. The lollowing
being Sunday I did not visit the hospital. On Monday I inquired
bim, and learned that he was out walking in the yard. Tuesday I
him, returning from a, walk in the yard, just us I wa.<t leaving the
^anl. lie was apparently in perfect nealth, but as I stopped him a
tnument to look at his arm I saw that the hand was swollen and
inirjile. The dressings were immediately removed, and the patient
placed in bed. There were upon the arm two spots looking like
^perlietal sloughs. He was suQering no pain. The gangrene subse-
futuily extended until it involved a. large portion of the hand and
'opearm, and on the eighteenth day after the receipt of the injury he
<liMl.
I will submit the case without comment, exwpt to say that a careful
ind daily observation of the condition of the hand, and a prompt
''WuvkI or loosening of the dressings wheu the hand first showed
' New Yurk Jour. Mad-, June, 1874.
338 FRACTURES OF THE RADIUS AND ULNA.
symptoms of arrest of circulation, would probably have prevented
this disastrous result. The splints and bandages were removed tlie
fir&t time I saw him after the orieinal dressings had been made, but
this was too late ; some one should have seen the approaching cloid
before it was ready to burst.
South also says that he has seen one or two instances of mortifioft-
tion produced by splints applied too tightly, and previous to the acoei-
sion of the swelling after fracture, and which had not been loosened ti
the swelling increased.*
How shall we explain the frequency of these accidents after fractURi
especially of the forearm ?
Malgaigne, speaking of factures of both bones of the forearm, re-
marks that " when the displacement is considerable, or more especially
when the outward violence has been excessive, we frequently see follow
a very intense inflammatory swelling, and there is no fracture whidi
complicates itself so easily with gangrene under the pressure of appa-
ratus.''*
Says N61aton : " If we make choice of the apparatus of J. L. Petit,
it is necessary that it shall not be applied too tightly, for, as Profeaaor
Roux has long since remarked, fractures of the forearm are those
which furnish mast of the examples of gangrene in cons(H]uenceof an
arrest of the circulation. This is easily understood, if we ct>n8ideroo
the one hand the superficial position of the two princi|)al arteries of
the forearm, and on the other the dis{)osition of the apparel, which
must almost infallibly compress the arteries to a great extent."^
I do not think that this accident is due always to the negligence of
the surgeon. It may be due many times to the carelessness of the
parents or of the patient himself; as in the case of the l)oy who .came
under my own observation, and who lost his arm at the shoulder-joiat.
Sometimes also it may be due rather to the severity of the originel
injury, which, the experience of every surgeon will prove, is (xrasioo-
ally competent to the production of such bad results. A number of
imfortimate circumstance^s may have concurred, such as a severe iojoiyi
especially where the skin has remained unbroken and the cffuaed
blood has had no op|>ortunity to esca[)e — the broken bone may hafo
rested against the trunk of a main artery, causing an arrest of its drco-
lation — the constitution may be impaired by previous illness, or it n*J
be suffering under the shock of the injury; yet that it may be and too
often is the result of maltreatment, on the part of the surgeon, i^iu*'
deniable. It is proper, however, to discriminate between the rcspo^"
sibility which attaches to the surgeon as the true exponent of the«t>**
of his art, and that which attaches to the art itself as taught by tin
masters.
The old surgeons applied first a roller to the hand and forearm* •*
over this their various splints. J. L, Petit thought he had mad« •
valuable improvement upon this simple plan in laying over tberrfl*
a compress, 8upjM)rted by a splint, designed to press between the boO<*i
' South, note to Cheliiis*B Surg., vol. i, p. 69.
' MHlgtti^nc*, Frac. et Dibloc , torn, i, p. 689.
' Nelnton, PHthologiti Chirurgicale, p. 786.
KKACTURBS OF THE RADIUS AND ULNA.
and to antagoDize thiii^ the notion of the roller in drawing the frag-
nietit^ toward each other. Duvt;rney believed that this object would
be best a<*ompliKhetl by placing the pad against the skin, and under a
«r<^ular coinprese ; while Desaiilt declares all of these modes inefficient,
and annnunrefi a method which he regards as aocomplishing at once
and coniplctely all of the indications; the sole peculiarity of which
method consiiits in placing the graduated pads against the skin, and
si'Ctiring them in plaw by a roller. Boyer adopts the same method
irithutit any modifications, and Mr. Hind, in his illustrations of frac^
Hires alreatiy referred to, has seen fit to rewimmend the same, at least
in fractnres of the radius.
It is ({uitc obvious that between these various methods there remninu
very lililc if anything to choose, the differenees being lx>o trifling and
itii«««^ulial to claim serious consideration. Each alike is inadequate
inacoomplieh any amount of useful pressure between tiie fragments;
CJch alike is calculated to bind the bones one against the other, and
alike exposes to tlie danger of ligation and of gangrene,
iflaya M. Dupuytren : "The practice of rolling tne arm before the
'Ints are applied, whether internal or external to the pads and corn-
eminently misi^hievous; and instead of fulfilling, directly
interacts, the indications which it is most important to keep in view
tlie treatment of fractures of the forearm."
And notwithstanding the same sentiment has been reiterated by Vel-
peiu, Malgaigne, N^laton, Samuel Cooper, Bransby Cooper, Erichsen,
AniMbnr)-, Gibson, and others, yet we find lo-day the great surgeon of
Heidelberg, Chetius, recommending the roller to be applied under the
^ntn, after the manner of Desault; while LIston, Syme, and Fergus-
who perhaps represent the Edinburgh school, use only pasteboard
lints above the compresses, over which is immediately applied the
practice which difVers very little from that recommended by
inlt, and is equally obnoxious to criticism.
Among the American surgeons, I believe, tiie advice and practice of
■pnytren have received almost universal assent, only that we have
•Iwiiys employed splints much wider than those recommended by this
Hininguished surgeon. I cannot therefore agree with my accomplished
I MintrycDsn, Dr. Reynell Coates, if in the following paragraph he
^^Bmiie to imply that Amerieao surgeons generally adopt Desuu It's treat-
^^Hdit. ^uch at least is not my cx])erience, "It would be wrong,"
^BlfB Dr. Coates, " not to bear testimony, on every possible occasion,
^Hl{>inRt the folly so universally prevalent, that induces surgeons to
' *Pi"lya bandage directly to the forearm before applying splints in in-
jiiria nf this character. We have often asked for a rational oxplana-
''"n of this practice, without eflect. It is directly at war with the ao-
"■Muledged indications in the coaptation of the fragments, and when
kwobjectof the whole apparatus is to thrust Jisunder their extremities,
"amimences by binding them together. Few plans iu surgery are
"'*'* generally followed; none can be more absuni."
Of the estimate placed upon the roller by M. Mayor, the rentier will
Mge by a reference to the passage which I shall quote further on, when
p*my»k of the vaine of the interosseous compresses.
340 FRACTURES OF THE RADIUS AND ULNA.
Amesbury and Bransby Cooper use no rollers at all — not eveo to
secure the splints in place, they being made fast to the forearm by stnpi
or tapes.
Mr. Amesbury and Mr. South also endeavor to give to their splinti
an appropriate shape, by having them constructed with more or loi
convexity. It must be noticed, however, that the practice of these two
gentlemen is very dissimilar, for while Mr. South applies the convex
surface of his splint to the interosseous space, Mr. Amesbury revcnei
this plan, and applies the concave surface directly to the skin.
As to the width of the splints, surgeons are also very genenllj
agreeil, at the present day, that they ought to be wider than the am,
so as to prevent the roller or the tapes from resting against its sides.
I do not intend to deny peremptorily, and without qualification, the
value of the graduated compresses, which, as we have seen, are osuallf
laid along the interosseous spac*e to press the fragments asunder. Its
necessary, however, to caution the surgeon against their injudicious OHi
M. N6laton has well remarked of the apparel employed by J. L.Petit|
that it must inevitably compress, to a great extent, the arteries of the
forearm; and the remark is apph'cable, in only a less d^ree, to all of
those other plans in which the compress is employed. And I suspeet
that to this portion of* the dressing, quite as much as to any other caoee^
are due those frightful acxiidents of which we have already spoken.
The arteries are not only exposed, from their superficial position, to
pressure from a compress, but, in addition to this, it will be noticed
that the two principal arteries, the radial and the ulnar, are situated
upon a broad and flat surface' of bone, along which this pressure moit
ojKjrate most advantageously. So early as the year 1833, M. Lenoiff
in his inaugural thesis at Paris, called attention to this danger, and
from time to tin^ surgeons have continued to advert to it, buttbej
have seldom given to its consideration that prominence which its ini-
portancc deserves.
I have oliserved another fact in this connection : when this compw*
is extended low down on the |)almar surface, within an inch or two of
the wrist-joint, it soon l)ecomes excessively painful, and sometimes even
wholly insupportable, in consetiucnce of the pressure made upon the
median nerve; and I find myself always obliged to exercise great care
in the adaptation of the pads at this point. For this reason alone, I
believe, in wise of a fracture near the base of the radius, the lower frij^
ment, if it were thrown toward the ulna, could not be retained io ^
place by graduated compresses.
In short, finding that broad splints, properly covered and padJ*^
answer very well to crowd the muscles into the interosseous space, ••
far as it is proper to do so, and believing that this mode is less paio"^
and less dangen>us, I seldom resort to graduated compresses, nor ca0 1
appreciate their necessity, or indeed their utility. Mr. Lonsdale vto
concurs with me in attaching Very little value to this part of the *^
customed ap]>arel.
But listen to the surgeon of Lausanne, M. Mayor : " What sigf"?
graduated compresses placed between the bones of the forearm fortht
purpose of separating them from each otlier ? These bones will ^
AND ULNA,
have that constant tendency to approach each other which has been
sappoeed, provided, first, that they have been well reduced; second,
fur the purpose of maintaining them in position we do not make
of a preliminary circular bandage, who»e action is an absurdity;
, in short, provided we make the retentive means act chiefly upon
the palmar and dorsal surfaces of the forearm,"'
M. Mayor proceeds to declare these convictions to be the result of
his own exjjerience, both in the treatment of simple and compound
fractuns of the forearm, and he intimates that in the use of the cir-
cular bandage with compresses, sut^oons seem to have rolled the arm
into a cylinder and drawn the bones together, in order that they might
tax their ingenuity to discover some means to again separate them.
I" Sui^ieons have generally, after the splints have been applied, placed
Be forearm in a position of senti-pronation, or midway between supi-
BMion and pronation, so that the radius should l>e up|>ermost ; it being
i'teumed that in this position the two bones are most nearly parallel,
and least inclined to displacement. Such, indeed, was the practice of
Hippocrates, Paulus .i^ineta, Celsus, Albucasis, and of most surgeons
down to this day; but Lonsdale, Robert Smith, Nflnton, and Sonth
have latelv caile<l in question the correctness of this mode of dressing,
at least when it is adopted as a universal rule.
I have before mentioned, when treating of fractures of the ulna,
tbt M. Fleury had, in one instance, been unable to bring the frag-
into apposition except by forced supination of the forearm ; and
,1b certain fractures we have seen the same position recommended by
[loDBdale.
Says Mr. South, in a note to Chelius: "In fractures of both bones
Ifc* forearm is best laid supine;" and Nelaton declares that in fractures
tftha railius and ulna at any point of their upper thirds it will be
iKusBary to supine the arm, both in the rc<)uctiun and during the sub-
Isiuent treatment; but that in fractures of the inferior two-thirds we
'>1T place the limb in a condition of semi -pronation.
It seems very probable, however, that both of these gentlemen have
'■cMved their suggestions from Mr. Ixinsdule, who, as we have already
1, has treated the question very much at length, and who has finally
•fiarwl his decided preference for the supine position in the treatment
tfnll fractures of the forearm. His arguments are certainly very in-
Siious, and as applied to fractures of the radius above the insertion of
pronator radii teres, they seem alt(^-ther conclusive; and, indeed,
.tteyromraend themselves very strongly to our judgment, as applied
' ill fractures of the forearm. They are sustained also by the results
big own experience, and I see no good reason why they should not
more thoroughly examined and tested by other surgeons. The ad-
hich he claims for this method are, more perfect coaptation
the broken ends, less liability of the fragments to encroach upon
iiilcmsseout< space, and consequently less danger of anchylosis be-
tbe bones and of non-union of the fragments, more complete
342 FRACTURES OF THE RADIUS AND ULNA.
restoration of the power of supination, and less tendency to lateral
tortion, or of falling off to the ulnar or radial sides.
My own cases^ treated by the usual method, have shown tliat w
supination is frequently impaired, and sometimes entirely lost, pn
tion is rarely affected ; and that lateral displacements are much n
common than displacements fonvards or backwards. How this {
tion, semi-pronation, may tend to the production of a permanent
nation, I have fully explained when speaking of fractures of thel
of the radius; and the influence of the same position, the ibre
resting upon its ulnar margin in the sling, in the production •
lateral deviation, is also easily understood. If the arm rests upon
sling so that its weight bears more upon the point of fracture t
upon the extremities of the bones, then the ulna, or both ulna
radius, will incline gradually to the radial side, and the hand will
off to the ulnar side ; or if the sling rests under the wrist or k
chiefly, the hand will ascend to the radial side, and the broken end
the two bones will project to the ulnar side.
If this plan is adopted, viz., laying the hand and forearm upoi
hack, instead of upon its ulnar margin, the elbow should remain at
side, the humerus falling per{)endicularly from its socket; and
forearm should rest in the sling directed forwards from the body.
The following is the method asually employed by the author:
Two thin, but firm, wooden splints are prepared, of uniform brea«
sufficiently wide that when the roller is applied it shall touch (
lightly the radial and ulnar mar]
Fio. 119. of the forearm. The palmar ^
should l)e long enough to extend f
the bend of tlie ell)Ow, the arm Iw
flexed, to the metaairpo-phalan
p«imar spiiDt. articulatious, the fingers being fle:
The dorsal splint should be a I
shorter, or of a length to extend from the base of the olecranon pre
to tlie carpus. Both of these splints must be covered with cloth,
pro|)erly padded with cotton batting; talking care to leave bnt littl
the cotton placed where it might press u|K)n the radial and ulnars
ries and median nerve ; that is, at the front of the wrist.
The splints being carefully fitte<l, are applie<I while the forean
held at a right angle with the arm, and in a |)osition mi<lway bet«
pronation and supination, one to the palmar and the other to thedc
surface of the forearm, and secured with a roller. There mu^tb
pressure against the humerus at the l)i»nd of the ellxiw; and the fin
must be flexed ea^^ily over the lower end of the palmar splint,
dorsjil splint should not extend beyond the lower end of the r»
and ulna. It is umlerstood, of course*, that while the splints are b
secunnl in place, extension an<l counter-extension are maintained
the pur|)ose of securing coaptation of the bn)ken extremities aa fii
possible. The dressing being completed, the forearm is susjtended
sling.
Finally, whatever may be the mode of dressing, let me repeal
injunction to examine the arm frequently. No surgeon can do jm
FRACTURES OF THE CARPAL BONES. 343
m toiiin»elf, or to his patient, who does not look at the arm at least once
m n tventy-four hours during the first ten or fourteen days, and in some
■ iSMes the patient ought to be seen twice daily.
I flTien the fracture is compound, it is often quite impossible to retain
tile forearm in the half-pronated position; since, when thus placed, and
oofysh'ghtly supported, as it must necessarily be, it inevitably falls
over upon its palmar surface.
There can be no doubt that in such a case we ought, from the first,
if it is found practicable, to place it upon its back, in a position of com-
plete or nearly complete supination. For this purpose, a single broad
tfiintj carefully cushioned, and covered with oiled cloth, is the most
citable. Upon this the forearm is to be laid, and secured gently with
tfcw tarns of the roller. If the patient is able to do so, and wishes
fowalk about, the board may be suspended to the neck, as recommended
hf M. Mayor.
I have said that we ought, in cases of compound fracture, to lay the
fcnearm upon its back, if practicable. I am sure, however, that the
Hui^n will find very many patients who cannot endure this position,
and he may be compelled, therefore, to lay the limb upon its palmar
nr&oe, or to leave it to assume any other position in which it may be
the most at ease. In conclusion, I desire again to call attention to the
Slint employed by Dr. Scott, and of which an illustration is given in
e chapter which treats of fractures of the radius.
CHAPTER XXIV.
FRACTURES OF THE CARPAL BONES.
The few cases of fracture of the carpal bones, which have come under
^y observation were, without exception, compound and complicated,
^ have resulted in the complete loss of the hand, or in some less
^oos, but never inconsiderable, mutilation or maiming.
In no case has a treatment been adopted which might be regarded as
wing reference to the fracture, or the purpose of which was to insure
Opposition and union of the fragments.
It may be proper to assume in a matter so easily comprehended, what
•ctnal and recorded experience has not proven, namely, that simple
fiictores of these bones will demand very little surgical interference,
*nd that they will unite generally without much displacement, and
^thout any considerable maiming. It is, indeed, quite probable that
*Hne degree of anchylosis between their adjacent surfaces will occur,
yet even in the uormal condition they enjoy so little motion as to render
itdoabtfiil whether its complete loss would be very sensibly felt.
In cases of comminuted, compound, and otherwise complicated frac-
^Wtt of the carpal bones, which accidents are sufficiently common, the
^fgeon has only, I conceive, to follow carefully those general- or special
344 FRACTUR£8 OF THE METACARPAL BONES.
indications which may happen to be present^ the precise character oi
which it would be difficult to anticipate, and for the treatment of which
it would be unsafe to attempt in a written treatise to provide.
CHAPTER XXV.
FRACTURES OF THE METACARPAL BONES.
Development of Metacarpal Bones, — These bones are each formed
from two centres of ossification. In the case of the metacarpal boM
of the four fingers there is one centre for each shaft, and one for eich
distal extremity ; but in the case of the metacarpal bone of the thnmb
there is one centre for the shafl and one for the proximal extremitf.
All these epiphyses unite with the shafls at about the twentieth yeir.
Causes, — These bones, also, are generally broken by direct blofi;
and in that case the injury is oflen of such a character as to demind
amputation, and does not therefore belong to that class of accidents of
which it is the purpose of this volume to treat. Not an inconsidenJik
number, however, are the results of indirect blows, and especially rf
blows upon the knuckles received in pugilistic encounters. Thus, in •
record of fifleen fractures, I find this cause assigned in six ; in one other
instance it was occasioned by falling uj)on the clenched fist, and in one
by striking a board ; so that the fracture has resulted from a blow upon
the ends of the bones in eight of the fifleen examples.
Point of Fracture; Direction of Dlsplacet)ient; Symptotns. — Oncetba
fracture has occurred in the metacarpal bone of the thumb; seven tim*
in the metacarpal bone of the index finger ; once in the second finger;
tliree times in the ring finger, and three times in the metacaqial booe
of the little finger. Two of those belonging to the ring finger, and the
three occurring in the little finger, were produced by blows with the
clenched fist, and in eac»h instance the fracture was in the lower ordww
third of the bone. Two of the fractures of the metacar|)al bone of the
index finger were produced also in the same way ; but the fracture!
were near the middle of the bone. Of the whole number, seven were
broken through the lower third, five through the middle, and three
through the up|)er third.
In every instance where the bone is known to have been broken hj
a blow upon the knuckles, the distal end of the distal fragment *••
thrown toward the palm, and this fragment was salient bacKwanls ^
the point of fracture.
In the following case the bone was probably separated at tJM
epiphysis.
Thomas Rose, aet. 8, fell down a flight of steps, September 11, 1^
breaking the metacarpal bone of the index finger of the right bti^
near its lower extremity, and apparently at the junction of the epipbj*
with the diaphysis.
J^BACTURES OF THE METACARPAL BONES. 345
•
I saw the lad about sixteen hours after the accident. The lower frag-
flient, projecting abruptly into the palm of the hand, could be easily re-
placed, or with only moderate effort, yet immediately when the support
was removed it would become displaced. There was no crepitus.
It was dressed very carefully with a splint and compress; but not-
Ti'tbtanding our continued efforts to keep the fragments in place, the
epiphysis united considerably depressed toward the palm.
lu one instance, also, I think the bone was rather bent, or partially
fiaetured, than broken completely. This was the case of fracture of
tile metacarpal bone of the ring finger, produced in a gymnasium by
striking with the clenched fist against a board, and to which I have
ilready alluded. I did not see the young man until four weeks after
Ite accident, when I found the lower end of the bone depressed toward
»e palm, and the angle made at the point of fracture was rather
*unded and quite smooth ; it was also tender at this point, but the
tne was firm and unyielding. Four years after I was permitted to
amine it again, and I found the same slight deformity still continuing.
A partial explanation of the fact that the distal end of the distal
igment is generally displaced toward the palm, may be found in the
itural curve of these bones, which is such that when the fracture has
en produced by a counter-stroke, the <listal end would almost neces-
rily be driven in this direction ; and a farther explanation has been
i^ested by Mr. B. Cooper, namely, the action of the interossei.
mmdts, — Genemlly, when the fracture is simple, and the displace-
lent is not considerable, the nature of the ac(tident is overlooked, and
Kne deformity must inevitably ensue. In a majority of the cases
hich have come under my observation this has been the fact, and the
one has remained slightly bent at the seat of fracture, but without
Krtiog in any degree the value of the hand.
The following example has furnished the most serious result of any
ue of simple fracture of these bones which has come under my notice.
Louis Mooney, set. 25, struck a man with his clenched fist, Novem-
ber 4, 1856, breaking the metacarpal bone of the index finger of the
ight hand near its middle. Great swelling and suppuration followed
he injury.
February 21, 1857, nearly four months after the injury was received,
)e consulted me. There existed at this time a complete anchylosis at
Aevrist-joint, and partial anchylosis in the fingers. The hand was
Reflected forcibly to the radial side. At the point of fracture the frag-
n»enls were salient backwards and quite prominent, but firmly united.
Even when the existence of the fracture is recognized, it is not always
^ to retain the fragments in place, as the case of epiphyseal separa-
tion already mentioned, and the following case, will illustrate.
Mi88 E., of Erie Co., N. Y., ajt. 18, fell, August 7, 1853, striking
ttpon her right hand with her fingers forcibly bent into the palm of the
wnd. On the following day she consulted me at my office, and I
fcond the metacarpal bone of the ring finger broken about three-quar-
^ofan inch from its distal end, and the distal extremity of the frag-
^t depressed toward the palm. A feeble crepitus, with distinct mo-
won, completed the diagnosis. The young lady was very anxious to
23
346
KPAL BONES.
have a perfect hand, and I was determined if possible to accomplish H. I
Finding that the joint end of the dialal fragment was ooiistantly di»- I
poeed to fall toward the palm, I constructed a ^itta-percha splint for |
the hand and lingers, ana afYer placiii? a pad directly nndcrucath this
fragment, I secured it firmly with a roller. From this time until the
end of fonr weeks she remained under my rare, visiting rae aa often a
once or twice a week, and at each dressing I found the distal fragment
slightly displaced in the same direction as at first, nor was I able ever
to make it resume completely its position.
Ordinarily, however, no such difficulty is experienced, and the bone,
supported by such simple means as we shall presently dirert, unites
quickly and without deformity.
An engineer was struck by a piece of iron in such a way as to break
his right forearm and the second metacarpal bone of the same hand.
The fracture of the metacarpal bone was com]iound and about tlin-*-
quarters of an inch from its proximal extremity. When he mlltNl
upon me, which was immediately afler the injury was received, I founj
the proximal fragment projecting directly backwards, its shaq> point
rising above the skin, into which position it was evidently drawn by
the action of the extensor carpi raoialis longior muscle. By prcesur*
alone it could be replaced, but it was much more easily reduced whes
the hand was forcibly carried backwards on the fiirearm. I tbcrefbra
secured the hand in this position vflth appropriate splints, and it WW
maintained in this posture during most of the subsequent trcfttmeot
Union finally took place, but not without some backward disiilacvment,
Four months after tlie accident occurred, on the Slst of llciccmbfr,
185S, I e.tamined the hand, and found the skin healed over oumplelrlr,
the end of the fragment having become nmndod and smooth, so ns not
to give him any degree of annoyance. His wrist was as flexible
Bs strong as before. No doubt the projection of the fragment mi}()il
have been preventetl entirely by cutting at the point of its atl£chm««t
the tendon of the extensor muscle, but this would have sensibly weak-
ened the wrist-joint, and I preferred the alternative of a projecttoo of
the fragment.
Treatment, — With moderate extension made upon the finger corrf-
sponding to the broken bone, while the fragments nrv forced honn* b/
firm pressure, the Itone may generally lie oronght at once into iiitt,
and we may now proceed to adapt a gutta-percha, felt, or thick pastfr
board splint, to either the whole surface of the luK-k or palm of tiM
hand and fingers, while they arc held in a jtoaition of easy flexion. It
18 not very material to which of these surfaces the splint is aiiplinl; of
[ rather, I may say, it ought to l>e applied to the one or the other awimf-
I ing as circumstances seem to indicate. It should be well padded, urn
|«q>ccially at certain points, in order to the mon^ effectual support'^
K4e fragments, It is then to bo secured in place with ee^'ODl tunvv
|.a roller. When either of the mctai«r[»al (xtncs, excopt those of iN
I great or ring linger, is broken, the splint must Ite wide enough to *«W
the sides of tlie hand against the pressure of the n)ller.
Thus dressed, the hand may be laid in a sling beside the chat,*
wlule sitting it may rest ujKm a table.
*
FRACTURES OF THE FINGERS. 347
The apparel must be examined daily, and readjusted as 'often as it
shall become disarranged, or as a doubt shall arise as to tlie oondition
of the parts.
When the fracture is followed by much inflammation, or occurs near,
and especially if it actually involves a joint, the -same precautions must
be adopted to prevent anchylosis as in the case of similar fractures in
other bones.
CHAPTER XXVL
FRACTURES OF THE FINGERS.
Development of the Phalanges of the Hand, — The phalanges of the
hand are formed from two centres of ossification, namely, one for each
shaft and one for each proximal end. Ossification commences in the
shafts at about the sixth week ; in the epiphyses of the first phalanges
between the third and fourth years, and in the epiphyses of the two
last phalanges somewhat later. Complete bony union takes place be-
tween the epiphyses and the shafts at from the eighteenth to the twen-
tieth year.
Causes, — I do not remember to have seen a fracture of one of the
phalanges produced by a counter-stroke ; I am aware, however, that
they are occasionally produced in this way, as by falling upon the
«Mfe of the fingers, and especially by the stroke of a ball in the game
of base.
The fact, however, that they are generally the consequence of a direct
blow, and that the finger bones are small and only protected by a thin
covering of skin and tendons, renders them peculiarly liable to com-
iniDution and to other serious complications. Thus, in a record of
thirty fractures, only eighteen were sufficiently simple to warrant an
attempt to save them , and only five arc recorded as simple fractures
without complications.
Point of Fracture and Direction of Displacement, — In the following
case there was probably an epiphyseal disjunction. A lad four years
old was admitted to the Hospital of the Sisters of Charity, Dec. 24,
1849, with a simple fracture of the first phalanx of the ring finger of
the left hand ; the fracture being at the proximal end of the bone, and
at the junction of the epiphysis with the shaft.
The finger was so much swollen at first, that no dressings were ap-
plied until the fifth day, at w^hich time a gutta-percha splint was
lOoalded to it carefully. It resulted in a perfect cure.
I have never seen the fragments much overlapping, except in one
'itetance. Frequently there has been no perceptible displacement what-
ever; but generally there will be found a slight displacement in the direc-
tion of the diameter of the bone.
The case to which I refer as presenting an extraordinary overlapping,
^as that of an Irish laboring woman, aged about thirty-five years, who,
kaving fallen down a flight of steps, broke the first phalanx of the
^umb below its middle. Dr. Cougar was first called on the day fol-
lowing the accident, but was unable to reduce the fracture, and on the
348 FRACTURES OF THE FINQERS.
same day invited me to see the patient with him. The disUiI frajrment
was displaced backwards, overlapping the proximal fragment a little
more than one-quarter of an inch. We made rejK»ated etfbrts, by pull-
ing upon the thumb with a sliding noose, and w ith all the strength of
our four hands, but to no purpose. The fragments could not be re-
duced for one moment ; and we left the patient as we had found her,
only somewhat the worse for our violent and repeated extensioni* aod
manipulations. The finger was already considerably swollen when we
began our efforts, and we cannot therefore say what might have been
accomplished at an earlier moment, but I confess that our defeat was
unexpected, and does not seem to me to be satisfactorily explained.
Results. — At least ten have left no appreciable lameness or deformity i
and possibly several more. It is therefore probably true that the**
consequences may be avoide<l with proj)er care in one-half of the e^
ampler in which we attempt to save the finger; and i)erha|)s it wi^
0(;casion surprise that a perfect result may not be daimetl in a larg^
proportion ; but when we consider how frequently the accident is coi^
pound, and that even when it is not, the blow having generally
received directly upon the point of fracture, how promptly swelli
ensues, it will be Ciusily understood that it will be often found diffici
to determine whether the bone is exactly in line or not, or to main
it in this position after absolute coaptation has been once se<'ured.
I have seen the finger in two or three cases deviate laterally, or
come permanently deflected to one side or the other ; and onw I ha.
found it united, but rotated on its own axis. This latter case is
without instruction.
A girl, aet. 6, had her little finger caught by a door violently sh
breaking one of the phalanges, and nearly severing the finger. 1 cl
the wound, and dressed the finger with a moulded pasteboard spliiv
My dressings were repeated often, and applied carc^fully; nor did —
detect the rotation which the lower fragment had made uj>on its o^
axis until the union was consummate<i. I then found the extremity
the finger turned so that its palmar surface presented diagonally —
ward the ring finger.
If the surgeon believes that this ought to have l)een prevent^!, a^
that the result evinces a lack of skill or of care, its reconl may a --
serve one of the purposes for which it was designeil, and soourt* to ^^
patient sometimes hei*eafter more faithful and assiduous attention.
Treatment, — Boyer, and after him Bransby Coojx^r, have taught iW^
when the extreme phalanx is broken, from the small size of the bo^
and from its having attached to it the nail and its nuttrix, it is lie
in all ciises to amputate at once, as the process of reiKiration Ls in s
case extremely slow and uncertain.
Whether in any of the cases treated by myself, or which liave \n
mien by me, the fracture involve<l the last phalanx, I am not now a
to say, but my impression is that such cases have come under :
notice which have been successfully treatetl, and I cannot hut
the rule establishe<l by these gentlemen as much too stringent,
amples must, no doubt, sometimes occur, in which the fracture is
simple in its character as to render prompt reunion pretty certain ;i
even though the restoratiou should prove tedious, tbia ought
FRACTURES OF THE FIHOERS. 349
■ tober^rded as a sufficient justificatinn for so eerioua a mutilation
I adiese Eurgeons propose, since tlie loss of even an extreme phalanx is
' Mt odI^ b deformity, but must prove in many occupations a trouble-
Mime maiming.
Prof. J. Lizars, of the Toronto school of medicine, C. W., has re-
farted to me a case exactly in point. " A man in the employ of the
oronto Rolling Mills Company fractured the distal extremity of the
ring finger of the right hand. The fracture was transverse, and the
nail was severely bruised, the accident being caused by a direct blow.
Crepitus distinct. A dorsal splint and bandage were applied, and in
a short time the fragments were united finnly by bone. The nail
sabsequently fell off, and a new one was formed."
The rule ought still to be held inviolat*?, which surgeons have so
often rei)eated in reference to injuries inflicted upon the hand and
fingers, namely, that we should save always as much as possible.
It is remarkable, too, how much nature, assisted by art, can do
toward the accomplishment of this purpose. If the bone of a finger
ie not only severed completely, but also all of its soft coverings, save
only a narrow band of integument, are torn asunder, a chance remains
for its restoration. And it is especially interesting to observe what
recuperative powers are possessed by the articular surfaces of these
smaller joints, so that although they may be broken into, or sawn
through, or comminuted, and although small fragments be entirely
removed, a complete restoration of their functions is sometimes per-
mitted. I have seen and reported some such examples. It is true,
however, that such fortunate results are rare, and they are rather to be
hoped for than anticipate<l.
Since, in the case of these delicate bones, the slightest deviation from
the natural form or position determines in the end an ugly deformity,
>t becomes exceedingly
*»ce8?ary, especially with ^"^ 'so.
ftmales, that we should ''r''V""-..
«pni the dressings and ex-
amine the fingers care-
ftlly from day to day, so
tint, as the swelling snb-
si«lw,we may discover and
vHnct any displacement
'vhicfa may happen to
«is.
Asasplint,! haVefoUnd GulU-perthnplmi for Unger.
Mthii^ so convenient as
ptta-percha, moulded accurately to either the dorsal or palmar aspect
"f the finger; and the form of which I have found it generally neces-
■ly to change slightly every third or fourth day, until consolidation is
"wly or quite completed.
If the fracture is near or extendi into a joint, Ihe finger ought to be
> little flexed so as to place it in the most useful [losition in the event
'w anchylosis should occur ; and as early as the end of the secoud
"ttk the joint surfaces should be slightly moved upon each other, in
k ttder to the prevention of fibrous or bony adhesions. Nor is there
350 FRACTURES OF THE PELVIS.
much danger of preventing the union of the bone by moving the join
at this early day. Uilion occurs between these fragments veryspeedil;
and I have never met with, a case of non-union of the phalanges, m
do I remember to have seen a case reported.
It is the lateral inclination of the distal end of the finger whic
according to my experience, it will be found most difficult to obviil
and which may,, perhaps, in some cases be most successfully combat*
by laying tlie two adjoining sound fingers agiunst the broken fing«
and then applying a moulded splint to the palmar surface of the who
In other cases it will l)e more convenient to apply the splint only
the broken finger-
Rotation of the lower fragment oa its ow» axis is especially to
guarded against, as the deformity which it occasions is more unsoem
and the impairment of utility more decided, than tliat occasioned b)
lateral deviation.
It may be well also to remind the surgeon of the convenience of c
tending the splint beyond the end of the last phalanx,, and mould!
it to this extremity, in order tliat the fi^iger may I)e protecteil agaii
injuries, and that when, from time to time, the splint is removed,
may be reapplied with accuracy.
In all cases the splint should be lined with cotton cloth, sofl flann
or patent lint, and seciu^ ia place with narrow and neatly cut cott
rollers. Bandages of this width should never be torn, but carcfii
cut with scissors.
CHAPTER XXVIL
FRACTURES OF THE PELVIS, AND TRAUMATIC SEPARATION"
OF ITS SYMPHYSES.
Development of the Os Innominatum, — This bone is formed fr
eight (^ntres, three of which are calletl primary, and five socomla
The three primary centres belong ri»s|)e<*tively to the ilium, is<'hiu
and pubes, and by their extension form eventually the greater porti
of the innominatum. They have a conwiion point of union in i
acetabulum ; and the ischium unites with the pubes, also, by the joi
tion of their rami. Th(»sc conjunctions occur usually between t
fifteenth and twentieth years of life. The secondary ccntri's do i
lx»gin to ossify until the age of pulwrty, and may therefore projierly
considered a** epiphyses. One forms the crest of the ilium ; one
anterior inferior spinous pHK-ess ; one forms the symphysis pubis ; i
the tuberosity of the isrhium; while the fifth constitutes the centre
the bottom of the acetabulum. The epiphyses become joined to i
primary bones, or the bodies of the innominata, at about the twcn
fiflh year.
{ 1. Pnbet.
Lcnte, in his reports fmm the New York Hospital, mcDtions
oaae of a young man, let. 18, who was crushed between a coapk
„ ._. Hall report'* a case in the Provincial MctUcfU and Surgical
•''^nal, Mav 1, 1844, in which the pubes, thus 9eparat«d, was actually
Inrugt iijio the bladder ; but in this example the ilium was broken also.
1 rwwi sain-elv add that this patient died ; ' but Sir Astley Cooper has
fiirnii-hfd u« with au example of a simple fracture or traumatic separa-
'inn at the symphysis, from which the patient after a long time almost
"ompletely recovered. The following is Sir Astley's account of the
CUM;
"Case 79. Richard White, at. 22, was admitted into Guy's Hospital
WilheSOlh of July, 1832, having sustained a severe injury in conse-
quence of a large quantity of gravel having fallen upon nia back while
'" tlie act of stooping. It knocked him down ; and on rising, which
•ii' did with considerable difficulty, he attempted to walk ; this produced
Vwlent pain in the region of the bladder, estcndiug upwards in the
FRACTDRES OP THE PELVIS.
course of the ureters to the kidneys. Upon inquiry, he stated that
the urine he had voided since the accident was bloody and parcel wiUl
difficulty.
"On examination, a fissure was found at the symphysis pubis, piw
during a ge[)aration of about two fingers' breadth. On pressure being
made ujkid any part of the ilimn, he complained of increased pain io
the region of the pubes, and of numbness down the left thigh.
" A catheter was immediately passed, and the urine whicli was drawn
off was clear and healthy. Leeches were applied over the pubes, and
B broad belt was firmly buckled around the pelvis sufficiently tight '
bring the separated pubes nearly in contact, and the patient onler
to be kept perfectly tjniet in the recumbent posture, on low diet. The
leech-bites ulcerated, and some slight degree of fever resulted, which,
however, readily yielded to the usual treatment.
" He remained in the hospital for three months without any check-
to the progress of his cure; the length of time it required being accounted
for by the difficulty of reparation in the amphiarthnklial articulation;
and when be left there was some slight separation of the pubes renisiiH
ing ; nor were the two lower extremities, or the anterior and su[x-ricir
spinous procesaes of the ilia, perfectly symmetrical, although he could
walk very well."'
Malgaigne has collected four cases of simple separation at the
physis pubis occasioned by external violence, and in three of the ifour
cases it was occasioned by pressing out the thighs with great force ; Ha
separation being directly due, therefore, to muscular action.
Two of these patieute succumbed to the accidents. The same aatbor
has brought together, also, seventeen ca^es of separations of this sym-
physis occurring in childbirth, of which only seven survived.
It is much more common, however, to fintl the pubea broken tlirongb
itfl horizontal or ascending ramus ; and Clark, of the MassachuscHi
General Hospital, has described a <?ase of simultaneous fracturt^ of At
pubes and ischium in three places. The man, let, 29, had W-en caii^
between two heavy timbers, and on the following day, May 7, 1S5!,
he was brought to the hospital.
No crepitus could be detected, but he was unable to lie i
![(on t
right side, and the right limb was nearly paralyzed. It was evitfcW
that the bladder or urethra had been ruptured, and on the thin! d«y
Dr. Clark npenetl the bladder through the perineum, evacuating a Iwff
amount of blond and urine, and affording to the patient very »«*iw
relief. On the 1st of June, however, he died, having survived tie
accident twenty-five doys.
The autopsy disclosed several fractures, all of which bolongied t*
the right os innonMnatum. First, a fracture of the pubes nmf t»
avmphysis; si-cond.a fracture near the junction of the pub*« and ilium;
third, a fracture lliruugh the nmiusuf the ischium unlt-rior to ilic tot*-
rosity."
Sir Astley mentions a case (Case 83) of fracture of the "ramus nf***
aark'>cjMorf
piibes," unacoompaDJ
suited in a complete recovery ; and in another case (Ca.se 84) the patient
rwwvered in eight weeke, and waa
' 'e to walk nearly as well as before ;
but lie soon after died of diaoase of
the chei^t. The os pubis was found,
at tlie autopsy, to have been broken
in three places ; there was also a
fracture extending in two directions
through the acetabulum, with an
extensive comminuted fracture of
the ilium, accompanied with grait
displacement.
Marat has even found it nccee-
sary, after a fracture, to remove
nearly the whole of the body of the
puSes by incision, in a girl of 18
yrars, and who not only recovered
completely, hut having subsequently
married, she gave birth to two ehil-
lirMi in easy and natural labors,'
L'uppel letti relates that a man, let. 54, jumped from a carrif^, the
Wtses having run away, and alighted with his feet to the ground, but
*illi one limb in the greatest possible degree of abduction, A surgeon,
»liosaw him immediately, found an enormoiB swelling at the superior
Sof the thigh, accompanied with very acute pain. When seen by
.pelletti, at Trieste, six months after, there still remained a slight
'Welling near the ramus of the ischium and pubc.s, under which a
<*frtn[ examination detected a fragment of bone two and a half inches
^^ and of tlie "size of the finger." The patient was able to walk,
•■m not without pain and limping. Cappelletti soon began to susp^'ct
I'wi this fragment of bone consisted of a part of the ramus of the
/schimn and pubes detached by muscular contraction. On examining
't anteriorly he found this part of the pelvis defective, and the loose
P«inioii of the bone had all of the anatomical eharactei-s of the defective
/*art. He felt distinctly the circular projection Indicating the point
Phen tlie ascending branch of the ischium unites with the descending
nnch of the pubes.*
I Wbitaker, of Lewiston'n, N. Y., saw the body of the left oa pubis
Token in a female while in the seventh month of pregnancy. She had
" 'en down a jmir of staii-s, striking astride the edge of an open, upright
n-l. The fracture was oblique, and with but little displacement,
it she complained of excruciating pain in the left pubic region on the
fesisl motion. The accident was followed by no positive attempt at
■*i»warriagc,*
Thi' lianger in these accidents consists not bo much in the fracture,
* Marat, r^oni Mnl^xigne, np. cit., p. MR.
1^' U(Fi|ia>UvUi> Ratiliiii^'a Abi^truct, No. Viii. p. 83 ; from Giurnait! per servire kI
■^•■ngr^.i driitt PolnloeiB dullu Tornpculica. 1847.
* irVtUbu, AmOT. Jonra. MBfl. Set., July, IMT, p. 288. ^^^
354 FRACTURES OF THE PELVIS.
as in the injury done to the bladder and other pelvic viscera. If th«
bhidder is opened into the peritoneal cavity, death is almost inevitable;
and even when the bladder or urethra has suflered laceration lower
down or at any point above the deep perineal fascia, ext«nsive urinaty
infiltrations, followed by abscesses and gangrene, generally expose thea
patients to the most imminent hazards.
The practice pursued at Guy's Hospital in the case of separation at
the symphysis pubis, commends itself both by its simplicity and by its
success. Antiphlogistic remedies stendily pm-sucd, rest in the recunf
bent posture, tlie use of the catheter when necessary, and in ivrtaio
cases the girding the pelvis with a 6rm belt or band, arc
which seem to meet all of the important indications.
If the fracture is accompanied with displacement it will be proper
I'to attempt to restore the fragments, but except in the ca-^ of sepant-
[ tion at the symphysis very little aid can be expected fniui a band or
any similar means in retaining them in place. It will be sufBdentj
generally, in such examples to place the patient quietly u[kon his hock.
with his thighs flexed upon his body, and to treat the accident "
other respects as a case of inflammation.
If the urine has become extmvosated underneath the pelvic &sd»j
no time ought to be lost in o|>ening freely through the [jcriDeum.sna
in esteiiding the incisions, if necessary, into the urethra and bladder.
I 2. Iiobiom.
When speaking of fractures of the pubes, we have already noiJCK
some examples of fractures of the ischium alsu; indeed it is seldom
that one of the hones of the innominatuni is broken without a coind-
dent fracture of one or both of the others. The records of surgiuy
furnish several other examples, pn>duccd generally by a fill upon tk
tuberosities; but, pi'rhnps, the most remarkable instance is tbatnMD-
tionetl by Marat lis having occurred in a female during labor.
The following summary of a case of fracture of the is<.'hiuni, reptirtrt
by Sir Astley Cooper, will serve to illuBtrate one of the nuisi finun»l»
terminations of these accidents when accompanied with a rupture of li"
urethra:
A young man who was driving a cart, was thrown dowii and >
wheel {tossed over him. On the following morning he was fouoJ W
have a fracture of the left leg and a contusion of the inner aide of ^
left thigh. There was also great swelling and ecchymoeis of iheitW-
turn, with a slight appearance of injury over tlie pnlies and left hyfO-
chondrium. No fracture of the pelvis was at that time diwxnini
The patient was suffering great pain, and was cold and cxluu*'''^
Bloo<ly nrino esinpeil from the bladdi^r. On the eighth day an iIk**
ha<l (minted on (he left side of the perineum, which, being opened,*!*
chargeil a great quantity of pus having the odor of urin<'; eiteW"
filouiirhing occurrtxl, and the patient sank very low. On inirodiWtBt
the ^nger into the wound, the ascending ramus of the iseJiiumcoaU
be distinctly felt, and the fracture traced in an oblique enuise, w
iip]>er fragment being slightly displaced forwards, When the calbettf
L
introduced into llie urethra it was found to enter this wound, and
pBOold be felt lasting agaiost the naked bone. From this time until
the twenty-sixth day, the urine continued to escape freely through the
wound. In about six weeks mure the fistulous opening had entirely
closed, and after several montiia his recovery was complete.'
The signs of this accident are generally even more oliscure than those
of fracture of the pubcs, bnt in a case of doubt the bones ought not
only to be carefully examim'd from without, but the finger should be
introduced freely into the rectum and the anterior sui-face e.xplored ; or
the tulwr ischii may be grjispcd between the thumb and finger and
moved laterally in order to deternjine the existence of motion or crepi-
tus. If the patient is a female, this exploration can be best made
tiirough the vagina. By Sexing and extending the thigh, also, crepi-
tus may sometimes bo discovered. The examination will generally bo
made while the patient lies upon his back ; but if turning is not found
ton painful, it will be well to lay him upon his face, that the tuberosi-
ti« of the i^^hium may be more pJainly brought into view,
A considerable proportion of the fractures of both the pubes and
llie ischium are accompanied with lesions of the bladder or of the
trethra, cither of which circumstances will render the prognosis very
I unfavorable; but In simple fractures recoveries may generally be ex-
1 pednl, yet only after a tedious confinement.
I It is not usual, except in cases which must almost necessarily prove
K&(at, to find much displacement of the fragments; nor is it probable
Bdut by any roanceuvres the slight displacements which are found to
^tetist can be entirely overcome. Instances may occur, however, iu
wbitih careful pressure from without, or the introduction of a finger
into the rectum or vagina, may aid in the restoration.
The posture best suited to these cases will be indicated usually by
tlwgen^ali'>n!^ of the patient himself. Ordinarily he will prefer to lie
"pun hii:> l>ack with his thighs fiexed and supported by pillows; and
nio hips slightly elevated by a firm cushion laid under the upper part
«f the sacrum. His knees ought also to be gently bound together;
hut if the pitcient finds this position painful or excessively irksome, as
'i'jmrtinies he will, he may be permitted to occupy any position which
fte finds most comfortable.
i 3. Ilinm.
Fractures of the ilium are much more t
sillier the ischium or pubes, and they asaumi
*lin'ctions, and degrees of complication.
In the two following examples the anterior superior spinous process
alone was broken off:
John Kelly, a?t. 36, admitted to the Hospital of the Sisters of Charity,
i*ee. 2-S, 1852, having just fallen and broken the anterior superior
'*iunuus process of the ilium. The fragment was displaced downwards
^boat nne-i}uarter of an inch. Motion and crepitus distinct. A slight
)mmon than fractures of
a great variety of forma,
■ Six A. Cuoper, by Btansby Cuuper, Amor, ed., p. 110.
356 FRACTURES OP THE PELVIS.
ecchymosis existed over the point of fracture, and other signs of con-
tusion about the hip were present. He was intoxicated at the time of .
the accident, and could not tell how or where he fell.
He was laid upon his back in bed, with his thighs flexed upon \m ^
bo<ly; and in this position we attempted to reduce the fragment and ;
retain it in place with a bandage, but finding this impossible, we left ■
him with only instructions to remain quietly in bed. In about two ,
weeks the fragment was firmly fixed in its new position, and he wii
allowed to get up and walk about, which he was able to do withool •
inconvenience. '
July 13, 1863, Matthias Morrison was caught under a bank of fiJl- ;
ing earth, and on the following day Dr. Mixer, his attending surgeoo, ]
requested me to see the case with him. He was unable to stand upon \
his feet. There was a lacerated wound and an extensive bniise on hit j
left hip ; but the thigh was not shortened nor everted, and he eooH j
flex it slightly upon his body. Noticing a swelling and discoloration
in the region of the anterior superior spinous process of the ilium, I \
Eressed upon it and felt it recede with a distinct crepitus ; the fragment,
owever, immediately resumed its place when the pressure was re-
moved. I was able also, by a careful manipulation, to trace the line
of fracture, and to determine that it included a small portion of the
anterior extremity and wing of the pelvis.
We directed the patient to remain quietly upon his bed with hi? kga
drawn up. He soon recovered, but I am unable to say what is the
present position of the fragment.
More frequently, however, the fracture involves a still larger portion
of the crest, as in the following examples:
Joseph Joquoy, a?t. 40, was caught by the bumpers between two
cars, Feb. 10, 1854, breaking obliquely tlie anterior su|>erior portion
of the ilium. I saw him within an hour, and found him greatly pros*
trated ; the fragment of the pelvis broken off^ w*as quite movable, and
crepitus was easily detected. His ab<lomen was very tender and slightly
bloated.
He was laid upon his back with his legs drawn up, and hot foment!-
tions of hops and vinegar were directed to be applied to his belly. He
also took one grain of morphine. The broken ala did not seem dis-
posed to become displaced. With no other treatment, his recover)' w«*
rapid; and the bones st^mcd to have unite<l without displacement.
James Roche, a»t. 41, fell March 7, 1854, from a height of fuurt««
feet, breaking off the anterior suptTior portion of the right ula of the
pelvis. On the following day, I found him at the hospital of the
Sisters of Charity. The fragment, which was quite large, was movshl<*t
and occasionally a crc^pitus (^ould be dete<»ted. It was displaced down-
wards and forwards alK)ut three-quarters of an inch.
He wjis laid upon his l)ack, with his thighs and legs inodertt«y
flexed. At the end of two weeks he found himself able to walk with*
out much difliculty, and he immediately left the hospital. At tbi»
time the fnigment was displaani in the same manner and direction *
at first, but I cannot say whether it had united or not
I have three other similar cases upon my rocordis; but in the !•■*
ILIUM. 357
example, the sixth, which has been especially recorded, the fracture
was caused by muscular action. William Alexander, aet. 70, on the
5th of September, 1869, after riding in a railroad car about half an
hour, arose to leave his seat, when he felt "something wrong" in his
right groin, and found himself unable to walk without great pain. He
was admitted to Bellevue Hospital on the same day, and I found a
fracture involving about three inches of the ilium, including the ante-
rior superior spinous process. It was inclined to fall outwards, but was
easily replaced with a distinct crepitus.
I have once seen a fracture of the posterior superior spinous process,
and I do not know of any other example.
Miss B., aet. 19, was thrown from her horse backwards, striking with
her back upon the ground. She was first attended by Dr. Coaii, of
Ovid, N. Y., and she did not come under my care until two weeks
after the accident.
I found a small fragment broken from the posterior superior spinous
process of the ilium, and displaced backwards in the direction of the
spine about half an inch. It was movable, and by pressure it could
be partially restored to place, but it would immediately return to its
abnormal position when the pressure was removed. The injured hip
was painful, and occasionally it felt numb. She had previously suf-
fered from spinal irritation.
I laid a compress behind the fragment, and secured it in place with
a roller, enjoining perfect rest. She recovered from her lameness in
a few weeks, but I believe the fragment remains displaced.
Extensive comminuted fractures of the ilium are generally accom-
panied with so much injury of the pelvic viscera as to prove rapidly
&tal; but the following example will show that this rule admits of
exceptions.
' June 5, 1854, Bernard Duffie, set. 32, was crushed under a very
heavy stone which fell upon his back. I found the left; ala of the
pelvis broken into several fragments, between the diflFerent portions of
Which motion and crepitus were distinct. The fractures were near the
^perior part of the bone, commencing about two inches back of the
interior superior spinous process, ana extending backwards irregu-
Wly. There was a narrow wound communicating with the fracture,
ftom which I removed a loose fragment of bone. The right leg was
^ko broken.
Four months after, he was still confined to his bed, and a fistulous
^^)ening continued opposite the point of fracture ; there existed also
* large and irr^ular mass of ossific matter or callus around the frag-
itients. He soon after left the hospital.
Dr. Sargent, of the Massachusetts General Hospital, has reported a
^^ase in which a man received a compound fracture of the left ilium,
*tid several small fragments were removed. He was discharged at
ttie end of three months with a fistulous opening still remaining, but
^ other respects he was quite well.* Dr. Cheever, of the same hos-
pital, reports a case of fracture of the ilium, with fracture of the ascend-
^ Sargent, Boston Med. and Surg. Journ., vol. liii, p. 121.
358 FRACTURES OF THE PELVIS.
ing ramus of the pubes, resulting in complete recovery ; bat the leg
became shortened and the toes inverted. Dr. Gheever believes that the
lines of fracture met in the acetabulum.*
The following case illustrates the more fatal injuries of this cha^
acter :
John O'Keaf was crushed under a heavy stone, Oct. 23, 18ol,bTeik»
ing and comminuting the alse of the pelvis on both sides, and wound-
ing also the iliac vein. He was taken to the hospital of the Sifters of
Charity, and died in a few hours, partly from the shock to his systeai,
and jiartly from the heemorrhage.
Lente, of the New York Hospital, has reported a case of dislocatioo
of the hip, which was accompanied with a fracture also of the alaof
the pelvis ujKin the same side. The dislocation was reduced on the
third day, and the patient soon after died. The autopsy discloaed
what had not Ix^en suspected during life, namely, that the left ilioA
was broken horizontally about through its middle, and verticallf
through the crest; and also that there was a fracture extending througi
the sacro-iliac synchondrosis, accompanied with considerable commi-
nution of the articular surfaces. It was also found that a |>ortion of
the small intestine was ruptured, and probably by one of the shirp
fragments of the broken [)elvi8.*
It is seldom, I think, that the fragments become much displaced i
such, at least, has been my ex|)erience; and I have noticed in Dr.
NeilTs aibinet three specimens of fracture of the crest of the ilium, all
of which had united without any appreciable displacement. Dr. X«li
also called my attention to the fact that in two of these specimens the
ensheathing callus was confined to the outer surface of the Ume; a«
observation which, this gentleman assures me, he has had frwjueol
occasion to make before where the fracture belonged to a flat bone.
If any displacement exists, the upper or loose fragment is generally
carrie<l slightly inwards; occasionally, however, it is found displaced
upwards, outwards, or downwards.
Treatment, — In a large majority of cases the fragments, if displacw,
cannot l>e completely replaced. 0(xusionally, however, as where the
anterior superior spinous process is broken off with only a small por-
tion of the crest, the fragment may be seized with the fingers and car-
ried outwards or upwards, or in whatever direction may l)e necessanr;
but to retain it in this position is generally quite im|X)ssible. The
bandage or broad lx»lt which we have recommended in certain fracturei
of the pnb(»s would Ik* in these cases not only useless, but alwol^wT
mischievous, since its effcH't must be to press inwards the fragment^
and thus to create a displacement which might not otherwise exist.
The surgeon ought to determine by a careful examination the extent
and direction of tlie fracture, and, having done what was in hu* p^^
to replace the fragments, he should lay his [mtient upon his back wiUJ
the thighs drawn up and sup|K)rte<l. This is the iK>sition which wiU
generally be found most comfortable; but, as in other fractures of the
* Chocvcr, Bost. Mt*d. and Sufje:. Journ., May 8, ISftTi,
' Lente, New York Journ. of Jiicd , Jan. 1S6], p. 29.
ACETABULUM. 359
pelvis, it may be well always to try the effect of other positions, and
especially to determine their influen(« upon the fragments, and finally
to adopt that precise posture which accomplishes the indications best.
If the fracture is compound, and the fragments have penetrated the
belly, the wound should be enlarged, and, as far as possible, every
piece of bone should be removed ; but if the fragments cannot be found,
the external opening should be allowed to remain so as to favor their
escape when suppuration shall have taken place.
{ 4. Acetabulum.
Although, strictly speaking, fractures of the acetabulum belong
always to one or all of those bones of the pelvis whose lesions have
already been described, yet the peculiar relations of this cavity to the
femur render it necessary that they should be considered as a separate
class of accidents.
Fractures of the acetabulum divide themselves naturally into two
varieties.
First. Fractures of the base of the cavity, with or without displace-
ment.
Second. Fractures of the rim, with or without displacement.
In fractures of the base of the cavity, not accompanied with displace-
ment, nothing but crepitus can be present as a sign of the accident ;
awl this will scarcely be sufficient, in itself, to enable the surgeon to
distinguish it from a fracture of the neck of the femur within the cap-
sale without displacement.
It is probable, therefore, that its existence will only be determined
by dissection. Nor is it of much importance that the diagnosis should
be made out; since in either case neither splints nor any other surgical
appliances could be of service. An injury so severe as to fracture the
^tabuluni will necessarily so much bruise the body, and concuss the
viscera of the pelvis, as to compel the patient to remain quiet for a
i^umber of days, and this is all that would be thought necessary if the
Jiature of the accident was exactly determined.
Dr. Neill's cabinet contains a specimen of this kind, in which the
fracture, commencing near the centre, extends in three directions across
^ cotyloid margins, and in which perfect bony union has occurred
Without displacement.
M. Bouvier related to the Academy the case of a man, set. 71, who,
Ui consequence of a fall from his bed, remained for three weeks unable
fe walk, and never was able afterwards to walk without crutches. No
fracture could be discovered during life, but after his death, which
^teurred some months subsequent to the accident, a fracture was found
Extending from the ilio-pectineal eminence to the spine of the ischium,
*iid traversing the centre of the acetabulum. The fragments were not
displaced, but remained slightly movable.*
The following case was reported by Mr. Earle, to the London
* Bouvier, Amer. Journ. Med. 8ci., vol. xxiii, p. 486; from Bullet, do I'Acad.
<oj. de M€d., August 15, 1888.
360 FRACTURES OF THE PELVIS,
Medieo-Chirurgical Society^ and will be found in the ninetentl
volume of its Transactions, It is also referred to by Sir AstleVyinlii
Treatise on Fractures and Dislocations,
In the month of October^ 1829^ a man, set. 40, ^'as admitted iat
St. Bartholomew's Hospital, with a severe injury, caused by bavioj
fallen from a height of. thirty -one feet and striking upon the lefl Mt
Tlie left leg was powerless and shortened. The foot was evertd
Any attempt to rotate the limb caused great pain, and was aoooo
panied with a sensible crepitus. The left trochanter was very mod
depressed, and when it was pressed u|X)n, the patient complaiued o
deepseated pain in the liip-joint.
He recovered in eight weeks, and was able to walk nearly as fd
as before ; but he soon after died of disease in the chest.
On dissection, a fracture was found extending in two dircctioo
through the acetabulum ; there was an extensive comminuted fracfur
of the ilium, with great displacement, and the os pubis was broken ii
three places.
The repair was very complete, and Mr. Earle remarked how natan
had guarded against any considerable dep>sit of new bone within tb
articulation, which might luive interfereii with the functions of th
joint, while there was an abundant dejwsit of ciillus around tlieotbei
parts of the fractured bone.
Mr. Travers has reported two similar cases, and in the paper accott
panying the report he maintains that very acute pain caused by pre»
ing upon the projecting spine of tlie os pubis, and tlie inability of th
patient to maintain the ere(*t posture, may be regjirded as signs di«p
nostic of the accident.* It is doubtful, however, whether these }^
nomcnn, so ronimon to many otiier accidents, (xmld be relied upooii
evidence of this pe(»uliar lesion.
Fractures of the base of the acetabulum, witli displacement of th
femur into the pelvic cavity, constitute a much more formidable, iM
unfortunately a more common form of accident.
Like the prccciling variety of acetabular fractures, they are producec
generally by falls upon the trochanter major, but the fort*c of theooft
cussion has Ikhmi greater.
Even licre, it is not often that the diagnosis has been clearly row'
out during life; and indeed, generally, the true character of the w©
dent has not even bwn susjKrtcd, the surgeons Ix'lieving that theyb*
to do with a fracture of the nwk of the femur, or with a disloctiti«
In two exan^plcs (Cases 71 and 72) mentioniHl by Sir Asllev l*oop*
as having bivn prcscntcHl at St. Tliomas's Hospital, the lliinh *•
thought to 1h» dislocjitcil backwanls.
In the following example reporteil by Lendrick, of Dublin, the pttic*
was su|>|M>se<l to have a fractun* of the nt»ck of the femur:
An ohi man, well known as the " Wandering Pijwr," was adinitis
into the Mercer Hospital in Januar}', 1830, suffering under phthb
pulmonalis and acute inflammation of the hip-joint. Some yean bi
lore, lie ha<l receivcnl a severe injury by the u|isi'tting of a ctwwh, »0
* Travcrs, lIolincri*i> Svstem of SurgiTy, vol. ii, p. 478.
BASE OF THE ACETABULUM. 361
was under treatment several months for what was supposed to be a
fracture of the neck of the femur. Since that time he had been lame,
but still able to take a great deal of exercise on foot both in Great
Britain and in America. The acute disease of the joint commenced
about two months before his admission, and he was at first under the
care of Sir Philip Crampton, who remarked that the thigh was only
shortened about half an inch, and expressed his surprise at this fact.
This man died on the 17th of February, and the dissection showed
that there had been no fracture of the femur, but its head and neck
were affected with ** morbus coxae senilis." The head was also thrust
through a rent in the acetabulum into the cavity of the pelvis; but the
head had again been covered by a bony case, complete, except in a
small portion about the size of a shilling piece, and at this point the
covering was ligamentous.
The OS pubis had also been broken at the same time, and it had
united so much overlapped that the space between the inferior anterior
spinous process and the symphysis pubis was shortened nearly an inch.
A portion of intestine was found protruding through an opening in the
pelvis and adherent to the bone, in which situation it seemed to have
been caught by the broken fragments and retained.^
Morel-Laval 1^, in his thesis upon complicated luxations, mentions
a case which had come under his observation, and which had been
treated as a fracture of the neck of the femur. The patient survived
the accident many years; during a part of which time he suffered such
pain in the hip-joint as to induce a belief that it was itself disciised.
At his death he was found to have had a multiple fracture of the bones
of the pelvis, and the head of the femur had penetrated more than an
inch into the cavity of the pelvis, pressing upon the obturator nerve to
soch a degree as to have, no doubt, caused the severe pain from which
he had suffered, and which had been ascribed to coxalgia.*
In the two cases mentioned by Sir Astley Coo|>er as having been re-
ceived into St. Thomas's Hospital, the toes were turned in. In the
example mentioned by the same author as having been presented at St.
Bartholomew's Hospital, the toes were everted ; the two persons seen by
I^ndrick and Morel- Laval 1^ were supposed before death to have had
4 fracture of the neck : it is probable, therefore, that in both of these
Qtees the toes were also everted ; while Moore has dissected a subject
whose pelvis was broken into many fragments — the left os innomina-
tum was divided into three portions, corresponding to the three bones
of which it was composed in infancy ; the head of the femur had com-
pletely penetrated the basin ; the limb was shortened two inches, and
iQ a position of slight flexion and adduction, but neither rotated out>-
^ris nor inwards.^
There seems, therefore, to be no certain rule in relation to the posi-
fen of the limb ; but it is found to take the one position or the other,
' L<»ndnck, Amer. Journ. Med. Sci., vol. xxiv, p. 481; August, 1839; from
iondon Med. Gazette, MHrch, 1839.
* Morel-LMvallee, from Malgaigne, op. cit., vol. ii, p. 881.
' Hoore, Med.-Chir. Trans., vol. xxxiv, p 107, 1851.
24
362 FRACTURES OF THE PELVIS.
probably according to the direction of the force which has inflicted the
injury, and perhaps in obedience to circumstances not always easily ex-
plained.
The shortening has been observed to vary from half an inch to two
inches or more ; the trochanter is also usually driven in toward the
pelvis. Pressure upon the trochanter occasions a deepseated pain. If
the limb is drawn down to the same length with the other, it immedi-
ately rcsiimes its position when the extension is discontinued. Crepi-
tus is more uniformly present than in fractures of the neck of the femur,
and it is especially felt while the limb is being extended or while it is
again shortening, and not so much in flexion or rotation.
If, in addition to all of these phenomena, we learn that the accident
has occurred! from a severe blow, or a fall from a great height upon the
trochanter ; and that the viscera of the i>elvis, and esi)ccially the bladder,
seem to have suffered considerable injury ; or if we detect at the same
time a fnicture of some other portion of the pelvis — we may reasonably
conclude that the head of the femur has penetrated the acet^ibuium.
Yet it must be confessed that no one of these symptoms is |)<)sitively
distinctive of this accident, and that they are seldom found sufficieotly
grouped to render the diagnosis certain.
The old "piper" mentioned by I^ndrick, and the man dissectc<lby
Morel-Laval 16(», lived many years, and managed to walk alwut, but
not without considerable pain ; the other three, to whom I have alluded,
died soon after the injuries were received.
Some have thought of treating these cases by extension and counte^
extension ; the latter being accomplished through the aid of a perincil
band ; but it is not probable that after an injury of this character, any
patient will be able to endure the requisite pressure about the perineum
or groins. It will be l)etter to lay the patient upon Daniel's invalid
bed, or some IhmI similarlv constructed, so that it mav be converted
into a double-inclined plane; allowing the knees to l)e suspended
over the angle thus formed, in order that the weight of the IkkIv may
have some effect to draw away the pelvis from the femur. Or we may
adopt extension without the perineal band, as will be described here-
after when treating of fractures of the femur.
Fractures of the rim of the a<»etabulum have frequently lieen dis-
covered in dissections; and the records of surgery abound with ca.<ies
of unre<luciHl dislocations of the femur, in which the failure to reduce
or to retain the bone in place has l>een ascribe<l, not always with sulB-
cient rea*^f)n i>erha|>s, to this fracture.
Dr. McTver, of the Glasgow Royal Infirmary, published, in the f f7a»
yow MnUra! Journal for February, 1830, four leases of this fracture.
The fiist was that of a man, tet. 27, on whose Uick a nunil>or a
bricks had fallen while he had his right knee platxni on the Uink of]
trench. I lis right leg was found shorteneti al)out one inch and a half
b<int, and the t(K»s turned a little outwards. The limb couhl be movec
withoiit nuich difficulty, but every motion gave him pain ; motion wai
also attend(Hl with crepitus. On making extension, the limb wa*^ cmh
brought to the same length with the other, but it l)ccanie shortoncd
•again imme<liately when the extension was discontinuctl.
RIM OF THE ACETABULUM. 363
The symptoms, differing but little, if at all, from those which are
usually present in a case of fracture of the neck of the femur, led to
the supposition that this was actually the nature of the accident. Sub-
sequently, the toes became slightly turned in, but this circumstance
was not regarded as sufficiently distinctive to warrant a change in the
diagnosis.
Having succumbed to the injuries after a few days, the autopsy re-
vealed a fracture extending through the bottom of the right acetabulum,
and about one inch and a half of the rim at its upj>er and posterior
margin completely detached, except as it was held in place by a portion
of the capsular ligament. The head of the bone could be easily pushed
upwards and backwards upop the dorsum, the fragment of the acetab-
ular margin being moved aside, and swinging upon its fibrous attach-
ment as upon a hinge, but resuming its place again perfectly when the
head of the femur was restored to the socket. The femur was not
broken.
In the second case the limb was found shortened, the knee slightly
bent, and turned a little forwards and inwards, and the toes pointing
to the tarsus of the other foot. It was thought to be a fracture also of
the neck of the femur, but the autopsy disclosed only a fracture of the
upper margin of the rim of the acetabulum.
In the third case, seen only after death, the limb was not shortened
much, but the toes were stretched downwards, and turned slightly in-
wards. It was supj)osed at first to be a simple dislocation, but on dis-
section the |)osterior and inferior margin of the acetabulum was found
to be broken and displaced towards the coccyx, while the head of the
femur rested upon the pyriformis muscle, over the ischiatic notch.
The fourth example was found in the dissecting-room, and the his-
tory of the case is not known. A fragment of the superior and {)os-
terior margin of the acetabulum had been broken off, and had reunited
slightly displaced.'
Several other similar examples have been established by dissection,*
8nd we are able, therefore, to determine pretty accurately what are the
'Koal phenomena and termination of this accident, though we are far
from having arrived at a satisfactory means of diagnosis; indeed, the
accident has seldom been recognized before death. Its causes are gen-
^Ily the same with those which produce dislocations of the hip, but
^n most instances the violence has been greater than in the case of dis-
locations.
The symptoms are, first, such as fhdicate a dislocation, to which must
be added crepitus and a difficulty, if not impossibility, of retaining the
head of the femur in its place when it is reduced. The crepitus is
^metimes discovered the moment we begin to move the limb, and this
^ill aid us to distinguish it from a fracture of the neck of the femur
^accompanied with much displacement, since, in the latter case, crepitus
* McTy»»r, Amer. Journ. Med. Sci., vol. viii, p. 617, Aug 1831.
' Maiitonneuve, Chirurg. Clin., 1868, p. 108. Sir Astley Cooper on Disloc. and
fnc, 1828, M»cond London edition, p. 15. M. Bernud, Bulletin de la Soc. de Cliir.,
1862, torn, iii, p. 185. Ibid., p. 226. Bigelow on Hip-Joint, 1869, p. 139 et seq.
364
FRACTUllES '
>F THE PELVIS.
ia not felt iieually until the extension is comiilctt, and tlie fragments
are again brought into apposition.
The msjorily of these aocidenls, eitLer from a failure to recognize
them, or from the impossibility of maintaining the head of the lemur
in place when once it has been reduced, have resulted in a permanent
dislocation of the hip and a serious maiming. The following cai-
recognized and reduced, but it was found impossible to maiulain tha
reduction.
February 3, 1847, a strong German laborer was crushed under a niaav
of iron weighing several tons. Drs. Spr»gue and Loomis, of Buiriilo^
were mlled, and found the letl thigh dislocated upwards and bitoku
and by tlie aid of six men they succeeded in reducing it, the rednetiuo
bein^ attended, as the gentlemen have informed me, with a slight seo-
Btttion of crepitus. The legs were then laid beside each other, and tbt
knees tied together, the patient lying on his back; and now the twtt
linilis appeared to be of the same k-nglh. On the second and thinj
days the injured limb was examined by the same gentlemen, and tlicr*-
was no displacement. On the fourth day I was invited to meet theM
gentlemen, the patient having had muscular spasms during the previ-
ous night, and the thigh being reluxated, I found the limb shortt-ned
one inch and a half, adducted and tlie toes turned in. We imnie<1i)i:
applied the pulleys, and soon drew the tniclianter down to n point ap-
parently opposite the acetabulum, and a careful measnrcnieni sbuw«<l'
that the two limbs were of the same length. The pulleys l>eing re-
moved, the leg did not draw up again, nor did the foot turn in, yet wft
liad felt no sensation to indicate that the bone had slIpjKtl into iU
socket, nor had we felt crepitus. The l^s and thighs wen> now laid
over a double- inclined plane, and well securc<l. He renminbi in this
condition three days more, during which lime Dr. Sprague wiw hint,
each day, and found nothing disarranged. On the night of the !W<>nth
day tlie spasms returned, and in the morning the thigh whs dj-tplwed.
The next day we again applied the pulleys, but soon found tnat ib«
bone wouhl not remain in place one minute alier the pulleys were re-
moved,
At this time, while moderate extension was being made at tbefuii
by rotuling tlie foot inwards, we could distinctly feci a. slight crrpitiM
A straight splint was applied, and as much extension made as be niaU
Bonveniently bear, and in this condition the limb was kept wvtia
weeks. 8even years after, 1 found the thigh still di.spliii'<'<l UjMin ik]
dorsum ilii. He limped badly, bflt he could walk fast, lUid perfbrxB;
OS much labor as l>elbre the accident.
In one case mentioned by Mr. Keate, the lione hail iKHvime diclo-
cated downwards, and could be felt lying against the tuber isehii, wk/
the presence of a "distinct grating as of ruptured cartilage" 1h1 him
to conclude that the cartilaginous labrum of the socket was brokai
off; but as the fracture was in the lower margin of the sockrt, M
ditliculty was ex|ierienced in re>talning the Iwnc in position.'
If the diagnosis is satisfactorily mndi- out, and upon complete^
> Keatc, Amer. Journ. of Mod. Sui., vol. ivl, p 2J3l
SACRUM. 365
daction the femur will not remain in place, the treatment ought to be
the same as for a fracture of the thigh, except that no lateral splints
or bandages to the thigh will be necessary. The limb ought to be
kept drawn out to its proper length, as far as this shall be found to be
practicable, by extending and counter-extending apparatus. A band
around the pelvis, so adjusted as to press the head of the bone into its
socket, may also be of service in preventing the tendency to displace-
ment; and in case the bone manifests little or none of this tendency,
the hip bandage will probably alone be sufficient, yet even here no
harm could come of applying the long straight splint and the extend-
ing apparatus, secured moderately tight, simply as a measure of pre-
caution. Dr. Bigelow recommends angular extension, effected by
means of an angular splint, such for example as Nathan R. Smith's, or
Hodgen's, suspended from the ceiling, or from some other point above
the ])atient; "or," he adds, "if any manoeuvre has reduced the bone,
the limb should be retained, if possible, in the attitude which com-
pleted the manoeuvre."
i 5. Sacrnin.
Simple fractures of the sacrum, known to be exceedingly rare,* are
occasioned either by such injuries as break at the same time the other
bones of the pelvis, or by blows or falls received directly upon the
facrum. It may be broken at any point, and in any direction, when
the fracture is produced by the first of this class of causes ; but if the
fracture is the result of a fall upon the sacrum, it will generally be
transverse, and below the sacro-iliac symphysis. The displacement in
this latter class of cases is almost invariably the same, the coccygeal
extremity being simply carried forwards, yet this is seldom sufficient
to interfere in any degree with the functions of the rectum and anus ;
hut in one case seen by Bermond it nearly closed the rectum. Some-
times, also, there is a slight lateral deviation. There is also in the
Dupuytren museum, at Paris, a specimen in which the whole of the
lower fragment is displaced a little forwards.
The signs of this fracture are pain at the seat of injury, aggravated
greatly in the attempts to flex or elevate the body, and especially in
the efforts at defecation ; swelling and discoloration of the soft parts
<^vering the sacrum ; displacement of the coccyx forwards ; an angu-
w projection at the point of fracture, with a corresponding retiring
^le upon the opposite side; mobility.
Experience has shown that where the fracture of the sacrum is
accompanied with other fractures of the pelvis, the patients seldom
'eoover; and only because so extensive an injury implies usually great
loroe in the cause which produced the fractures, and, of necessity,
peater lesions among the pelvic viscera. Simple fractures, from falls
^pon the sacrum, occurring below the sacro-iliac symphysis, are gener-
ally followed by speedy recoveries, although the inward displacement
Js not often completely overcome.
' Mal^igne has referred to eight cases ; and I have not been able to find a record
of anjr others.
366 FRACTURES OF THE PELVIS.
By introducing a finger into the re<3tum, the lower fragment can
easily pressed back to its natural position, but the difficulty con8istb
finding any means of retaining it there until bony union is effecCi
Judes succeeded to his satisfaction with a wooden cylinder, which
compelled the patient to wear forty-five days; removing it, howev
every third day, in order to cleanse the rectum with an enema. Be-
mond introduced first a linen bag, which he immediately proceedeil
fill with lint; but during the night it became necessary to remove
in order to relieve the bowels of wind and stercoraceous matter,
now sul^stituted a silver canula covered with a shirt, which latter
filled with lint in the same manner as before. This was retail
without much inconvenience nineteen days; having only been remov
once during this time. The union now seemed to be firm, and the cr
paratus was removed. Plugging the rectum in this manner may
necessary whenever the inward inclination of the lower fragmem
found to be considerable, but not otherwise; ordinarily it will be sik
cient to lay the patient upon his back, with a firm cushion above
point of fracture, so as to prevent the bed from pressing in the lo^
fragment; and having emptied his rectum thoroughly by an enenu
warm water, he should be placc^d under the influence of an opiate su
ciently to restrain the action of the bowels for several days, or foi
long a time as may be consistent with health or comfort. To the si
cud, also, the diet ought to be light and dry ; nothing should
allowe<I which might prove laxative. By constipating the bow
two ends may be gained. We shall prevent that frequent actioi
the sphincters, which might tend to disturb the union; and the hi
ened fleces, by their accumulation in the rectum, may serve to p
back the lower fragment of the sacrum, in a manner much more nj
ral and quite as effwtive as any apparatus wliich can be contrive^l.
I have already nu»ntione<l a case of separation of the l)ones at tw
sacro-iliac symphysis, reported by Lente, but which was a<^H)mpac^ »'*^j
also with a fracture of the ilium and a dislocation of the hip. Ses -^'^'
other similar examples have been reportcKl, in some of which IxH ^^ ^^^
the sacro-iliac symphyses have been separated, or displaceil. Snchr » ***"
cidents are the results only of great violence, and the subjects of t J^^^
seldom rtn'over.
Dr. J. T. Banks, of Griffin, Ga., has reported one example of ir^i-
plete rc<*overv in an adult male, in which the right sacn)-iliac
physis wiis separated " by a blow received ui)on the tuberosity of
ischium, driving the ilium up an inch or more, causing coraiilete:
ralysis and anaesthesia of the right leg for two or three weeks; * mc
of the hi|) caa<ed also severe |Kiin. No attempt was made to
the bones, but union occurred, and he gradually regainwl the n
his limb.* In a few instancc»s this articulation has lKH.>n known to
way during labor, while the symphysis pubis h«is suffered little o
diastasis; and in these ca»<c»s recovery has generally taken place.
1 Banks, Atlanta Mod. and Surg. Journ., May, 1866.
FRACTURES OF THE FEMUR. 367
In nearly all the traumatic examples reported, the diastasis has been
accompanied with a fracture extending parallel with the margins of the
synchondrosis ; and it is for this reason that I have preferred to con-
sider these accidents as fractures, rather than as dislocations.
i 6. Coccyx.
Cloquet mentions two cases as having come under his notice, one
produced by a kick, and the other by a fall. In the latter case one
thigh and both legs were also broken, and the coceyx having become
carious in consequence of the fracture, was gradually exfoliated.*
The symptoms, mode of diagnosis, and the treatment in case of a
fracture of the coccyx will scarcely demand of us consideration after
having treated fully of these points in their relation to fractures of the
sacrum.
It is more common, however, to meet with examples of separations
of the coccyx from the sacrum, which may be regarded in «ome cases
as veritable fractures, and in others as a species of luxation.
Due to the same causes which produce fractures of the coccyx itself,
its symptoms differ only in the increased length of the movable frag-
ment, and its consequent greater projection in the direction of its dis-
placement. If it is thrown forwards, as it usually is, the rectum may
be almost or completely blocked up by its presence ; or, if it is carried
backwards, its pointed extremity presses almost through the skin.
Its mode of reduction and retention is the same as in fi-actures of
the coccyx and sacrum.
CHAPTER XXVIIL
FRACTURES OF THE FEMUR.
Development of Femur, — The femur is formed from five centres of
^^i^ation : namely, one for the shaft, commencing at about the fifth
''^eek of foetal life ; one for the lower end, including the condyles, com-
pieneing at the ninth month of fojtal life; one for the head, commenc-
^^g at the end of the first year after birth ; one for the great trochanter,
^mmencing during the fourth year; and one for the lesser trochanter,
<^mmencing between the thirteenth and fourteenth years. None of these
epiphyses are joined to the shaft until after puberty, but consolidation
^ generally completed at the twentieth year. The order in which
Qnion occurs is exactly the reverse of the order in which ossification
commences, the lower epiphysis being the first to exhibit traces of ossi-
fication, and the last to unite.
I Cloquet, art. Basain^ of Diet., 8d vol.
368
FKACTUHES OF ■
Dhnelon of FractureJi. — Of 1 56 fractures of the femar. Dot iDciading
gnnshot, which have been re<-onlecl by me, 63 belong to the upper
third, 67 to the middle third, and 26 to the
lower third ; or, if we confine our analms to
the shaft alone, 23 Iwlong to the upper third, 67
to the middle, and 2K to the lower.
(I have personally examined many more cases
of fraeture of the femur than are above enumer-
ated, but these include ail which have been sub*
jected to this species of analysis.)
Dr. Frederick E. Hyde, in his analysis of 323
cases in Bellevue Hoepital, states that 95 occuired
in the upper third (inrludiu(; fractures of the
neck); 169 in the middle third, and 38 ia the
lower third (including the condyles). In the
20 remaining cases the pjint of fracture is not
stated.
To give a summary of these valuable tabh
more in detail, 61 belonged to tlie nook, of
which 14 are stated in the records t« In; intra-
capsular, 17 extracapsular, and 30 undetermined.
Tlih'ty-Ibur wore in the upper third of the shaft ;
16!) in the middle third, and 31 in Ihe Inwer;
the exact point of fracture of the shall being
undetermined in 20; 7 fractures belonged to th»
condyles.'
The femur constitutes, therefore, a striking^
exception to the rule which ray observatioM
ijfnm Qny.i have established, that in the case of the loi^
lioues the lower third is most often the eeat
of fracture. The femur is moat often broken in ita middle third, and
generally near the upi>cr end of this third ; that is to say, above its
middle.
! 1. Neok of the Femur.
Forty of the whole nimibfr reci>rtleil and analyzed by myself W*
fractures of the neck, either iutra- or extracai)Mulur. The yonngeet
these patients, excepting one case of supposctl epiphyseal sepanKio
was thirty-nine years, the oldest eighty-four, and the aven^ age w,
about sixty. Seventeen were malm and twenty-throe females. A
were simple. Thirteen were believed to be without the i.«|i«ule, an _
sixteen were believed to be within ; the remaimlcr were undelerminn^.
We have already given the number of fractures of the neck, boftft
intra- and e.xtmcnpsular, reported in Dr. Hyde's lubhs. Having rrf
ercnce to age, 19 years was the youngest, and f(5 the ohhwl ; 20 ynus
tmd under presented two «u*e8 ; from 20 years to .10, five i-jl** : (nm
30 to 40, nine ; from 40 to 50, eight ; from 50 to 60, fourtwn ; from «?
< HyAf, Atmlvsln of aS2 aatm ot Fripturn of Iha Pomur, at BolUvM BMfW
from liwe to 187S, indiuive. Mmlical Koeord, IBTS.
NECK^ WITHIN THE CAPSULE. 369
to 70, fifteen ; from 70 to 80, seven ; from 80 to 90, one. Of the whole
namber, thirty-nine were males, and twenty-two females ; none of the
fractures were compound ; fourteen are recorded as of the right leg ;
seventeen of the left ; and thirty are undetermined. Fourteen were
diagnosticated as intracapsular, and seventeen aS extracapsular, thirty
being undetermined.
Surgeons have diifered in their opinions as to the relative frequency
of fractures of the neck of the femur within or without the capsule.
This has arisen, no doubt, in part from the difficulty and probable
inat^curacy of many of the diagnoses. Malgaigne, who has adopted a
mode of deciding this question which, it must be conceded, is much
less liable to error than simple clinical observation, namely, an exam-
ination of cabinet specimens, finds in four large collections sixty-one
intracapsular fi-actures, and only forty-two extracapsular. So that,
acooniing to his observations, they stand in the proportion of about
three to two ; the intracapsular l>eing the most common. On the con-
trar\', Nelaton believes that extracaj)sular fractures are much the most
common, and Bonnet, of Lyons, affirms that they constitute the im-
mense majority. Bonnet made four dissections, and in each case he
fuund the fractnre extracapsular. This testimony, so far as it goes,
is positive, but the number is not sufficient to establish anything more
than a probability in favor of the greater frequency of extracapsular
fractures.
Clinical observations are too uncertain to be made available in so
nice a question. Cabinet specimens may have been collected for a
special purpose, and this is well known to have been the fact with the
celebrated Dupuytren collection, the specimens in which constitute
nearly one-third of the whole number referred to by Malgaigne. I
allude to the effort which was made while the controversy was pend-
ing between Dupuytren and Sir Astley Cooper as to the probability
of bony union in intraca|>sular fractures, to accumulate cabinet speci-
mens of this fracture; and which effort extended itself, no doubt, both
to Ij(»ndon and Dublin, from which sources alone Malgaigne has gath-
ered the balance of his figures. In Dr. Mutter's collection, at Phila-
delphia, I think there are only three examples of intracapsular fracture,
to seven extracapsular.
Dr. Reuben D. Mu&sey, of Cincinnati, has in his cabinet twelve
examples of fractures of the neck of the femur without the aipsule, and
only ten within.
We ought, therefore, to regard the question of relative frequency as
still undetermined.
(a.) Neck of the Femur within the Capside,
Oit(«»«. — Jn no other fractures do the predisposing causes play so
important a part as in fractures of the neck of the femur, and this
whether within or without the capsule ; indeed, experience has shown
that without the concurrence of those pathological changes which usu-
ally accompany old age, these fractures can scarcely occur.
Dr. Merkel considers the fragility of the neck, within the capsule,
370
FRACTURES OF THE FEHUR.
in old persons, Jne to the absoriitioii of that process of the cortical sub-
staiK'e which arises from about the level of the trochanter minor, and
ends close under the head of tlie bone, at the anterior jmrt of the neck;
thus occupying the situation where the greatest pressure is made id the
erect position. This jirooess lie calls the " calcar femorale." In newij
born children it is absent ; it apjtears when tliey begin to walk, attaint
its greatest development in middle age, and completely disappcan
in old persons.' Dr. Merisel saya that no account has hitherto been
given of tills process; but tins statement is scarcely correct, inasmuch
as it lias been both described and represcnte<l by various surgical and
anatomical writers for a long time (sec Fig. 127 of this volume). Tbt
fact of its absorption in advanced life is, however, an original observa-
tion.
Sir Astlcy Cooper thought that the majority of fractures of the neck
after the fiftieth year were intracajisnlar ; but Robert Smith has gives
us the ages of sixty persons having fractures of the neck of the femur,
and the average age of thirty-two in whom the fractures were witibis
the capsule, is sixty-two years, while the average ag;e of twenty-eight
in whom the fractures were extracapsular, is sixty-eight years. Mal-
gaigiie has referred to this testimony in proof of the inaccuracy of the
opinion held by Sir Astley Coojtcr; but I trust it will not be r^i^nled
impertinent or liyjicrcritieal for us to inquire how Mr. Smith becanie
posses.se4l of the ages of all tlieoe [to-
'"'"'■'-*■ sons from whom these specimens were
obtained ; fur more than half of the
wiiole number, that is, just thirly-tmi^
have their ages set down in round deci-
mals, such as 50, 60, 70, etc., and, it
would be easy to show by the inevita-
ble law of chances, that this could not
possibly be a true statement. If Mr.
Smith docs not pretend to have givca
the (^es with aecuratry, but only to have
arriv(s:las near to the truth as his »>ourc«
of information would permit, then I prtK
test that these tables do not constitute
projK-r evidence in rchilion to this point;
and until better evidence is furnished I
shall continue to think, with Sir .Vstlejr
C'ooper, that fractures within the i«p-
sulc iH'long generally to an older chm
of snbjcL'ts than fractures without the
ca|isute. This opinion, confirmed t^
) not, however, as Malgaigne seems Ut think,
I the ca|)sulc may not ncca^ioiially oivur in
:*, d<K
uiply that fractunrs withii
per
years.
I much younger than the average limit, namely, under 6tty
Dr. Hyde's tables present two cases under 50 years, and twelve i
> Ucrki'l, Am. Journ. Hod. Scu, Jm. 1S74.
NECK, WITHIN THE CAPSULE. 371
or over 50. Of the two under 50 years, one was 48 years of age, and
the other 39. Of course the reader will make what allowance he shall
tbink proper as to the accuracy of these diagnoses, inasmuch as such
dii^oses are notoriously diflBcult, and often inaccurate.
It is also believed that intracapsular fractures are more frequent in
women than in men. In Dr. Hyde's tables there are ten females and
£M2r males.
The position of the neck of the femur, and the great thickness of the
mosculor coverings, render its fracture from a direct blow a very rare
dreumstance ; indeed, it can only happen as the result of gunshot ac-
cidents, or other similar penetrating injuries.
It is broken therefore usually by indirect blows, such as a fall upon
the bottom of the foot, upon the knee, or upon the trochanter major ;
or by muscular action alone, as has sometimes happened with very old
people, who, in walking across the floor, have tripped upon the carpet,
breaking the bone in the effort to sustain themselves. We must not
always infer, however, because the patient has tripped, that the bono
was broken by muscular action ; since it is quite as likely that the fall,
consequent upon the tripping, has occasioned the fracture ; and we ought
in such eases to make a careful examination of the hip over the tro-
chanter to ascertain whether it has been bruised, and to interrogate the
patient as to the manner of the fall.
Rodet has attempted to show by a series of experiments made upon
the dead subject, and by other observations, that the direction in which
the. force had acted will determine the situation and direction of the
fracture. Thus he maintains that when the person has fallen upon the
foot or knee, the fracture will be intracapsular and oblique; that if the
front of the trochanter receives the blow, the fracture will be intra-
cap8ular also, but transverse ; if the back of the trochanter is struck,
the fracture will be partly intra- and partly extracapsular; and if the
person falls directly upon the side, or receives the blow fairly upon the
oaterside of the trochanter, the fracture will be entirely without the
cap(5ule.*
Without intending to give my unqualified assent to these proposi-
tions so ingeniously maintained by Rodet, I am nevertheless prepared
to admit their general accuracy; and especially has my ex|>crience led
me to believe that falls upon the feet or knees in most cases produce
intracapsular fractures, and that falls upon the outside of the hip, or
upon the great trochanter, generally produce extracapsular fractures.
There are, however, frequent exceptions to this latter proposition. Es-
pecially have I observed that in persons over fifty years of age, or
somewhat advanced in life, a fall upon the trochanter has caused an
intracapsular fracture. The following case, verified by an autopsy, is
conclusive :
A man, 75 years of age, was received at Bellevue March 24, 1875.
He stated that on the same day he had slip(>ed and fallen upon the
sidewalk, striking with great force upon the trochanter. The house
1 L'£xp4riencc, March 14, 1S44.
872
PBACTUHGS OF THE FEHUB.
Bui^eoD, Dr. E. A, Lewis, examined the limb immediately on a
sion, and diagnosticated an inti
^"'"'^ sular fracture. I saw him durin
day and confirmed the diagnosis,
was feeble, but not suffering i
apparently, from shock or from
tood and stimulants were adi
tered, but no sui^ical treatmeu
adopted. On the following nio
he was found to be sinking, and bi
before night. No complete autop
obtained, and the cause of liis ae
undetermined. After death Drs.
nis and Isham repeated the ezai
tion, and found tne evidences i
iotrucapsniar fracture very ma
including a slight crepitus and rot
in»K> uj.r Kmiiui. »u»« u ■ I.I. "^^ '''^ trochanter upon a short
.i.HK.piu.^.^.™.u^«u™ «j . ,.,. "pjigjjccompanying woodcut, taken
the specimen now in the |>08scsEi
Dr. Dennis, shows that the fracture was close to the head, ai
course, entirely intracapsular. It was not impacted, and no absoi
of the neck had taken place.
Pathology. — I have alreiidy, when speaking of {tartinl fracture
presseil my conviction of the possibility of a partial fracture, or
sure of the neck of the femur, and I have referred to the ca-sc ref
by Dr. J. B. S. Jackson, of Boston, a« having determined this qiK
Ix^yond all possibility of a doubt; yet its occiirreniv must be reg;
as an exceedingly rare, and, we may say, improbable event.
It is much more common to meet with examples of complete fn
of the neck both within and without the capsule, unaccompanied
a rupture of either the periosteum or the reflected capsule. SucI
the fact in eight cases exaniine<1 by Colics; in three of which, Hon
he believed the fracture not to have been complete, but Rol>ert i
thinks they were all of them examples of complete fracture.' St
has also related a case of complete separation of the bone nnai
panied with laceration or injury of eitlier the pcriosicuiik or oa[
ligament. This was in the [Kirson of a man aged sixty ycar«, wb
been knocked down in the street. On being admitted into St.
tholoniew's IIa<ipital, shortly after the injur}', he omiplained of
in the hip, hut tiicrc was neither shortening nor eversion of the
and its sevend motions could !« executed with freedom and \tovtt
fracture was not susitccti-d ; but five weeks after this he died of in
niation of the )H>welri. The dissection sbowwl a fracture exlei
through the neck, acconijumied with a slight bloody effusion, bi
displacement of the fragments or laceration of the soft [lartii.'
KECK, WITHIN THE CAPSDLE.
373
Id other examples the bone is not only broken, but displaced to such
10 extent that the capsule is completely torn in two.
Bat in a larce majority of cases both the capsule and the periosteum
tie only partially torn asunder.
The intracapsular fracture is generally somewhat oblique, and ita
direction is usually from above downwards, and from within outwards.
Sometimes its direction is such as to include a portion of the head ; oc-
asionally it ia quite transverse. In one example of an old fracture I
h»ve seen the ends dovetailed HiK>n each other, the fracture having a
double obliquity, and not admitting of displacement.
There may occur also a species of impaction, the lower portion of the
neck entering the cancellous structure of the head, while iti^ upper por-
tion rides upon the articular surface, a circumstance which is well illua-
tratcd by the annexed woodcut (Fig. 126), copied by Mr. Smith from
I specimen in the Dnpuytren Museum at
Paris; or the impaction may occur without fio.im.
toy degree of either upward or lateral dis-
placement.
Mr, Liston savs: "Even in children
nparation of the head of the bone may, on
goud grounds, be sup|H)sed occasionally to
tike place;'" by which we understand him
to mean that a seiMiration of the epiphysis
which completes the bead of the femur may
ofciir, Jlr. South relates a ca-'e in a boy
ten years of age, who had fallen out of a
fiM-floor window u[)on his Icit hip. The
limb was slightly turned out, hut scarcely
It all shortened. Thethighcould bereudily
moved in any direction without much jiain, impiciMifriifiurcwiiiiiati>c»p9uie.
bat «n bending the limb and rotating it
outwards, a verv distinct dummv sensation was frequently felt, ap-
parently within the joint, as if imc articular surfiicc had slip|ied off
■Dother. This was regarded by Iwth Mr. South and Mr. Green as an
tuunple of epiphyseal si<[)!iratiiin, and he was plated upon a double-in-
clined plane, but he felt so little inconvenience from it that he several
timre left hi^ bed and walked about. We have no iiilijrmation as to
the result or as to the further progress of the case."
A girl, ttt. 18, was brought bcfiire Dr. Parker, of New York, at his
surgical clinic, Nov. 1850, who had been injured by a fall upon a curb-
Mone, when eleven years <)ld. The accident wsis followed by siippura-
tton and a fi.-tulous <lischarge, from which, however, she linally re-
rovered, but with the foot everted, and a shortening of one inch and a
, half. " Flexion and rotation of the Joint occasioned no iiicimvcnience."
Dr. Parker thought this cin^umsiauce alone sullicient to distinguish it
^m hip disease in which auchylosis is the termination.^
' Li*^ln, Elpnicntfl of Siirepry, Pliili
■ S-Mitli. N.iio ^. Ch.-liiii''s Si.raery, '
• PitrkiT, Anier. Jled. tJHZutte, vul.
p. 34.', Nov. 30, 1830.
374 FRACTURES OF THE FEMUR.
At a meeting of the Kappa Lambda Society, held in New York,
March 25, 1S40, Dr. Post mentioned a case which he had soon in a
girl sixteen years old, who, in taking a slight step with a child in her
arms, made a false movement, and ieeling something give way, sheets
obliged to lean against a wall. Dr. Post saw her the next day, when
he found the affected limb one inch shorter than the opposite ono, mov-
able, the toes turned outwards, no swelling, some slight miii at the
upper part of the thigh. The trochanter major moved with the shaft.
There was also crepitus. From the age of the patient, and the slight
amount of violence by which the injury was pnnluced, Dr. Post thought
a separation of the epiphysis of the head had taken place. The ex-
tending apparatus was applie<l, but the limb remains from a quarter to
half an inch shorter than its fellow.*
Aug. 14, 18Go, Andrew I^eroy, a?t. 15, in attempting to es<'a|K»from
th(! House of Refuge, fell from the fourth story. On the followine
morning he w-ius admitted into my wardft, at liellevue Hospital. I
found his right thigh shortene<l three-quarters of an inch, and slightly
alKluctwl ; toes everted. Placing him under the influence o{ chloro-
form, w(» detected a dull crepitus in the vicinity of the j<»int. It wa.<
unlike the crepitus of broken l)one. With fiftwn pounds of exton*loD
we were able to overcome the shortening entirely, and to |)ut the limb
in position. This wjus maintained with Buck's apparatus. At llieeoH
of two weeks, however, it was ascertaininl to bo shorUMied half an ini*h.
Four more pounds were then added. At the close of my term of ^*r-
vice 1 lost sight of the boy, and have not betm able therefore to verify
my diagnosis; but I believe it to have been a separation of the u[»|>er
epiphysis.
These four constitute the only examples of this accident which I 6m
reported or of which I have any knowle<lge, and although then- nmy
be much reason to suppose that the diagnosis was coriXK*t in «u'h in-
stance, I rannot regard any one of them jis actually proven ; iht fan
1 admit the accident as fairly establishe<i, or the diagnostic signs a*
l)eing pro|K;rly made out, until these important |>oints have niviveu
the confirmation of at least one diss(»i*tion.
SifinpfoNhs, — Whether the lind> will lie shortened or not must <iepeiHl
upon whether the fragments are impacted, or have b(H»ome di>plac«l in
the direction of the axis of the shaft of the femur. It is well e^^ab-
lislunl that in this frac'ture the broken ends frequently remain in eon-
tact for several hours or days, or until the gnuiual contraction of the
muscles or the weight of the IhkW u[M)n the limb o<'casions a st'|ian»-
tion, and that consecjuently there is often at first no apprtviaMe «^r
actual shortening of the limb. To determine, however, its exi*ten<v,
it is not sui!i<Ment to lay the patient upon his back, an<l pla<*e thelinjh*
beside each other; we ought also to measure cairfully with a ia|»e-l''|^
fr<»m the pelvis to the leg or f(M>t, and from various other |M)ints, u"^"
we have place<l this question beyond a doubt.
If shortening occurs, it may xixvy from one-(juarter of an iiH4i ^^
two inches, or even more; but this extreme shortening is not nwW
> Pu**!, Nt'w Yi»rk Joiirii. M<'d., vt»l. iii, p. 1<.K), July, 1810.
NECK, WITHIN THE CAPSULE. 375
usually, except after the lapse of several weeks or months, when the
ligameuts have gradually given way under the weight of the body in
walking, or not until the ne(;k has undergone a partial or almost com-
plete absorption.
Sir Astley Cooper has stated that a shortening to this degree may
occur at once; but Boyer, Earle, and others doubt the accuracy of
this opinion, and Robert Smith declares that he does not think the
capsule would admit of such an amount of immediate displacement,
unless it were extensively torn, an occurrence which he thinks very
rare indeed.
With this qualification, the opinion of Mr. Smith does not differ
from that entertained by Sir Astley, who only admits its possibility as
a rare event; in a large majority of cases the shortening does not
exceed one inch. Of the methods of measurement I shall speak here-
after.
Crepitus, unlike shortening, is generally absent when the displace-
ment of the fragments is complete ; but under no circumstances is it
easily developeil. When the fragments remain in apposition, and the
femur is rotated for the purpose of moving the broken surfaces upon
each other, the small acetabular fragment, resting in a smooth cup-like
socket, and holding upon the opposite fragment by denticulations or
by the untorn periosteum, or capsule, glides about in obedience to the
motions of this latter, and no crepitus can be produced. Nor is the
difficulty rendered less by pressing firmly upon the trochanter, as
some surgeons have recommended, since, while this pressure tends,
no doubt, to fasten the upper fragment in the ac^abulum, it tends
much more to fasten the broken ends together, and thus defeats the
purpose in view. When, on the other hand, the fragments have be-
come completely separated, it is almost impossible to bring them again
into contact. The limb may, perha[)s, be easily brought down to the
same length with the other, but it must by no means be inferred that,
eonseauently, the broken ends are in apposition. It is almost certain,
indeed, that in its progress downwards the trochanteric fragment has
Qwght upon the acetabular fragment, and pushed its floating and
broken extremity downwards before it. Under these circumstances,
the discovery of a crepitus must be accidental, and is scarcely to be
looked for. Sometimes, however, we mav recojjnize a sound not un-
like crepitus, but less harsh, produced by the friction of the trochan-
teric fragment against the rim of the acetabulum or dorsum of the
ilium.
One thing we ought never to forget, namely, that by extraordinary
rforts to obtain a crepitus we may lacerate the capsule or produce a
displacement of the fragments Avhich we never can remedy, and which,
^thout such unwarrantable manipulation, might never have occurred.
Eversiou of the foot is almost uniformly present in some degree,
W[ing place immediately or more gradually, in proportion as the
fragments become displaced, and the external rotators contract. The
Opposite condition, or an inversion of the foot, is occasionally present,
^ sometimes also the foot is neither turned in nor out, but the toes
point directly forwards. In sixty cases of fracture of the neck seen
376 FRACTURES OF THE FEMUR,
by Cloquet the foot was never turned in, and Boyer never met wi
such an example in all of his immense exi)eriencc; but linngstal
Guthrie, Stanley, and Cruveilhier have each seen one example, in
Robert Smith has seen two.* I have mvself seen one.
The explanation of the fact that the foot is usually everted is no
difficult. In the case of an intniwipsular fracture it is prol)ablydiH
first, to the relative friability of the laminated or cortical structure oi
the posterior asj)ect of the neck, in consequenc*e of which this portioi
gives way more readily than the cortictil structure on the anterio
aspect ; second, to the natuml forn) and position of the foot and leji
which incline them to fall outwards by their own weight; and third
to the powerful action of the external rotators, which are so fcebl;
antagonized upon the op|)osite side.
In the case of an extracajwular impacte<l fracture, in addition t
the second and third causes assigned as influencing the iKv*iii(»n of th
limb in intra(*apsular fractures, there are other s{)e<Mal causes. Th
cortical lamina on the posterior aspect of the neck, everywhere nwff
frail than upon the anterior as|KK't, beconxv? greatly weiikeiie<l as i
approaches the trochanter by dividing itself into two lamime, one <
which penetrates towards the crntre of the bone, and the other, th
thinnest of the two, lK»ing scarcely thicker than a sheet of jui|kt, fimn
ing the wall of the bone as it becomes continuous with the tnK'hantei
This delicjite |xn)ery wall easily gives way under the nppruntion c
force, while the anterior wall yields only partially, constituting thus
sort of hinge upon which the rotation of the thigh is jKTformwI. Iti
probable, also, as suggested by M. Robert, that the angle at which th
external surface of the trochanter unites with the ntvk increa««es ih
tendency to fracture and impaction jM)steriorly.
An explanation of the fact already state<l, that in rare and cscpp
tional cases the limb is invertwl or the toes aR» |K'rmitt«l to poin
directly iljrwards, lias l>ecn thought to be more diilicult. Dr. BijH<>'
has had an opportunity of examining a s|HMMmen taken from an oh
woman in the diss(rting-r(M)m, and he concludi»s that the invmini
was due to the extent of the comminution, which had sepaRilc*! th
walls of the sliaft so as to rinvive in the interval the whole mvk, in
stca<l of the posterior wall only, tus commonly <Krurs. Dr. K«»l*'
Smith, of Dublin, cites a similar case verified by the autopsy ; ami l^
Bigelow remarks that the s|>ecimen numlMTcd 24S, in the MuW
museum, at Philadelphia, presents the same kind of im|>:ictiun witlNW
either inversion or ever^ion.
Fracture of the nc<'k of the femur within the tnipsule is not ibtwH]
attendiMl with much pain when the patient is at rest, but any atiemp
to move the limi) pHnluces intense suffering, and es|M'<'ially whiH a'
attempt is made to nitate the limb inwards, or to carry it upwanlsa»
iiiwar(l>.
()<'c:i«iionally, als<>, during the first few days or hours after theft**
tun», a spasmodic* action of the muscles coui|k*1s the |Kitient to cry**
from the severity of the pain which it i>r(Mlurt.*s. At first the suflii*
* Uobort Smiili, t»j). cit., p. 2o. A. Cooper by B. Cooper, op. cil., p. 15l| »••••
NECK, WITHIN THE CAPSULE. 377
k uaible to indicate clearly tlic scat of this pain, or, pei-lmi», it is
diffiksed and uucertain in its ponition ; but after a time he is able to
kAt it cLiefly to the r^iou of the groin, opposite tlie neck of tlie
(From Bigrluw
bone, or to near the point of attachment of the psoas nia^nus and
3iacus internus. Thore is also usually in this region a great degree of
Imlerness and an nuusual fulness.
If DOW the limb be seized, and extension gradually but firmlv ap-
plied, it will be soon made of the same length with the opposite tfiigh ;
wt, the moment the extension is discontinnod, the shortening and
WMsion will recur, aeoompanied with pain, and perhaps crepitus.
Thi; tr«chaut<?r major is less prominent than upon the opposite side,
ud if everxion of trie limb exists, the tn>ehanter may Iw felt indis-
tinctly upwards and backwards fn>m its usual piviition. The [taticnt
oving been placed under the influence of an anaesthetic, we niav prose-
nite the investigation still farther, and by rotating the limb inwards
ind outwards as &r as it will admit, we shall notice that the trochanter
4«mbes the arc of a smaller circle than in the opposite limb, or that
th* length of its radius has been shortcneil. It ought to be said at
2S
378 FRACTURES OF THE FEMUR.
once, however, that this amount of manipulation is often injurious, and
seldom proper.
The patient is generally unable to move his limb, or to bear the
least weight upon it ; but many examples are on record of persons who
walked some distance after the fracture had taken place, the capsule,
and perhaps also the periosteum, not being torn, and consequently the
fragments not being displaced ; or, possibly, it was at first an impacted
fracture.
On the 6th of May, 1875, Mrs. R., of Brooklyn, was ascending a
flight of steps when her limb suddenly gave way under her, in conse-
quence of an intracapsular fracture. Mrs. R. was 78 years of age, large,
and rather fat. For several years she had suffered from rheuiratism
of the right leg, which comj>elled her, in walking, to bear her weight
chiefly on the left, and it was this limb which gave way. She was
assisted to her feet, and with the aid of her daughter ascended another
flight of steps, bearing some w^eight on the broken leg. On the follow-
ing day she got out of bed alone, and unaided, walked a few steps
moving her limb very carefully. On the same day I saw her and
found her in bed, the limb shortened half an inch and slightly everted.
The head of the femur moved with the trochanter and without causing
crepitus or pain. There was very little tenderness about the hip or
groin ; no swelling and only a heavy, dull aching pain in the limb.
The age, the manner of the accident and the shortening of the limb
were the only signs of fracture, but these were sufficient.
Finally, after having examined the patient as well as we are able to
do, in the recumbent posture, if any doubt remains, and it is found
practicable for the patient to be elevated upon his sound foot, this
should be done. The broken limb can now be examined thonmgbly
on all sides, and a more accurate opinion former! of the amount of
shortening and eversion. It will be especially noticed that if the
weight of the bo<ly is alloweil to rest upon the limb, in most cases it
produces insupportable pain.
Dr. Packard, of Philadelphia, informs me that M. Maisonneuve has
lately suggested and practiced the following method of diagnosis in
certain doubtful cas(^. I^y the patient flat on his lx»lly, and then
bring the suspected thigh into extreme extension backwanls. If it is
not broken, the neck will strike against the posterior lip of the a(«-
tabulum and the progress of the thigh in this dinH?tion will be arrested.
If it is broken, it can be carrietl backwards much forther. Of this
method as a means of diagnosis, it seems proper to say that, if the frag-
ments have slid pa<^t each other and the limb is shortened, it is unneces-
sary ; and if thoy are still in apposition, it will be pretty certain to
cause displacement, and thus do irreparable mischief.
Prof/nosis. — The question of bony union after a complete fnicturc of
the neck of the femur within the capsule has oc<»upied the attention of
the ablest surgeons and pathologists for a long {)eriod ; and while great
differences of opinion have l>een expri*sscd as to the probabilitv of the
oc<'urrence, and as to the value of the testimonv on the one side or the
other, very few have ventureil to <leny its possibility.
Among these latter are found^ however, the distinguished names of
lion, and to maintain that no exception to the general rule
place, would be prcswraptnous, especially when we consider
lies of direction in which a fracture may occur, and the degree
!e by which it may have been produced. For example, when
ire 18 through the head of the bone, with no separation of the
ends; when the bone is broken without its periosteum being
when it is broken obliquely, partly within and partly exter-
the ca{>snlar ligament, I believe that bony union may take
bough at the same time I am of opinion that such a favorable
ion of circumstances is of very rare occurrence. Much trouble
taken to impress the minds of the public with the false idea
ve denied the possibilitv of union of fracture of the neck of
-bone, and therefore I deg at oiK*e to be understood to con-
he principle only, that I believe tJie reason that fractures of
>f the thigh-bone do not unite, is that tlie ligameutoiis sheath
steum of the neck of the bone are torn through, that the bones
{uently drawn asunder by the muscles, and that there is a
ourishmcnt of the head of the bone; but lean readily believe,
ire should happen without the reflected ligament being torn,
le nutrition would continue, the bono might unite; but the
of the accident would differ; the nature of the injury could
e discerned, and the patient's bone would unite with little
on the part of the surgeon.
XK)f of the correctness of my opinion, I enumerated in the
ions of this work, forty-three s[)eciraens of tliis fracture, in
ollections in London, which had not united by bone. At the
ly these might be multiplied, were it necessary.
has been the accumulated evidence of the want of power of
if the femur to unite by bone, in my practice of forty years, 11
lich period I have seen but two or three cases which militate ■'
lis opinion, for many of the jweparations whicli liave been |
380 FRACTURES OF THE FEMUR.
^ I find in a report of the Baron Dupuytren's lecture that he attrib-
ntes to me the opinion that fractures of the neck of the thi|rh-l^>nc,
within the capsular ligament, not only * never unite, but that it is im-
posj^ible that they should unite by bone.'
" Jt is quite true that, as a general principle, I l)elieve that thoee
fracrtures unite by ligament, and not by bone, as do those of the jMiti'lIt
and olecranon. But I deny that I have ever stated the im|)05«ibility
of their ossific union ; on the contrary, I have given the reason why
thev may occasional Iv unite bv bone.
"The follo^ving are my words: ^To deny the possibility of their
nnion, and to maintain that no exception to this general rule may take
place, would be presumptuous,^ " etc., etc.
In (conclusion, Sir Astley remarks: "I should not have given you
this trouble, nor should I have taken it myself, but for the re!s|)cctl
bear my friend, the Baron Dupuytren ; for although I have alreadr
submitted myself to be misrepresented by many individuals, yet I
should Ik? sorry to be misunderstood by so excellent a surgeon and 80
valuable a friend as Le Baron Dupuytren."^
Sir Astley, then, so far from denying, frankly admitted the |K«fii-
bility of lx)ny union when the neck was broken within the capsule, and
explained the circumstances under which he believed it might occur.
The true point in dispute was, whether certain cabinet specimens were
actually examples of complete fractures, wholly within the ral16ul^
united by bone. Some of them Sir Astley thought were only examples
of chronic rheumatic arthritis, or of interstitial and progressive alx?orp-
tion. Some were partial rather than complete fracturcw; ot here were
partly within and partly without the capsule; and for this hewi§
accuseil of wilful blindness or stupidity, chiefly by those who them-
selves being owners of these rare pathological treasures, might {wssibly
have felt somewhat annoye<l at seeing their value thus depreciated, and
who, no doubt, would he quite as apt to fall into blindness and porti-
sanship as Sir Astley himself. The truth is, however, that althoiigb
the claim has been set up and stoutly maintained for more than thirty
cabinet specMuiens, in one part of the world or another, a majority oi
tlu*se, including several whose claims were urged upon Sir Astley, ha\t
beiMi at length declared by all parties unsatisfactory, or absolutely ^
titious, and only a fraction of the whole number i\>ntinue to be meo*
tioneil by any .surgical writer as probable examples.'
> St'O also Sir Astloy'H letter to Prof. Cox, writton in 1835, and puMi>h»Hi in lb«
Prov. Mod. and Sur;;! J«>uri> for July 1-', 1848, N<»w York Journ. M«ti. for S^-p^-
1848, and appendix to (?(><>per on Dis. and Frac, Anier. od., 1851, p. 48'J
'■' The foUowinix Eur<»|"'an ^u^4Je<)ns^ have claimed t»> have m their [Hi>»>t»<*i«»n.<^»
one example: LMni^stall' ( M<'d.-('hir. Trans., vol. xiii, 1827) ; BriiUt«»ur (I^"|»
vol. xiii, 1827) ; Stanley i Ihid., xviii i ; Swan iSwan on Diiiease* of N»'rve#, p '■^'^''t
Adams (ToddV Cyelop., p. 81.S) ; Jones (Med.-Chir. Tran?., vol. xxiv) ; CIi^tI^T
(Ame'*hiiry on Frae., p. rio) ; Field ( n>id., p. 128) ; Sooinmerini; /Cli«diufr'>Snrt'*'y
by South, 'vol. i, p. 021 ) ; South (Ihid., p. r,21 ). South aUo mention*. anothiT fi*«J*
pleas beini; in the mus(Mnn of St. Bartholomew's Hoiipital. Thi* i«* probably J"'*'* •
eas«.', which Robert Smith hays i.s pr(»sorved in this museum, and which ha.* »h''*'Y
b»M-n enumerated. Hryant i Memphi.s MchI. Rec, vol. vi, p. 108, from Briti-h M**-
Journ., March 14); Fawiiinirt«>n (Amer. Journ. M«»d. Sci., vol. xv. p. i*»34i^«^**
London Med. Gaz., Aug. 10, 1834;; Harria (Ibid., vol. xviii, p. 246, from I)i»W»"
NECK, WITHIN THE CAPSULE. 381
Robert Smith reduces the number to seven, but Malgaigne recog-
nizes only three, namely: Swan's case, admitted by Sir Astley himself;
Stanley's case, and one specimen in the Dupuytrcn museum. In
neither of these cases, he affirms, has the neck lost anything of its form
or length by absorption, from which we are to infer that he would
reject as doubtful all such specimens as had undergone these patho-
logical changes.
Indeed, I think, we are not left in doubt as to Malgaigne's opinion
upon this point. Six of the nineteen cases which I have enumerated
are declared by him to resemble much more rachitic alterations of the
neck than true fractures; and yet Ilol»ert Smith admits three of the
six as well-established examples ; but as to the precise grounds upon
which he rejects these cases, he shall speak for himself: "And it is
sufficient that we consider the beautiful drawings designed by Sir
Astley Cooper, to illustrate certain varieties of the alterations, to place
us on our guard against every pretended consolidation which presents
itself, accompanied with a shortening and deformity of the Tiead and
neck. When fractures unite by bone, they do not suffer such enormous
losses of substance which it would become necessary to admit for the
neck of the femur." ^
A reference to Stanley's case, as reported by Robert Smith, will
show that, contrary to Malgaigne's statement, this was also shortened
and deformed, and that, consequently, according to his own rules of
exclusion, it also must be rejected ; after which only tw^o remain,
namely Swan's case, admitted by Sir Astley himself, and No. 188 of
the Dupuytren museum.
I should do injustice to my'ow^n convictions, moreover, were I not
to refer my readers to the very judicious criticism upon Mr. Swan's
case made by Dr. Johnson, and published in the Neiv York Journal of
Mediciney vol. ii, 3d series, p. 295.
Since writing the above, my friend Dr. Voss, of this city, has placed
in my hands an elalx)rate paper on this subject, from tlie pen of Dr.
Edward Zeiss, of Dresden, and which has been translated by Dr. R.
Newman, Prosector to Chair of Surgery, Long Island College Hospital.
Dr. 2^iss, after rejecting all other European specimens, claims that
bony union has occurred within the capsule in a specimen now in his
possession, and also in a specimen which may be found in the patho-
logical cabinet of the medico-chirurgical academy of Dresden.- I
regret that I am not able to publish these cases at length, as well, also,
as the able review of their claims sent to me by Dr. Newman, in which
Dr. Newman clearly shows that Dr. Zeiss has completely failed to
Joarn., Sept. 1S35). Robert Hn mil ton says that Prof. Tilanus showed him tliroe
ipecimens in the museum of the Hospital of St. Peter, at Amssterdam (Ibid., vol.
xxxi, 470, from Lond. Med. Gaz., Jan. G, 1843). Malgaigne says there are three
specimens in the Dupuytren museum which have been described with ihe same
interpretation. The whole number claimed by transatlantic surgeons is therefore
nineteen.
* Malgaigne, Traits de« Fractures et des Luxations, tom. i, p. 678.
* Description of two specimens of intracapsular fracture of the neck of the femur,
and onion by callus, by Dr. Edward Zeiss, Dresden, 18G4.
382 FRACTURES OF THE FEMUR.
establish the correctness of his opinions. There is no conclusive evi-
dence that tlie bones were ever broken, nor, if they were broken, that
the fractures were entirely within the capsule.
On this side of the Atlantic, the number of specimens for which the
honor is claimed is nearly equal to the original number in Europe;
but they have not yet, all of them, been subjected to the same sifting
process as their foreign congeners; and it remains to be seen how many
of them will come successfully out of a similar fifty years' content
Three of the specimens belonged to Reubgn D. Mussey, late Pro-
fessor of Surgery in the Miami Medical College, at Cincinnati, Ohio.
He has himself furnished a complete history and description of the
specimens, accompanieil with drawings.* One may be found in the
Wistaraud Horner Museum at Philadelphia;^ one belongs toWillard
Parker of this city ;^ two to the Albany College Museum ;* two to tire
Harvard Medical College, Boston ;* one to the Mutter collection (Speci-
men B, 71); one to Dr. Pope, of St. Louis. Dr. Sands, of this city,
has also lately presented a supposed example to the New York Patho-
logical Society.*
In the former editions of this book I have examined the claims of
several of these specimens very nuich at length; but as new s[)ecimen8
arc every now and then being presented to our notice, for each of which
special claims are set up,and inasmuch as no practical results arc likely
to follow upon a further discussion of this point, or u|K>n its definite
decision, I have concluded to refer those of my readers who feel a pa^
ticular interest in the matter to either one af my earlier editioas, and
to the various monographs to which I have furnished references.
I have also in my own cabinet a feniur of no inconsiderable preten-
sions, belonging clejirly to tliat class of si)ecimens recognized by Robert
Smith. Its neck is greatly shortened, and this surgeon would regard
it, I think, as an impacted intracapsular fracture, but its claim would
be promptly denied by Malgaigne, on account of the absorption and
distortion of its ne(*k. Its history is as folloAVs:
About the year 18S^^ Mrs. Wakelee, of Clarence, Eric County, New
York, ajt. {)S, who was then very low with tubercular consumption,
and sa ill as to be scarcely able to walk across the fl<K>r, trip|H?il upon
the carpet and fell, striking upon her left side. Slie was unable to ru*e,
but was laid upon a beil by her son, Dr. Wakelei^ a very intelligent
physician, residing in the same house, who did not susj>ect a fracture.
Dr. Bisscl saw heron the following day, and, on rotating the limb out-
wards, he says that he discovertH.1 a (Tcpitus* His examiuatiou was
greatly facilitated by her extreme emaciation.
Mrs. W. was placed upon a double inclined plane, with apfwwtus
for extension, etc., and left in charge of Dr. Wakelee. On the fifth
* Amor ,U>urn. MihL Sci., April, 1857.
» 11. H. Srnitirs Surirrry, p S*M).
* .JolinsoriV puixT on I tUracnp^ulnr Fnicliircs, o[). cit.
« Trims. New York Stale Med. St)c., 18.">8
* Hi;;fl<)w on l)i>locaitior), etc., of Hip, 1809, p. 125.
* Now York Med. Kec, Juno 1, 1869.
KECK, WITHIN THE CAPSULE
383
splint was removed, and from this time no dressings of any
e applied. The reason for this cliange of treatment was, that
ikely tu live but a few days, in
ace of the state of her lungs, and na. i».
confinement would only hasten
h. Contrarj-, however, to all
auB, she gradually eonvalescod,
^r two or three years she could
crutches, her toes turning out
imb becoming somewhat short-
our years after the accident she
Dr. Bissel obtained from Dr.
the specimen, of which the ac-
iog (Irawiog Is a faithful deline-
eorge K. Smith, of the Long
>IIege Ho^jpital, has made a most
contribution to our knowledge
itoray and pathology of the hip-
ch will explain in a great meas-
iscrepaiicies of opinion which at
xht among surgeons as to the
of L-crtaiii specimens, and may
enable us to decide with more Venlcil wi^tlon of Mn, Wakdee'i
and may lead to a better agree- ftmur, •ceuhuium, mii c»i«uie.
pinion.
eervatioiis prove that anatomists have not hitherto correctly
the attachment of the ca|>sulc ; that the capsule is seldom, if
cbed at the same point in different (jersons, while it is as
■ ibund attached at the same point in the opposite femurs of
person. In order, therefore, to determine whether the line
•e in any given s|>ocimen was without or within the ca[>siile,
ilways compare the fractured bone with it^ congener, and not
lemur of another person.
i further shown that after a fracture, and the consequent
a of the neck, the norniul position of the capsule is almost
/ changed; so that its jtresent attachment does not declare
e the points of its attachment before the fracture occurred ;
ly, that the absorption proceeds unequally and irr^ularly,
^reat ra])idity, in the two fragments; and as the l>ony union,
takes place, probably occurs subsequent to the arrest of the
1, the line of union cannot in itself alone determine whether
re was near the head or near (he trochanters,'
ts to me probable that under certain favorable circumstances
1 will occur; these favorable circumstances have relation to
FRACTDKE8 OF THE FEMUR.
several conditions, such as age, health, decree of fiieparation of the
fragments, laceration of the ]>eriostenm ana capsule, treatment, etc.
Robert Smith thinks it is not
Flo. ijo, likely to occur unless the fra^
nients are impacted; but Sir Art-
ley Cooper, as we have already
.scen,aclniiltc<l its possibility when-
ever the reflected cnp^ule and the
I>eri<>steun) were not torn, and at
the same time the fragments were
not displaced. If to these condi-
tions we were to add nioilcnite
but not extreme age, with good
health, we can see no sufficient
reiLSon why, under jtidiciou.s treat-
ment, bony union might not occa-
sionally l>e exi>ected. But such a
combination of circumstiincis is
pnibably exceedingly rare ; and,
what is more unfortunate, if th*y
exist, tlic fracture i^ not likely (o
be recognized, and the surgeon
will fail to avail liiniRcIf of thtkae
advantageous coincidences which
might, if understtMxl and profifrly
impacti^i frsciuro nithin ihp papsuii-. (Kram treated, sccu re a Iwuy union. Hu-
'"'^'''""■' piiytren says, when the fragments
are not displace<l "its existence
may be snw(>crtotl, bnt cannot Ih? positively asserted. " There will not he
wanting, hi)\vcvcr, examples in which surgeons will lielieve or alKm
that they have n-cognizcd the fracture and wrought the cure. I have
hcanl of many such instances, and Mr. Smith has refcrretl to one,
which is (piitc iKT(incnt, as having lK,fii ri'(>orted in the Hazt-Hr tin
lIopUiiux. A woniiui, ict. i>\, wa.s treated for an intra(n|tsular frai^
ture of the ue<-k of the femur iit one of the hospitals in Paris, and "at
the end of four weeks she wsis disrhat^l j>erteetly cured, ami without
shortening." Wc fully [Kirlake of Mr. Smith's surprise at the impu-
dence of this claim, yet we do not sec in it much greater impmhuliility
than in Mr. Swan's case, rcecivtHl by IkiIIi Mr. Smith untl Sir AstW
himself, where the neik w.^s found almost wholly united by lione in
five wi-eks, nllhoiigh the woman wa.< )jO yenrs old, and actually dying
while the pHM-i-ss was going cm ! Ways Dnpnytron, " I would \xv it
down as a ficncnil principle that all fractures of the neck of a cylindri-
cal lione should l>c kept at rest twict^ as long as ordinarj- fractures of
the same bone ; and even after that jieriod f have seen dis|ilneenient
tjikc place. The term may, tlicn-fore, be lengthened to a hundml
days, <)r even longer iu aged and feeble i)er8on9, whoiio powers of rep-
iinitioti are much tlcterionitcd."
It is not ihc )><n')Mise of the writtT to descrilw particularly all of the
Jiceicluits or jmtholi^ical conditions with which these fractures may be
NECK, WITHIN THE CAPSULE.
385
cotifbnnd^. It is sufficient to allude to them, and leave to others the
labor of a complete historical record ; but I am temjKcd to devote a
paragraph to what has been variously termed "morbus coxje senilis"
(Robert Smith) ; " chronic rheumatic arthritis " (Adams) ; " interstitial
absorption of the neck of the thigh-bone" (B. Belt); " rheumatic gout"
(Fuller) ; and by others " interstitial and prc^ressive absorption y' but
the exact nature and cause of which morbid ehan)rcs arc not yet fully
understood. Mr. Oolles does not think this )>artakc3 of the nature of
rheumatism. I have myself a specimen of what has been more gener-
ally called chronic rheumatic arthritis,
occurring in the knee-joint, accompanied > ui
with a flattening and ebnrnatiou of the
articnlarsiirfaccs,and Gulliver has shown
that similar changes of form m the iicck
of the bone may occur in tolerably voung
persoDS.
I Huspcct a]so that it will be found to
occur under a greater variety of circum
gtani'ee, and to prexent a greater variety
of forms than nave yet been described ;
tTid we shall perhaps find a partial ex-
planation of this diversity and frequency
in one single circumstance, namely, the
peculiar anatomical structure of the neck.
The neek of the femur stands nearly at
a nght angle with the shaft, or at an
■nele so great as that the weight of the
body, even in health, has the ofFect to scciioo of « sound »duii femur.
gradually depress the head below the top
of ihe trochanter major, and to diminish its length. This is seen con-
stantly in the striking change of form which occurs between childhood
lod old age. Now, if from any cause whatever, .inch w* a bl()W uj>on
(be trochanter or upon the foot, the neck or head is made to suffer, and
inflammation, or perhaps only a slight degree of increasc<1 action in the
ibsorbents, ensues, resulting in an e<jually slight softening of the bony
tiseue, these pathological circumstances may end, sooner or later, in a
^king change of form in the neck or head. But it is not uwessar)-
to suppose an external injury to explain the oi-currencc of this inflam-
Bution, and consequent softening of the bone; a scroliilou.-*, or rickety,
or tuberculous constitution may occasion it, and we see no rciison why
these conditions are not as likely to lead to a change of form here as in
the bones ofthe leg or of the spine. A change of form in the head
may be the result of an ulceration of the cartilage ; and a. change of
form in the neck, of ulceration of the neck. Among other causes, also,
"clirmiic rheumatic arthritis" may operate in a large proportion of those
cianiples which belong to advanced life. One case, rei)ortcd by Gul-
liver, would seem to show that a deformity may occur liere as a result
of disease, and independently of pressure,' yet it is plain, from the di-
> Ouiliver, Lund. Ut.'d.-Chir. Rev., vol. xxiix, p. 644.
386 FRACTURES OF THE FEMUR.
rection which the deviatioa of the head and neck usualljr I
pressure performs an important part in the causation.
From these various causes, operating in these diverse wajn
have the different deformities enumeratecl and described b
writers. The head flattened, irregularly spread out, depr
polished; the neck shortened and irregularly thickened and <
the trochanter major rotHtcd outwards and drawn npwards
charms travt^rriing the nct^k, produced by ulceration ; and fina
ening of the necK, by a true interstitial absorption, and wit!
no increase in its l>r<^^adth, the trw-lianter major also being ro
wards. If would lie stningo, moreover, if the interior of th
did not present some changes in structure, 8u<'h as have been J
observed, namely, an irregular ex])ans!on or condensation o
lular tissue, and which latter might easily be snpposcd, by on
inattentive to all of these oirt-um stances, to indii-ntc the li
imaginary fracture.
The following example will illustrate the ineijiicnt stage ol
of these cases, namely, that in which the neck is not only i
but its surfuce is irregiitarly M'amc<i, as if it had btvn bn»i(ci
perfectly uiiiletl.
William Clurkson, ipl. 4^, was admitted into the Toronto
C, W., May 5, ISOS, with tulwrcnlar consumption, of whicl
on the 25th of the same month.
He had l>ecn under the rare of Dr. Scott, and it having b«
that he eoniplainc<l of his right hip at the time of admission, a
was made on the 25tli, at which I was, through the courtc
house surgeon, permitted to be present.
NECK, WITHIN THE CAPSULE. 387
We examined both hip-joints, and found the neck of the right femur
shortened, especially in its posterior aspect. At the junction of the
head with the neck, posteriorly, and extending about half-way around,
the bone was carious, and so for absorbed as to leave a sulcus of a line
or two in depth, and of about the same width. Adjacent to this, also,
the bone was quite soft, yielding under the slightest pressure of the
knife. There was no other appearance of disease. The opposite femur
was sound.
The hospital record furnisheil the following account of his case, so
far as the injury to his hip was concerned :
Al)out nine months before admission, then laboring under the mal-
aiiv of which he finally died, he received a blow upon his right tro-
chanter, ever since which he had been lame, and suffered pain in the
rejrion of the hip-joint. The pain was felt especially in the groin,
when the trochanter was pressed upon, or when the sole of his foot
was i)ercussed. The thigh was slightly flexed ; the toes a little everted ;
and he walked with some halt.
The ease of the soldier. Fox, reported by Gulliver, and who died of
tuherciilosis, presents a case also exactly in point, but illustrating a
later stage, or the completion of the same process.
Of* the precise nature of the changes in the two following examples
I cannot l)e certain, since thev have not been determined bv dissection.
They will serve, however, to illustrate the usual history and progress
of a wnsiderable number of cases. They certainly were not examples
of fracture.
Ephraim Brown, when twelve years old, fell from a tree and struck
upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called.
Of the [articular symptoms at this time, I have only learned that the
leg was not shortened. The doctor laid a plaster upon his hip, and
left him without anv further treatment. In three davs he was able to
walk on crutches; in three weeks he walked without crutches, and in
f«>ar months was at work as usual. There was at this time no short-
ening or deformity of any kind.
Mr. Brown sul)sequently enlisteil as a soldier in the war of the
American Revolution, and ex|KTienced no difliculty in this hip, until
after a severe illness which followed u|Km an unusual exposure, when
he was about thirtv-five vears old. At this ]x*ri<Kl the Icjr U'jran to
Miorten, hut the shortf-ning was uaecompanied with pain or soreness.
He consults! me, July 17, 1845, at which time he was eighty-three
years old, and a reniarkablv stnmir and healthv-lookinjr man. The
shortening, which had ceased to pr(»gress some years lx*fore, amounted
»tthis time to two and a half inches.
An ofiBcer in the United States army addressed to me the following
letter, dated Nc»veml>er 1 3, 1 SAi) :
**My mother-in-law. Mrs. S., of D., some three years since fell down
» flight of stairs, striking on her side ujxm a stone, injuring the hip-
j«int severely ; but, upon examination, her physician declannl that
there was neither a fracture nor a disNx-ation, and said that she would
gradually recover. Something like one year since the injure<l limb
commenced shortening, so that she can now barely touch her toe to
388 FRACTURES OF THE FEMUR.
the floor as she walks. She can bear but little weight upon it, and
is compelled to use a crutch or a cane constantly. So much time has
now elapsed, and the limb is so little better, and constantly becoming
shorter, I have proposed to ask your opinion," etc.
I need scarcely say that I had no hesitation in pronouncing this a
case of chronic inflammation of the bone, accompanied with softening
and gradual change of form, either of the neck or head, or of l)oth.
It is proper that I should state briefly, before I leave this subject,
what constitute the chief difficulties in the way of union by bone within
the capsule.
The persons to whom the accident occurs are generally advanced in
life, and consequently the process of repair is feeble and slow.
The head of the bone receives its suj)ply of blood chiefly through
the neck and reflecte<^l capsule, and when both are severed, the small
amount furnished by the round ligament is found to be insufficient.
When the fragments are once displaced, it is difficult, as I have al-
ready explained, if not impossible, to replace them. ,
The direction of the fracture is genenilly such, that the ends of the
fragments do not properly support and sustain each other when they
are in apposition.
The fracture is at a point where the most powerful muscles in the
body, acting with great advantage, tend to displace the broken end>j.
Ageil persons, who are chiefly the subj(H*ts of this a(*cident, do not
bear well the necessary confinement, and especially as the union rc^quires
genenilly a longer time than the union of any other fracture; so that a
persistence in the attempt to confine the i)atieut the I'cquisite time often
causers death.
Whether the absence of provisional callus as a l)ond of union, and
the interposition of synovial fluid l>etween the ends of the fragments,
constittite additional obstacles, I am not fully prepared to say. In the
opinion of many surgeons these circumstanct^s constitute very serious,
if not the chief, obstacles.
It remains only to consider what is the usual result of this fracture.
The fragments, more or less displaced, undergo various changes.
The acetabular fragment is generally rapidly al)sorl)eil as far as the
head ; and occasionally a considerable portion of this latter diapi)ears
also ; while the trochanteric fragment ap|K»ars rather as if it had been
flatteneil out by pressure and friction, it having gained as much gene-
rally in thickness as it has lost in length. To this ol)servation, how-
ever, there will l>e found many exceptions. Sometimes the tnx'han-
teric fragment forms an open, shallow s(K»ket, into which the acetabular
fragment is received; or its extremity may Ihi irrt»gularly convex and
concave, to correspond with an exactly opjxxsitc condition of the ace-
tabular fragment. (Fig. 133.)
Ordinarily the two fragments move upon each otiier, without the
intervention of anv substance ; but often thev l)ecome uniteil, more or
less completely, by fibrous bands (Fig. 134), which bands may l)e short
or long, according to the amount of motion which has been maintained
between the fragments while thex are forming, or to the degree of sep-
aration which exists.
NECK, WITHIN THE CAPSULE. 389
The capsular liganiente are usually considerably thickened, and
elongated iu certain directions, and not unfrequently penetrated by
spictilee of bone. They are also found sometimes attached by firm
bands to the acetabular fragment.
A permanent shortening, and either with or without eversion of the
limb, are the invariable consequences of this accident. Indeed, not a
1. I'gitod Y-y llHunicnt. l>ai{ent
s aftor the acgldi'nl. Thi Iro-
few Miccumb rapidly to the injury, perishing from a low, irritative
fever, or from gradual exhaustion, within a month or two from the
time of its occurrence. Says Robert Smith : "Our pr<^nosis, in cases
of frsctnre of the neck of the femnr, must always be unfavorable. In
nany instances the injury soon proves fatal, and in all the functions
of the limb are forever impaired; no matter whctlicr the fracture has
taken place within or external to the capsule — whether it has united
by ligament or bone — shortening of the limb and lameness are the in-
evitable results."
Treatment. — In case, then, of a complete fracture within the capsule,
existing without laceration of the reflected cafwulc, or displacement of
the fT^ments, and equally in case of a fracture at the same point with
impaction, the treatment ought to be directed to the retention of the
We in place, by suitable mechanical means, for a length of time sutfi-
(nent to insure bony union, or for as long a time as the condition of the
patient will warrant.
The means which are, in my judgment, best calculated to fulfil this
important indication, are complete rest in the horizontal posture, the
limb being secured by the same api>aratus which we employ with so
ACTURES OF THE FEMUB.
much encress in fractures of the sliafl;. In fractures of the neck, how-
ever, whether within or without the capsule, we employ no coaptation
splints ; and the amount of extension ought to be only one-half of that
generally employed in fractures of the shaft, aay about ten pounds.
The long Ride-splint, with a foot-board, to prevent eversioo of the
limb, must not be omitted. In my hands, and in the hands of my
expert house soi^ons, the apparatus has undergone so many modifica-
tions from the original plans of Crosby and Buck, that I shall liereaflor
find it necessary to designate it as my own.
Another apparatus, formerly employed by me in fractures of the
neck of the R'mur, but for which I have lately substituted my own, is
Gibson's modilication of Hagcdorn's, in which the sound limb is firat
BccunKl to the foot-board, and the broken limb is subseqneutly bnmght
down to the same point. By this method, as by my own apparatus,
we may avoid the necessity of a jieriueal band, which is so painful, in-
supjHirlable often wlien the fracture is at the neck.
In treating this fracture, supposing no displacement to exist, no ex-
tension beyond that which is necessary to insure perfect quiet can be
proper, inu^tnuch as the fragments are not overla[>])etl ; and they need
only a moderate assistance to enable them to maintain their prnwnt
position against tlie action of the muscles. Moreover, if the fragments
are impa<^ed, violent extension would disengagt.' them, and render their
displacement and non-union inevitable.
I am pre|)arcd to affirm, from my own experience, that more patients
will endure quietly the position of esteusion for a length of time thu
NECK, WITHIN THE CAPSULE. 391
the flexed position, whether in this latter the patient is placed upon
his side or upon hia back.
How long the patient will submit to this, or to any other mode of
ncuring perfect rest, is very uncertain, and tlic decision of this question
must rest with the individual coses and the good sense of tiie surgeon.
Gltnou'i modllied iplli
Sot very many old and feeble people will bear such confinement many
d»ys without presenting such palpable signs of failure as to demand
their complete abandonment.
Horizontal extension was adopted in Jones's case, and aI)SO in the
ase reported by Fawdington, and is said to have l)een successful. In
Bnibtour's case the limb was kept extended two months; in Mussey'a
•Mond case Hartmhome's straight splint for extension remained upon
the limb eighty-four days; in Bryant's ca?e a long splint was used
"some weeks."
It is true, however, that other plans of treatment seem to have been
nually successful. In the case reported by Adam;; the limb was
pLiped over a double-inclined plane, made of pillows, five weeks ; and
in Knssey's third example the limb remainc<l in the same position
three months. Chorley laid his patient upon the sound side, with the
th^hs flexed, for a space of two weeks, and then turned him upon his
hack, still keeping the thighs flexe<]. At the end of .six weeks he was
placed in a straight position, etc.
But in a majority of the examples reporte<i, the exij^ti-nw of the
fracture was either not suspected, or lx>ny union wa= n'.t antii-i|iated
or desired, consoqucntlr no treatment having in view the cf-nfinement
of the broken bone was adopH-d. Yet the success, it wa-; clainmi. was
» great as that which has followed either of the <.l her pl.-in*. Harris's
patient was simply laid on a Kifa. Field's jiaticnt.wholipike the neck
of both femurs within the 'Sp^ule at different times, wa- in each ca.'^
Irfl without trpat men t, except ttiai -he Jar u)i<in her U-d- Mu-^^y him-
self removed all dressing* fr^n Ih-, lyd.]u<n'- patient ..-n the tiwhu.^^nth
•iar, and placed him nprMi hi- fe*t. and Dr. Wakelee rem'.vefl the
ipporatos from his- mother on the fifth dav.
Nor are we withoat e^-idence tliat (he careful and jndici.-ui applica-
tion of splints, lone contintKd, and cmplored under the ok^X javfrable
nrcumstances, will eocaeume^ fell. The two f .lU-win^ fa.'^*- fv.nfirm
lhe« remarks. The fin* oor^rreil in the praeti'* of Dr. Jam's B.
Wood, of thiB city : " it J., » yxing l*dv, let. It; years, of vigwrooB
FBACTURES OF THE FEMUR.
oonslitution, perfectly free from any constitutional taint, either «
scrofula, nypliilis, or cancer, was cauglit between the wheels of t«
carriages, the one stationary, the otJier in motion. The blow wi_
received directly ou the troclmuter major of the right side Tn
symptoms which presented themselves showed conclit-sively that thei
was a fracture. There was shurleiiing, loss of voluntary motion, aa
eversion ; by placing the finger on the trochanter major, and the ibuinl
in the groin, a well-marked crepitus could be felt oii extension and
rotation being made. There was no laceration or other complication
of the injury. She was placed on Amesbury's splint, with side splintt
accurately adjusted, and every precaution taken to insure a perfeflC
uniou. The limb was kept on this splint without being distiirbe<l foC
six weeks. At the end of that time it was takeu from the splint, aail
examined with care; the signs of fracture still remained. The lioi|
was replaced on the splint, and the dressings as before; everythiflj
viaa attended to in tlie general management of the case which the docta
thought would be cononcivc to perfect union. The patient was kq
for three weeks longt'ron the splint, which was then removed. It wi
found that there was no union. Patient lived for three years, and wi
so lame that she was always obliged to use a crutch in walking. A
tlie expiration of three years she died of an acute disease.
'■ On examiuatiuo of the cervix femoria, it was found that there hiL
been a transverse fracture of the bone ja-it at the junction of the hail
and neck. The head of the bone was Btill altached to the aeeiahulus
by the ligaracutum teres. The process of absorption had Iteen pi'tag
on, and the head of the Iwne had alreatly lieeii absorl>ed below tht
level of the acetabulum, and what remained was soft and sponjj,
easily broken with the handle of the scalpel. The neck of the l«a
was rounded off, and covered with a 6broup> dejwsil. This was nntt
case of diastasis, as has been suggesti>d by an eminent surgeon, who
judged simply from the age of the patient. She was full sixttxa wbi*
the accident happened, and over nineteen when she died."
The second was in the person of a man, Kt. 25 years, who wwsttb*
time of the accident robnst and in good health. "He was dancing it
his sister's wedding; while cutting a pigeon wing, he stnick theftw*
upon which he was resting from under him, and fell, striking dinrtl.'
upon the trochanter major. He was unable to rise ; a ttirria^' ***
called, and he was taken directly to the Kew York Moepital. Tii>i>
he came under the charge of Dr. J. Kearney Rinlgers. A fracluff *■»*
immediately diagnostimled, and for a few days he was kept ua tH
doublc-inclineil plane. The straight splint was then used, and u*
dressings kept up for six weeks; at the end of that lime they »*'
taken off, and the limb examined; there was no union. The limb"*
continued in the straight splints for three weeks longer, and ajtwn «f'
amined ; theru was still no union. The patient was again replwol •
the straight spluit fur In'o weeks longer, but no union occurrpl. ^
the end of three montlia from his admi.-ision he whs dischargMl; tw*^
in good health, but so lame that ho was obliged to use two cmtth
walking. After his diiKtharge the jHtlient licssmu very iatHnp*
" ' 1 the course of a few wveks he applied for uditusioa to BcUw*
NECK, WITHOUT THE CAPSULE. 393
Hospital. He was miicli debilitated, and had au extiauBtio^ diiirrh<^.
Shurtlj af^er his admissioD an immense abscess formed uver tbc joint,
whieL discharged profusely. The man died shortly atler from exhaus-
tion, and tlic specimen came into Dr. Van Biiren's handn, the patient
having been in his service. Dr. Van Bnren was aware of the patient's
previous history, the treatment, etc., at the New York Hospital, and a
careful examination was mitde.
"The ra|isular ligament was dfistroyeii entirely by the suppurative
process; there was a formation of calUis upon the trochanter major; the
ligamentiim teree was entirely absorbed ; the head of the bone was spongy,
as if worm-eaten ; the direction of the fracture was oblique, commenc-
ing just at the articnlating sur&ce of the head and ending just within
tbe cajisule ; the upper end of the slinft of the bone showed this same
appearance that was marked in the head. These point* are beautifully
shown in the specimen at the present time. The opinion of Charles E.
Isaacs, Ar.D., the able Demonstrator of Anatomy of the University
Medical College, is, that this fracture was entirely within the capsule."'
The bone may be seen in the museum of tlie University Medical Col-
lege, Scw York.
Such equal results from opposite plans, and unequal results from
similar plans of treatment, are not calculateil to increase our faith in
rlie testimony which most of the foregoing examiiles are supposed to
^^^miiU) of the possibility of bony union. On the eoutrary, they cannot
^|bto suggest a doubt as to whether some of them, at least, were not
^^■peurately diagnosticated.
^HtBnt odtnitting that they were not, the testimony which they furnish
■D relation to treatment is too inconclusive to be made available for
instruction, and we are still at liberty to adopt that which seems most
rational, without reference to the experience of others.
The rea^ions why I would prefer my own plan have already been
staled in part, to which I will now add, that if an error should occur
in the diagnosis — if it should prove finally to have been a fracture
it-ithoiit the capsule — then this treatment would be correct, and no in-
jury would come to the patient from the error in {liagnoeis ; but if we
a«)opt Sir Astley Cooper's suggestion, namely, to get the patient u]>on
umtches aa soon as possible, perhaps as soon as fonrteen days, an error
^dft diagnosis might be followed by the most disastrous consequences.
^^B (b.) Neck of the Femur without the Capmk.
Qiugrg. — Like fractures within the capsule, these also occur most
frequently in advanced life. They are not, however, as often met with
in extreme old age as are fractures within the capsule ; and they are
•nnch more often met with in persons of middle age, and in younger
persons, than are intracapsular fractures. Of fractm-es recognized as
•^iiracajwular, in Dr. Hyde's tables, ten were under fifty years, and
*evBn at or over fifty. The three youngest were respectively thirty,
Lt»eiity-five, and twenty years of age.
i JabnBon, op. cU., pp. 18-16.
392 FRACTURES OF THE FEMUR.
constitution, perfectly free from any constitutional taint, either of
scrofula, syphilis, or cancer, was caught between the wheels of two
carriages, tlie one stationary, the other in motion. The blow was
received directly on the trochanter major of the right side. The
symptoms which presented themselves showed conclusively that there
was a fracture. There was shortening, loss of voluntary motioo, and
e version ; by placing the finger on the trochanter major, and the thumb
in the groin, a well-marked crepitus could be felt on extension and
rotation being made. There was no laceration or other complication
of the injury. She was placed on Amesbury's splint, with side splints
accurately adjusted, and every precaution taken to insure a perfect
union. The limb was kept on this splint without being disturbed for
six weeks. At the end of that time it was taken from the splint, and
examined with care ; the signs of fracture still remained. The limb
was replaced on the splint, and the dressings as before; everything
was attended to in the general managementof the case which the doctor
thought would be conducive to i)erfect union. The patient was kept
for three weeks longer on the splint, which was then removed. It was
found that there was no union. Patient lived for three years, and was
so lame that she was always obliged to use a crutch in walking. At
the expiration of three years she died of an acute disease.
** On examination of the cervix femoris, it was found that there had
been a transverse fracture of the bone just at the junction of the head
and neck. The head of the bone was still attached to the acetabuluB
by the ligamentum teres. The process of alisorption had been going
on, and the head of the bone had already been absorbed below the
level of the acetabulum, and what remained was soft and gpongji
easily broken with the handle of the scalpel. The neck of the bona
was rounded off, and covered with a fibrous deposit. This was not a
case of diastiisis, as has been suggested by an eminent surgeon, who
judged simply from the age of the patient. She was full sixteen wbeo
the accident happened, and over nineteen when she died."
The second was in the person of a man, a^t. 25 years, w^ho ^"asatthe
time of the accident robust and in good health. "He was dancing it
his sister's wedding; while cutting a pigeon wing, he struck tlie ftot
upon which he was resting from under him, and fell, striking directly
upon the trochanter major. He was unable to rise; a carriage was
called, and he was taken directly to the New York Hospital. Thera
he came under the charge of Dr. J. Kearney Rodgers. A fracture waa
immediately diagnosticatcil, and for a few days he was kept on the
double-incliiuMl plane. The straight splint was then usotl, and the
dressings kept up for six weeks; at the end of that time they were
taken off, ami the limb examined; there was no union. The limbwH
continued in the straight splints for three weeks longer, and again eX*
amined ; there was still no unicm. The patient was again replaced Ui
the straight splint for two weeks longer, but no union occurred. At
the end of three months from his admission he was discharged; hcwl*
in good health, but so lame that he was obliged to use two crutoheis*
walking. After his discharge the patient became very intemperate!
and in the course of a few weeks he applied for admiasioD to Bellevot
NECK, WITHOUT THE CAPSULE. 393
Ioq>itaI. He Mras much debilitated, and had an exhausting diarrhoea.
Ihortly after his admission an immense abscess formed over the joint,
rliich discharged profusely. The man died shortly after from exhaus-
00, and the specimen came into Dr. Van Buren's hands, the patient
aving been in his service. Dr. Van Buren was aware of the patient's
pevious history, the treatment, etc., at the New York Hospital, and a
iiefiil examination was m4de.
"The capsular ligament was destroyed entirely by the suppurative
rooeas; there was a formation of callus upon the trochanter major; the
gunentum teres was entirely absorbed ; the head of the bone was spongy^
) if worm-eaten ; the direction of the fracture was oblique, commenc-
ig jost at the articulating surface of the head and ending just within
le capsule ; the upper end of the shaft of the bone showed this same
ipearance that was marked in the head. These points are beautifully
town in the specimen at the present time. The opinion of Charles E.
ttCBy M.D., the able Demonstrator of Anatomy of the University
edical College, is, that this fracture was entirely within the capsule."*
18 bone may be seen in the museum of the University Medical Col-
;e, New York.
Soch equal results from opposite plans, and unequal results from
lilar plans of treatment, are not calculated to increase our faith in
i testimony which most of the foregoing examples are 8upiK)sed to
tiish of the possibility of bony union. On the contrary, they cannot
I to suggest a doubt as to whether some of them, at least, were not
locorately diagnosticated.
Bat admitting that they were not, the testimony which they furnish
reiation to treatment is too inconclusive to be made available for
(traction, and we are still at liberty to adopt that w4iich seems niose
joual, without reference to the experience of others.
The reasons why I would prefer my own plan have already been
kted in part, to which 1 will now add, that if an error should occur
the diagnosis — if it should prove finally to have been a fracture
itbont the capsule — then this treatment would bo correct, and no in-
ry would come to the patient from the error in diagnosis ; but if we
bpt Sir Astley Cooper s suggestion, namely, to get the patient upon
otcfaes as soon as possible, perhaps as soon as fourteen days, an error
diagnosis might be followed by the most disastrous consequences.
(b.) Neck of the Fermn* without the Capsule.
Cautes. — Like fractures within the capsule^ these also occur TDoOBi
eqnently in advanced life. They are not, however, as often met with
(extreme old age as are fractures within the capsule; and they are
luch more often met with in persons of middle age, and in younger
enoDS, than are intracapsular fractures. Of fractures recognized as
ctncapsular, in Dr. Hyde's tables, ten were under fifty years, and
Bven at or over fifty. The three youngest w^ere respectively thirty^
wenty-five, and twenty years of age.
^ Johnson, op. cit., pp. 13-15.
2S
Ab to the immediate causes, v/e have stlready nieutioned in the pre-
oediug section that fractures without the /»psu]e seem to be the resnlt
generally of falls or of blows received directly upon the trochanter;
occfl.'^ionally, also, they are produced by falls upon the feet or niwn the
knees.
Pathology. — These fractures may occnr at aoy point external to the
capsule, but generally the line of fracture \a at the base, correspond ingi
very nearly with the anterior and p^terior intertrochanteric crests.'
Almost invariably the acetabular penetrates the trochanteric fragment
in such a manner as to split the latter into two or more pieces. The
direction of the lesions in the outer fragments preserves also a remark-
able uniformity; tlie trochanter major being usually divided fn>m near
the centre of its summit, obliquely downwards and forwards toward
its base, and the line of fracture terminating a little short of the
chanter minor, or penetrating beneath its base ; while one or two lines
of fracture usually traverse tlie trochanter major horizontally.
In an examination of more than twenty specimens, I have ooticaf
but two or three exceptions to the general rules above stated.
In Dr. Mutter's collection, 8i>ecimen marketl B 115 is not acoomp*-^
nied with either impaction or splitting oi the trochanteric fragment;
but the neck iiaving been broken close to the intertrochanteric lines,
has, apparently, slid down upon the shaft about one inch, at whidi
point it is firmly united by bone.
Dr. Neill has also a specimen of fracture at the same point, but with-
out union of any kind, in which no traces remain of a fracture of ibo
trochanters. The acetabular fragment has moved up and down upna
the trochanteric until it has worn for iraelf a shallow socket three ini'ha
and a half long; the approximate surfaces being smooth and ptiliiKlid
like ivory.
The trochanter major is usually turned backwards, the shaft of lii»
femur being rotated in this direction, the same as is usually obwrvrd
in other fractures of the neck of the femur. I have seen one exceptiui
to this general rule in a specimen belonging to Dr. Mntrer (No. 29);
the trochanter in this instance is turned tbrwards, ao that the oork i*
shorter in front than behind.
The upper fragments of the trochanter major, whenever U»e Iin»»
fracture are transverse, are generally incline<l inwanis toward tbeowk.
as if displaced in this direction by the force of the blow, or pcrlup
by the resistance offered by certain muscles and 1igamrntoti» b«Di
which find an insertion upon its summit.
The neck is found, in most caseft, standing inwards at nearly a r^)*'
angle with the shaft, the head being much more deprra^eil than tbr
outer extremity of the neck ; in consequence of which the lower mufw
of its broken extremity is driven much deeper into tlie trochintw
fragment than is the upper margin.
Mai gaigne l>cli eves that impaction, with consequent fractor* nf I'l'
trochanters, is never absent in true estrampMular fractures, onW '•
be in that very unusual variety in which the iroohanler forma i Ptf*
of the inner fragment (fractures through the trochanter major and utt
of th« neck), Kobert Smith ent«rtains the eame opinion, atUnwC^
jne does not seem to have so understood him. I cannot i^jree,
__ wever, with either of these gentlemen that the rule is so invariable,
since I am confident that no such splitting has occurred in either of
the two s])ecimens to which I liave referred as belonging reapeetively
to Drs. Mfitter and Neill. It is trae these arc both old fractures, and
Q some extent the signs of fracture may liave bewime obliterated, but
in Mutter's specimen an abundant callua indicates plainly enough
where the shaft separated from the neck, while tlie trochanter major
is smooth as in itfi normal condition, nor docs its giimrait incline either
my from its usual position, Neill's specimen, though less satisfactory,
' es not fail to convince me that neither impaction nor splitting of th«
ichanters ever occurred.
I It is certain, however, that impaction and comminution of the outer
^^ment are very constant, and that, whether the fracture is produced
f u fell upon the feet or upon the trochanter major. But the impac-
Im does not necessarily continue ; sometimes, indeed, it does, and the
irition of the limb, whatever it may be at the moment, remains un-
_terably fixed ; either very little or considerably shortened, according
I the degree of impaction ; rolat«fl outwards or inwards, or in neither
*ction, perhaps, according to the direction of the force and the
lount of comminution. In other eases, owing to the extreme com-
iDDtion, and to the wide separation of the trochanteric fragments, or
■ the contraction of the muscles inserted into the top of the femur, or
llhe weight of the body in attempts to walk, or to injudicious hand-
g on the part of the surgeon, such as fomUle rotation, by which the
i is made to art as a Ic^-er, and to actually pry the fragments apart,
II violent extension, by which the impaction is overcome — owing to
tome one or several of these causes it often happens that the fragments
Wparate, and the leg becomes immediately mure shortened, movable,
tnd more inclined to rotate outwards.
396 FRACTURES OF THE FEMUR.
Symptoim. — The symptoms which indicate a fracture of the neA of
the femur without the capsule, are pain, mobility, crepitus, shortening
and eversion of the limb. The trochanter major is not as prominent
as upon the opposite side ; and, especially where the fragments are not
impacted, but are completely separated, it rotates upon a shorter axis.
There are also several other signs to which I shall refer when consider-
ing the differential diagnosis.
Before considering more in detail the value of these several signs, I
wish to call attention to a fact which has been often observed by myself
and others, namely, that the patient is able, sometimes, immediately
after this accident, to take a few steps; yet never, perhaps, without
considerable pain. The same may happen in an intracapsular im-
pacted fracture, but it happens much more often in the extracapsular
impacted fracture ; but the following case is the most remarkable, in
this point of view, of any which has come under my notice: A labor-
ing man, about 50 years of age, presented himself at myelinic at Belle-
vue Hospital, some tinie during the fall of 1874, who stated that two
years before he had fallen a distance of nine feet, striking upon his
side; that after a little he arose and, with the aid of a stick, walked a
mile or more to his home. Walking caused great pain in his hip, and
he was much exhausted when he reached home, and w^nt to bed; but
having no suspicion that his limb was broken he did not call a surgeon.
Within a fortnight from this time he l)egan to walk about, and a week
later he l)egan to ])erform ordinary labor, yet not without jmin.
When this man came before the class I found the limb sliortened
three-fiuarters of an inch, the toes everted, the trochanter major de-
pressed— that is, flattened — irregular in form, and much increased in
breadth. He is a man of intelligencte, and is certain that tliese changes
of form, etc., were observed by him ver}'^ soon after his recovery. It
seems projKjr, therefore, to assume that this was not an example of
gradual change of form and |>osition due to a chronic ostitis, but that
it was an extracaj)suhir fracture.'
Tlie pain and tenderness, accompanied sometimes with swelling and
discoloration, are situated most often in front of the neck of the bone.
Mobility exists in a majority of cases, even when the fragnientti are
im{>acted ; that is, the limb c^n be moved pretty easily in any direction
by the surge<m, but not without producing pain or provoking muscular
spasms, yet the [xatient himself is unable to move the limb by his own
volition, or he can only move it slightly.
Cn'pitus is present whenever there exists a moderate but not com-
plete ini[)actian. It is also present generally when, the trochanteric
fragment having bet»n exteiksively comminuteil and looseneil, the im-
paction becomes excessive ; and it is only absent when the impaction
is su<*h that the fragments are completely and firmly locked into each
other.
A shortening is inevitable, at least in all cases accomjKinied with
either temj)orary or permanent imiKiction, and wc have seen that on<»
^ Canton on IntorstitiHl Absorption of tliu Neck of tbo Fumur frtim Brui*«, etc.
London Med. Gn/Atto, Aug. 11, 1848.
NECK, WITHOUT THE CAPSULE.
397
of these cooditioDS seldom faila. According to Sir Aatley Cooper the
Ehortening varies from half an inch to tliree-mmrters of an inch, but
Bobert Smith has established the folloning distinction. When the
fncture is extracapsular and impacted, that ie, when it remains im-
pacted, the shortening is only moderate, varying from one-qimrter of
in inch to one inch and a half; in fourteen cases measured by him the
iverage was a fraction over three-quarters of an inch ; but when it
does not remain impacted it ranges from one inch to two inches and a
half; indeed, Mr. Smith mentions one example in which the shorten-
ing reached four inches, and forty-two cases gave an average shorten-
ing of something more than one inch and a quarter.
EvCTsion of the toes is very constant; but in a few instances u|ion
record the toes have been found turned In, or even directe<i forwards.
Daring the winters of 1804 and 1865,1 found
>case of this kind in my wards at Bellevue fio.mi.
Hoepital. In the specimen referred to as being
band in Dr. Mutter's collection, with an in-
wid or forward rotation of the trochanter
major, the same relative position of the whole
limb most have existed; and in my remarks
on iractnres of the neck within the capsule, I
have referred to several examples, some of
vbich were probably extracapsular.
The trochanter major usually seems de-
preeeed or driven in ; and when the two main
frigmeoto are completely separated, if the
limb is rotated, the trochanter will he found
lotQm almost upon its own axis, or upon a
very short radius.
Id enumerating the signs of extracapsular
(ricture, itwill be seen that I have, with only
ili^t variations, repeated the signs of a frac-
ture within the capsule. It will become nec-
tvary, therefore, to indicate, as far as possi-
ble, a differential diagnosis. And without
imtendiog that all of the differential signs "'""^"(K"°g",^o.') '""""'
vhich I shall enumerate are thoroughly cstab-
'iiibed, or that in everj- case, even after a careful grouping of all the
i^mptoros, a sat Isfactor}- diagnosis can be made out, I shall state briefly
my owD coDclusions, or rather what seem to me to be the probable facts.
8l8S« or A raACT-DK* WITHIM the 1 SlONU OP A PRACTURE WITHODT TBI
CAFSULK. ! CAPBULIt.
Pradaeed oflea br iligbt violence. | Produce] utimllr liy greater violence.
A fall apoD the loot ur kne«, or a trip ; A fall upon the trochanlGr mi<jor.
■pon the camet, etc.
I Often undpr flfly yp«ra of age.
I Relative frequency in males or female*
■ not eslBblif hed.
Pain, swelling, and lenderness greater
find more Bui-erScial. It it especially
painful to preM upon ftod around th«
trochanter.
398
FRACTURES OF THE FEMUR.
Signs or a fracture within thx
CAPSULK (continued),
(The two following meaeurements to
be made from the anterior superior spin-
ous process of the ilium to the lower ex-
treroitj of the malleolas externus or in-
ternus.)
Shortening at first less than in extra-
capsular fractures, often not any.
Shortening after a few days or weeks
greater than in extracapsular fractures.
Sometimes this takes place suddenly, as
when the limb is moved, or tlie patient
steps upon it.
Measuring from the top of the tro-
chanter to the condyles or to the malleoli,
the femur is not shortened.
Trochanter mnjor moves upon a rela-
tively longer radius.
If the patient recovers the use of the
limb, not restored under three or four
months.
No enlargement or apparent expansion
of the trochanter major, after recovery,
from deposit of bony callus.
Progressive wasting of the limb for
many months after recovery.
Excessive halting, accompanied with a
peculiar motion of the pelvis, such as is
exhibited in persons who walk with an
artificial limb.
Signs of a fracture without the
CAPSULE (continued).
Shortening at first greater, almci^t al-
ways some.
Shortening after a fnw days or weeks
less than in intracapsular fractures. Tbiit
is, the amount of shortening change^ but
little, if at all ; if the impaction continues,
not at all; if it does not continue, it may
shorten more.
Measuring from the top of the tro-
chanter to the condyles or to the malleoli,
the femur may be found a little short-
ened.
Trochanter major moves upon a rela-
tively shorter radius.
If the patient recovers the use of the
limb, restored in six or eight weeks.
Enlargement or irregular expansion of
trochanter, which may be felt sometimet
distinctly through the skin and muscles.
The limb preserving its natural strength
and size.
Slight halt, motions of hip natural.
Prognosis. — In attempting to establish the diflerential diagnosis, we
have necessarily been led to consider most of the essential points of
prognosis. Very little, therefore remains to be said upon this subject.
Union occurs as rapidly in this fracture as in fractures of the shaft;
and perhaps in general more promptly, owing to the existence of im-
paction.
But whether it occurs promptly or slowly, or, indeed, if it does not
occur at all, a remarkable deposit of ossific matter almost invariably
takes place along the intertrochanteric lines, where the bone has sepa-
rated from the shaft, and also, not unfrequcntly, along the lines of the
other fractures of the trochanter.
This deposit is no less remarkable for its abundance than for its
irregularity, long spines of bone often rising up toward the pelvis and
forming a kind of nobby or spiculated crown, within which the acetab-
ular fragment reposes. In a few instances these osteophytes have
reached even to the bones of the i)elvis, and formed powerful abut-
ments, which seemed to prevent any farther displacement of the limb
in this direction, and by some writers they have been supposed thus
to fulfil a positive design. A sufficient explanation of their existence,
however, we think, can be found in the fact that they proceed entirely
from the trochanteric fragments, whose extensive comroinution aou
prcat vascularity would naturally lead to such results. The same, but
in a less d^ree, has already been noticed as occurring in impeded
KECK, WITHOUT THE CAPSULE.
Iractures at the anatomical neck of the humerus, where certainly such
boDy abutments could not serve any useful purpose.
Eitncipulmr rrKtun. (Erlchsen.)
Probably in all, certainly in nearly all cases, the limb will be foiind,
»fter the union is consummated, more or lees shortened, generally be-
tweeo half an inch and an inch. If exceptions ever occur it must be
in those examples in which there Is no impaction, and it is certain that
»nch examples are very rare. Such is the united testimony of all sur-
geoDB whose opinions have ever been respected as authority ; and the
ttme is true of intracapsular fractures. What ignorance of the ele-
nwatary facts of surgical science do these men exhibit then, who affirm
thit they are able to treat off fractures of the femur without shortening.
Eversion of the foot is not so constant as shortening, but it wilt be
fbond to exist in some degree in a large majority of cases, even when
the case has been managed in the most skilful manner ; yet in this re-
gard something will depend upon the position in which the limb is
maintained during the treatment.
TrealmaU. — The same principles of treatment are applicable here as
ID iracturefl of the neck within the capsule; by which I mean to say
that, as in all of those examples of fracture within the capsule where
the relation of the fragments is such as to warrant a hope that a bony
anion may be consummated, namely, where the fragments are not dis-
placed or are impacted,, the straight position, with only moderate ex-
tension, constitutes the most rational mode of treatment ; so also in this
fmcture, whenever the fragments are impacted and remain impacted,
the straight position, with moderate extension, employed only as a
means of retention, but not so as to overcome impaction, is the most
witable. It is only by employing this plan of treatment, which no one
has yet shown to be inapplicable to either of these two varieties of ao-
400 FRACTPBES OP THE FEMDB.
cidenta — I do not speak of the opinions which men may have enter-
tained, but of the practical testimony — it is only, I say, by employioz
this uniform plan of treatment in both
^o- '"- cases, that those serious misfortunes to the
patient can be avoided which would neces-
sarily continue to occur if Sir Astley
Cooper's advice were followed, namely, to
allow the patient in the one case to dis-
pense with splints wholly, and to get npon
tiis crutches as soon as tiie ooadition of his
limb and of his body will permit, when it
is certain that in tne other case some re-
tentive apparatus is generally necessary.
This conclusion is based upon the admitted
difficulty of diagnosis. If, as is well un-
derstood, the dii^nosis between these two
Eitniciiinuimr ftMiure. Varieties of fracture is often impossible
during the life of the patient, then how
shall we know in any given case which of the two plans to adopt ? If
we act upon the supposition that it is within the capsule, adopting
Sir Astley Cooper's method, and it proves to have been a fracture
without tne capsule, we may do irreparable injury to our patient. It
is precisely here that this distinguished surgeon committ<Ml his great
error; not in denying that certain s|>ecimens were fractures of the
neck of the femur within the capsule united by bone, nor in constantly
ui^ing upon his contemporaries the improbability of such an event,
but in that, while he admitted its possibility, he chose to recommend
a plan of treatment which was unlikely to insure such a union, and
which, in the uncertainty if not impossibility of diagnosis, was liable,
upon his supposed authority, to be adopted in many canes of extra-
capsular fractures.
Again, if the fracture be extracapsular and not impacted, or the
impaction has been, for any cause, overcome; or, if tne fracture be
intracai)sular and not impacted, or if the caitsule is laoerated and the
fragments are in conseqneucc displaced; then again no injury need
result from the treatment, if wc adopt tlie straight position with mod-
erate extension, such as may be obtained from the use of my own ap-
paratus, Gibson's, Miller's, or Desault's. That it is, or is not impacted
we may know generally, by the amount of displacement, altnough
we may not cittily decide whether the fracture is within or without the
capsule. Now, the amount of shortening will determine pmnerly
enough the amount of extension to be employed. In either ease, now-
Gver, wc shall not employ as much extension as in fracturen of the
shaft ; and while in the one case wc may only gain a shorter and firmer
ligamentous union, in the other we shall insure a better and more
spcisly bony union.
If any surgeon, acting npon the su^estions here made, shall confine
a feeble or an aged person in the horizontal posture, with or withont a
straight splint, until the powers of nature have become exhausted, and
death ensues, as our readers have already been admonished may bapiien,
THROOGII THE TKOCHA JJTEH UAJOR.
401
ve are not to be held responsible for his want of judgment or of skill.
Ve have advised this plan of treatment only for so long a period aa
the condition of the (latient renders it entirely safe. No doubt, then,
in a large number of cases it will have to be abandoned very early, and
ID not an inconijiderablc proportion all constraint will be plainly inad-
mmihhfrom the beginning; aud it is for sueli examples that the treaf-
ment recommended by Sir Astley Cooper for all intraca)>sul]Lr fractures
ongiit to be reserved,
(c.) Fvacturen of the XrcJ: partfi/ vithin inid paiily without Ike Capmk.
It ia scarcely necessary t^ say that the line of fracture through the
Deck of the femur may be such, that it shall be in part within and in
part without the capsule; and such fractures will be even more difficult
to diagnosticate than either of those forms of which we have just
spoken. The symptoms will be mainly, however, those which charac-
terize fractures within the capsule, while the treatment ought to be
Bach as we would adopt in those fractures which are wholly without
the capenie. The chances for bony union are increased in proportion
as the line of separation extends outside of the capsule, and we ought
to be diligent in our efforts, if we have made ourselves certain that the
fracture is partly extracapsular, to secure a good bony union ; a result
which exjierience has shown may be reasonably anticipated.
The necessity for some extension, and of firm retentive ap[>aratu3 in
this form of iracture, furnishes another ai^umcnt in favor of the em-
ployment of the same means in fractures wholly within the capsule.
We sball thus avoid the mischief which might arise from mistaking a
fracture of the character of which we are now speaking, for a fracture
wholly within the capsule.
This fracture, which Sir Astley Cooper calls a fracture of the "femur
through the trochanter major," ' passes obliquely upwards and outwards
' Sir Aitle; Cooper, op. cit, p. 163.
402 FRACTURES OF THE FEMUR.
from the lower portion of the neck, hut instead of traversing the neck
completely, it penetrates the base of the trochanter major ; the line of
fracture being such as to separate the femur into two fragments, one
of which is composed of the head, neck, and trochanter major, and the
other of the shaft with the remaining portions of the femur.
The following two examples are all in relation to which we possess
any positive information, or in which the diagnosis has been confirmed
by an autopsy. The first is thus related by Sir Astley Cooper.
"The first case of this kind I ever saw was in St. Thomas's Hoa^
pital, about the year 1786. It was supposed to be a fracture of the
neck of the thigh-bone within the capsule, and the limb was extended
over a pillow rolled under the knee, with splints on each side of the
limb, by Mr. Cline's direction. An ossific union succeeded, with
scarcely any deformity, excepting that the foot was somewhat everted
and the man walked extremely well. When he was to be discharged
from the hospital, a fever attacked him, of which he died ; and upon
dissection, the fracture was found through the trochanter major, and
the bone was united with very little deformity, so that his limb would
have been equally useful as before." '
The second example is reported by Mr. Stanley.
"A woman, in her sixtieth year, fell in the street and injured her
right hip. On examination, the limb was found slightly everted, and
shortened to the extent of three-quarters of an inch, but movable in
every direction. The extremity of the shaft of the femur was in its
natural situation ; but behind the femur, and at a little distance from
it, a bony prominence was discovered, resting upon the ilium, toward
the great sciatic notch, strongly resembling the head of the femur.
Various opinions were entertained as to the nature of the injury, some
believing it to be dislocation, and others a fracture. After a confine-
ment of several months to her bed, the woman was sufficiently recov-
ered to walk with the assistance of a crutch, and in this state she con-
tinued till her death, which took place about three years after the ac-
cident, during the whole of which period 1 had watched the progress
of the case. Having obtained permission to examine the seat of the
injury, I ascertained that there liad been a fracture extending obliquely
through the trochanter major, and through the basis of the neck into
the shaft of the femur, and that the prominence which had been mis-
taken for the head of the bone was occasioned by the posterior and
larger portion of the trochanter drawn backwards toward the iaehiatic
notch." 2
Sir Astley relates tliree other examples in which he believes the
fractures to have been of the character above described; and he details
the peculiar plans of treatment which, in each case, he saw fit to recom-
mend. I can see no reason, however, why the treatment need difler
from that which has already been recommended for fractures of the
neck, since the indications are nearly identical in all of these cases;
namely, moderate extension, and steady support of the limb in its
natural position.
* Op. cit., p. 1S4. > Stanley, Med.-Chir. Tram., toI. xiti.
SPIPHYSIS OF THE TROCHANTER MAJOR.
13. Fntoton of the Epiphyiia of the Trochanter Major.
So far as I know, the only well -authenticated example of this acci-
dent is the one reported by Mr. Key to-Sir Astley Cooper.' The sub-
ject of this case was a girl, aged about sixteen years, who fell, March
15, 1822, upon the sidewalk, and struck her trochanter violently
■gainst the curbstone. She arose, and, without much pain or difficulty,
iralked home. On the 20th she was received into Guy's Haspital, and
the liinb was examined by Mr. Key. The right
leg, whicfa was the one injured, was considerably
everted, and appeared to be about half an inch
longer than the sound limb. It could be moved
in all directions, but abduction gave her consider-
able pain. She had perfect command over all the
muscles, except the rotators inwards. No crepi-
tus could be detected. Pour days aAer admission
she died, having succumbed to the irritative fever
which followed the injury.
The autopsy disclosed a fracture through the
baae of the trcwhanter major, but without lacera- ^^^-^ Btvmi '
tioD of the tendinous expansions which cover the
outside of this process, so that no displacement of the epiphysis had
occurred, nor could it be moved, except to a small extent upwards and
downwards. A considerable collection of pus was found, also, below
and in front of the trochanter.
The absence of displacement in the fragment, with its peculiar and
limited motion, snfSciently explained why the fracture could not be
detected during life.
In the eighth volume of the TranKactions of (he Medical and Physical
SodHy of QUcuOa (1825), J. Clarke, Esq., reports a case of comminuted
fracture of the trochanter major, which has been mentioned by Mal-
gaigoe as an example of simple fracture of the tro<'hanter; but, after
reading the case carefully, I cannot avoid the conclusion that it was
an example of fracture of the neck without the cai>sule, aocompanied
with impaction and extensive comminution. "Extravasation,' says
Mr. Clarke, "was discovered within the capsular ligament and around
the trochanter major; and, on clearing away the muscles, the trochan-
ter was found crushed and shattered, several pieces entirely detached,
and fissures extending deeply into the shaft of the bone."'
I shall venture to express the same opinion in relation to the case
reported by Bransby Cooper.* The diagnosis was not confirmed by
an autopsy, and the testimony drawn from Mr. Cooper's account of
the case is far from being, to my mind, conclusive. It may, indeed,
have been a simple fracture of the epiphysis; but there is nothing in
thenarrativetorender it improbable that there existed also an impacted
extracapsular fracture of the neck.
> Sir Ailley Cooper on DItlnoitiona nnd Fmctiirtu. cti'., A.'naT. ed., 18SI, p. 192.
■ Cl«rke, Amer. Journ. M.-d. Sei., Nov. 183(i, vol. ii, p. ISl.
' B. Coap«r, A. Cooper on DislucHliona, eti:., op. i-it , p. 192.
404
FRACTURES OF THE FEMUR.
Mr. Poland reports a case, also, which occurred in a boy twelve
years old, at Guy's Hospital, and which was seen by Mr. Bryant; but
this was not confirmed by an autopsy.^
I have also myself reported one example of this fracture as having
come under ray own observation,^ but of which I wish now to spetk
somewhat less confidently. The patient, James Redwiek, a travelliog
showman, aet. 23, fell, in August, 1848, from a high wagon, striking
upon his left hip. When he got upon his feet, he found himself un-
able to walk, and was carried to his room. Dr. Wilcox, of BufialOy
was called to see him, and applied a long straight splint. Fourteen
days after the accident I saw the patient with Dr. Wilcox. The thi^
was not appreciably shortened, nor was there either eversion or inver-
sion ; but the epiphysis of the trochanter major was carried upwards
toward the crest of the ilium half an inch, and slightly sent in. No
crepitus could be detected. The splint was continued five weeks; and
about a month after, I found the fragment in the same place, but he
was able to walk with only a slight halt.
I think this also may have been an extracapsular impacted fractore.
Fio. 147.
Sir Astley Cooper's mode of treating fractures of the trochanter major. (FrcMn A. Gooper.1
With the small amount of positive information which we possess in
relation to this fracture, we might venture a few conjectures as to what
would constitute its symptoms, or as to the probable results and the
most suitable treatment; hiit we prefer to occupy ourselves with a
simple statement of the facts, so far as they are known, leaving all
mere speculative inferences to those who choose to make them.
i 4. Fractures of the Shaft of the Femur.
FAiology. — Unless the fracture has taken place just above the con-
dyles, or immediately below the troc^hanter minor, in a very large pn>-
portion of cases it has been produced by a direct blow, such as the
pa«*sage of a loaded vehicle across the thigh, or the fall of a piece rf
timber directly u[>on it. An analysis of twenty-one cases, taken in*
discriminately, presents three fractures immediately above the condyles,
and these were all produced by falls upon the feet; but of the remain-
* Pciland, Bryant r Surgery, 1st ed., p. 950.
' Uamilton, Trans. Anier. Med. Assoc*., op. cit., Tol. x, p. 254.
FBACTUBES OF THE SHAFT OF THE FEMUR. 405
ing eighteen, all of which occurred higher in the limb, only two were
the result of falls upon the feet or of indirect blows, and one of these
was a fracture just below the trochanter minor.
Paihology. — It has already been remarked that this bone is most
finequently broken in its middle third, and usually at a point somewhat
above the middle of the shaft. I have made the same observation in
an examination of specimens belonging to Dr. Mutter. In his cabinet,
of twenty-four fractures of the shaft, three belonged to the upper third,
two to the lower, and nineteen to the middle third.
In the adult these fractures are, with only an exceedingly rare ex-
ception, oblique ; and the obliquity is generally greater than in the
case of other bones. This fact, which it is very difficult to determine,
in most cases, upon the living subject, I have established by a consid-
erable number of observations made upon cabinet specimens. Atrans-
vcree fracture is found only twice in Dr. Mussey's collection, containing
thirty examples of fracture of the shaft ; and in Dr. Mutter's collection,
specimen B 71 is an adult femur, broken nearly transversely through
its middle third; and it is united with a shortening of about one inch.
Indeed, it is more common to find a transverse fracture in the middle
third than at any other point of the bone; but in the upper third the
obliquity is extreme and almost constant.
At whatever point of the shaft the bone is broken, the degree of
obliquity is generally such that the fragments cannot support each
other when placed in apposition ; unless indeed the fracture is near
the condyles, where the greater breadth of the bone creates an addi-
tional support; but even here the cabinet sj>ecimens still present a
striking obliquity, with more or less overlapping. I believe that in
each of the three specimens of fracture at this point found in the col-
lection belonging to the Albany Medical College, the obliquity is such
that the fragments were not supported, and an overlapping has taken
place. In specimen 719 the fracture extends into the joint; and al-
though it is united by bone, a shortening of about one inch has occurred.
In the case of children, and especially of infants, the rule is reversed ;
the bone is either broken transversely or nearly transversely, or it is
serrated or denticulated, so that complete lateral displacement is much
less frequent.
The same remark is probably true of some fractures occurring in
extreme old age; but as the shaft of the femur is not often broken in
verv old persons, owing to the readiness with which the neck yields to
violence, 1 have not had an opportunity to verify this opinion.
The direction of the obliquity varies excee<lingly, esjKHMally in the
middle and upper thirds ; in the middle third, however, it is generally
downwards and inwards ; but in the lower third its direction is, with
only rare exceptions, downwards and forwards, and the suiHjrior frag-
ment is found lying in front of the inferior.
In one instance I have found both femurs broken at the same point
and in the same manner. Mr. L. Brittin, aged about fifty-five years,
while employed upon a building, fell from a fourth-story window upon
the stone pavement below, striking upon his feet. In addition to
several other fractures, I found both femurs broken obliquely down-
406 FRACTUEES OP THE FEMtJR. "
wards and forwards, just above the condyles. Very little inflamif^
tion entjued, and although it was found Impossible to employ extcnrio^^
union occurred readily, and with only #i
Fio. 148. moderate overlapping. In the left liml
however, the upi>er fragment pressed
sufficiently to interfere somewhat with
patella, and the patient was unable,
several months, to straighten the knee cois>^?:
pletely. The motions of the right knee wtttyi
unimpaired. p
I have only once met with a fracture tt^
this point in which the line of separation «M V.
downwards and Iwickwards. As the ttm t
presents several points of interest, it will bt «
firoper to narrate the facts soroewhat ift <
ength.
George Taylor Aiken, of Loekport, N.T, .
Kt. 7. May 18, 1854, in jumping down ■ ,
bank of about three feet in height, he hnk» \
the right thigh obliquely, just above the knee*
FrHJtuteitbMBof condjiM. joint. Direction of the fracture obliqnelf
downwards and backwards.
Dr. G., an accomplished surgeon, residing in Loekport, was called.
The limb was not then much swollen. He applied side splints, rollen,
etc., carefully, and then laid the limb over a double-inclined plane.
The knee was elevated about six or eight inches. Before applying dw
splints, suitable extension had been made, and after completing tlw
dressings, the two limbs seemed to be of the same length.
On the second or third day, Dr. G. noticed that the toes looked nn-
naturally white, and were cold.
Counsel was now called at the request of Dr. G., when it was dfr
termined to abandon all dressings, and direct their efibrts solely to
saving the limb.
The result was that slowly a considerable portion of his foot died
and sloughed away, leaving only the tarsal bones. The fracture united,
but with considerable overlapping and deformity.
Feb. 26, 1856, the boy ^tos brought to me by his father. On ex-
amining the fracture, I noticed that the anterior line of the femur
seemed nearly straight, and this appearance viaA owing in some decree
to the muscles which covered and concealed the bone, and in some de-
gree, also, to the manner in which the fragments rested upon each
other ; the pointed superior end of the lower fragment resting snugly
upon the front of the upper fragment, so that no abrupt angle exisbed
in front. On the back of the limb, however, the lower end of the
upper fragment, quite sharp, projected freely downwards and back-
wards into the popliteal spatv, so that its extreme point was onlv about
half an inch above the line of the articulation. The limb had shr>rt-
ened one inch, and this enabled us to determine accurately that (be
lower point or the commencement of the fracture was one inch and a
rii*TTiE« or THE SHAFT OP THE FEMUR. 407
yf%i>nr> » irJg*.Jaiion, while the point where the line of fraetiire
lamasEC zr ^cs v*s« pcobably quite three inches and a half above
p
Ebfr jDTO'OB « the knee-joint were pretty free. The l(»p was ex-
tPiBiJr nsc. asi the anterior half of the foot having Klon^hod otf,
Aefnv imi ^ym- cocnplcitely healed over. He was able to walk toler-
lUr »fcZ -wriatztaz eitber cmtch or cane.
Ssfasensslj. X^. G. found it necessary to sue tlx; father of the
(Ud ibr izif aar.^ot of his services, when Mr. Aiken put in a i>lea of
pi that consequentlv the services were without value.
nied in the Marcli term of the Niagara ('inniit of 1 H6(S,
X- Y- the Hon. Benjamin F. (inn^'ue presiding,
Ob me parr of the detence, it was claimed that th(> death of the foot
rnce of the bandages being too tight. Thi^y faile<l,
'. TO dKiW that they were extraonlinarily or unduly tight.
Whije €«Q zbe port of Dr. G., the prosecutor, it was shown that the
death cf the toes vias preceded by a total loss of <*olor, an<l that it was
Boc am-mpanicd with either venous or arterial congestion. 'rhc> mhhU-
ol eentiesien examined as witnesses declared that this cinui instance
the moi&t positive evidence whi(!h cxnild be <I<sire<l that the
«jf the toes was not due to the tightness of the l)au<lages, but that
i& fatiae ma*t be looked for in an arrest of the arterial or ihm'voum cur-
rents supplying the limb, or in both. They iH'lic^ved, also, that the
pi«j^i'ti<:»D of the superior fragment into the popliteal space was sulli-
cient in canse this arrest. Thev also believ(Ml that overlapping and
eonmnent projection could not have l>ecn pr(>vente<I in this rase, and
that tnetefure, the treatment was not responsil)I(> for this unfortunate
Rsalt : indeed, they regarded the treatment as corre<'t, and the n»sult
a« a triamph of skill, in that any portion of the limb was savi^d ; the
k^ and f«jrit now remaining being far more useful than any artifuMal
le^ and foot could be.
The Hon. Judge, in a speech remarkable for its clearness aii<l libe-
rality", sought to impress upon the jury the value of the medical t(»sti-
ini>ar. The jury returned a verdict for Dr. 0., allowing the amount
of his claim for services, with the costs of suit.
Specimen 121, in Dr. March's collection at Albany, presents a
!?imilar disposition of the fragments. The fracture* is ()l)li<|ue, trom
above downwards and backwards, and the upper portion lies Ix'hind
the lower. It is firmly united by bone, but with an overlai)ping of
from two and a half to three inches. The young gentleman who
showed roe the specimen remarked that it had Ix^^n found imp()ssil)le,
owing to an ulcer ui)on the heel, and to other causes, to employ in the
treatment any degree of extension.
These two are the only examples which have come under my obser-
vation in which a fracture at this point luis taken this direction.
Sir Astley Cooper does not seem to have recognized this form of frac-
ture and displacement. Araesbury hiis, however, recorded one case,
which came under his own observation, where, altliough the bloodves-
sels and nerves escaped, the bone projected through the skin in the ham,
408 FRACTURES OF THE FEMUR.
and finally exfoliated.* And he thinks the point of bone may ^me-
times so penetrate the artery and injure the nerves as to render ampu-
tation neces.sary, in order to save the life of the patient.
M. Coiiral also has related a case in which an epiphysary disjancttoo,
occurring in a child twelve years old, was attended with a displaoement
of the upper fragment backwards, and amputation became necessary.*
I shall refer to this case again.
I know of no other cases of this rare accident which have been re-
ported. Lonsdale refers to it as "the rarest direction for a fractare to
take;" and thinks that in case of its occurrence, the vessels in the
popliteal space will stand a chance of being wounded ; but he mentioos
no example. The popliteal artery hugs the bone so closely at this point,
that a displacement of the upper fragment in a direction downwards
and backwards must always greatly endanger its int^rity. Indeed, it is
here that the artery and vein are in the closest contact with each other,
and with the bone ; an anatomical fact which has been used by Rich-
erand and others to explain the greater frequency of aneurisms in the
ham.
The direction of the displacement, however, in fractures of the shaft
of the femur, does not always depend upon the direction of the line of
fracture. In fractures of the upper third, whatever may be the direc-
tion of the line of fracture, the lower end of the upper fragment inclines
forwards and outwards, and the upper end of the lower fragment in-
wards; unle&s, indeeil, this inclination is controlled by actual entangle-
ment of the broken ends with each other.
In the middle third the fragments also generally take the same rela-
tive position, whatever may be the direction of the fracture ; but when
the fracture takes place at or near the condyles, where the diameter of
the bone is much greater, the dire(?tion of the obliquity determines
pretty uniformly the direction of the displacement.
Si/mpfams. — The symptoms which characterize a fracture of the shaft
of the femur are those which are common to all fractures, namely, mo-
bility, crepitus, displacement of the fragments, pain, and swelling, to
which are added generally a shortening of the limb, with eversion of
the foot and leg.
Owing to the great amount of muscle covering the thigh, and some-
times to the swelling which immediately follows the injury, it is often
very difficult to determine at what precise point the fracture has oc-
curred, and still more difficult to say whether the fracture is oblique or
transverse; indeed, this latter question is sometimes decided approxi-
mately by a reference to the age of the patient rather than by the ex-
amination of the limb.
The immediate shortening varies from half an inch to an inch and a
half, or even more; and it will average about one inch in the case of
healthy adults.
Profinosis. — Whatever may have been the general opinion of expm-
eneed surgeons as to the question of shortening in other fractures, very
' Remark8 on Fractures, etc., by Joseph Amesbury, toI. i, p. 298. London, ISSl.
' Archiv. Gen. de Med , toiii. ix, p. *2ti7.
FBACTUBES OF THE SHAFT OF THE FEMUR. 409
few certainly have ever claimed that in fractures of the femur a com-
plete restoration of the bone to its original length was generally to be
expected. There seem, however, to have existed only certain vague and
indefinite notions as to the proportion and amount of this shortening,
and which have had for their basis nothing better than a few imper-
fectly analyzed observations.
Says Scultetus (quoting first from Hippocrates): " 'For the bones of
the thigh, though you do draw them out by force of extension, cannot
be held so by any hands ; but when the first intention slacks, they will
run together again ; for here the thick and strong flesh are above bind-
ing, and binding cannot keep them down.' — Hippocrates de fract.
Which Celsus seems to confirm, lib. 8, cap. 10, where he writes as
follows of the cure of legs and thighs : ' For we must not be ignorant
that if the thigh be broken, that it will be made shorter, because it
never returns to its former state.' And Avicenna, lib. 4, fen. 5, saith
' that it is a rare thing for the thigh once broken to be perfectly cured
again.'
" These words admonish us," continues Scultetus, " that we should
never promi&e a perfect cure of the thigh ; but rather, using all dili-
gence, we should foretell that it is doubtful that the patient will be
aiwajB lame ; but when this shall happen from the nature of the frac-
tare, or, which most frequently falls out, from the impatience of the sick
p^son, it may be imputed to our mistake, and, instead of a reward,.
bring us disgrace."^
Says Chelius: "Fracture of the thigh-bone is always a severe acci-
dent, as the broken ends are retained in proper contact with great diffi-
culty. The cure takes place most commonly with deformity and short-
ening of the limb, especially in oblique fractures, and those which occur
in the upper and lower third of the thigh-bone. C()mi>ound fractures
are so much more difficult to treat.'*^
Says John Bell : " The machine is not yet invented by which a frac-
tured thigh-bone can be perfectly secured.'' And Benjamin Bell de-
clares that "an effectual method of securing oblique fractures in the
bones of the extremities, and especially of the thigh-bone, is perhaps one
of the greatest desiderata in modern surgery." " In all ages," he adds^
" the difficulty of this has been confessedly great ; and frequent lame-
nees, produced by shortened limbs arising from this cause, evidently
shows that we are still deficient in this branch of practice."^
Velpeau says that " after fractures of the femur there is no limping
anless the shortening exceeds three-quarters of an inch ; and the same
19 true if the shortening occurs in the tibia." The reason is, that the
pelvis inclines toward the shorter limb, and thus compensates for the
deficiency in length. In speaking of the various contrivances for
dressing the fractured femur, he remarks that " most of them fail to
obviate the shortening, and produce eschars, anchylosis, or troublesome
^ The Cbirurf;eon'8 Storehouse, by Johnnnes Scultetus, a Famous Physician and
Cbinirgpon of Ulme in Suovia. London, 1647.
' System of Surgery, by J. M. Chelius, translated, etc., by South. First Amer.
ed., vol. i, p. 627, 1874. See alno p. 625, paragraph 679.
* System of Surgery, by Benjamin Bell, vol. vii, p. 21. Edinburgh, 1801.
27
410 FRACTURES OF THE FEHUB.
arrests of the circulation. This is the price that is usually paid for
the employment of these complicated machines, and a shortening of a
quarter to three-quarters of an inch is not avoided after alL The
simplest apparatus that will maintain the adjustment of the fractured
femur, so that union may take place with shortening of only half an
inch, is the best."*
N^laton holds the following language :
" A fracture of the body of the femur, with an adult, is always a
^rave accident, inasmuch as it demands so long a confinement to the
bed, and especially on account of the shortening of the limb, which it
is almost impossible wholly to prevent; accordingly, Beyer recom-
mends to the surgeon, from the first day, to announce to the parents
of the patient the possibility of this accident. With infiiots, on the
contrary, it is almost always easy to avoid the shortening.'**
While Malgaigne declares his opinion on this subject thus, at length :
'^ When we do not succeed in drawing back the misplaced fragmentBi
end to end, so that they may oppose themselves to the action of the
muscles, it is impossible to preserve to the member its normal length,
whatever may be the appareil or method employed. Surgeons are not
sufficiently agreed upon this question.
'' At a period quite recent, Desault pretended to cure all fractorai
without shortening, and his journal contains several examples. In
imitation of Desault, various practitioners have modified, oorrected,
and improved the apparatus for permanent extension, and they claim
to have themselves obtained as complete success. I ought then to
declare here, in the most positive manner, that I have never obtained
like results, either in the use of my own apparatus, or with that of
others, nor indeed where, in pursuance of my invitation, several in-
ventors have applied their apparatus in my wards. I have examined,
more than once, persons declared cured without shortening, and yet,
upon measurement, the shortening was always manifest. The misfiNT-
tune of all those who believe that they have obtained those miracoloas
cures is, that they have not even thought of instituting a comparative
measurement of the two limbs ; I wQl say even more, that they are
most generally ignorant of the conditions of a good and fiuthful meas-
urement. Sometimes, also, they have been deceived in another war
— in falling upon fractures which were not displaced, especially with
young persons; and they have believed that they have cured with
their apparatus a shortening which had never existed. In short, when
the fragments are not displaced, or even when they are brought again
into a contact maintained by their reciprocral denticulations, it is easy
to cure the fracture of the femur without shortening; aside of thoee
two conditions, the thing is simply impossible.
'^ Several distinguished surgeons of our day have acknowledged thb
impossibility, and have renounced, in consequence, permanent exten-
> Peninsular Journ. of Hed., vol. iii, p. 8S4; also Memphis Med. Journ., Tot ir,
p. 254, 1856.
' Kl^mens de Pathologic Chirurgicaloi par A. Nilaton, tom. prem., p. 761
Paris, 1S44.
FBAGTUBE8 OF THE SHAFT OF THE FEMUR. 411
son. They all^e, moreover^ that an overridiDg of even three centim-
eCres is of little importance, and occasions no limping. I cannot agree
with this opinion. I have seen persons walk very well with a short-
ening of one centimetre ; beyond this limit, either they limp, or they
have lifted the heel of the shoe, or, in short, the limping is only con-
cealed by a lateral deviation of the spine.^ We thus are made to com-
prehend how a fracture with overlapping is always serious, and how
Gaotions we ought to be in our prognosis."'
That the forgoing remarks are intended by the author to be equally
applicable to other multures of the shaft of the femur than to those of
the middle third, is made evident by what he has said before, when
speaking of fractures of the upper third.
"The prognosis is sufficiently favorable when the fragments are
denticulated (engren^) ; when they ride, on the contrary, we must
look for a shortening as almost inevitable."^
In our own country several of the most distinguished surgeons have
testified to the constant difficulty, if not impossibility, of curing frao-
tores of this bone without a shortening. In a suit instituted against a
surgeon in New York city, for alleged malpractice in the treatment
of ao oblique, comminuted, and otherwise complicated fracture of the
femor near its condyles, Dr. Mott is reported to have testified that
^'more or less shortening of the limb is uniformly the result afler frao-
tored thigh, even in the most favorable circumstances."^
In a very interestine communication made to the author by Jona-
than Knight, of New Haven, late President of the American Medical
Association, occurs the following passage:
^ I have seen but few fractures of the femur in the adult, unless of
the most simple kind, in which there was not some remaining defor-
mity ; often slight, so as not to impair the usefulness of the limb, and in
others considerable and apparently unavoidable." Dr. Knight adds,
however: "In the greater proportion of the fractures in children the
recovery has been so nearly perfect that no marked deformity or lame-
nem has followed."
Dr. Detmold, in his remarks made before the New York Academy
of Medicine, at its meeting in March, 1855, declared his belief that a
shortening of the femur always occurs after fracture, and that '^ but one
inch of shortening in an average of twenty cases is a good result."*
Dr. J, Mason Warren, of B^ton, writes to me as follows: "As you
ire making observations on fractures, I would state that, afler a long
and very careful observation, I have never yet seen, either in Boston
* Dr. Buck, of New York, thinks that with a shortening of one inch, or even one
iocb and a half, the patient may have " a useful limb, with little or no halting in
h» gait." N. Y. Journ. of Med., vol. xvi, p. 294.
* Traits des Fractures et des Luxations, par J. M. Malgaigne, torn, prem., pp.
72S. 724. Paris, 1S47.
» Op. cit., p. 718.
* Boston Med. and Surg. Journ., vol. xxziv, p. 450. See also opinions of Drs.
Beese, Post, Parker, Cheeseman, Wood, etc., in relation to the prognosis in this
particalar cate.
* New York Journ. of Med., second series, vol. xvi, p. 261.
412 FRACTURES OF THE FEMUR.
or elsewhere, an oblique fracture of the thigh, in a patient over seven*
teen years of age, in which there was not some shortening. I have
had cases shown to me in which it was averred that the limb was not
shortened, but on measuring myself I have found the fact otherwise.
In children, I believe that union without shortening may be aooom-
plished."
Dr. Bigelow, of the Massachusetts Greneral Hospital, writes to me.
May, 1875, as follows: ''In our hospital cases shortening is the role
in adults. Young subjects do better. Three-quarters of an inch short-
ening in the adult is a good result, and easily compensated by the pelvis.
Greater shortening may occur."
In a paper published by Dr. Lente in the number of the New Y^rk
Journal of Medicine for September, 1851, he states that he believes the
average shortening after treatment in the New York City Hospital to
be three-quarters of an inch ; but subsequently. Dr. Buck, one of the
hospital surgeons, has furnished Dr. Lente with more exact atatistks.
Says Dr. Buck :
" Aft^r carefully scrutinizing over one hundred cases of fracture of
the femur, taken from the register of the New York Hospital, and elimi-
nating such as involved the cervix, or condyles, or belonged to the class
of compound fractures, there remained an aggr^ate of seventy-foar
cases, of both sexes, and of all ages from 3 to 63, in which the shaft of
the femur alone was fractured. In all these cases the difference in the
length of the fractured limb, resulting from the treatment, ¥ras ascer-
tained by careful measurement with a graduated tape, and the follow-
ing deductions were drawn from the analysis :
^^Of the 74 cases of all a^es, 19 resulted without any shortening, a
proportion of about one-fourth. The average shortening of the remain-
ing 55 cases was a fraction less than three-fourths of an inch.
^^ Seventeen cases in the above aggregate were under 12 years of age,
of which six resulted without any shortening, a proportion of about
one-third. The average shortening in the remaining 11 cases was a
fraction less than one-half an inch.
"Of the 67 cases over 12 years of age, 13 resulted withoat any
shortening, a proportion of about one-fourth ; and the average short-
ening in the remaining 44 cases was a fraction over three-fourths of an
inch?'^
Mr. Holthouse, surgeon to Westminster Hospital, states that a care-
ful examination of fifty cases of fractures of the femur in the various
London hospitals, made by himself, showed that 90 i>er cent, (includ-
ing twenty children) were shortened, the amount of shortening ranging
from one-half an inch to three and one-third ; and as some of wese
oases were still under treatment, he entertains a doubt whether the final
result will prove to be as favorable as above stated. For hiuit^elf he
declares, with a frankness which is most creditable to his courage and
honesty, that at Westminster, with all the appliances known to surgery
at his command, he has never succeeded, in the adult, in effecting union
' Buffalo Med. Journ., vol. xt, p. 22, June, 1859.
FRACTURES OF THE SHAFT OF THE FEMUR. 418
withoot shortening. He has also examined more than one hundred
qpedmens in the various museums of the metropolis^ and they are all
shortened.
After Quoting the opinions of several writers upon this subject^ in-
cloding the author of this treatise, Mr. Holthouse adds in a footnote :
'' Notwithstanding this strong testimony, surgeons are still to be found
hardy enough, or ignorant enough, to repeat the fallacies which have
been so often refuted, and to vaunt their success in the cure of oblique
fiadores in the adult without shortening. Why do not these surgeons,
instead of publishing their cases in the journals, produce their patients
at some of the medical societies.''^
It is not to be denied, however, that a few surgeons in all parts of
the world have claimed, and still continue to claim, in their own prac-
tice, or from the adoption of their own peculiar plans of treatment,
much better success. Indeed, some of them do not hesitate to afBrm
that, as a general rule, any degree of shortening is quite unnecessary.
Mr. Amesbury declares, that when the fracture is in the " middle or
lower third/' under a "judiciously managed '' application of his own
flplint, '' consolidation of the bone takes place without the occurrence of
Jiortening of the limb^ or any other deformity deserving of particular
notice.''*
Mr. South, in a note, commenting upon an opposite sentiment ex-
pressed by Chelius, and already quoted, remarks : " In simple fractures
of the thigh-bone, except with great obliquity, I have rarely found
difficulty in retaining broken ends in place, and in effecting the union
without deformity, and with very little, and sometimes without any,
shortening. For the contrary results the medical attendant is mostly
to be blamed, ds they are usually consequent upon his carelessness or
ignorance.''*
Mr. Hunt, of the Queen's Hospital at Birmingham, who treats all
fiactcres with the apparatus immobile of Seutin, has published the re-
sults of his observations; and of the simple fractures of the femur only
one presented, after the cure, any degree of shortening ; and he adds
that all other fi'actures which he has treated by this method were fol-
lowed by "equally good results."* In relation to which statements,
Mr. Gamgee exclaims : " This is conservative surgery. What other
mode of treatment would have given such results ? And those cases
are not exceptional. Mr. Hunt tells us he has selected them from
amongst many others equally successful. They accord with the experi-
ence recorded in my little treatise on this subject ; and the works of
Seutin, Burggrseve, Crocq, Velpeau, and Salvagnoli Marchetti record
numerous cases no less remarkable and demonstratively conclusive."^
* Holthoofe, Holmes's System of Surgery, 2d ed., 1870, vol. ii, p. 866.
■ Practical Remarks on Fractures, by Joseph Amesbury, vol. i, p. 384. London
•1, ISSl.
» Op. cit.,.vol. i, p. 627.
* Reaearches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson
Oami^ee. London ed., pp. 159, 160.
* Op. cit., p. 167.
414 FBACTUBES OF THE FEMUB.
Desaulty also^ accordiDg to the passage from Malgaigne which I have
already quoted, "pretended to cure all fractures without shortening."
I do not find, however, any other authority for this statement, as here
made ; neither in his Treatise on Fractures and Luxations^ edited by
Bichat, nor elsewhere. Bichat even says positively that " Desault him-
self did not always prevent the shortening of the limb/'* He declares,
however, that '' Desault has cured, at the H6tel Dieu, a vast number
of fractures of the os femoris, without the least remaining deformity.*"
Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault,
as modified by Physick and Hutchinson (Fig. 149), was equally suc-
cessful.'
FlO. 149.
Phyaick's splint— The splint Is intended to reach to the axilla, bat the counter-extension Is
by a perineal band. Physick employed a second, long, inside splint.
Dr. Scott, of Montreal, Professor of Clinical Surgery in the McGtll
College, and Physician to the Montreal Greneral Hospital, has reported
19 cases of fractures of the long bones, taken promiscuously and without
selection, from his hospital service, of which 3 belonged to the clavicle,
7 to the femur, 8 to the tibia and fibula, and 1 to the condyles of the
humerus. All of which recovered without any d^ree of shortening
or deformity ; except the case of fracture of the condyles of the hume-
rus, which resulted in death .^
It is never a pleasant duty to call in question the accuracy of an-
other's statements as to what he has himself alone seen and experi-
enced. The circumstances which would justify such an expression
of skepticism, where the witnesses, as in this case, are presumed to be
intelligent and honest men, must be extraordinary. Such, however, I
conceive to be the circumstances in this instance. It is certainly very
extraordinary that a few gentlemen of acknowledged skill, but whose
means and appliances are concealed from no one, are able to do what
nearly the whole world besides, with the same means, acknowledges
itself unable to accomplish. Such is the fact, nevertheless ; and oor
lack of faith in their testimony is only a necessary result of our expe-
rience, and of the experience of the vast majority of practical sui^geons
as opposed to theirs.
I might properly enough dismiss this subject with no farther arji^-
ment than may be found in the overwhelming testimony of practical
surgeons, that broken femurs do in their experience rarely unite with-
out more or less shortening; but I cannot avoid calling attention to
1 A Treatise on Fractures and Luxations, etc., bj P. J. Desault, edited by XaT.
Bichat Amer. ed.,p. 251. 1806.
» Op. cit., p 228.
» Elementg of Surfjory, by John Syng Dowev, vol. i, p. 168. PhiUdelphiAv ISli.
« •• Medical Chronicle," of Montreal, vol. i,'No. 7, 1868.
FBACTURES OP THE SHAFT OF THE FEMUR. 415
ibe evidence of the falsity of the opposite opinion^ which is furnished
fc? the testimony of the very persons who themselves claim to have
obtained sach fortunate results.
It is not, as mi^ht have been supposed^ one particular form of dress-
iDg, which, in itself peculiar, and more perfect than all others, has fur-
nished these results. On the contrary, the plans of treatment have
been constantly unlike, and sometimes ouite opposite. Thus, Desault
used a straight splint, with extension ana counter-extension, and he re-
fbsed to adopt the flexed position recommended by Pott, because his
experience, and the experience of other French surgeons, had taught
him its inutility.* Adopting the straight position, he made perfect
limbs ; with the flexed position he found it impossible to do so.
Dorsey used the splint of Desault, as modified by Physick and
Hutchinson.
South, whose success seems to have been, equal to that of Desault
or Dorsey, adopts also the straight position ; but he makes no perma-
nent extension, except what may be accomplished through the medium
of four long side splints applied after " gentle ^^ extension has been
made by the assistants.
Mr. Amesbury, on the other hand, made perfect limbs only with his
own double-inclined plane ; and speaking in geneml of the various
plans hitherto contrived, not excepting that invented by Desault, or
the method practiced by South, which had already been recommended
by several surgeons, he declares that " they are seldom able to prevent
tne riding of the bone, and preserve the natural figure of the limb.
Indeed, so commonly does retraction of the limb occur under the use
of the difierent contrivances usually employed, that I have heard a
celebrated lecturer (now retired) in this town publicly assert that he
never saw a fractured thigh-bone that had united without riding of
the fractured ends!"* And in his General Inferences he uses the
following emphatic language: "The contrivances which are commonly
used in the treatment of these fractures do not sufficiently resist the
operation of the forces abovementioned, but suffer their influence to
be exerted upon the bone, in all cases more or less injuriously, and at
the same time often assist in producing displacement of the fractured
ends ; so that deformity, diflering in kind and degree in different cases,
is almost the constant result of fractures of the femur treated by these
means.***
On the other hand, Mr. (Jamgee broadly contradicts the statements
of Desault, South, Dorsey, and Amesbury, and does not hesitate to
administer a severe rebuke even upon the illustrious Listen : " Pott's
plan, the long splint, Mclntyre, and their modifications, as a rule entail
sensible deformity, which in many cases is very considerable. It is a
significant fact that though the example established in University
Coll^ Hospital by the late Mr. Listen, of treating fractures of the
thigh by the long splint, and of the leg by the modified Mclntyre (a
' Works of DesAult, op. cit., p. 225.
' Amesbury on Fractares, etc., vol. i, p. 810. * Op. cit., vol. i, p. 884.
416 FRACTUBES OF THE FEMUR.
double-inclined plane), which are admitted equal, if not superior, to
other splints, was rigidly followed in that institution, the patients
FlO. 150.
Listen's method, recommeDded by Samuel Cooper, Fergasaon, Pirrie, and otbtra.
admitted with broken thighs or legs were frequently discharged with
manifest deformity."^
With how much force Mr. Gramgee's own remarks as to the expe-
rience of the University College Hospital will apply to the starched
bandages used by himself, the reader will be able to determine when
referred to the opinion of Velpeau, already quoted, who claims no
result better than an average shortening of half an inch. M. Velpeau
E refers and advocates the starched bandage, but he does not claim to
e able to prevent a shortening of the bone.
"What other modes of treatment would have given such results?**
This question, propounded, no doubt honestly, by Mr. Gramgee, has
here its fair and satisfactory answer. Almost any of the various modes
named ; for if we must receive his testimony, we are equally bound to
receive the testimony of Desault, South, Dorsey, Amesbury, and Scott*
If we give credit to Mr. Gamgee, so far as to doubt the statements of
these latter as to the degree of success claimed by them, by the same
rule we must doubt his own statements also as to the d^ree of success
claimed by himself. This I say with all sincerity and kindness, fully
believing that these gentlemen are mistaken, and not that they inten-
tionally misrepresent the facts.
By a reference to my Report on Deformities after FradureSy it
will be seen that the average shortening in fractures of the upper third
of the femur, in the cases examined by me, was about four-fiflhs of an
inch ; in the lower third it was a fraction over three-quarters, and in
the middle third a fraction less than three-quarters of an inch ; and
the average of the whole number was almost exactly three-ouarters of
an inch (three-quarters and one-forty-seventh). These analyses were
made upon simple fractures, and were exclusive of those in which no
shortening at all occurred. An analysis which included also those
which had not shortened, reduced the average shortening to half an
inch and about one-tenth.
An cTcamination of cabinet specimens does not present a result so
favorable even as this. Of nineteen fractures of the shaft of the femur
* Advantafr<»^ of the Starched Apparatus, by Joseph Sampson 6ftinffe«. London,
1858, pp. 64, 56.
FRACTURES OP THE SHAFT OF THE FEMUR. 417
eootained in Dr. Mutter's cabinet, not one seems to have been short-
ened less than one inch. Specimen B 63, fracture of the middle third,
ii nnited with a shortening of two inches and a quarter; and specimen
B 130, imperfectly united after a fracture through the middle third, is
overlapped three and a half or four inches.
In conclusion, I wish to say briefly that, in view of all the testimony
which is now before me, I am convinced —
First. That in the case of an oblique fracture of the shaft of the
femur occurring in an adult, whose muscles arc not paralyzed, but
wbich offer the ordinary resistance to extension and counter-extension,
tod where the ends of the broken bone have once been completely
displaced, no means have yet been devised by which an overlapping
ind consequent shortening of the bone can generally be prevented.^
Second. That in a similar fracture occurring in children or in per-
sons under fifteen or eighteen years of age, the bone may quite oft;en
be made to unite with so little shortening that it cannot be detected
by measurement; but it must not be forgotten that with children
especially it is exceedingly difficult to measure very accurately.
Third. That in transverse fractures, or oblique and denticulated,
ocearrine in adults, and in which the broken fragments have become
completely displaced, it will generally be found equally difficult to
E^ent shortening; because it will be found generally impossible to
ng the broken ends again into such apposition as that they will rest
open and support each other.
Fonrth. That in all fractures, whether occurring in adults or in
ehildren, where the fragments have never been completely or at all
displaced, constituting only a very small proportion of the whole
Dumber of these fractures, a union without shortening may always be
expected.
Fifth. That when, in consequence of displacement, an overlapping
oocarSy the average shortening in simple fractures, where the best
ipplianoes and the utmost skill have* been employed, is from half to
three-quarters of an inch.
If we consider the muscles alone as the cause of the displacement in
the direction of the long axis of the shaft, the shortening of the limb,
other things being equal, must be proportioned to the number and
power of the muscles which draw upwards the lower fragment. This
will vary in different portions of the limb, but nowhere will this cause
cease to operate, nor will its variations essentially change the prognosis.
I have not intended to say that other causes do not operate occasion-
illy in the production of shortening, but only that muscular contraction
' In the three flnt editions of this treatise the word " generally " is omitted ;
Imt a later experience, with improved appliances, has supplied to me, hoth in my
own practice and in the practice of others, a few examples of perfect union under
the conditions named. The word *'f^onorally " was therefore added in the fourth
edition, and is retained in this. Exactly what percentage of perfect cures may
rcatonahly be expected cannot at present be determined, but it is certainly very
nnall. It has never been my opinion that a shortening must inevitably result as
a consequence of the absorption of the ends of the bone. When shortening occurs
I think it is always, or almost always, the result of overlapping of the fragments.
418 FBACTUBES OF THE FEMUR.
is the cause by which this result is chiefly determined, and that its
power will be ordinarily the measure of the shortening.
Conditions of a Faithful Measurement of the Thigh, — The fact that
a patient walks without any halt, is no evidence that the limb is not
shortened. In this regard patients are very unlike; one having a
shortening of only half or tnree-quarters of an inch may limp per-
ceptibly, while another with a shortening of an inch, or even an inch
and a half, may not limp at all. This has been frequently observed;
and it will be easily understood if, standing erect with one foot on a
block one and a half inches in height, the other foot is planted opon
the floor. It will then be seen that this limb can be brought to the
floor without disturbing the erect position of the body. Nor is it any
more a proof that the limb is not shortened because, while in the re-
cumbent posture, the heel can be brought down to the level of the
other.
Measurements made from the umbilicus, or from the symphysis
pubis, are always indefinite and unreliable. Velpcau's idea of meas-
uring from the folds of the belly, immediately above the ilium, is mi-
sound. Mr. Bryant's suggestion that we measure from the trochant^
major, by what he terms the ilio-femoral triangle, in order to determine
the question of a fracture of the neck, is liable to the very serious
objection that the exact position of the top of the trochanter cannot, in
most cases, be clearly determined.
The method most generally practiced, is to measure from the round
end of the anterior superior spinous process of the ilium to the internal
or external malleolus; but even this is not very trustworthy. It is
exceedingly difficult to fix accurately upon the same point U{>on the
two sides, and an error of half an inch is very common when this
method is adopted.
The patient should repose upon his back, upon an even surface, with
the lower extremities as nearly as possible in the line with the axis of
the body, the two wings of the pelvis being»in the same (horizontal)
line. A flexible, but firm, graduated tape is to be preferred to the
steel tape measure. The foot being stcauied by an assistant, the snr-
geon should put his thumb-nail against the line where it joins the
ring, and push his nail into the skin just below the anterior superior
spinous process of the ilium, pressing firmly up and back, the flat
surface of the nail resting upon the skin. In this way he will obtain
a fixed point, and he can obtain an exactly corresponding point upon
the opposite side. Below, the measurement may be made trom either
malleolus, but the outer has the most defined extremity, and is gener-
ally to be preferred. In most cases, for some months after the termin-
ation of the treatment, there is some swelling about the ankle, which
renders it necessary to use great care in defining the point of the
malleolus. The thumb-nail of the opposite hand may be used for this
purpose, resting vertically ujwn the skin (flat against the lower end of
the malleolus). The same method may be employed in measuring a
I^, as in measuring a thigh.
There may be occasional sources of error, which cannot well be
avoided. In very rare cases, as the observations of Coiydon Le Fold
FBACTUBES OF THE SHAFT OF THE FEMUR. 419
have shown, the malleoli of the opposite limbs are of unequal length, or
one limb may be congenital ly shorter than the other.
IhreaimerU. — ^All the early surgeons, so far as we know, adopted the
straight position in the treatment of fractures of this bone, either with
aimple lateral splints, or with long splints, with or without extension,
(V with only rollers and compresses, or with extension alone.
Sach was the unanimous opinion and practice of surgeons until
about the middle of the last century, at which time Percival Pott wrote
his remarkable treatise on fractures, a work distinguished for the origi-
nality and boldness of its sentiments, and which was destined soon to
revolutionize, especially throughout Great Britain, the old notions as
to the treatment of fractures, and to establish in their stead, at least for
a tune, what has been called, not inappropriately, the '^ physiological
doctrine," the peculiarity of which doctrine consisted in its assumption
that the resistance of those muscles which tend to produce shortening
can generally be sufficiently overcome by posture, without the aid of
extension ; and that for this purpose, for example, in the case of a
broken femur, it was only necessary to flex the leg upon the thigh, and
the thigh upon the body, laying the limb aflerwards quietly on its
outside upon the bed.
Very few surgeons, even of his own day, ever gave in their full ad-
hesion to the exclusive physiological system as taught and practiced
Fio. 161.
Doable-inclined plane, employed in Middlesex Hospital, London.
by Pott himself, but multitudes, especially among the English, adopted
in eeneral his views, only choosing to place the patients upon their
backs rather than upon their sides, and laying the limbs flexed over a
double-inclined plane. To the support of this system of Pott's, thus
modified, Sir Astley Cooper, C. Bell, John Bell, Earle, White, Sharp,
and Amesbury lent the influence of their great names, and its triumphs,
80 fiur as the judgment of British surgeons was concerned, soon became
complete.
In France, and upon the continent generally, the reception of this
system was more slow and reluctant; but Dupuytrcn, now for once
taking ground with his great rival. Sir Astley Cooper, adopted almost
without qualification these novel views. The decision of Dupuytren
determined the opinions of a large portion of the continental surgeons;
and had it not been for the early and decisive opposition of Desault
and Boyer, the great surgeon of St. Bartholomew might have con-
tinued K>r a long time to have enjoyed a triumph upon the continent^
BACTUB^S OF THE SHAFT OF THE FEMUB. 421
r of 1872, 1 do not remember to have seen the flexed position
iloyed in the treatment of a broken thigh ; and I shall pres-
>w that the straight position is at the present moment very
' adopted by the best American surgeons.
have been, then, three grand epochs in the history of the
t of fractures of the thigh.
That in which the straight position was universally adopted,
h reaches from the earliest periods to the period of the writ-
^ott, or to about the middle of the last century.
1. The epoch of the flexed position, which, inaugurated by
[ already begun to decline at the beginning of tne present
and which may be said to have been completed within less
hnndred years from the date of its first announcement.
The epoch of the renaiasancey or that in which surgeons, by
9f an overwhelming majority, have declared again in favor of
;ht position. This is the epoch of our own day.
igh American surgeons have generally adopted the straight
in the treatment of fractures of the thigh, yet the form and
ion of the splints employed have been greatly varied. The
og splint of Desault, and the more complicated apparatus of
ig. 154), have each their advocates; but it is seldom that we
1 these, or with any of the other forms of apparatus originally
Fio. 155.
Nathan B. Smith's suspending apparatus, or double-inclined plane.
in foreign countries, without noticing that they have been
to considerable modifications; indeed, most of the straight
I well as double-inclined planes in use at present among
surgeons may fairly be regarded as original inventions.
I Smith, of New Haven;* Nathan R. Smith, of Baltimore;*
8 McNaughton, of Albany ;^ and Nott, of Mobile, are the
Med. Rev., published at Philadelphia, 1825, vol. ii, p. 355; also Medical
il Memoirs of Nathan Smith, published at BHltimore, pp. 129-141.
id Surg. Memoirs, pp. 143-162. See also Oedding8, Buftimore Med. and
i.,vol. 1, 1833 ; and Sargent'* Minor Surgery, p 171.
Imer. Med. Ajs8oc.,vo1. x, p. 317. Rep. on Defor. after Frac.
422
FRACTURES OF THB FBUOR.
only American Burgeons of distinguished reputattOD, and wiUi wboee
practice I am familiar, who have recommended exclusively the douUe-
mclined plane.
Fia.lM.
Joilnh C. Notl-i doDble-tncliDHl pluw.
I> Hcqred tolheiptint hj itrllcot plnitnil 1eU)i«r atrapi ; thcsFrfr
irT«l out ■ lillLr, Ui fl( the thigfa ; the In portlou in utkalalcd bf
g rule. Bndthlijiitnt mar be •ladled bTabDIiioBMI bar UI ~
Dr. Nathan R. Smith has introduced a modification of the doable-
inclined plaue in what is known as his " anterior splint," and which
Fid. in.
is intended also as a siigpending apparatus. I have seen it employed
lately a good deal in the treatment of gunshot fractures of the thigh
and leg in our various military hospitals. It is my opinion, however,
4. K. Smith'g interior ipUot, ipplled fbl K fMcUn of tb* tU^
FRACTCBBS OP THE SHAFT OF THE FEMUB.
that it is more applicable to gunshot fractores of the leg than to those
of the thigh.
The splint, if splint it can be properly called, is simply a frame
composed of stout wire and covered with cloth, which being suspended
shove the limb, allows the limb to be suspended in turn to it by rollers ;
the rollers passing around both limb and splint from the foot to the
groin. Wire of the size of No. 10 bougie is usually employed. The
length of the splint should be sufficient to extend from above the
anterior superior spinous process of the ilium to a point beyond the
toes, the lateral bars being separated about three inches at the top and
one-quarter of an inch less at the lower extremity.
Id the case of a broken thigh, the upper hook, to which the cord
for suspension is to be fastened, ought to be nearly over the seat of
{raoture,and the lower hook should be placed a little above the middle
of the leg.
The modification of Smith's anterior splint, su^eeted by Dr. James
Palmer, United States Navy, will be sufficiently explained by the ac-
companying woodcut,' Fig. 159.
424 FBACTUBES OF THE FEHUB.
Dr. J. S. Hodgeo, of St. Loais, Mo., has invented a wire aoBpeinickai
splint, wbicli I much prefer to Smith's. The bars of wire ar« tmvos^td
with a cotton sacking, upon which the limb is laid. He does oot, how-
ever, advocate its general use, but he has designed it especially for gua-
shot fractures.'
On the other hand, among the advocates of the straight position are
found the names of Physick, Dorsey, Gibson, Horner, J. Hartshome,
H. H. Smith, Ncill, R. Coates, H. Hartshonie, Norris, Gross, Buck,
Markoc, A. W. Stein, Post, J. W. Howe, S. B. Ward, F. Weir, E.
Mason.
Says Dr. Gross : " Many years ago, before I had much experience id
this class of injuries, I occasionally employed the flexed |>osilion, but
I soon found tliat it was objectionable, on accouDt of the great difficulty
in maintaining so accurate a))[>osition to the ends of the fragments. Of
late years I have confined myself entirely to the use of the straight i»o-
sition, and I have never had any cause to regret it. In the adult, I
sometimes employ the apparatus of Desault, as modifie<l by Physick,
hut much more frequently one of my own construction, somewhat u|>on
the priuciple of that of Dr. Neill, described in the Philadelphia M<tii-
cal Examiner for Ifi.'jS. I have used it for nearly twenty years, and it
has generally answered the purpose most admirably in my hands. It
consists simply of a box for the tliigh and leg, with a footpiece and two
crutches, one for the axilla and the other for the perineum, to make the
requisite extension and counler-ext^nsion. With such au apftaralus,
an oblique fracture of the thigh can be treated with great c<.>mfort to
the patient, and with the assurance of a good limb. In children, I have
effected wime excellent cures simply by means of a sole-leather trough,
well padded, and provided with a footpiece.
■ ilodgen, Treatiteon Mil. Surg., bjP. H. Hunilton, 18«tt, p. 411.
FRACTUBES OF THE SHAFT OF THE FEHUB. 425
"Tbe great objectiou to the flexed position is the difficult; of keep-
iif the ends of the broken bones in apposition; the upper one having
icongtant tendency to pass away from the inferior. Other objections
night Italgb tpUnt.— Eitenglon nad i^oui
might be ni^ed against the flexed position, but this is quite sufficient to
induce me to reject it."'
Fropl Tlaw, vllb tclded aheet Uld
TIte perineal strap (Fig. 170), correspomliiig U^ the iojured oidr, is k ,
constantly buckled, while the other may be ocmsionally Ioa<en«t, •
left off, as its purpose is only to steady the appanitut^ Whm
Htmps pass iinaer the periiienm, they are covontj with wash-ltw
Before applying the belt, a pillotv-eose or tn-o niuy be poMied i
the waist. The padlock is only lo be used in im^- the patient p
in unbuekling the Btrajis. The splints being applied with i'
FBACTDKES OF THE SHAFT OF THE FEMUR. 427
udMplintR, junks, containing bran or sand, etc, are to be secured more
firmly to the limb by bands of webbing and buckles."
Dr. Bigelow iuforms me that Flagg's apparatus is not now in use at
thii eimlent hospital, and has not been for some time; but I have
retained the iliutitrations because they exhibit much ingenuity, and
serve to explain the gradual progress of improvenient in the treatment
of ihfse fractures.
At present, the surgeons of the Massachusetts General Hospital
employ eeiientially Buck's apparatus; extension being made by a weight
idJ pulley, with the aid of adhesive straps, and counter-extension
leing effected by the weight of the body, by elevating the foot of the
bed. After which, coaptation splints and junks are applied in the usual
maner. Ether is employed in all cases before making extension,
tbeapparatus being applied at the earliest possible moment.
Tlie two Warrens, father and son, of Boston; Kimbalt, of Lowell;
Suborn, of Lowell, Mass; Mussey, of Cincinnati, Ohio; J. B. J'lint,
ofLouisville, Ky. ; Armsby, of Albany,' have also recommended some
fcrm of the straight splint. Said the late Dr. Mussey :
" For all fractures of the thigh-bone I employ the extended position
of the limb. There are but few cases in which extending force is not
necessary to prevent the degree of deformity
or shortening which would occur without it. ■"'" '™-
Of thirty specimens of fracture of the shaft,
in my collection, only two are transverse. In
fiadures of the neck, especially with old
snbjects, I sometimes avoid the application of
»ny kind of apparatus for |>ermanent exten-
sion ; hut in all cases, whether of the neck or
shaft, where such extension is attempted, I
have found the straight position of tlie limb
to l>e the most reliable."
Daniell, of Savannah, Gcoi^ia, recommends
the straight position, the limb being laid in a pa<iiocii.
kind of long box, and the extension being
nude with a weight and pulley.' Dugas, of Aiigusta, Georgia, em-
ploys the pulley and weight also, but uses the long side-splint instead of
the box.' Howe, of Boston, rccommende<l a similar method in 1824.*
Dr. Gurdon Buck, of New York, uses the pulley, without the long
side-splint. His perineal band is conijK>setl of india-rubber tubing,
"of one inch calibre, two feet in length," stuffed with bran or oottou
lampwick, and covered with canton flannel, which covering may be
renewed as often as may be necessary. The extending bands or adhe-
siveplasters terminating below the foot in an elastic rubber cord. The
weight necessary to make suitable extension will vary from five to
tventy pounds.
' Tr»n«. Am. Med, Aiwo., vol x. Rop-rt on Dofiirr
' Amer. Joiirn. Med. ScU-npes, vol, iv, p 330, 1829.
• Southern M^d. and Siirg. Joiirn., F.'b. 1854.
• Bow«, New Eng. Med. Joiirn., July, 18:^4.
■s after Fmcturea.
428 FRACTURES OF THE FEMUR.
William E. Horaer, of Philadelphia, employed a loDg outside spl S
extending into the axilla, and padded, so as to avoid the neceasitjr
junks ; with fenesl-ne, for extending and counter-extending bauds ; a.
also a foot-piece; and a short inside splint, made to extend from C
perineum to the bottom of the foot. Across the excavated upper a
of this splint, a strip of leather is stretched to receive the pre^iure
the perineum, while the perineal band is made to pass through ty
firm leather loo|t3 on the outside of the splint.'
Dr. Joseph E. Hortshonie, of Philadelphia, rejected the pcriiu
band altogether, an<l sought to make the counter-extension by mea
of the internal long splint alone; and for this purpose he nushioiv
the head of the inside splint, as will be seen lu the acoompanyii
drawing. The head of the outside splint may also be cushioned, b
not for the purpose of cniplnyinj
The outside splint is bo adjuste*
it as a means of counlor-extcnsio
to the fuot-piecc, that it may be t
' TrMtiM on the Prmutice of Surgery, by Uenrj U. Smith.
FBACTURE8 OF THE SHAFT OF THE FEMUR. 429
moved in case of a compound fracture, without disturbing either the
eitension or counter-extension.^
Fio. 174.
D. Gilbert's mode of Inaking counter-extension and extension.
I Anterior and posterior counter-extending adhesive bands, two and a half inches wide, crossing
aeh fAhtT before they pass through the mortise holes. 2. The same, crossing at the upper part of
thigh and perineum. 3. Horizontal pelvic band, which may be three inches wide. 4. Extending
btndi, receiving strap of tourniquet in the hollow of the foot. 5. Tourniquet.
Dr. David Gilbert, of Philadelphia, has published an account of a
method of making counter-extension with adhesive strips, which he
had employed successfully not only in fractures of the thigh, but also
Fio. 175.
Gilbert's apparatus applied in a case of fracture of both thighs.
1. Aoterfor adhetire counter-extending strips. 2. Distal extremity of posterior adhesive strip of
tbciide. S. Adhesive strip surrounding pelvis, binding the anterior and posterior strips to pelvis.
4. Inner extremity of the extending adhesive strip, forming stirrup under the foot, to receive the
trap of the tourniquet. 5. Cicatrix of left thigh. 7, 7. Pctit's tourniquet, by which the power was
Applied.
of the 1^, extension being made with the tourniquet of Petit. A
broad piece of plaster also is made to encircle the pelvis, in order to
bind down the counter-extending bands more firmly to the body.
Additional strips are employed when they seem to be required.^
H. L. Hodge, also of Philadelphia, adopting the same means of
counter-extension, namely, adhesive plaster bands, has modified the
idea of Gilbert by securing the strips of plaster to the sides of the
body instead of the perineum, and attaching them to an iron rod
* Treatise on the Practice of Surgery, by Honry H. Smith.
' Gilberti Amer. Journ. Med. Sci., April, 1850. pp. 410-424.
430 FHACTUBE8 OP THE PEMDR.
which is made to project from the top of the spliDt bevond dM
shoulders.'
Lente, of New York, has also occupied himself in the coostmclMi
I. L.IIolge'imethodor>
of an apparatus by which he hopes, in some raoivure, to obvia
inconveniences of the perineal baud, by digtributing the
'■ (high >p)lnk
I)etween the tubero»ity of the ischium and the giroin. He hu, thi
-on brace, extending io a curved ]
I. Hed.Scl., April, IBM.
?, supplied his spliut with i
■ Hodgs, Amer. lot
FBACTUBEB OF THE SHAFT OF THE FEMUR.
431
fiwn the upper part of the external splint, directly acroes the body, to
the median line, and cushioned on its inner surface. To this is attached
tie anterior extremity of the perineal band. By this arrangement the
pressnre is not only in a great measnre removed from the f^roin, and
from the vessels, etc., on the inside of the thigh, but also the direction
of the counter-extension is in a line with the axis of the body. The
pcsterior extremity of this hand is secured, not to the upper end of the
^liut, as is usually done, but to the splint several inches lower down,
where it will take a more secure hold u|M)n the under surface of the
toberosity and nates. Both extremities of the band are elastic. Ex-
tension is made with a screw, inclosine a strong spiral spring in its
iemile, or with adhesive plasters, n piilley and weight, at the option
of the surgeon.
The splint is made in sections, for adaptation to ditferent pereons,
ind for convenience in packing. It extends no higher than the atte
of the pelvis, and is secured to the body at this point by a padded
pelvic band. The accompanying illustration will sufficiently explain
the remaining features of the apparatus.
The apparatus invented by Dr. Biirge, of Brooklyn, ia both a frac-
ture-bed and a splint, and was constructed with the same view of re-
moving pressure irora the front of the groin. The principles involved
ind the general plan of construction will be sufficiently explained by
1 study of the accompanying woodcuts.
There are a few, however, of our most distinguished sui^cons, who
retain the flexed position in certain fractures, such as an oblirjue down-
ward and forward fracture, occurring ju.st below the trochanter minor,
ud a similar fracture just above the condyles, or in certain cases of
tnetarea in children, or in very old people, hut who, nevertheless, give
a decided preference to the straight splint in tIio.sc oblique fractures of
the shaft vhich constitnte by far the greatest proportion of all these
■ocidents. Among these, I will mention the names of Nott, of New
York, Pope, of St. Louis, Mo., and Eve, of Nashville, Tenn. Drs.
Parker and Weir, of this city, retain the double-inclined plane only in
fractures of the upper third.
At the "German Hospital," in this city, under the observation of
Drs. Krakowieer and Guleke, visiting surgeons, five cases are reported
as having been treated by Buck's extension and one by plaster of Paris.
Back's extension had given the best results. At the " Presbyterian
432 FRACTURES OF THE FEMDR.
Hospital," also, Dr. D. M, Stimson reports that Buck's extension i*
generally employed. Drs. Goulcy, Masou, Sayre, Sands, of Bellevoe
Hospital, prefer the plaster of Paris, Dr. Alfred C, Post, Professor
of Surgery m the University Medkal College, speaks a.« follows ;
" My ordinary practice is to treat fractures of the femur by exten-
sion with a weight and jnilley. The method seems to me as nearly
perfect as any plan of human device can be, in promoting the airafort
of the patient, in facilitating the urinary and fecal evacuations, and in
securing union without dcforniity. In some cases union occurs ab-
solutely without shortening, and in other cases the shortening is so
slight as only to be detected by careful measurement. In cases care-
fully treats! by this method it is rare to meet with shortening much
exceeding half au inch. I have never seen a ca** of simple fracture
of the femur treated in this way in which there was any such shorten-
ing or deformity as I have seen in some cases which have been treated
by the use of plaster of Paris bandages."
Says Dr. Weir, of St. Luke's Hospital :
"In hospital practice, and where in private practice I can myself
apply plaster, I do it ; hut to my studcDts I point out that Buck's
apparatus is a much safer method for them to use, and generally liir
gractitioncrs whose opportunities for acquiring laive experience are
■w : because I find that unless carefully applim ana watniet], by -fre-
quent reopening, etc., curvature and shortening will sometinioi occur
unperceivcti, which ciuinot be the case in Buck's apparatus."
Dr. Paul F. Eve, Professor of Surgery in the Nashville Medit^
College, employs of late the plaster of Paris, but not as an immovable
form of dressing. Extension and counter-extension are made a^ in
Buck's apimratu.s, and the limb is exjHised to view daily and spongii).
In order that tlu^ ne»«san.' examinations may be made the pla.-<ter is
applied according to tlie Bnvurian niclhiKl, so that it may be spreati
open without breaking the s]ilint.
The practitx^ of treating fractures of the thigh, as well ai* all other
fraiturcs of the long bones, with the roller alone, and without eiilier
lateral splints or extending a]>i>aralus, Iin4t suggeolett by Uatllcy, hm
FRACTURES OP THE SHAFT OF THE FEMUR. 433
/(Hind in this country but one distinguished advocate, the late Dr.
Dudley, of Lexington, Ky.* Nor, with all my respect for that truly
great surgeon, can I persuade myself that the practice is able to ac-
complish, in a majority of cases, the indications proposed, nor indeed
that it is, at least in the hands of inexperienced surgeons, wholly safe.
Dr. D., of Aberdeen, Miss., has reported to rae one example in which,
after the application of this bandage by a pupil of Dr. Dudley's, to a
negro slave, who had a fracture of the femur, death of the limb ensued,
and amputation became necessary. The negro was sixteen years old,
and healthy ; the fracture was caused by the fall of a tree or of a
branch, and was simple. The bandage was applied from the toes up-
wards to the groin, and was not opened for several days, at which time
the whole limb was found to be in a state of dry gangrene, with the
exception of the upper two-thirds of the thigh, which was swollen
enormously, and partially gangrenous as high up as the groin.
Dr. D. says: "Having heard the history of the case carefully stated,
observing the leg and the lower part of the thigh to be in a state of
dry gangrene, and seeing the marks of the bandage visibly impressed
on the surfiioe, my opinion was made up at the time that the gangrene
bad resulted from pressure of the bandage. The femoral artery at the
groin was in a sound and natural state, and if I mistake not, after the
limb was removed, it was traced to the point of obliteration where the
gangrene commenced, and where the impression of the bandage was
observed ; thus far, I think, it was of natural size and calibre. Hence
tbe conclusion is inevitable, that the death of the limb resulted from
the pressure of the bandage, and not of one of the fragments.
"It was a curious specimen of dry mortification, and I regret that I
did not use the means of preserving it. I was then engaged in a very
laborious practice, thirty miles from home, on horseback, and conse-
quently could not conveniently spare the time to attend to it as an
object of surgical curiosity. Dr. H. and myself cut into the leg in
various places, in order to examine the muscles, arteries, nerves, etc.,
bat found the int^uments so hard that it was really difficult to pene-
trate them with a knife; the resistance to the knife was more like that
of dry hickory wood than anything else."^
I cannot think it necessary to do more than allude to the practice of
Jobert, of Paris, and of Swinburn, of Albany, who, rejecting side or
coaptation splints altogether, have relied solely upon extension as a
means of support and retention in the case of fractures of the shaft of
the femur.
The treatment of these and other fractures by plaster of Paris, paste,
starch, or dextrin has been already considerc<l when speaking of the
treatment of fractures in general. Thus far my experience will not
warrant me in recommending the immovable apparatus as a general
plan of treatment in fractures of the thigh.
In the fourth edition I spoke somewhat more favorably of the re-
> Aroer. Journ. of the M«'d. So!., vol. xix, p. 270; TrnnHylvanm .Journal, April,
1886. Boston Med. and Sur^. Journ , vol. xxxiv, p. Bo.
' For a morp complete nccount of this interesting case, see Buffalo Med. Journal,
▼ol. ziv, p. 198, S«pt. 1858.
434 FRACTURES OP THE FEMUR.
suits of this practice as declared by some of the House Surgeons of
Bellevue ; still more lately one of the visiting surgeons has published
some statistics which indicate a better average result than has beeo
hitherto obtained by other methods; but having since learned that
these statements were not based altogether upon measurements made
by these well known and able writers themselves, I am unwilling to
awjept of them as trustworthy testimony.* In order to assure myself
as to whether we were able to make longer and straighter thighs by
the use of the plaster of Paris than by the method of extension as
employed by myself and others, my later experience has been carefully
collated, but not selected ; every case in which the opportunity was
afforded being recorded, and the results being confirmed by mv own
testimony and the testimony of others. The facts thus obtained con-
stituted the basis of an article written by me for the NewYork Medical
Journal, and published in the August number for 1874; but the great
interest taken in the discussion of the merits of the Mathiesson plaster
of Paris dressings, both in this country and abroad, during the last
few years, seemed to me to call for a statement of experience which
should cover a larger number of cases, although it could not be ex-
pected in a treatise like this to give all the cases in detail, as was done
in the journal communication already referred to. Of the cases treated
by plaster of Paris, and recorded in the accompanying tables, a ma-
jority were from the hands of other surgeons, and all were hospital
cases; in almost every instance the surgeon treating the case having
had a large experience in the use of plaster. With very few exceptions
the plaster was applied while the patient was under the influence of
ether. After the plaster was applieil most of the patients walked
about with crutches; but there were pretty frequent examples in which,
for one reason or another, this was found impracticable, and the patients
remained in bed.
The amount of shortening has six times exceeded one inch. A con-
siderable bend at the seat of fracture has occurred six times ; anchy-
losis of the knee, requiring surgical interference, has occurred six
times, and in almost all cases it has been more troublesome than it is
usually found to be after other plans of treatment; once gangrene,
amputation and death followed, and once abscesses of the leg, paraly-
sis, etc., etc.
The cases reportt^l as treated without plaster were all treated by my-
self. The method adoptwl l)eing in the case of adults essentially that
which is known as Buck's extension, but which I have, as will here-
after be seen, considerably modified. In the case of children, the
method has l)een uniform Iv that which I shall hereafter describe in itn
pro|wr place as the method preferred by me in these cases; permanent
extension, such as is used in Buck's ap})aratus, being very seldom em-
ployed. Not one of tlu^e limbs has presented an excessive shortening
— one inch l>eing the maximum. Not one is bent at the point of frac-
ture. None of the patients had bed-sores, or troublesome auchyhkus
> Prof. H. B. Sftnds N. Y Med. Journ., June, 1871. Dr. J. D. Bryant, N. Y.
Mod. KocM.rd, Sept. 15th, 1871. Dr. S. H. St Johns, Amer. Journ.* Med. Sci.,
July, 1872.
FRACTURES OP THE SHAFT OF THE FEMUR.
435
at the knee-joint. In one there was delayed union. Case 23 has been
measured by many of tbe gentlemen connected with Bellevue, and all
agree that the broken limb is longer than the other, yet it united
promptly, and he walks without a halt. We have been unable, thus
fiir, to find any other explanation of the increased length but the fact that
extension was employed, the amount employed being about the same
as in other cases. Five children and one adult had perfect limbs ; or, if
we are permitted to include the case in which the limb is lengthened,
two adults have recovered with perfect limbs.
Ques treated with Plaster of Paris, Continuous Roller, Mathiesson^s method.
Ko. Age
Character of
fracture.
11
15
I
8; 16
Simple.
4 17
&12
6! 16
K
(I
{
With frac.
of legs.
Simple.
7! 7
s'so
i »87
10 68
i 111 26
i I
■ 12 24
18 25
14 80
15, 21
lei 26
I '
17 29"
18
19
24;
39.
20' 70
2i;44
22; 66
23; 50
24; 22
25 38
i<
(«
((
11
n
it
(I
<t
tl
II
(t
It
It
It
Point of
fracture.
Middle.
11
II
tl
f Below
\ troch.
u
Middle.
t(
tl
Compound
Simple.
2A
28
271271
28; 46 I
29' 51 1
80 28'
<<
u
«t
(I
l(
(i
Compound.
Simple.
Extracap.
Middle.
It
tl
II
11
It
It
It
It
(I
II
It
II
Extracap.
( Below
\ troch.
II
{Above
cond.
i(
Middle.
UospiUl.
Amount of
shortening.
Inches.
Bellevue.
f
St. Francis.
t
Park.
14
99th St.
1
Park.
I
Bellevue.
i
tl
i
It
1
it
1
It
i
Park.
i
It
n
(1
1
tt
H
Bellevue.
n
it
I
t<
i
tt
i
99th St.
1*
Bellevue.
• • ■ •
i(
2
tl
1
It
1
It
i
It '
1
It
Perfect.
ft
11
Park.
1
Bellevue.
i
99th St.
• m • •
Deformity.
{
Slightly
b«'nt.
Much bent.
It If
Bent.
Much bent.
Bent.
Remarks.
Anohylo8i8of
knee.
Anchylosis
broken up
under ether.
Anchylosis.
tl
• • . .
Delayed union,
No union.
Anchylosis.
Anchylosis.
{
ParalysiSjab-
scess, etc.
{Gangrene,
amp., death.
FBACTUKE8 OF THE PE:
Oatet treated by myielf, by my oton and 1
i Compound
I ; Simplo, I
Point
HoaplUl.
Shortened.
Middle.
Bel lev u».
InebM.
i
Perfect.
"
Private.
Perfoct.
BoUevuo.
*
Perfect.
\
1
Int™o.p
Long r». C.
Park.
*
i
Eilracap.
BpIlevuB.
LongKU.
Private,
I
»
I
J
*
\
i
Abo.0 knee.
Middlo.
BollevLie.
Lcnglbtntd.
It will be seen that the Gret table includes two uises in wbich aeri
ous results enauei:!. In ctisc 30 gungrenc supervened on the thinl <b,
af^er the accident, and on the second, after the dresgin^rs were applied
amputation was made, and the [tatietit died. In case 27 the pisrtt
was ap|)lie<l on tlic fifth day after the accident (November 13th, I8T!
and removed twenty dayR later, when the patient found he had no tet
nation in the limb below the knee; the Ic^ was also much swolU-n belo'
the knoe. Subsequently alisceKses formed in the leg, lai^ slou^rhs w
cum.-<1, and the calcaneum became carious.
Both of the preceding; cases are reported at inon> length in the nun
l)er of the New York MeiUcal Journal for August, 1874.
These two constitute the only examples of serious accident* whic
mi^ht |)ossibly have been due to the mode of dressing, in this table i
30 cases, which, ox ha^ been already explained, were reeonlrU withoo
»elct:tiou ; but they are not all which liave oonte under the wrifo'
FRACTURES OP THE SHAFT OF THE FEMUR. 437
notice. In one case at Bellevue an enormous perineal slough was
erased by the pressure of the plaster. In addition, also, to the case of
gtngrene and death included in the first of the preceding tables, the
following have to be recorded :
Lizrie Gibbons, set. 24, fell upon the sidewalk and broke her thigh
ibout six inches above the knee-joint. She was carried to Bellevue
H»jpital, and on the same day, under the influence of ether, and with
limb extended by pulleys, plaster dressings were applied. Twenty-
foor hours later the toes looked dark, and tne splint was opened about
the foot. On the following morning the house surgeon found the limb
cold, and sensation greatly impaired. The dressings were at once
opened freely. Death took plac^ on the third day.
Charles Grim, set. 62, admitted to Bellevue Jan. 2d, 1871, with a
fracture of the cervix femoris, which had just occurred from a fall on the
ice. On the fourth day plaster of Paris was applied with aid of ether
and pulleys. Two days later the record reads : " Patient has a large
sore on sacrum, extending almost to the loins ; splint taken off; ex-
tremities cold and blue; pulse felt with difficulty; suffering from some
civspnoea; lungs emphysematous, and old fracture (?) somewhere; this
VM. he died."*
The two following cases deserve to be mentioned in this connection,
inasmuch as the class of casualties to which they belong are chiefly in-
cidental to the plaster of Paris method. In no other forms of dressing
kave anaesthetics been employed so universally.
John Stockander was admitted to Bellevue August 2d, 1872, with a
fracture of the lefl femur below the trochanter. Buck's, extension was
applied at first, and on the eighteenth day the patient was placed under
the influence of ether, the pulleys attached, and the application of the
plaster commenced. The breathing was soon observed to be gasping.
Kther was withheld a few minutes, when, as the breathing became
regular, it was resumed. Soon after the pupils rapidly dilated, the
breathing ceased, and in a few minutes more, in spite of every effort to
resuscitate him, death supervened. There is every evidence to sustain
tie opinion that the ether was given carefully and in the usual manner.'
In the case of Mary Shules, No. 11 of the second table, ether was
administered for the purpose of applying plaster; and while extension
irith pulleys was employed, and the bandages were being applied,
"she suddenly ceased to breathe, and her face became purple." By
prompt resort to various expedients, including Marshall Hall's method,
Sylvester's method, and electricity, she was rescued. "Dr. Figaro
thinks her respiration was completely suspended two or three minutes."'
The attempt to apply plaster was then abandoned, and Buck's extension
substitateu, with the result of giving her a limb shortened only three-
eighths of an inch.
• A Comparison of the Results of Treatm&nt of 308 Cases of Fracture of the
Femar, etc., Bellevue Hospital, by Frederick E Hvdo, M.D., New York- l^ew
Tork Med Jour., October, 1S74, p. 868.
* Death fmm Ether, by W. B. Dunning, M.D., Acting House SurgeoDy Bellevue-
Hwpital. New Tork Med. Kec., October Is-t, 1872.
> New Tork Med. Jour., August, 1874, p. 134.
FRACTUR
OF THE FEMUR
It lias been almost the constant practice of late, in this country, to
employ ether and the pulleys while applying the plaster, and this b
considered one of the grent essentials to success. It is proper then to
put into the account, as against tliis method, the danger from anns-
thetics, and to inquire, perhaps, whether the usual danger attendins
the exhibition of these agents is not increased by the condition of forced
decubituij, and of extension to which the patients are subjected while the
plaster in being applied.
A case reported to the South Carolina State Medical Association, io
1874, by Dr. Robert W. Gibbes, of Columbia, S. C, furnishes the first
opportunity yet presented to me to observe in the autopsy the result of
treatment, in a case in which plaster of Paris has been employed accord-
ing to the method just described. Dr. Gibbes has been kind enough
to send me the specimen, and also photographs, from which the accom-
panying woodcuts are made.
Mr. J. H. W., EEt. 83, weighing 165 pounds, enjoying robust health,
fell eighteen feet, January 2d, 1873, striking, as he thinks, upon the right
hip. Dr. Gibbes was called and detected a fracture of the right ferour
just below the trochanters. Fifteen hours after the accident. Dr. Gibbes,
assisted by other surgeons, applied " the plaster of Paris dressing after
the well-knowD method in vogue for several years past in Bellevue
Hospital, my venerable patient l>cing kept for some time suspended
above the table and fully under chloroform."
On the fourth day he made an attempt to walk, but the attempt was
Dr Glbbci-i
A, B, C. Ihret
; d. booj brid(*.
not resumed until about the eighteenth day, after which "he began Io
walk around his room daily." The apparatus was removed on the forty-
thinl day. The union was firm, and the limb appeared to be shorteofd
three-quarters of an inch, as determined by several carefQl i
FRACTURES OF THE SHAFT OF THE FEMUR. 439
*
ments. On the 29th of June, about six months after the accident, he
died of apoplexy. In the autopsy it was found that the femur was
broken just below the trochanters into three fragments.
The result of the treatment, considering his age and weight, was all
that could have been expected ; and the preference given to the plaster,
in this particular case, was judicious; but the point to which I desire
to direct the attention of the reader is, that the specimen does not sus-
tain the claim made by certain advocates of this method, that it is able
to prevent a shortening in all cases. In this case there is, according to
the measurements made before death, a shortening of three-quarters of
in inch. An examination of the specimen convinces me that it is some-
what more ; but however this may be, one thing is certain, the limb
shortened to the same degree that it would have done if no apparatus
whatever had been employed. It shortened until the upper end of the
lower fragment struck and was arrestetl by the neck. The apparatus
enabled the patient to walk sooner than he could otherwise have done ;
ind this is a consideration of more importance often in an old man than
the length or form of the limb, and I doubt whether any other plan
wonld nave made the limb in this case any longer.
It will be necessary to describe a little more in detail than has been
done in the chapter devoted to the general consideration of fractures,
the method of applying the plaster of Paris in fractures of the thigh,
which we usually adopt at Bellevue.
A plaster of Paris bandage is applied to the foot and leg some hours
before the complete dressing is made. It is better that this should be
done twelve or twenty-four hours before, in order that this portion of
the apparatus may become solid, and not remain liable to be indented,
or pn^ased inwards toward the limb when extension is applied, and
al«o in order that the surgeon may know, by an examination of the toes
after the lapse of a sufficient time, that the dressing is not too tight.
This section of the apparatus should extend from a little above the
metatarso-phalangeal articulation of the to<« to about the junction of
the middle and lower thirds of the leg. Instead of the soft woollen
cloth, which is generally to be prefcrretl in the upper part of the limb, we
may here lay next to the skin a sheet of cotton batting, and this should
be thicker over the instep and above the heel than elsewhere. We can-
not take too many precautions in protecting the limb about the ankle
from undue pressure. It will be remembered, also, that while at the
ankle the splint should be thick, composed of five or six consecutive
turns of the roller, it may be light upon the foot, and near the upper
end of the splint upon the leg.
While the dressings are being applied, and until they have hardened,
the foot must be held carefully at a rigirt angle with the leg, and in a
pro{)er line as to inversion or eversion ; but the assistant must take care
that he does not, with his hand or fingers, indent the plaster.
A temporary congestion of the toes almost always ensues upon the
application of the bandage, but this usually subsides within twenty-
four hours. If it does not, the bandage is too tight, and must be cut
open.
In applying the final dressings on the following day, or when the
440
FRACTURE
OF THE FEMCR.
first dreasiug has become solid, the paticot is laid upon a bed oompOf«d'
of two or three mattresses, or of a sufficient number of folded blankctB,
his loius, shoulders, and head resting upon the bed thus constructed,
while his hips, thighe, and legs extend beyond the bed. In order to
support the lower portion of the body in this position apiece of a cottoa
roller, three inches wide and two yards long, having been lubricateA
with sweet oil, is passed under the pelvis, aiid tied above to a bar sup-
ported by a stanchion, as seen in the woodcut. Various methods of
supporting the pelvic have been devised, but this is the most simple and
efficaoious. The piece of bandage is directed to be soflenctl with oil,
in order that it may be easily withdrawn when the dressing is bard;
but if it has not formed a cord this may not be necessary, and it ■
sometimes cut off and left inclosed with the splint.
The iron stanchion, wrapped with woollen cloth, is now brought
agaiust the perineum, uiid the pulleys made fast to ihe foot by a noose
of cotton bandage. Mnleratc extensiou is made, suMcicDt to support
and steady the limb, but not sufficient to overcome the shortening. .
The surgeon now wra])9 the limb, including the }>elvis, thigh, and
leg, down to the first splint, with soft but coarse woollen cloth, culliw
out i»rtions here and there, and fitting it smoothly to all the irregulari-
ties of surface, and stitching it loosely, when it is in place, over the'
region of the tuberosity of the ischium and perineum. Where tbespliat<
is liable to make undue ])re»sure, two or three thicknesses of cloth niajr
be placed, or cotton batting may be used instead.
Everything being ready, the assistant places the patient completelr
under the influcuc« of an amestlietic, and then extension is made witli<
the pulleys until the limb is restored, if possible, to the same length a
the other.
The bandages, filled wilh dry plaster, and previously soaked a (eiTi
minutes in water, are then applied from below upwards, including^
finally, the pelvis as high us the loins. At no point must they bf
drawn tightly, but only with suflicicnt firmness to insure (lioir acoiiniM
adaptation to the limb. Three, four, or five thicknesses are rcquirM},,
according tu the size of the limb, or (he age of the jialient. In fn>n|i
of the groin, where the splint is most liable to become broken when tite
patient gets up, there should be laid two or three stripe of binder*
board, or narrow metal strips, tin or zinc.
After each sucL'Cssive layer is applied, the surgeon will spHnkle t
little dry powder upon the surtiicc. and smooth it over with his baud
previously dip|>ed iu water. As soon as the plaster is liard, usually
within twenty or thirty minutes, the sus])ending apparatus ia removMl
and the patient placed in l>ed.
Those surgeons who omit to include the fiiot and ankle in Chc plaMor
splint dn not, I think, avail themselves of the most imiwrtuit ud miitf
reliable means of making extension in thb< form of <inM«ing. When
the limb shrinks the condyles of the femur and ihe calf of tlw W nff'-f
very imperfect resistance to the action of the muscles of the thigli, and
extension is often completely lost. I.«t it be understood, al.'^t, ual the
author does not recommend that the perineum shall be made the point
442
FRACTURES OP THE FEMUR.
Fio. 184.
by our best surgeons both at horae and abroad, I desire to describe in
greater detail those methods and forms of apparatus which my own ex-
perience has taught me to prefer.
As to posture, my opinions are in accord with the opinions of a vast
majority of the most experienced surgeons of the present day. The
straight position will, on the average, give the best results. Careful
measurements made by myself in several hundreds of cases, a portion of
which have been published in my statistical tables,* have demonstrated
that the average shortening of the limb is greater after any method of
treatment in which the flex^ position is employed, than after treatment
with extension in the straight position. These observations have also
shown that the flexed position, contrary to the reiterated statements of
its advocates, is more apt to entail angular deformity.
There are a few who, rejecting the flexed position in fractures of the
middle of the shaft, still declare for this position a preference when the
fracture occurs just below the trochanters, and in the case of fractures
at the base of the condyles.
According to Malgaigne, who has devoted especial study to this
subject, there is no satisiactory evidence in favor of the flexed position
when the fracture occurs below the tro-
chanters. It is not directly forwards,
but forwards and outwards, that the
lower end of the upper fragment is car-
ried by the action of the psoas magnns
and iliacus internus; so that in order to
meet the supposed indication it would
be necessary to carry the lower part of
the limb outwards also, a position which
would certainly be found inconvenient,
if not actually impracticable, in the ma-
jority of cases. Nor can the tendency
of the upper fragment to advance in the
forward direction, and consequently to
separate from the lower, be met effectu-
ally by posture alone, unless the thigh
is completely flexed upon the bi>dy. In-
deed, it is apparent that the |Kisition of
moderate flexion will rather favor the
action of those muscles which are sup-
posed to be chiefly responsible for toe
displacement. When the thigh is ex-
tended upon the body, the psoas magnud
and iliacus internus are acting in the
direction of, and parallel to, the axis of
the femur, and consequently to a disadvantage; but when the limb is
lifted, their action is more nearly at a right angle with the shaft, and
their ability to displace the fragment is greatly increased.
Moreover, it ought to be understood that broken bones are seldom
Fracture of femur Just belo
ter minor.
trochan-
> Fracture Tables, by F. U. Hamitton, 1868.
FRACTURES OP THE SHAFT OF THE FEMUR. 443
or never displaced or separated, in the same manner they would be if
they were not surrounded with many other structures which have suf-
fered little or no disruption : they pass each other, but do not separate
widely, being held together by shreds of periosteum, muscles, tendons,
ligaments, etc The same happens when this bone is broken just below
the trochanters; the upper fragment lies always, or almost always, in
immediate contact with the lower, and whatever force is brought to
bear upon the lower fragment more or less directly influences the
apper ; we can then by extension, applied to the leg, draw down not
only the lower fragment, but we can drag into line the upper fragment.
No doubt in this attempt we shall meet Avith some resistance from the
muscles above named; but experience has always shown that even
moderate extension, applied steadily and without interruption, seldom
or never fails to overcome the resistance of the most powerful muscles.
We constantly avail ourselves of this principle in overcoming the ab-
normal contraction of muscles in connection with diseased joints, in the
reduction of old dislocations, and in many other ways.
Whatever the advocates of flexion in fractures of the femur may say
to the contrary, they are never able in this position to employ effective
extension and counter-extension. A careful examination of all the
doable-inclined planes which have been brought under my notice,
including Nathan R. Smith's and Dr. Hodgen's suspending apparatus,
will convince any experienced observer that such is the fact. What-
ever other excellences they may possess, this does not belong to them.
Bat extension is, of all tne indications of treatment, that which is of
the greatest importance in nearly all fractures of the thigh, and no less
important in the upper third than in the lower. In fact, the higher
we ascend in the limb, the greater is the tendency to shorten, as my
measurements have shown, in consequence of the action of those pow-
erful muscles which, arising above, have their insertions into the lower
fragment.
In the case of all those double-inclined planes where the body rests
upon a bed, there can be no counter-extension except the weight of
the pelvis and its contents. It will not do to fasten the pelvis to the
bed by bands, as every one who made the experiment would soon
learn ; nor will the groin tolerate the pressure of counter-extending
splints or bands. These things have been tried in a thousand ways,
and abandoned. The weight of the pelvis alone, not of the entire
body, is the only counter-extending force which can be made available,
and this is wholly insufficient. In Nathan R. Smith's anterior sus-
pension splint, not even the weight of the pelvis is employed as a means
of counter-extension, the pelvis being secured to the splint by rollers,
equally with the thigh and leg.
Afler all, I prefer to leave this question to the verdict of experience,
and happily this seems to be conclusive, if we may accept the almost
unanimous testimony of those surgeons who have enjoyed the largest
hospital practice. In my own experience the ordinary double-inclined
planes have constantly given the worst results, both in regard to length,
and lateral displacement; they are the most difficult to manage, and
are the most fiitigning to the patients. Nathan R. Smith's suspending
444 FRACTURES OF THE FEMUR.
apparatus permits the limb to shorten more than the present methods
of extension ; and it aflTords inadequate support along the centre of the
shaft, in consequence of which the limb is apt to unite with a backward
curvature or angle. In some gunshot fractures treated by this appar-
atus this posterior curve or angle has been excessive.
Even the old methods of extension were preferable to flexion ; but
they had always two serious drawbacks. First, in the excoriations
and ulcerations incident to the application of extending bands or gaiters,
or whatever else was employed for this puri)ose. Again and again I
have seen ulceration of the instep, of the integuments above the heel,
and of other parts of the foot and ankle, from extending bauds ; and
second, from similar excoriations, ulcerations, and deep slough:» about
the groin and perineum, caused by the counter-extending band. It is
true these accidents did not occur often, and sometimes they were due
wholly to negligence ; but in order to avoid them we were compelled
to limit very much the amount of extension, and to exercise unceasing
vigilance. Only recently, at Bellevue, an attempt was made to employ
counter-extension in the perineum of an adult, by plaster of Paris
applied in the usual manner for a broken femur, and as a consequence
a perineal slough was soon formed two or three inches in depth by
several inches in length. Lente, the Burges, myself, and others sought
to overcome some of the difficulties of the perineal baud by varic^us
contrivances ; and perhaps in some measure we have been succesftiful,
but still the danger of ulceration existed wherever much forw was
employed, or the integuments were unusually delicate. Gilbert's plan
of substituting adhesive plasters for the usual counter-extending band,
and Buck's plan of employing elastic tubing, possess no real advan-
tages. The truth is, there is no point about the groin, perineum, or
Eel vis upon which, by one surgeon or another, the pressure has not
een made, and more or less distributed, and there is no metliod |ht-
haps which has not been employed, yet, after a fair trial, the results
are the same. The pressure must be moderate, or serious accidents
will occasionally happen.*
Hodge's attempt to make the counter-extension from the sides of
the trunk by strips of adhesive plaster, as already described, is wholly
inefficient in a large majority of cases.
Our first great step of progress in tlie treatment of fractures of the
thigh consists, then, in having secured counter-extension by the weight
of the body alone, and this is accomplished by simply elevating the
foot of the bed from four to six inches. I have not used a {lerineal
band, except in case of children, for eight or ten years ; and in the ca.-^e
of children the weight of the lx)dv is still my chief reliani^e. None
of my c()lleagu(»s at Bellevue use the p<Tineal band to-day.
The second step of progress was the introduction of the nieth<Hl of
extension by adhesive plasters, weights, and pulleys, without which
we would l)e unable to employ effectively the weight of the IhhIv a^ a
means of counter-extension, and by the use of which all danger of
* For caMes of ^lou^hinf^, etc., from porinoiil bund, »ee N. Y. Journ of Med.,
vol. xiv, 2d scr., p. 261, March, 1S50; aUo same Journal, Jan. 1810,
p. 239.
FRACTURES OF THE SHAFT OF THE FEHDB.
446
exooriatioD, ulceration, and sloughing about the foot is completely
avoided. The suggestion of adhesive plaster extension has been
claimed for both Dr. Gross and Dr. Wallace, of Philadelphia, and for
Dr. Swift, of E^toD, Pennsylvania ; but, however this may be, to Dr.
Josiah Crosby, of New Hampshire, is certainly due the credit of hav-
ing brought it conspicuously before the profession.'
As to the bed upon which the patient is to repose, it eeenis proper
to say that, whenever the circumstances of the patient will warrant
tlie expense, a bed constructed with especial view to fractures of the
thigh ought to be regarded as an essential part of the apparatus;
ilwaye contributing to the comfort of the patient, if it is not absolutely
necessary to the attainment of the most complete success. Indeed,
»bere some form of fracture-bed cannot be procured, or extempora-
neoosly coustructed, and the patient is compelled to lie upon a com-
mon cot-bedstead, or a common post-bedstead, or upon the floor, I
annot think the surgeon ought to be held in any degree responsible
ibr the result.
The fracture-beds in use among American surgeons are exceedingly
various, among which I will mention, as being especially ingenious,
tbe beds invented by Jeuks, Daniels, the Purges, Addinell Hewsou,
of Philadelphia,' J. Bhea Barton, B. H. Coates, of the same city,* and
J. Crosby, of Manchester, N. H.*
JcDki'i (mluK-bpd. {From Ulbton.)
Of these several contrivances, Jenks's bed (Fig. 185) has been for the
longest period in use among Americau surgeons, and its excellences
< NcwHampihire Jnurn. Med., 1831; Trnns, Amer. Med. Assoc, vol. iii
» HewHin, Amer. Journ. Med. Sci., Julj, 1858, p. 101.
■ Eolf^tic Kepertor}', 6lh nnd 9th vols.
* Croiby, TrentiK on Miltt. Surg., by Frnnk H. HamilUtn, 1865, p. 41S.
p. 382.
446
PHACTURES OF THE
mcitit thoroughly testixi. It is composed of " two upright poets aboat
six feet high, supported each by a pedestal ; of two horizontal bars t'
the top, somewhat longer than a contmoQ bedstead; of a windlass o
the same length, placed six inches below the iipper bar; of a cog-whe*!
and handle; of linen belts, from six to twelve inches wide; of straat
secured at one end to the wiudlasii, and at the otiier having ho<»t
attached to corresponding eyes in the linen belt«; of a head-pieoc
made of netting; of a piece of sheet-iron, twelve inches long, and hoi*
lowed out to fit and surround the thigh ; of a bed-pan, bos, and!
cushion to support it, and of some other minor parts.
" The patient lying on this mattress, and his limb surrounded by the
rm of lulublo liDglh imd ir
■lIuhHl ■ CIUU-plHC, 1. >l
ic plmfnrni it
hoi.. <■ (In I
■poDd wllh Ihut of ihe [ilitRinn A, und wktQ dc|irc»i
the pUtfonn. Tbo 'Ida uf the bodj' ploDF luaj' bs vli
lU auut lurTicp. To the oppmlte >tdi> or edge of lh« ci
cut OT rscm [umicd b; ihi *jicrlnr* t, Ibr-n are ilti
■ro pratldid with gnwies or wKn *t Ibglr ddm. In o
CC.t> Dtuar on »ch Mr) in Mgb pi* In, and II
rtl<^,
Intoi
.r pUl.
night r^t' of ■>>• w I
bod)' pliDO, lh« *tdth at sblA muf
ciga nuijr b> •?» «Hb It* •tv't
JiwI lo u la b> iJlKbUr
OH^iwe A. nnd It rKb >14* et Um ■
:hed l>T hln«flk e, cul-Inn |ibWk C C •*■*
'h>ta«D*hleb td»«I>D«rt. TVfbM
iclr cdfc* ur proildfd vllk prqtntlM/-
1 flbilft ff th*re it placed • ploInD, vkkb fi
iDD.
ch pnwltj, alfkHid piwlihHDgsllichfd lo lh« ildn of U» |tolH CC T*(
outer cdgHoI Iba plulei £ il ire ulliehed hf hiUKOLt. bonrdi, JliT.- Ib»* bouib wa 1^ )*■
kndansatlghtlr rUK^d itUMlriiiBgT snd>,vh«nilbrx*'>™DUBet«d lutha pt(U« AISHdnlt*!
dcpKiiloiia W mrmpood to ihe fhipo of Ihe legi. To Ihe undei lurfkoe of enh Itf ^l*M Ihiie
JccliDg frgm tliem ai right inglei. To sub leg planit b attachrd aidiaft, a, h»1og * |<lBlK,«ia
niFhct, t, ihcieon, and pawla. r. which eaich Inlo the ralehcii, f , ilie pawli bEliig altaih^ » <
MItraMeiurthnlrgplRnia. Thvplolonigearlnlatbx mki n. Till bud; pUn«.aail ikBOtiM
•Bd Irg pUD«. are Eortrsd hr • niUable tBBttrm. X^ «ltb ■ hole made Uiivugh liloimii^iMt'l
■lie hole In the iiUifann ^.and the uttlteB ii •llLoreut lacoier propirl; lb* Uilgb Md >>«|ta
vllhiHil InlarlV-rlng vlth Iheir niiitementa. T<i the under ilde of Ihe plaltunn It kUmM *t M
a flap, y. h««lng a iliiIIM pad orciuhlon.t, upon 11, vhlch, vhrn the llap li neund wpawfci^
the pUlfuroi, fill In Ibu buin In Ibc vlatlunu and luatttvia. Tbit flap li aRuti^ agalxl tti |b*
FBACTUBE8 OF THE SHAFT OF THE FEMUH.
■ppsratus of Desault, Hagedom, or any other that may be preferred,
toe surgeon, or any common attendant, will only find it requisite to
jts& tbc lineu belb> beneath his body [attaching them to the noode on
ihe ends of the straps, and adjusting the whole at the proper distance
ud length, so as to balance the body exactly], and raise it from the
i by turniog the handle of the windlass. While the patient is
ttius suspended, the bed can be made up, and the fteces and urine evao-
ualcd. To lower the patient again, and replace him on the mattress,
the windlass must be reversed. The linen belts may then be removed,
ud the body brought in contact with the sheets." '
-£^,
Bat in my own experience no bed has proved so complete and
naivenally upplicable as the fracture-bed invented more recently by
Diniels, of Owego, New York, and which may be used either as a
448
FBA.CTUBES OF THE PEUUB.
double-i DC lined plane or as k siDgle horizoDtal plane suitable for the
support of the patient when his limb is dressed with the straight splint.
Sometimea I have had constructed a simple frame, covered with a
stout canvas sacking, having a hole at a point corresponding with the
position of the nates, and this I have laid directly upon a common
four-post bedstead. A mattress and one or two qnilts must be pl&rad
upon the boards of the bedstead underneath the saclcing, and a sheet
or two above the sacking, upon which last the patient is to be laid.
In arranging the linen underneath the {.ratient, the most ooDTeoient
plan is, instead of using only one sheet, which will require that a bole
shall be made in it corresponding to the hole in the sacking, to employ
two sheets, and, doubling them separately, to bring the folded margin
of each from above ana from below to the centre of the opening.
When the patient has occasion to use the bed-pan, it is only nevessa^
that two or four persons should Wit this frame, and place under eatm
corner a block about one foot in height, or it may be raised by a pulley
and ropes suspended from the ceiling.
The " invalid-bed," to which I have already alluded as a " fracture"
bed, invented by Dr. Josiah Crosby, of Manchester, N. H., and which
was introduced into many of the United States general hospitals by order
ibj'iloTitld-bcd.ctond.
of the Surgeon-General, has licen found to be of great service, not only
in the management of invali<lH, in the general sense of that term, hut
also in the treatment of (runshot fractures of the thigh. Indeed. 1
have had occnsion to ase this bedstead in ItellovueHnttpital, and I can
say that its value in many cases can scarcely lie overestimated.
We may also floor over a ronnnon betlsteatl, having previously, in
case it is an adnit whom we have to treat, removed the foot-l>oard, no
that we may extend the floor two or thn-e feet beyond the usual length
of the bedstead. In the centre of this floor we may make an openings
so arranged as to be closed by a board slid underneath, or by a door
&etcncd with a couple of leathern hinges, and closed by a spring catch.
A very comfortable bed, especially for children, can sometimes be
FBACTUHES OF THE SHAFT OF THE FEMUR. 449
nude from a cot. But it will be necessar)' alwajB to nail a piece of
basid firmly across the ton and bottom of the bedstead when the sock-
ing is at its utmost tension, in order to prevent the side rails from
■^-t
Cro.br.
nT.lld.b«i,optn.
TWbtdlino
nble.lDdoaberupoutlVDn:
under I
e pattent an
dcb>
XKcd I.f..be
niDbiirk,
IkkookiSbrI
guide
Bjt..tn
>tHl.i.p.Hr.
PM.Il.g
Q«rlb. pul1fTe,.n
i Ihe h«
iUp.
iltlon, IbuB UklDE Dir Ibe
nl(ht or Ihe paiienl Cram tbg Iwndg bf whlcb
bewu
cinpnr»rlLy
u.pcodi>d.
filling toge
ther.
The top board
must
be nailed on
vertically,
like an
ordinary head-board, no aa to prevent the pillows from falling off, but
the bottom piece should be at least one foot wide, and laid
Iwriiontallf to support and steady the apparatus as it ex- fio, 191.
tends beyond the foot.
Having had occasion to assist the late Dr. Treat in the
management of a fracture of the thigh in the case of a
litUe girl not quite three years old, I was struck with the
simplicity and completeness of an arrangement which he
had made to prevent the bed and the dressings from be-
coming soiled with the urine. It was only to leave directly
andemeath the nates a complete opening through to the
floor for the escape of the iirine, and to protect the margins
of the sacking and sheets, which came nearly together at
the opening, with pieces of oiled cloth folded ui>on them-
selves. It was found that not only the l>ed was in this way
kept dry, but the dressings also; it being now observed
that the dreexings hod become wet heretofore by soaking
ap the moisture from the bed, rather than by the direct
&11 of the nrine upon them.
Having prepared the bed for the reception of the [mi-
tient, and elevated \tx lower end about four inches by
placing blocks underneath the foot-posts, the following
additional preparations should be made l)eforc wc procccil to reduce the
fracture and dress the limb :
There should be provided a piece of board of the requisite length
ud breadth, famished with a slot to receive the pulley, and called the
"atandard," a small iron rod, a pulley, a yard of rope, and a vessel or
450
FRACTURES OF THE FEMUR.
bag to receive the weights. The slot should have sufficient length, and
the standard should be perforated in the direction of its breadth at short
distances, to enable the surgeon to elevate or depress the pulley, as may
be required. In case a metallic pulley cannot be obtained, a s|)ool will
answer as a tolerable substitute. The adhesive plaster which I have
generally used both in private and hospital practice is that which is
usually found in drug stores, spread upon linen ; but some of my col-
leagues j)refer the plaster spread upon jeans or canton-flannel, as being
stronger. I cannot, however, appreciate their advantage, since the ordi-
nary plaster seldom gives way, when properly applied.
A thin block or piece of board, called the " foot-piece,^' is to be pro-
vided, perforated in the centre to receive the cord, and of sufficient
length to prevent the adhesive strips or " extension bands " from press-
ing upon the malleoli. An average size for the foot -piece in the case
of an adult is about three inches and three-quarters in length, by two
and a half in breadth.
The adhesive plaster may be cut in the shape shown in the illustra-
tion : five and a half inches wide in the centre, and two and a, half
inches wide at the narrowest point,
and gradually widening again to-
ward each extremity to four inches ;
the narrower portions being slit
down two-thirds of their length.
For an adult we generally require
a strip of about four feet and eight
inches in length, namely, sixteen
inches for the central and widest
portion, and twenty inches for each
Foot-piece. cxtrcmitv. The shoulders of the
central portion are cut as repre-
sented, in order that when folded upon the foot-piece and upon itself
it may reinforce the lateral bands at their weakest jK>ints.
Fio. 192.
Fio. IM.
7
ExtonsioD-baDd and foot-piece.
The lateral or side-splints may l)e made of stout k»ather, cut and
moulded to the limb, or of thin pieces of board covered with cotton
Fi«. 194.
Same, folded and readj for uae.
cloth, and stuiTed on the sides next to the skin with cotton batting to
fit all the inequalities of the limb. The cotton cloth must be 8tit4.*hed
over the splints like a sac, but left open at the ends until the padding
FBACTUBES OF THE SHAFT OF THE FEMUR. 451
k properly adjusted. Loose cotton battine always becomes displaced.
Four splints are generally required : one tor the anterior surface, ex-
tending from the groin below the anterior spines of the pelvis to within
half an inch of the patella; one for the posterior surface, extending
from the tuberosity of the ischium to a point two inches below the
knee ; one for the inside, extending from near the perineum to the inner
condyle ; and one for the outside extending from above the trochanter
major to the outer condyle. These splints ought to encircle the limb
completely, only leaving an interval of from half an inch to one inch
between each of the adjacent splints. The outer and inner splints
may be extended below the knee when the fracture is low down ; but
in that case they must be carefully fitted to the irregularities of the
condyles. The posterior splint is the most important of them all. It
should be wider and longer than either of the other splints, and it
must be fitted with great accuracy to the back of the thigh, ham, and
upper part of the leg. It is important also to cover this with a sac of
cotton cloth so that it may be stitched to the centre of the bands,
which are to inclose all the splints. If this is not done, it is very
liable to become displaced.
A long side-splint must now be prepared, long enough to extend
from about four inches below the axilla to five inches below the heel ;
four and a half inches wide, by half an inch in thickness, and provided
with a cross-piece at the lower end, two feet long by three inches wide
and half an inch thick. The purpose of this splint is not to make ex-
tension or to serve as a side coaptation splint, but solely to prevent
eversion of the foot, which purpose is never aO/Complished effectively
by junks or by any other method I have yet seen adopted. It is to be
empIoye<l in all fractures of the thigh, including fractures of the neck.
The inner surface of this long splint must be padded through its
whole length, and thus fitted accurately to the sides of the IxkIv and
limb.
Four or six strips of cotton cloth, each two inches wide by one yard
in length, are now stitched by their centres to the outer surface of the
long l^ck-splint, and these are laid upon the bed in position for the
splint to receive the limb.
Supplied with rollers, several additional strips of bandage, and
cotton-batting, we are now ready to reduce and dress the fracture.
The }>atient being placed in position upon the bed, one assistant
seizes the limb by the knee, and a second by the foot, drawing upon it
firmly and steadily, while the surgeon lays the extremities of the ex-
tendon strips ujion each side of the leg, with the centre, containing the
foot-piece and the rope, about one inch below the sole of the foot.
With a muslin roller, inclosing the limb from near the metatarso-pha-
langeal articulation to the tuberosity of the tibia, the adhesive strips
are held in place. As a rule, and especially in the case of women, and
of persons of a delicate lax fibre, it is well to lay against the tcndo
Achillis^and over the instep, a little cotton batting before applying the
roller. In some cases I am in the habit of applying a thin sheet of
cotton wadding over the whole surface of the limb. Any excess of
the bands at the upper end are disposed of by turning them down, and
462
FRACTURES OF THE FEUUS.
iDoIo$;mfr them in a few additional tuma of the roller. As soon as the
applk'ation of the adhesive strips is completed the weight oiay be
adjiist«<I, and extension applied. The amount of extension required
for adults will vary from eighteen to twenty-three pouncb. In a large
proportion of cases twenty or twenty-one pouuds will be borne without
complaint; and the ability of the |)atient to tolerate the extension,
alone limits the amount. Occasionally, even a few pounds, when firet
applied, causes pain in the ligaments about the knee-joint ; but io k
few hours the amount may lie increased. It is l)etter to apply eighteen
or twenty {tounds at once, if it can l)e borne. Lifting the knee slightly
by a pad placed underneath, will often relieve the pain caused by th«
extension.
Sometimes, in the case of very mnscular patients, and whwe the
primary sliortening is considerable, I believe we make a (wisitive aod
pennanent gain if we place the mtient under the influence of cbliffo-
form for a few minutes, when the weight is first applied. In thne
cases, us in dislocations, I generally jirefi-r chloroform to ether, for the
reason that the patient is less liable to muscular contra<'tiua'4 when be
is pu.'ising under the influence of the aniesthetio.
Extt-nsiou being effected, and the (taticnt already resting nj»on the
pnsterior coaptation splint, the three other side-spliots arc applied, and
the whole secured in jilacc by the four or six transverse bands already
desoril>cd as attached to the posterior splint ; the bands being tied over
the front splint firmly.
It remains only to lay the long splint beside the body, and to Mcore
it in place by a few sc|Hirate strips of bandage.
From this time onward, the patient should be seen daily, and the
coaptation splints loosened or tightened from time to time, H8 vamj In
FBA.CTURES OF THE SHAFT OF THE FEMUR. 453
required. Ordinarily it is not necessary to distiiib the extension until
the union is completed. The ii»iual time retjuire<l fur consoliilution io
the caae of an adult is from six to eiglit weeks ; but if the bune fecla
pretty firm at the end of four Meeks, the extension may be a little re-
laxed. When at length the patient is permitted to leave his bed, a
pair of crutches are indisjwnsable; and duriiiffthe following two months
but little weight should l>e borne upon the limb.
Fractures of the thigh in children have generally been found more
difficult to manage thuii fractures of the same bone in the adult, owing
chiefly to the shortness of the limb, the deliwicy of the skin, and the
re^tlesi'nesa of the patient. I have tried nearly all forms of apparatus
io those canes, including double-itieliiied planes, boxes, single long
splints, etc., and the result of my experience is that they arc nil ineffi-
cient ; and for some years I have employed a Tnode of dressing, partly
my own and partly the suggestion of others, but of which 1 am able
to say that it never disappoints nie in the result obtained ; while it is
siinple, ea.sy of management, and comfortable to the little patients.
Extension by means of adhesive pla.-'ter and a weight eniploywl in
the same manner as in adults, constitutes a valuable aid in most cases;
but I cannot say that it is indUpensable, since, with children under
five or seven years, the fractures are pretty often so nearly transverse
that, when once reduced and well supporter! by lateral spHuti, union
without shortening may generally be expecte<l ; but these results l)ecome
lee and less frequent as we advance toward adult lile. It is safe and
proper, according to my ex{)crien<«, to employ in auy case extension,
somewhat according to the following rule. One {xiund for a child one
year old, two for a child two years old, and so on, adding one pound
for every year up to the twentieth. Of much more consequence, how-
e\-er, is it to confine, at the same time, both iJnilw, for as long as one is
It liberty it is almost imixissible to secure any degree of <]iiict. It is
of equal imponance, in my opinion, to give to the limbs an extended
rather than a flexed position.
My plan of treatment, therefore, in the case of children, is in alt
casential respects the same as in adults, except that instead of one long
■ide-splint, I employ two. The accompanying illustrations will ex-
I>lain more fully my meaning. Two long side-splints connected by a
owB-piece at the lower ends, and reaching upwards to near tiie axilloe,
Mptnlted a little more widely below than above, so as to render the
454
FBACTUKES OP THE FEMUH.
Crincum more accessible, are laid upon each side of the body. The
f of the broken limb is secured to the long splint with a roller. Tbe
remainder of the limb, the opposite limb, and the body, are made fart
with broad and separate strips of cloth. The coaptation splints, in tbe
case of children, may be made of binder's board.
Thus secured and laid upon a bed, such an I have already described
as appropriate for children, the least possible annoyance will be given
to the Bui^on. Tiie dressings are but little liable to become wet with
urine, and when the Ix-d is soiled, the child can be taken up with the
splint and carried to another ; indeed, this may be done aa often as the
patient becomes restless or weary, without any risk of disturbing the
fracture.
Fia. 197. Flo. isa.
In case the surgeon desires to use extension with adhesive plaster
and weights, the necessary apparatus may be made fast to the bed-
steud, and taken off when the child is moved; or it may, if thought
bcNt, lie made fast to the foot-piece of the splint.
<)ccnsioiially, with children, I employ, as a means of extra mfety, ft
perineal band, drawn moderately tight, and &st«Ded to tbe t4^ of tlw
FRACTURES OF THE CONDYLES. 455
splint on the side corresponding to the broken limb. The best peri-
i^eal Imnd is a piece of soft cotton cloth, one or two yards long, by
three inches wide, folded lengthwise, to a flat band of one inch in
breadth, and inclosing, where it passes through the perineum and
ander the nates, a few thicknesses of ])aper. The paper prevents its
drawing into a round cord. Sometimes I place between the paper
and the folded cloth, on the side which is to be laid next to the skin,
one or two thicknesses of cotton wadding. To absorb the moisture,
it is well to lay a piece of sheet lint between the band and the skin.
The perineal band may be removed daily and renewed ; and the peri-
neum examined and washed.
Four or five weeks is generally a sufficient length of time for per-
fect consolidation, in children under five years of age.
The treatment of compound fractures of the thigh, caused by gun-
shot injuries, will be considered in the chapter devoted to gunshot
fractures. Other badly comminuted and compound fractures of this
bone are to be managed upon the same general principles as gunshot
iraetures.
Those compound fractures of the femur which have been caused
by the thrusting of the sharp fragments through the flesh, and in
which reduction has been easily eflected, have in most cases done as
well as simple fractures, except that the limb is generally a little more
shortened. The wound usually soon heals, and the future progress of
the case is the same as that of a simple fracture. They may be treated,
therefore, in the same manner as those which have just been described.
2 5. Fractures of the Condyles,
.(a.) Fractures of the External Condyle.
Dr. Alph B. Crosby,* of New Hampshire, has published an account
of a case of simple fracture of the external condyle, in a young man
twenty-one years of age, and which happened from a sudden twist of
the limb, while he was undressing himself to
bathe. He was "standing on a shelving bank, _ ^^^'- ^^•
with the right leg flexed over the left in order to
remove his pantaloons; he lost his balance, par-
tially twisted the leg, and fell to the ground."
Six months after, the fragment was removed by
I>r. Crosby, through an incision below the con-
dyle. The recovery of the young man has been
Gomplefe.
The accompanying drawing represents the
specimen as seen from its lower or cartilaginous
biir&ce, and of its actual size.
John O'Neill, set. 40, fell down stairs in Dec.
1873. bending h« left leg under his body and .ruroyZt^J
fracturing the external condyle. About three condyle.
mooths later the patient was brought under my
notice by Dr. Stanley. The patient was able to walk with a slight
^ Crosby, New Hampshire Journ. of Med , 1857.
456
FB4CTURE8 OP THE PBMUB.
halt; the fragment, apparenlly about one inch in diameter, inoyiDg
upwards about half an inch when the leg is flexed, with a dietiuct mud
painful crepitus. When at rest, the fr^ment formed a marked pro-
jection. It is not certain whether the line of fracture entered Uw
joint.
I examined the limb several times during the succeeding two j'ean,
and found the coudition of matters uochanged, except that the useful-
ness of the limb has steadily improved. Bandages and kuee-supports
have served no useful purpose, and have been laid aside.
Dr. T. S. Kirkbridc has also reported an example of simple fracture
of this condyle, which was produced by the kick of a horse, the blow
having been received upon the inside of the knee. When this patient
entered the Pennsylvania Hospital, Dec. 183-1, the knee was much
swollen, and crepitus was plainly felt, but the fragment was not dis-
placed ; the muscles upon the outer aide, however, were so strongly
contracted as to abduct the leg, and produce considerable angular
deformity. The limb could be easily made
straight, biit it returned to its former positiim
of abduction as soon as it was released. When
fully extended, slight bending of the Joint did
not give severe pain ; but when in any degree
flexed, all motion was very painful.
The limb was placed in a long straight frno
ture-box, and cold applications were made;
great swelling followed. It was kept extended
in this manner, or in the long splint of De-
saulf, twenty-eight days; at which time union
sceme<l to have taken place, but the motions at
the joint were very limited, and productive of
creat pain. From this period tlie limb was
laid in a splint, so construct(.-d as that ibe angle
of the knee could be changed daily. At ine
end of about six weeks he began to walk on
crutches, and he could then flex the 1^ (o t
right' angle.'
Sir Asiley Cooper has related a case of com-
dyif- imiind fracture of the samc<'ondyle, produced by
falling from a curlistone ujion jihe knees. The
man die<l on the twenty-fourth day. On examination after death, the
external condyle wns found to be broken ofl", diid also a vonsidereble
fragment was dctache<l from the shaft higher up.'
(b.) Fractures of the Internal Condyle.
Dr. Thomas Wells, of Columbia, S. C, has reportetl an example of
fracture of the internal condyle, nrcom|ianie<l with a dislocation of the
head of the tibia outwards and backwards. The man was about forty
years iild, and intemperate. Dr. Wells was not called until two days
i., MHy, t8S.^, vol z*i, p. S3
FBACTUBES OF THE CONDYLES. 457
•fter the injury was received, when he found the limb greatly swollen
and gangrenous. The man's account of himself was that while walk-
ing in the back yard he fell, and thus dislocated his knee, and that he
was then brought into the house, being unable to stand upon his feet.
It does not appear that any attempt was made to reduce the limb,
probably because his general condition indicated that speedy death was
inevitable. On the fourth day he died. The autopsy disclosed, in
addition to the dislocation of the tibia, that a thick scale of bone was
broken from the inner part of the inner condyle, but it remained at-
tached to the ligaments.^
A case reported to me by Dr. Lewis Riggs, a very intelligent sur-
geooy practicing in Homer, Oneida Co., N. Y., was more successful.
A lad, jet. 15, was kicked by a horse, the blow being received upon
the right knee. Dr. Riggs saw him within three hours after the acci-
dent, and found the internal condyle of the right femur broken off,
carrying away more than half the articulating surface of the joint ;
the tibia and fibula were at the same time dislocated inwards and up-
wards, carrying with them the broken condyle and the patella. The
displacement upwards was about two inches, and the sharp |X)int of
the inner fragment had nearly penetrated the skin. There was no
external wound. The knee presented a very extraordinary appearance,
and the lad was suffering greatly. Being at a distance from town, and
the Doctor having no chloroform or pulleys with him, he was obliged
to depend solely upon the aid of five men who were present. The
first attempt at reduction was unsuccessful ; but in the second attempt,
when the men were nearly exhausted in their efforts at extension and
counter-extension, and while the Doctor was pressing forcibly with both
hands upon the two condyles, the bones suddenly came into position,
except that the breadth of the knee seemed to be slightly greater than
the other, a circumstance which was probably due to the irregularities
of the broken surfaces, which prevented perfect coaptation.
Neither splints nor bandages were required to maintain the bones in
place ; but anticipating the probable occurrence of anchylosis, and with
a view to making " the limb as useful as possible in this condition," he
was placed upon "a double-inclined plane," which being supplied with
lateral supports, would also prevent any deflection in either direction,
in case the limb was disposed to such displacement.
The subsequent treatment consisted in the use of cold water dress-
ings. Very little inflammation followed. A portion of the integu-
ment sloughed, but the bone was not exposed, and it healed rapidly.
On the twenty-fourth day Dr. Riggs gave to the joint passive motion,
and this was repeated at intervals until, at the end of three months,
he was able to walk with a cane. At the end of a year Dr. Riggs
examined the leg, and found the knee a very little larger than the
other, and he could not flex it quite as completely. In all other re-
spects it was perfect, and the boy himself declared it was as good as the
other.
Treatment of Fractures of eiihei* Condyle, — The few cases of these
> Wells, Amer. Journ. Mod. Sci., May, 1832, vol. x, p. 25.
80
458 FRACTURES OF THE FEMUR.
accidents which I have seen reported have been, with one or two ex-
ceptions, treated in the straight position. In Kirkbride^s case any
degree of flexion was painful, although there was little or no displace-
ment of the fragment ; and we think we can see, in the relative posi-
tion of the articular surfaces of the tibia and femur, a sufficient reason
why the straight or nearly straight position must generally be pre-
ferred. Whichever condyle is broken, the remaining condyle will be
sufficient to prevent a dislocation and consequent shortening of the
limb, unless, indeed, the dislocation has already occurred as an imme-
diate consequence of the injury. It is very certain that it would not
take place from the action of the muscles when the limb was straight
In the flexed position I can (conceive that it might take place, but yet
not easily. It is not a dislocation of the limb, then, that we seek
chiefly to avoid, but a deflection of the leg to the right or to the left,
according as one or the other of the condyles has been broken. It
will be readily seen that, in order to resist this tendency, uothinc but
the straight position will answer, and that for this purpose it will be
necessary to lay a long splint upon one or both sides of the limb, and
to secure the whole length of both thigh and leg to this splint. The
long fracture-box used by Kirkbride, if well cushioned on all sideSi
seems to me at once to answer most completely this important indica-
tion, rendering it even unnecessary to employ a bandage, since the
opposite sides of the box will compel the limb to adopt the proper
position.
As to the remainder of the treatment, it must consist essentially io
the active employment of such means as are calculated to prevent and
allay inflammation ; especially ought the surgeon not to omit to a%*ail
himself of so valuable an antiphlogistic agent as cool water lotions.
As soon as the union is consummated the joint surfaces should be
submitted to passive motion, in order to prevent anchylosis ; and it
would be better to commence this so early as to hazard somewtiat m
displacement of the fragment, rather than to wait too long. It may
not, in some cases, be improper as early as the fourteenth day, and in
nearly all cases it should be practiced as early as the twenty-eighth.
(c.) FraHures between the Condyles and act'oss the Ba$e,
Etiology. — A fracture of this character may be produced by a blow
received upon the side of the limb or upon the lower extremity of the
femur; sometimes the blow has l>een received directly upon the patella
when the knee was bent, and Bichat mentions a case in which it was
produced by a fall upon the feet.
Symptoms, — This fracture is easily distinguished from the preceding
by the much greater mobility of the fragments and by the tmlpable
shortening of the limb, since an overlapping of the broken end is here
almost inevitable. Each fragment mav be felt to move scparatelvi
and the motion will be accompanied with crepitus.
Prognosis. — The danger of violent inflammation in the joint is im-
minent, and anchylosis of the knee is to be anticipated as the most
favorable result, since the joint surfaces are likely to be rendered im-
FRACTURES OF THE CONDYLES. 459
movable by fibrinous deposits in their immediate vicinity, and also by
tbe adhesion of the muscles to one another and to the bone higher up,
where the fracture of the shaft has occurred. More fortunate results
than these may, indeed, be hoped for, inasmuch as they have occasion-
ally been noticed, but they caimot fairly be expected.
Iq a majority of cases such accidents have demanded, either imme-
diately or at a later period, amputation. If recovery takes place, a
shortening of the thigh is inevitable. Mr. Canton, of London, has
twice performed successfully resection of the joint end of the bone in
such accidents.^
Treatment. — Malgaigne saw a patient who had been treated by
Guerbois with the aid of extension and counter-extension, who was
confined to his bed five months, and who had at the end of eight years
very little motion in the joint, and he seems disposed to charge in some
measure these unfortunate consequences to the position in which the
limb wus placed, namely, the straight position. But, in my opinion,
it 18 much more reasonable to suppose that, if the treatment was at all
responsible for the results, the error consisted in too long and unneces-
sary confinement, and in too much extension. I suspect that the mere
matter of position had nothing to do with the anchylosis. Malgaigne
does not, however, himself recommend anything more than a very
slight amount of flexion at the knee ; and to this practice I am pre-
pared to give my assent; since it will give to the limb a useful posi-
tion in case anchylosis does occur, and it is not inconsistent with the
employment of the moderate amount of extension which alone is justi-
fiable after this accident. If the young surgeon should differ with me
in opinion as to the necessity or propriety of using great force to retain
the fragments in place and prevent overlapping, I beg him to consider
that this fracture probably never hapi>ens except from the application
of an extraordinary force, and that consequently intense inflammation
and swelling are almost certain to ensue; and that in some cases, the
very feet that immediately after the accident, or for some hours suc-
ceeding, no swelling occurs, or muscular contraction, and that replace-
ment of the fragments is easily accomplished, is evidence only of the
great severity of the injury, and that the whole system is lying under
the shock ; to which, if the patient does not succumb, sooner or later
reaction will ensue, and the fragments will be gradually drawn up
with a resistless power. The surgeon ought to remember also that to
make extension in this case, he is obliged to pull upon those very liga-
ments and tendons about the joint which, having been torn or bruised,
must soon become exquisitely sensitive.
The long straight box, already recommended when speaking of
fracture of one condyle, is equally applicable here; only that it needs
a foot-board, or some sort of foot-piece to which an extending appa-
ratus may be secured, and that a pillow should be placed under the
knee to give the limb the proper flexion.
Case. — A man was admitted into St. Thomas's Hospital, Ijondon,
Sept. 17, 1816, with a fracture between the condyles, accompanied also
" Lancet, Aug. 2S, 1868. Trans. London Path. Soc, 1860.
460 FRACTURES OP THE FEMUR.
wiOi a fracture through the shaft higher up, occasioned by being caught
in the wheels of a carriage while in motion. There was a small wound
opposite the jxiiut of fracture, and the external condyle was displaced
outwards.
The limb waa laid in a fracture-box, and in a position of semU
flexion.
Ou the 18th of November, the external condyle, having protruded
through the skin, and being dead, was removed with the forc«pfl^
bringing with it a portion of the articular surface.
Ou the 6th of December he was dischai^red from the hospital, and
in February following he was walking without ajiy support, and with
the free use of the joint.'
Cb«e. — A gentleman living about eighty miles from town was thrown
trom his carriage, breaking tlie left femur just above the condyles into
many fragments, so that when I saw him on the following day the at>
tending physician showed me about four or five inches of the entire
thickness of the shaft which he had removed. The exterual condyla
was completely separated from the internal, and was <juite
In this ease the attempt to suve the limb resulted in the loes of the
patient's life on the tiixth or seventh day.
(d.) Sejjaraiion of the Lotee^- Epiphysis,
M. Coural relates the case of a boy 1 1 years old, who, while hia leg
was buried in a hole up to his knee, fell forwards, separating the lower
epiphysis from the shaft, and at the same time driving the shaft behind
the condyles into the jwplitcat space. The epiphysis also became tilted
in such a manner that its lower extremity was directed forwards. Th«
limb was amputated,
Madame Lachapelle mentions a case in which traction at the foot of
a child in the act of birth tensed at the same time a .separation nf tha
lower epiphysis of the femur and the upper epiphysis of tlie tibia. The
child was born dead.^
Dr. Little presented to the New York Pathologictil Society, May 24,
1865, a specimen obtained from hia own practice. A boy, lei. 11,
while hanging on to the back of a wagon, had his right k^ caught
between the spokes of the wheel while it was in rapid motion. A ft*
hours after the accident, Dr. Little found the upper fmguiont of tlx
femur projecting through an opening in the up[)er and outer jturt uf ih«
popliteal space. Ou examination, the wound did not ap|>ear tn com-
municate with the knee-joint. Under the influence of an antblbetif
the fragments were reduced ; the reduction occasioning a dull eartil-
Bgtnous crepitus. There was at the time no pulsation in the postcriM'
tioial artery, and the limb was cold. The limb was laid over a dootile
inclined plane. The following day the upper fragment was again ^
Sinccd, and it was found that it could only ite kept in place by exlniW
exion of the leg. This position was therefore adoptctl and nuin*
■ Sir A. Coo|ier on DUIoc., etc., op. ciu, p. 380.
* llalgNtgno, op. cit., t. i, p, 6B,
PBACTUBE8 OF THE PATELLA. 461
teined ; considerable traumatic fever followed, with swelling, and on
the thirteenth day a secondary hsemorrhage occurred from the anterior
tibial artery near its origin, and it became necessary to amputate. The
boy made a good recovery. The specimen showed that the line of
separation had not followed the cartilage throughout, but had at one
point traversed the bony structure.
Dr. Voss at the same meeting remarked that he had met with the
same accident. There was no protrusion of bone, but an abscess
formed, and it became necessary to amputate.
Dr, Buck saw a case which occurred in the practice of Dr. Hugh
Walsh, of Fordham. The subject was a boy 14 years old, and it hap-
pened in the same manner as with Dr. Little' s patient.^ I know of
DO other cases of this accident.
CHAPTER XXIX.
FRACTURES OF THE PATELLA.
Cau^s, — Of forty fractures of the patella which have been recorded
by me, thirty-five were the result of direct blows or of falls upon the
knee. In tne remaining five examples the fracture was due solely to
muscular action; one, a sailor, aged about thirty years, had caught the
heel of his boot in a knot-hole in the floor, which threw him back-
wards, and in the effort to sustain himself the patella was broken trans-
versely. Dr. Kirkbride has reported a case in which both patellae
were broken in a similar manner, but at different periods. The patient
was a girl, set. 29, who was admitted into the Pennsylvania Hospital,
Oct 16, 1833. "In falling backwards, and making an effort to save
herself," the right patella had been fractured. She was dismissed cured
on the 2d of December, and on the 20th of April following she was
readmitted, with a fracture of the left patella, produced in the same
manner as before; but in her effort to save iha right limb, the left re-
ceived all the strain, and the patella gave way.^ Dr. Kirkbride records
another instance of fracture from muscular exertion in a man set. 32,
who attempted to jump into a cart, by raising his body with his hands
resting upon the bottom of the vehicle;^ and Dr. Hay ward, of Boston,
8tw a case in the Massachusetts General Hospital, in a man set. 67,
which occurred in consequence of a false step in descending a flight of
stairs.'
Paikology. — All the fractures produced by muscular action have
been found to be transverse, and the same is true generally of fractures
prodaced by direct blows ; occasionally, however, we meet with lon-
> Little, VoM, Buck, N. Y. Journ. Med., Nov. 1865.
' Kirkbride, Amer. Journ. Med. Sci., Aug. 1835, vol. xvi, p. 330.
• Havward, Amer. Journ. Med. Sci., vol. xxx, from New Eng. Quart. Journ.,
July, 1M2.
PBACTUEE8 OF THE PATELLA.
gitiidinal fractures, or with fractures more or less oblique and com*
minuted. Thirty-two of the fractures seen by me were simple and
transveTse, three were simple and oblique, three were comminuted, and
two were compound. Dupuytren, A. Cooper, and others, have also
mentioned cases of longitudinal fracture.
I have seen a double transverse fracture, or a fracture of both
Entellee, in a man set. 22, who fell from a third-story window, striking,
e says, upon his knees. He was taken to the Hospital of the Sirtere
of Charity, in Buffalo, and, afler a few weeks, made an exoeileat
recovery.
Symptomg. — The symptoms which characterize a transverse fracturv
of the patella are sufficiently diagnostic. The fragments are »eparat«>l
from each other, the superior fragmral
*■'"■ ***■ being dntwu upwards more or less, ac-
cording to the power and activitv of the
muscles or the degree to which t)ie liga-
mentous coverings and attachments of the
jiatclla have been torn. Seldom, however,
is the interval of separation greater than
half nil inch. But in a few cases the violent
flexion of the knee has been known to draw
the up|)cr fragment quite three inchca from
the lower. \\y passing the finger along the
anterior sorface of the limb with a mode-
rate degree of firmness, the deproMion be-
tween tlie fragments will be made nuwiftst.
No crepitus can be expected unless tike fragments remain in contact,
FrM'X'inU H-paiiUd bjr fl»»lon of
FRACTURES OF THE PATELLA.
463
a condition which is unusual. The patient is unable to stand, and
especially is the power of extending the leg upon the thigh completely
lost. Usually a goo<l deal of swelling immediately succeeds the acci-
dent, and after a time the skin becomes more or less discolored from
effusions of blood. If the fracture is longitudinal or oblique, a slight
separation is usually present, but not always very easily detected.
PrognoBis. — One of my patients, who had a comminuted fracture,
with other serious injuries, died, but not as a consequence of the frac-
ture. In the following case the fragments appear never to have united,
although the patient recovered :
John Sharkie, set. 24, a soldier in the British service, while serving
in the East Indies, was struck on the right knee while he was in a
sitting posture, with his leg bent under him.
He was immediately placed under the charge of the surgeon of the
89th regiment of infantry. During the first eleven days no splints or
bandages were applied, on account of the severe inflammation and
swelling. A compress was then placed over both fragments, and they
were bound together by rollers, etc. The whole limb was suspended
on an inclined plane, the foot being made fast to a foot-board. This
treatment was continued four months. When the bandages were re-
moved, the limb was badly swollen, and immediately the upper frag-
ment was drawn up toward the body. Eighteen mouths elapsed before
he could walk, even with the aid of a cane.
March 27, 1855, twenty-nine years after the injury was received, he
was an inmate of the Buffalo Hospital, and I was permitted to examine
his knee carefully.
The lower fragment is not displaced, but when the leg is straight
upon the thigh the upper fragment lies two and a half inches from the
lower, and when it is flexed upon the
thieh the upper fragment is removed five
iDches from the lower.
There is no ligament or other bond of
nnioDy so far as I can discover. He walks
with very little or uo halt, but he cannot
walk fast.
At my Bellevue Hospital clinic, Jan-
nary 8y 1866, I presented a man, set. 38,
who had fractut^ his left patella trans-
versely four years before. The fragments
liad anitedy when he ruptured the liga-
ment again by a fall. I found a separa-
tion of three and a half inches, and the
patient unable to walk except with the
aid of a leather splint.
In the case of a man, set. 40, the liga-
mentous union, at first complete, seems to have subsequently given
way in part. He called upon me for advice nine weeks after the frac-
ture had occurred. The patella was surrounded with bony callus, so
that it was considerably wider than the other. The fragments appeared
to be united by a short ligament, except on the inner side, where there
Fig. 205.
464 FRACTURES OP THE PATELLA.
was a separation or rupture of the ligament to the extent of one-quarter
of an inch. The patient explained this by saying that the splint was
removed at the end of four weeks, and that after a week more he tx^ao
to walk, but that he almost immediately felt it tear or give way on the
inner side.
During the autumn of 1865 I examined the leg of Dr. B., a graduate
of Bellevue Medical College, and found a transverse fracture of the
right patella with great displacement of the upper fragment. He in-
formed me that he had fallen six years before, when nineteen years old,
upon a stone, striking upon the patella. The fracture was recognized,
and the limb was laid upon a straight splint At the end of three
months the limb was removed from the splint, and the union was
found to be complete, with a separation of the fragments to the extent
of half or three-quarters of an inch. The knee was much anehylosed.
Soon after this the upper fragment began to draw up, and at the end
of a year was as much displaced as it is now. At this moment it is
displaced three inches, and seems to be held to the lower fragment
only by a narrow ligament attached to their inner margins. He ex-
tends and flexes the leg perfectly, and walks without the least halt,
but this limb wearies sooner than the other.
February 16, 1866, John Donahue, set. 50, was admitted into my
wards at Bellevue, with a refracture of the right patella. He stated
that it was first broken eight weeks before, and that it had united, but
that the day before his admission, while seated on the ground, he at-
tempted to rise, and that the ligament suddenly gave way. I found
the fragments separated one inch, and by pressing the up|>er fragment
against the lower a slight crepitus was occasioned. His limb was
placed upon a single-inclined plane, and union soon occurred.
Without treating at length of other similar cases, I will state that I
have met with four more examples of refracture of the patolla ; in
three of which the separation was from three to four inches, and in
one two inches. In neither of these cases had anything been accom-
plished by the various modes of treatment employed to effect a reunion.
Mr. Adams has shown, according to Druitt, that in these cases of wide
separation there is no union at all by ligament, but that the fragments
are merely held together by the subcutaneous fascia, somewliat thick-
ened.
Dr. Kirkbride has reported a case of ligamentous union of the pa-
tella, in which the ligament was two and a half inches long, and was
attached only to the inner margins of the fracture. " He was able to
walk as nipidly as ever, and witliout perceptible limping."* A similar
case is reported by Dr. Watson, of New York, in which the fragments
became separated three and a half inclu^.^ In both instances the frag-
ments were supj>osed to have united by a short ligament, which had
become lengthened by premature use of the limb ; in the case reported
by Kirkbride, the ligament seemed to have partly torn, as in the case
rejwrted by myself Dr. Coale presented to the Boston Society for
* Kirkbride, Amer. Journ. of Mod. Science!*, vol. xvi, p. 82
' WiftUon, N. Y. Journ. of Med. and Surgery, vol. iii, flrtt series, p, 366.
FRACTURES OP THE PATELLA. 465
Medical Improvement, at its April meeting in 1856, a specimen of a
fractured patella taken from a man sixty-five years old, the fracture
having occurred ten years before. The fragments were at first so
cloeely united that no division between them could be discovered, but
sabsequently they became separated at their outer edges one inch, and
at their inner edges one-eighth of an inch.^
In every instance in which a fracture of the patella has been treated
by myself, union has taken place at periods varying from twenty-four
to fifty-eight days, the average being about thirty-eight days. Twenty-
five cases have united by ligaments, varying in length from one-quarter
to one-half an inch. These measurements, made upon the living sub-
ject, may not be mathematically accurate, but they cannot be far from
the truth. In no case has the function of the limb been in any degree
impaired by this ligamentous union ; from which it must be inferred
that a short ligamentous union is as useful as a bony union. Practi-
cally speaking, my results have been perfect.
Twice, I believe, I have seen a bony union of the patella. The first
instance is that to which I have already referred as an oblique or lon-
gitudinal fracture across one corner of the patella ; and in the other
example the action of the muscles upon the upper fragment was pre-
vented by the occurrence of a fracture of the shaft of the femur at the
same time, which permitted the thigh to shorten upon itself. The
man was about twenty-five years old, and in a fall from a scaffold had
broken his left femur, and also the patella. The patella was broken
transversely near its middle, and also longitudinally near its inner
margin. The fragments w^re all distinctly made out. Drs. Lewis and
Dayton, of Buffalo, were in attendance, and on the fifth day I was
called in consultation. We dressed the limb with a long straight
splint, employing moderate extension and counter-extension. The
patella was covered with strips of adhesive plaster. On the fifty-
eighth day I found the fragments of the patella united. June 3, 1854,
five months after the accident, I examined the limb carefully. The
femur was shortened half an inch, and, although the two main frag-
ments of the patella were separated half an inch, the bond of union
seemed to be bone. It was hard, and allowed of no motion in the
upper fragment separate from the lower. The lateral fragment was
also apparently united by bone and in place. He had but little motion
in the knee-joint, yet he walked very well, and was able to pursue his
trade, as a carpenter, without much inconvenience.
Sir Astley Cooper succeeded in obtaining a bony union in some lon-
gitudinal fractures, but in a majority of cases it failed, owing to the
want of apposition in the fragments. It might seem that it would be
easy to accomplish apposition in all longitudinal fractures, but expe-
rience has shown that it is not always, the fragments being kept
asunder partly by the action of the oblique fibres of the vasti and
partly by the pressure of the condyles of the femur, especially when
the leg is slightly flexed.
Whether the fracture is transverse or longitudinal, a bony union
^ Coale, Boston Med. and Surg. Journal, vol. liv, p. 402.
may occasionally be obtaioetl when thi' fragments are retained in abso-
lute contact for a sufticient length of lime ; but the failure tu procure A
bony union is not a matter of consequence, since a short liganient '
equally useful.
Post, of New York, has reported three cases of compound fracture
of the patella extending into the knee-joint, brought to a successful
termination.' I have myself met with one or more similar results.
In a case mentioned by Eve, of Augusta, occasioned bv the kick of
a horse, and in which amputation became necessary on the tenth day,
" the knee-^joint was found filled with dark gruroous blood ; a porttua
of the cartil^e of the internal condyle of the ns feraoris was chipped
off", and the patella broken into a number of fragments.'"
Lewitt, of Michigan, has related a case of fracture in a lad a;t. 16,
produced by striking his knee against a piece of timber, which resulted
lu suppuration of the knee-ioint, but from which he finally recovered
with the pei-fect use of the limb. The fracture of the patella was ob-
lique, traversing only its upper and outer margin, and it was ncv
much displaced.'
Dr. Levergood, of Pennsylvania, has reported a similar case, in which
it became necessary tfl open the joint freely, yet it was followed by
excellent recovery, only a slight anchyloais remaining at the knee-joint.*
Treahnmi. — The dressing which I have generally eninloywl in tbt
treatment of this fracture i^nsists of a single-inclined plane, of
cient length to support the thigh and leg, and about six inches wider
than the limb at the knee. This plane rises from a horizoulal floof <*'
the same length and breadth, and is supported at its distal enJ lij ""
upright piece of board, which serves both to lift the plane and to »"?'
port and steady the foot. The distal end of the inclined plane nufW
I PoBl, N..W York J-urn. of Med,, vol. ii, flnliwi
> Kve, Southern Mod. and Surg, Journ., IBIS;
xxxyW.p.vn.
' Lnwitt, U«)ic>l Indc!pondont. Scpl. I8S6.
* Leverguod, Aoiar. Jour. Hed. Sei., Jan, 1800.
FBACTUBG8 OF THE PATELLA. 467
elevated from six to twelve inches, according to the length of the limb
and other circamstances. Upon either side, about four inches below
tbe knee, is cut a deep uotcli. The footpiece stands at rif^ht angles
with the iDclioed plane, and not at right angles with the horizontal
floor.
Having covered the apparatus with a thick and soft cushion carefully
adapted to all tbe irregularities of the thigh and leg, especial care being
taken to fill completely the space under the knee, the whole limb is
DOW laid upon it, and the foot gently secured to the footboard, between
whicb and tbe foot another cusbion is placed.
The body of the patient should also be flexed upon the thigh, so as
the more effectually to relax the quadriceps femoris muscle.
A roller is now applied to the knee by oblique and circular turns;
commencing above the patella, and traversing the notch in the splint;
each successive turn covering more of the front of the knee until the
whole is inclosed. With a second roller the entire limb must then be
serofed to the splint, this roller extending from the ankle to the groin.
The great advantage which this mode of dressing possesses is, that it
does not ligate the leg or thigh completely ; since, on either side, between
the broad margins of the splint and the points where the bandages
touch the limb, there is a space, more or lesu considerable, against whicb
no pressure is made, and through which the circulation may go on
without impediment; so that, however Urmly the bands are drawn
■cross tbe knee, no swelling occurs in the foot.
The plan adopted by M. Gama, of Val de Grac-e,' is similar to that
which I have now described, but the splint uiwn which the limb re-
poses is not so wide, while width is an essential point in the attaiument
aS the objects which I propose.
The dressing and apparatus employed by Wood, of King's College
Hospital, are very similar to my own, but, as will be seen by the ac-
companying drawing, the splint is only tive or six inches wide. Dr.
Wood has substituted hooks for the notches.'
Dr. Dorsey, of Philadelphia, employed a very simple apparatus
which will serve to illustrate the general plan adopted by many sur-
gWDS, both at home and abroad. It is liable, however, to the objec-
468
FRACTURES OP THE PATELLA.
tion already stated, namely, that it interrupts too much the circulation
of the limb. His apparatus consists of a piece of wood half an inch
thick and two or three inches wide, and long enough to extend from
the buttock to the heel ; near the middle of this splint, and six indiee
apart, two bands of strong doubled muslin, a yard long, are nailed*
Fig. 208.
John Syng Donej's patella splint.
The splint is then cushioned, and the limb laid upon it, a roller being
first applied from the ankle to the groin, encompassing the knee in the
form of the figure of 8 ; after which the two muslin i:Mind8 are secured
across the knee in such a manner as that the lower one shall draw down
the upper fragment, and the upper one elevate the lower fragment.
A single instance will explain the danger of ligation to which I
have allude<l, and which, although it may be greater in case a starch,
plaster of Paris, or dextrin bandage is used, exists in some degree,
whatever material for bandaging is employed, if it is applied to the
whole circumference of the limb, and constant attention is not paid to
the progress of the swelling.
" A vine-dresser, jet. 40, of a good constitution, fell and received a
simple transverse fracture of the patella on the 15th of January. The
medical officer called upon to attend him applied first a bandage for
the purpose of drawing together the fragments, and afterwards a
starched bandage extending from the toes to the upper part of the
thigh ; the limb was then put upon an inclined plane. The patient
Fio. 209.
Sir A. Cooper's method by circular tapes.
was visited a few times, but, as he scarcely suffered, the apparatus ^^
in no way disturbed. On the first of March (sixteenth ciay) the at-
tendant returned to remove the bandage, when the odor arising from
PBACTURE8 OP THE PATELLA.
469
Uie limb led him to believe that gangrene had taken place, and Dr.
Defer was sent for. Dr. Defer found the limb in the following state :
The toes, which were not covered by the bandage, were completely
insensible and mummified. The bandage being removed, the gangrene
was perceived to extend within seven inches of the knee, and was
arrested in its progress. The foot was cold, and was totally insensible ;
the epidermis was raised up, and was beginning to be separated from
the skin. The articulation of the ankle was exposed, and the liga-
ments destroyed. The bones of the leg were also exposed in their
lower third, and the tendons were in a sloughy state. Amputation
was performed, and the patient recovered."^
Very little better than the starch bandage, and exposing the patient
in a still greater degree to the dangers of ligation and strangulation,
are either of the methods recommended by Sir Astley Cooper.
Fig. 210.
Sir A. Cooper's method by a leather counter-strap.
Mr. Lonsdale's instrument is ingenious, but complicated. It is also
liable to the serious objection that it forbids almost entirely the use of
Fio. 211.
I'Ovtadale's apparatus for fractured patella.— A B. Two Tertical iron bars, each supporting a hori-
zontal one; these horiaontal arms slide upon the vertical bars, but can be secured at any point bf
**« •crews C D. To the horizontal beams are attached other verticul rods, which are movable, and
^H fixable bj screws, as at E. Finally, to each of these last upright pieces is fixed an iron plate, F F,
^ Beans of a hinge-jolut, which keeps the patella In place. The fuot-plece is movable up and down
|'|N>n the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to
'**ib8 of different lengths.
^ndages, which, while they are capable of doing great mischief when
^ey bind the limb too closely, are capable also of proving eminently
* Amer. Journ. Med. Sci., vol. xxiv, p. 462, from Gazette Medicate, No. 28.
i
• t •»
•. .; •
N . I. ..
I .
• • ». t
■ I ' . . (
i: ;..r: ••: r. .
t. ...
r :' ■ ■ '• .' ' ■ ■•
, ., . M. i :>• J " .'■' .!■ r ■. . .f .11, IsT'i
%•. M'«v l-'> '^' • ii\ il'" .1" .rri. M«'«l.. p'. •
PBACTURE8 OP THE PATELLA.
469
the limb led him to believe that gangrene had taken place, and Dr.
Defer was sent for. Dr. Defer found the limb in the following state:
The toes, which were not covered by the bandage, were completely
insensible and mummified. The bandage being removed, the gangrene
was perceived to extend within seven inches of the knee, and was
arrested in its progress. The foot was cold, and was totally insensible ;
the epidermis was raised up, and was beginning to be separated from
the skin. The articulation of the ankle was exposed, and the liga-
ments destroyed. The bones of the leg were also exposed in their
k)wer third, and the tendons were in a sloughy state. Amputation
was performed, and the patient recovered."*
Very little better than the starch bandage, and exposing the patient
in a still greater degree to the dangers of ligation and strangulation,
are either of the methods recommended by Sir Astley Cooper.
FlO. 210.
Sir A. Cooper's method by a leather counter-strap.
Mr. Lonsdale's instrument is ingenious, but complicated. It is also
liable to the serious objection that it forbids almost entirely the use of
Fio. 211.
Lonsdale's apparatus for fractured patella.— A B. Two vertical iron bars, each supporting a hori-
sotttalone; these boriaontal arms slide upon the vertical bars, but can be secured at any point by
thcicrevsC t). To the horisontal beams are attached other vertical rods, which arc movable, and
Jtt fixable by screws, as at E. Finally, to each of these last upright pieces is fixed au iron plate, F F,
bj means of a hlnge-joiut, which keeps the patella In place. The foot-piece is movable up and down
■pon the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to
limbs of different lengths.
bandages, which, while they are capable of doing great mischief when
they bind the limb too closely, are capable also of proving eminently
^ Amer. Journ. Med. 8ci., vol. xxiv, p. 462, from Gazette M^dicale, No. 28.
470
PATELLA.
serviceable when they press upon rertain portions of the limb, and not
with too much foree.
Malgaigne's hooks or clamps I regard as liable to more serious ob-
jeetiooB, and, notwithstanding considerable testimony in their lav
cannot recommend them.'
For the saoie reason the apparatus invented by tlie late Dr. Turner,
of Brooklj'n, N. Y.,' is objectionable. Moreover, nil forms of ap|»-
ratus which, like this of Dr. Turner's, are secured to the limb by
straps with intervals, are objectionable, since these stra)» do not, like
bandages, give uniform support to the surface of the limb,
Mr. Hutchinson, of London, lias of late oniitled to elevate the foot
in the treatment of this Iracture, and h«
p„. ;,: thinks that the fragments are maintained
in apposition with quite as much easi
cannot agree with him that nothing is ever
gained by the elevation of the fiH)t. Oa
the contrary, in the treatment of a certain
proportion of cases this pfwition will
Jbund essential to the beKt sm-oess, while
in others it may be of little cunsoiuenoe
whether the fool is elevated or not.
I have seen in use at the I^ong Islaod
College Hospital a very ingenious api>aram«
devised by l>r. J. H. Hobart liurge, oneof
the surgeons of that hospital ; the frag-
ments l)eingapproximaled by well-ad)u8t«i
sole-leather |mds, which are operated upon
by weights, cords, and pulleys.'
Lausdalc, U. S, N., has contrived n
paratus similar to that invented by Burgi^
but more simple.'
The apparatus devised by Dr. H. E, Beach,
of Illinois,' composed of wire, is csspntiollj
the same as that employed by Burgc, Lou
dale, and Lausdale, except that ilitt fn
the Muck (F), ments are a|iproximati?<l by wirw nntn
with buckskin.
Gibson, of St, Louis, has introduced, in a modified form, the drcnl
B.d or ping, first devised by Albucasis.' Dr. Eve, of Naslivilk, u
r. Blackman, of Cincinnati, have employed this metlioil, and npa
of it in terms of high commendation." I cannot think, howevwr, tli
> Med. Titii«e and Ometle for 1604, vol. i, p. U. Report of Eight Cum, bjr H
Pylp, ■.•{ Ihe MiddlMitx Bofpital.
■ T.irnur, N. T. Med, Bee., July. 1897.
' Hiitcliinson. Lnndun Hiiapitnl Keporu, vol. ii.
• BurgD, N. y Hed. Kn:., April 16, 1MB, p. 80.
• Laiildal.', Walen'i Suricerv, p, 476.
• BMch. R. K,, St. L»ui> Med. and Surg. Journ . Jan 1S75.
1 Gibion, Amtr. Jniirn Med. H.-i., Jan. ISHT, p. 281.
> Wmbrn Journ. Ucd., Hay, ISflS. If ailiTlllo Juurn, Mfd., February, IBR.
iviinliiil rl^btinglcairllblhi
Ldof. and dt^cend perpdnill-
It (o lhi> alll OT nl
h Is plLWOd am ei
FRACTURES OP THE PATELLA.
it win be fonnd applicable to any large number of cases, and especially
to such cases as arc attended with much contusion and swelling of the
soft parts.
Beach's appantua ippllecT-
In ease the fracture is oblique or longitudinal, it will only be oeoe»-
nry to lay the limb in a straight position, so as to prevent that lateral
displacement of the fragments whiuh has been p,Q ^u
shown to occur when the limb is flexed. It will
not be necessary to employ a splint, unless the
pttient is nnmanageable and demands restraint,
DOT to elevate the foot. After the swelling has
nbeided, a slight amount of lateral pre^ure,
iKomplighed by a few turns of a roller, with
or without compresses, as the circumstances may
Mem to demand, will complete the mechanical
part of the treatment.
I have not mentioned the rapid and some-
times intense inflammation to which the knee-
joint is liable after a fracture of the patella; and
which is often greatly aggravated by the iiijiidi-
cions application of bandages. In no instance
ought the bandages to be applied very tightly
at the tirst dressing; and during the tin«t five
K six days the patient ought to be seen once
472 FRACTURES OF THE TIBIA.
twice daily, and the most prompt attention given to any complaints of
pain or soreness about the knee.
If the swelling and inflammation increase rapidly, it would be&r
Fig. 216.
Lausdale's apparatus.
better to remove the bandages altogether for a few days, than to take
the risks consequent upon their continuance.
The anchylosis which often follows the recovery of the patient, and
which is sometimes almost complete, is to be overcome by long-con-
tinued passive motion ; but great care must be taken not to rupture
the ligament, as we have already seen happen in some cases.
Dr. Alfred C. Post, of the New York Hospital, has excised the
knee-joint in a case of anchylosis of long standing; the limb being w
much flexed in consequence of a comminuted fracture of the patella, tf
to be not merely useless, but an intolerable incumbrance. The patient
was a laboring man of about forty years of age. This operation vns
made in preference to amputation, at the request of the man himself.'
CHAPTER XXX.
FRACTURES OF THE TIBIA.
Dei?elopment of the Tibia. — The tibia is formed, usually, from threi
centres of ossification— one for the shaft, and one for either extperaitv.
Ossification commences in the shaft at about the fifth week of fiTtal
life. In the upper epiphysis it appears at birth, and unites with the
shaft at about the twenty-fifth year. Genenilly it forms the tubemlei
but o<*casionally the tubercle has a distinct |>oint of ossificsitiou. The
lower epiphysis commences to ossify during the second year, and unites
» PoBt, New York Med. Gazette, vol. i, p. 809, Nov. 1850.
FKACTUBES OF THE TIBIA.
473
Fig. 217.
! Bhafl at about the twentieth year. The malleolus internus is
ally formed from an independent centre.
gy of Fractures of the Tibia. — Fractures of the tibia alone are,
je majority of cases, produced by direct blows, such as the kick
rse, or a blow from a stick of wood ; in one
I have seen it broken by a kick from a Dutch-
oot. It is occasionally broken by a fall upon
the force of the impulse being expended before
a gives way, but almost always the fibula breaks
ame moment, or immediately after the fracture
n place in the tibia.
'roudfoot, of New York, has reported an ex-
f fracture of the tibia in viero, produced in the
onth of pregnancy, by violent pressure upon
)men.*
^logy^ Division^ etc, — In an analysis of twenty-
actures of the tibia, not including fractures of
leoli, six were found to have occurred in the
bird, eleven in the middle third, and eight in
;r third. Six of the twentv-seven arc known to
en transverse, or only slightly oblique. It is
^ also, that several of the remainder were trans-
In this respect, therefore^ fractures of the tibia
ill be found to differ materially from fractures
ibia and fibula; but it is only in accordance
e general observation that indirect blows pro-
nost constantly oblique fractures, and direct
^mewhat more frequently transverse.
examples of fractures of the tibia extending
knee-joint are recorded by surgeons, most of
rere compound, or otherwise seriously complicated, so as to
mputation necessary, and the consideration of which scarcely
properly to a treatise uj)on fractures.
nalleolus internus is broken frequently at the same time that
le-joint is dislocated, and this accident will be considered in
nection.
aiion of Epiphyses, — We have already mentioned that Madame
lie has reported a case of separation of the upper epiphysis of
J and of the lower epiphysis of the femur, occasioned by puU-
le foot during birth.
088, of New York, has seen a separation of the lower epiphysis
14 years old, who in falling had caught his foot between two
f wood. The upper fragment protruded through the skin.
>D was effected, but subsequently a portion of the epiphysis
necrosed and was removed. He finally recovered with a use-
DevclopineDt of
the tibia. (From
Gray.)
Ifoot, Bo«t. Med. and Surg. Journ., vol. xxxv, p. 268, 1846; from New
m. Med.
N. Y. Journ. Med., Nov. 1865, p. 183.
81
474 FRACTURES OF THE TIBIA.
Dr. R. W. Smith has reported a similar case in a boy 16 years of
age, and which, having occnrred six months before, remained unre-
duced. The lower end of tlie shaft was displaced forwards. Richard
Quain records one other example, in a lad 17 years old, which was
easily reduced and maintained in position.*
Prognosis. — No shortening can occur in this fracture unless one or
both ends of the iibula are displaced, a complication which I have
noticed in two instances, but in neither case did the shortening exceed
one-quarter of an inch ; unless, indeed, the fracture occurs above the
fibula, or the fibula bends and remains bent, or the comminution and
direction of the fracture is such at either end as to allow the femur or
the astragalus to become impacted. I have never recognizeil either of
these conditions.
Occasionally the upper fragment has been slightly displaced forwards.
With these exceptions, and one other of delayed union which I shall
presently mention, this lK)ne, in my experience, has been found to unite
promptly and without any appreciable deformity. Other surgeona
have noticed occasionally that the upper end of the lower fragment
has become displaceil toward the fibula. Dr. Donne, of Louisville,
has reported an example of delayed union in a simple transverse frac-
ture of the upj>er end of the tibia. The man was intemjx'rate. Ten
weeks after the acKiident no union had occurred, and Dr. Donne intro-
duced a seton, and in about six weeks the fragments were firm.*
If the fracture extends into either the knee or ankle-joint, the danger
of anchylosis is imminent, yet experience) has shown that it may t«orae-
times be avoided.
When the malleolus is broken off, it generally becomes slightly
displaced ilown wards, and in this position a complete bony or iigt-
mentous union takes place.
Treaimeni. — The tendency to displacement, in a fracture of the tibia,
is usually so slight, if it exists at all, that simple dressings, light splints
of leather, felt, or binder's board, with rest in the horizontal posJture
upon a pillow, fulfil nearly all the indications which are pre^^nt. The
following cases will illustrate the usual course of these aciMdents.
Mrs. W. fell, Oct. 19, 1848, striking on her right knee, brtaking
the tibia transverselv iust below the tuberositv.
The fall was the result of a misstep on level ground, and was at-
tended with only slight bruising of the sofl part8. She says that on
attempting to rise she discovered what had hap|>ened, the bone pn>-
jecting very distinctly, and she pusheii and pulled it into place with
her own hands.
I dressed the limb by laying it upon a pillow, outside of which
were placed two broad deal splints, tying the whole snugly ti>getber j
with several strips of bandage. At a later pcrio<l the 1^ and thigh
were laid over a double-inclined plane.
* New York Journ. Med., Juno, 1808; from British Mod. J
' Dontio, Ainer. Journ. Med. Sci., vol. xxvlii, p. 624; fr
Med. und Surg., Aug. 1841.
ourn., Auij. 31,ll^»"-
from Western J^uriu
< ^ttlie end of six weeks all dressings were removed, nnd the frae-
Bents were fotind to have united firmly, and so perfectly as that the
' point of fracture could not he traced,
Peter Hamil, tet. 29. was admittwl into the hospital Aug. 3], 1849,
ffitli an injury to his left leg, which had occurred two days l>elbre. A
Toung surgeon had examined the limb, and thought the femur was
Woken just above the joint. He had applied a roller from the toea to
the thigh ; and to the thigli were appliwl lateral splintA. These dress-
inga were on the liml* at the time of his adniipsion, and were not re-
moved until the next day, I could not then discover any fracture or
displacement, and the dressings were discontinued, the limb being
merely laid upon pillows.
Oct. 4, when examining the limb, I detected a slipping sensation,
like that produced in a false joint, through the upper end of the tibia,
and I now easily understood what had been mistaken fur a fracture of
tlic femur. It was a transverse fracture through the ujiper end of the
tibia, and without displacement.
No splints were afterwards applied, and on the 2.5th of November,
three month.i after admist-ion, he was dismissed, the motion between the
fragments having ceused, but the knee still remaining quite stiff.
. The presence of inflammation, with other complications, may, bow-
er, occasionally render the treatment more difficult and the results
B sfltisfactorv.
John Mahaii, set. 39, admitted to the hospital Feb. 16, 1853, with a
rorapound fracture of the right tibia, near the middle of the lee. The
bone woA broken by the kick of a Dutchman. I found the limb much
swollen and very painful, and I laid it carefully over a double-inclined
plane, and directed cold water irrigations ; I also directed morphia in
fnll doses. The inflammation for several days threatened the complete
loss of hia limb. On the tenth <lay the distal end of the u[)|»er frag-
wat was projecting in front of the lower, and I depresm.-d the angle
r the splint and made moderate pres.'ture u[ton the up]ier fntgment.
In the twentieth day the fnignients were bent backward*!, and I placed
'a compress behind. On the thirty-seventh day we tc»ok the limb from
the inclined plane, and trusted alone to side-splints. On the forty-
fifth day we removed all dressings. The fragments had not united.
The limb was then laid upon a pillow, and six days later a firm gutta-
percha splint was applied for the purpose of steadying the bone, but
the splint was removed daily in onlcr that the leg might be bathed and
nibbed. He was allowed to sit up. On the fifty-ninth day motion
could still be perceived between the fragments, and he was directe<l to
tise crutches. On the ninety-third day the union was found to be firm,
the upper fragment remaining slightly displaced forwards.
In case the fracture extenils into the knee-joint, it is best to lay the
lirah upon pillows or in a nicely cushioned box, and nearly straight.
No extension or counter-extension is necessary here any more than in
1 other fractures of the tibia alone, nor are lateral splints or rollers
j^BMe^ary or proper at first as a general rule; but especial attention
^ftuuld constantly be given to the prevention of inflammation, and of
_ fhigm<
L Th*
Hprer, i
loss ol
lllLUt
pin III
476 FRACTUBES OF THE TIBIA.
subsequent anchylosis. The omission to employ splints in a case oi
this kind was charged against a surgeon in Vermont as evidence of
malpractice. I am nappy to say, however, that, in this particular case^
he was sustained by the testimony of the medical men and bv the
verdict of the jury; but the attempt which the reporter has made to
defend tliis as a universal practice in fractures of the leg, or of the
tibia alone, is unfortunate, and evinces a lack of practical expericDce.*
Whatever position is adopted, and whatever means of sup|K)rt or
retention ai*c employed, if bandages and splints are applied tightly or
injudiciously, great suiicring and irreparable mischief to the knee-joiot
may be the consequence.
A man, jet. 23, entered the Pennsylvania Hospital, July 18, 1838,
with an oblique fracture through the head of the tibia. A physimn
had applied a bandage and splint to the leg, and sent him twenty Diiles
to the city, and, on examination afler his arrival, the whole limb as
high as the groin was much swollen, red, and excessively painfiiL
The knee-joint was distended and very tender. All dressings wew
immeiliately removed, and the limb laid in a long fracturc-lx)x slightly
elevated at the foot; cool lotions were applied, and the patient WM
freely bled, both from the arm and by the application of leeches. The
limb was kept in this position al)out six weeks, and at the end of two
or three weeks more he was dismissed, cured. Dr. Norris, who w»
the hospital surgt»on in attendance, has, in his report of the ca*»e, ve^
properly taken this occiision to warn surgeons of the danger of cxoei-
sive bandaging and splinting in this kind of fracture, as well asioill
other fractui'cs of the lower extremities.-
Fractures of the malleolus, unaccompanied with any other aaideoti
demand only that the limb should be laid upon its outer or fibular
side, with the foot so sup|)orted as that it shall incline inwards toward
the tibia. In this simple disfKK'iition of the limb we have done all
that can be done by any mecluinical contrivan(*e toward approachiog
the lower fragment to the shaft from which it has been broken.
* Boston Mo(i. Journ., vol. liv, p. 1, March. 185»i.
* Nurriff, Anier. Jourti. of Med. Sci , vol. xxiii, p. 291.
FRACTURES OF THE FIBULA.
477
CHAPTER XXXI.
FRACTURES OF THE FIBULA.
Fig. 218.
Development of the Fibula. — The fibula is formed from three centres
of ossification — one for the shaft, and one for each extremity. Bone
begins to be deposited in the shaft at about the sixth
week of foetal life, in the lower extremity during the
second year, and the upper extremity during the fourth
year. The lower epiphysis unites with the shaft a'bout
the twentieth year, and the upper about the twenty-fifth
year.
I have not found any recorded examples of separation
of these epiphyses.
Causes of Fracture. — In a record of thirty-two cases I
have been able to ascertain the cause satisfactorily in
eighteen, of which number three were the results of falls
directly upon the bottom of the foot, but which were
probably accompanied with a twist of the foot, four of a
slip of the foot in walking on level ground, or on ground
only slightly irregular, and twelve of direct blows.
Pathology. — In all of the fractures which have been
produced by falls upon the bottom of the foot, and in all
except one produced by a slip of the foot, the accident
^was accompanied with a dislocation of the ankle; the foot
being turned outwards. In the one exceptional case men-
tion^, the dislocation may also have occurred, but the fact
is not known.
Both Malgaigne and Dupuytren have noticed a dislo-
cation in the opposite direction, or a turning of the foot
inwards, more often than a turning outwards. I cannot
think their observations were carefully made.
Moreover, in at least seven of the twelve fractures produced by di-
i^t blows the tibia has been thrown more or less inwards, and conse-
q^uently the foot has turned out.
In twenty-four examples the fracture of the fibula has taken place
'Within from two to five inches of the lower end of the bone. Twice
the external malleolus was broken off, and seven times the internal
*nalleolus.
Four of the fractures occurring in consequence of direct blows were
impound, and one was also comminuted.
Prognosis. — In a majority of cases, where the fibula has been broken
^mtwo to five inches above the lower end, the fragments have united
Development of
the fibula. (From
Gray.)
478
FEA.CTUBES OF THE FIBULA.
inclined toward or renting against the tibia; occasionally I have seea
tlieni <)isplace<I backwartJs or forwards. Once the fibula refused to
unite altogether.
TIte lualleuli have generally united nearly or quite in place, but id
two instances the external malleolus has been found dieplac-ed verj-
mucli downwards.
Of tho compound fractures, two required amputation, one was treated
by resection of tlie lower end of the tibia, and one dieil without anv
operation. Douglas has re|)orted a caae of compound dislocation witn
fracture of tho fibula, which being reduced, he was able
Fio. 219, to save the limb, but not without much difhculty, and the
ankle remained stiff.' Oilier Hurgeons have met with
similar success, but I shall refer to this subject again
under the head of comjMund dislocations.
Of those which recovered, twenty-eight in number, ten
have been found to have more or less unnatural promi-
nence of the internal malleolus, and in two of tiicse the
malleolus, or lower end of the tibia, projects very much.
In nearly all of thcise examples tlie foot apiiviira some-
what inclined outwards.
Generally the ankle-joint has remained stiff for some
time atler the bandages have been removed; and prob-
ably in all cases in which the accident was accompanied
with a dislocation of the tibia. But this stiQ'nuif has
usually di.-iappearetl after a few weeks or months. Twice
I have noticed consi<lurablc stiffness after about six
months ; three times after one year; in one case uftor two
yoiirs ; and in one ca.se after twenty yt.ars the ankle would
occasionally swell, and become quite stiff. In one ca^e
it remuintnl almost immovable after twenty years; and in a slitl moie
remarkiibte instance, I examined the limb thirty years after tiie aivi-
denl, when tho man was sixty-three years old, and nltbough there cx-
ist<-<l no swelling or deformity, yet this Icjr was nut as uiuseiilar as the
other, and he declared that up to this time the ankle reuiained quite
tender to the touch, and that occasionally it beeanic painful.
When I l.^>tnc to K{>eak of dislocation of the ankle, I shall adopt the
usual nomenclature, and shall name all those dislocations in wliioh the
tibiu )irojocts inwanls from the foot, "inward dislocations of the tibia;"
yet I have some doubts ns to the projiricty of this anjxilhition. This
accident seems to ine to have been in geneml rather a lateral rotntion uf
the f(M>t, or of the astntgalus, uikhi the h)wer articulating surfaera uf
the tibia and fibula. Of all theginglymoid joints, the ankle apjtriKU-ht.'S
m<)st nearly in form to a ball and socket-joint, in consetjuvuci- (.'si|>evially
of the marked prolongations of the malleolus internus and exteniiui.
In other giiiglymoid articulations lateral displu<x-ments an- not uuft^
quent, but lateral n>tiition can siureely by any OLvident occur, llerv,
d Surg. Juur
>-, p. 336, from Southern Juurn. of 11(4.
FRACTURES OF THE FIBULA. 479
however, the reverse holds true; lateral displacement is difficult, while
lateral rotation is comparatively easy of accomplishment.
The majority of cases which occur, involving a disturbance of the
lelative position of the ankle-joint surfaces, are, I am satisfied, of this
latter character, viz., lateral rotations within the capsule, rather than
true dislocations ; and although the restoration of the joint surfaces to
position is, in general, easily accomplished, yet in consequence of either
a fracture of the fibula or malleolus internus, or of a rupture of the in-
ternal lateral ligaments, it will generally happen that some deformity
will remain. The fragments of the fibula will fall inwards toward
the tibia, and the foot, unsupported by either its fibula or its internal
ligaments, will incline perceptibly outwards. Nor can this be wholly
prevented, in most cases, by any mechanical contrivance. Indeed, it
would be easy to demonstrate, as I have often done to my pupils, that
even Dupuytren's splint, usually employed in this accident, must fail
of success in a great majority of cases, since the subsequent deformity
is due less to the fracture of the fibula and its (X)nsequent displacement
than to the loss of the internal ligaments, whi<;h loss nature can seldom
fully repair. As further evidence of the correctness of this view, I
will state that in three of the examples in which I have found the
fractured fibula united and resting against the tibia, the motions of the
ankle-joint have been completely recovered.
If, however, it were true that a fracture and displacement of the
fibula is the sole or essential cause of the subsequent deformity, it
would still be found often impracticjible to avoid the maiming, since
it would still remain impossible to lift the broken ends from the tibia,
i^inst which, or in the direction toward which, they are so prone to
iall. Inversion of the foot does not accomplish it, nor have I ever
been able to make anything but the most trivial impression upon the
upper end of the lower fragment by pressure upon the lower extremity
of the fibula.
I think too much confidence has been placed in the efficiency of
"Dupuy trends splint." I believe, indeed, that this splint is a very
appropriate means of support and retention after this accident ; but
I doubt whether it is able to accomplish all that its illustrious inventor
proposed.
Treatment. — Dupuytren's mode of dressing is essentially as fol-
lows:
A pad, or long junk, made of a piece of cotton cloth, stuffed with
cotton batting, is constructed of sufficient length to extend from the
condyles of the femur to a point just above the malleolus internus.
This pad must be about five or six inches in width, and thicker by
two or three inches at its lower than its upper end. This is to be laid
upon the inside of the leg, with its base or thickest portion resting
against the tibia just above the internal malleolus. Over this pad is
to be placed a long firm splint, extending also from above the knee
to three inches beyond the bottom of the foot. With a few turns of
a roller the upper end of the splint will now be made fast to the knee,
and with a second roller the lower end must be secured to the foot.
480 FHACTORES OF THE FIBDLA.
The application of this last bandage requires, however, some care in its
adjustment. Its purpose is simply to rotate the foot id-
Fm. 220. war<ls, while at the same time the tibia is pressed out-
wards ; and to this end it must be applied tn the form of
a figure-of-8 over both splint and foot, embracing alter-
nately the heel and the instep. In order to he effectual,
it must t»e drawn pretty firmly, and no portion of the
bandage must pass higher than the malleolus extemus.
In some surgical books I have seen this ajiparatus repre-
sented with a roller embracing the whole length of the
leg; and in others it is represented as encircling the limb
two or three inches above the malleolus; hut it is evident
that tluse modes of dre-'sing must defeat the great object
which Dupuytren had in view, namely, the throwing out
of the upiier end of the lower fragment.
When the limb is thus dressed, the knee may be flexed
and the leg laid n{>oii its outside, supported by a ]>ilIow,
or upon its inside, as in the accompanying engraving.
DupnyiMn'. ^' ■' '^ *'"'>' * fracture of the external malleolus, or if
■pKtit incur- the fracture has occurred in the middle or upper third of
trcHj ippiied. flip I>one, this treatment is no longer appropriate, and it
will genendly lie found sufBcieut to place the limb at
rest for a few days u(>on a suitable cushion or upon a pillow.
Of late years 1 have not employed Dupuytrcn s splint quite so niadi
as formerly, and esi>e(ially because I have met with sevenil eXEimplen of
backward displaccmcMt of the foot following fractures of the fibula,
which Dupuytren's splint is not com[ietent to prevent or to remedy.
iiiginillf ipr>ll«l bT hi
This subject will he considered more fully in connection with fnratrd
luxations of the tibia at its lower end ; but it is neccnmr}' to nav here
that this accident can l>e most certainly avoided by employing tb«
plaster of Paris or starch dressing; taking care in applying the dreeing
to secure a thorough inversion of the toes and foot, the same at in rase
the limb were dres.>^t wilh Dupuytren's splint. Care must be taken,
also, not to pr«>ss upon the tiud) much with the Itandages aliove (he
malleolus cxternus. The same results may l)c attaiue<l, also, by a well-
a<ljusted leather splint, or by two sptint->, which shall inclose the heel
as well as the sides and front of the limb.
It is scarc'ely necessary to say that, since after this accident anchy-
losis is BO frequent, early and unremitting attention should l>e fi'ivtn
to the establishment of j):is.sive motion in the joint. Indeml, I cannot
FRACTURES OP THE TIBIA AND FIBULA. 481
bat think that a desire to accomplish the indications recognized and
urged by Dupuytren has led to the neglect of the indication which
ought to have been regarded as of equal, if not of the greatest, ira-
portaDce^ namely, the prevention of contractions and adhesions around
and between the joint surfaces.
As a general rule, the dressings ought to be wholly laid aside by the
end of the third or fourth week ; and although it may be well fiw a
Bomewhat longer time to keep the foot turned in, by having it properly
sapported as it lies upon the pillow, yet after this date I regard the
use of splints and bandages as only pernicious.
CHAPTER XXXIL
FRACTURES OF THE TIBIA AND FIBULA.
Cawfes, — Probably four-fifths of these fractures are the results of
direct blows or of crushing accidents, s^ich as the kick of a horse, the
passage of a loaded vehicle across the limb, the fall of heavy stones or
timbers, etc.
In an analysis of one hundred and eleven cases I find tlie bones
broken in the upper third from a dire(;t cause four tiujcs, and from an
indirect cause once. In the middle third forty have been referred to a
direct cause, and two to an indirect ; and in the lower third thirty-nine
to a direct cause, and eighteen to an indirect. An observation which
does not sustain the remark of Malgaigne, based npon his analysis of
sixty-seven cases, that fractures of the upper third are produced by
direct causes alone, those of the middle third much more frequently by
indirect caascs, and that those of the lower third are especially due to
indirect causes. Direct causes produce a large majority of the frac-
tures of the lower third, but the proportion is smalkr than in the
middle third.
Of the indirect causes, falls upon the feet from a considerable height
*-as from a scaffolding, or from the top of a building — are by far the
most common. Four times I have found the bones broken by mus-
cular action alone, as in the following example :
Mre. W., of Buffalo, aged about twenty-five years, and weighing at
this time nearly two hundred pounds, was dei?ccnding her door-steps
with an infant in her arms, when, the step being covered with ice, she
slipped and fell, breaking her right log just above the ankle. Mrs. W.
says she felt and heard the bones snap before she touched the steps.
Of this she is certain.
We found the tibia broken obliquely, the fragments being quite
movable, bat not much, if at all, displaced. The limb was dressed
with a carefully moulded and well-padded gutta-percha splint, and
then laid in a pillow upon the bed. Mrs. W. experienced unusual
482 FRACTURES OF THE TIBIA AND FIBULA.
pain from the fracture for several days, for the relief of which we were
compelled at tiraes to permit her to inhale chloroform. She was of a
nervous temperament, and had frequently resorted to chloroform before
to relieve neuralgic pains. The limb became very much swollen, and
remained so for a week or two. No extension was ever employed.
Within the usual time the bones united in [>erfect apposition, and
in about four months she was able to walk without any halt.
Pathologyy SipnptomSy etc, — We have seen that fractures of both
bones through some part of the lower third are most frequent. Thu«,
of one hundred and fifty-five fractures, eleven belonged to the upper
third, forty-five to the middle, and ninety-three to the lower. In six
cases the two bones were broken in different divisions. It is probable
that in this analysis some errors have occurred, and that in a larger
proportion than here stated the two bones have given way at opjKisite
extremities, since it is often difficult, and sometimes quite ini|^K>ssible,
to determine precisely where the fibula is broken; but the analys^is is
sufficiently correct to illustrate the much greater frequency of fractures
of the lower third, and also the fact that the two bones generally break
nearly on the same level ; usually the jK)int of fracture in the tibia is
between two and three inches above the joint.
In an examination of twenty museum specimens, I have found both
bones broken at the same point, or within two or three inches of the
same point, sixteen times, and at extreme points four times ; and in
these last examples the tibia has always been broken in the lower
third, while the fibula has been broken in the upper third.
In seventeen of the fractures mentioned as belonging to the lower
third only the malleolus of the tibia was broken, while the fibula wad
broken two or three inches above its lower end. Some of these were,
perhaps, examples of dislocation of the ankle.
I have seldom seen a transverse fracture of the tibia, except in its
lower or upper extremity, in the expandetl portions of the bone ; and
even in those examples which we are accustomed to call trausveree,
because they are sufficiently so to prevent any sliding or overlapping
of the fragments, there has existed, generally, a marked inclinatioo of
the line of fracture in one direction or another.
The examples of fracture produced by muscular action have, without
an exception, occurred in adults. Three of them were in the lower
third of the leg, and one in the middle third. I think they were all
of them nearly transverse, since they never became much, if at all,
displaced.
Most of the fractures of the tibia produced by falls upon tlie feet
are very oblique, and the direction of the fracture is generally dowu-
wards, forwards, and inwards; but I have found almost every con-
ceivable variation from this general rule.
The fra(^ture in the fibula is even more constantly oblique tiian the
fracture in the tibia; but this is a point of very little practical coase-
quenc(», and one which we can seldom determine positively, unless one
of the fnictured ends protrudes through the flesh.
Compoimd and comminuted fractures are more frequent here than
in any other of the bones of the body. My tables, which have rejected
FBACTUBE8 OF THE TIBIA AND FIBULA.
483
ill fractures demanding immediate amputation, most of which are eom-
poand, do not for this reason give a just idea of their proportion to
simple fractures, yet even in these tables, of one hundred and seventy-
two fractures, sixty-two were compound, and also, generally, more or
kae comminuted. Of eighty cases reported by W. W. Morland, of
Boston, from the Massachusetts General Hospital, and in which the
character of the accident is recorded, thirty-nine were compound.^
The symptoms indicating a fracture of both bones of the leg are the
nme which are usually present in other fractures, namely, mobility,
crepitus, shortening of the limb, distortion, swelling, etc. Generally
Fio. 222.
Compoand and commiDuted fracture of the leg.
the lower end of the upper fragment projects in front, and can be seen
or felt; but in some instances the swelling follows so rapidly that it is
impossible to feel distinctly the point of fracture, and its existence can
only be determined by the crepitus, mobility, and shortening of the
Jimb, or, perhaps, by the marked deformity or deviation from the
natural axis.
The shortening, where it exists at all, varies at the first from a line
or two to a half or three-quarters of an inch. Generally, it is about
half an inch.
Prognosis, — The average period of perfect union in twenty-nine
cases, including those in which union was delayed by extraordinary
causes beyond the usual time, w'as forty days. The general average,
under ordinary circumstances, may be stated at about tliirty days.
Union has been delayed in seven cases, five of which were simple
fractares, and two were compound. The longest period was seventeen
weeks.
F. C. T., of Erie Co., N. Y., set. 35, had an oblique, simple fracture
of both bones, in the upper third, caused by jumping from a buggy, in
June, 1852.
The limb was dressed with lateral splints, compresses, and bandages,
and laid upon a pillow.
Eight weeks after the fracture had occurred, the gentlemen in at-
* Tninsac. of Mass. Med. Soc. for 1840; Fractures, by A. L. Pierson.
484
FRACTUHES OP THE TIBIA AND FlBfLA.
tendance wished me to see the limb with them. I found Mr. T. still
in bed, and the fragments not at all united.
Mr. T. had enjoyed average health heretofore, but he was never
very robust. When I was eallcd to see him he looked pale ; his skiQi
was cold and moJst, pulse 120, and apjietite poor. The broken le^
and foot were greatly swollen. The swelling; was (edematous. Coo-
siderabte excoriations existed on the back of tlie lefr. The fragmenU
were quite movable, and were overlapped three-quartere of an inch.
We agreed that the patient ought, as soon as possible, to \w got ool
of bed, 80 as to enable him to recover his streugth, which had eadl^
declined. To this end, a gutta-percha splint was made to fit accurately
the whole length of the leg; and, having attached a large number of
tapes, it was to be seeured upon the limb. .Several times each day ifi
was to be removed, and the limb bathed with brandy and water.
Gradually, also, the limb was to be brought down to the floor, and tht
patieut be made to sit up, and, as soon as possible, he was to walk with
crutches, or to ride.
Nov. 4th, 1852, Mr. T. visited me at my house. The directions had'
been followed implicitly. About two weeks after my visit he rod*
out, and in about nine weeks, or seventeen weeks from the time o
the fracture, the bones were found united. His health and strength
were quite restored, and the limb was no longer cedematons. It waa
found to l>e straight, or with only a slight projection of the upp«r
fragment in front of the lower, and shortened three-quarters of an inch.
A gentleman, cet. 33, from Bergen, N. Y., was struck by a billet o^
wood on the 3d of August, 1856, breukiug his left leg nearly In
versely, three and a half inches above the joint. The fracture >
fiimple. A flutwon was called immediately, who applie<l l>andagtv iiMf
side-splints, and then laid the limb over a double-inclined plane. M
the end of six weeks the dressings were removed, but the lK>nc« lisd
not united. Four years after the accident, this gentleman consulled
me. I found him in good health, but no union had yet taken piv-
This is the only example, except where amputAtion or death inter-
posed, in which the union hn-s been so long delayed as to entitle il »
I be considered as a case of non-union. My own observation wooMi
' therefore, incline me to think that, while non-union is a rare event in
fractures of the leg, delayed union is more frequent than in most other
fractures.
It has once occurred fo me to see a complete non-union of ihc fifxil*
after a period of several years, while the tibia had united well. Tab
circumstance oocasioned no inconvenience to the patient, and w» w'
known to him until I had made the discovery.
A little more than one-half of those oasi« in which an tctx
note of the result has lieen made, have l)wn found to l>e more or !«•
shortened by overlapping, namely, sixtj'-one cases out of one hiHW""
and ten. The greatest amount of shortening iu any om- ca.se li» 1**
one inch and a half; and the average 8hort»^'ning of the sixty-one o
has been half an inch and a fnu-tiou over. This analysis iiidndt*''*'
simple and compound fractures ; but a pretty large proportion of A*
FRACTURES OF THE TIBIA AND FIBULA. 485
simple fractures have also been found shortened, as in the following
extreme illustration :
John Granger, of England, cet. 43, was tripped by a stone while
walking, breaking his right leg through its lower third. Fracture
simple and oblique. It wi\s treatinl by a surgeon, of Hungerford, Eng-
land, who employed only side-splints.
Two years after, I found the leg shortened one inch, the upper frag-
ment riding upon the front and inner side of the lower.
Generally, when a shortening has occurred, I have found the upper
fragment in front of the lower, and oftener a little more upon the inner
than upon the outer side.
The deviation from the natural axis of the limb has been noticed by
me in a good many instances. Seven times the lower part of the limb
ha? fallen backwards, and five times it has, in a degree much less
marked, inclined inwards. Once I have seen it inclined outwards, and
twice forwards.
Ulcers upon the back of the heel, seen by me seven times, as a result
of ondue pressure upon this part, have, however, been pi-esented but
three times in cases of simple fractures.
It is not very unusual to find, also, over the exact point of fracture,
and afler the lapse of several months, or even years, an ulcer, or sinus,
which is due sometimes to the presence of a small fragment of bone
which has remained in the wound from the time of the accident, or to
a thin scale which has subsequently exfoliated. In other cases it is
doe to the prominence of the salient angle when the lower part of the
limb inclines considerably backwards, and in still other cases, no doubt,
to the general dyscrasy of the system, and to the same causes which
produce chronic ulcers in the lower extremities where only the skin
has been originally injured. I have reported elsewhere examples of
this complication existing after five months, two and three years,* and
in the remarkable case which I shall now briefly relate an ulcer existed
at the end of twenty-three years.
Tburstone Carpenter, when four years old, received an injury, break-
ing both bones of one of his legs near its middle. The fracture was
compound. It was dressed and treated by an excellent surgeon, then
residing in Buffalo, but long since dead.
Twenty-three years after the accident, Mr. Carpenter called upon
me on account of a paralysis of his lower extremities, which had re-
cently occurred. He stated that from the time of the fracture until
within about one year an open ulcer had existed over the seat of frac-
ture, and that soon after it had closed over completely he began to lose
the use of his limbs. During the time it was open, small scales of
bone have frequently been thrown off. The limb is half an inch
shorter than the other, but straight.
A gentleman residing in Quincy, Chautauque Co., N. Y., had his
tibia and fibula broken near the ankle-joint in the year 1844, by the
passage of a carriage-wheel across his limb. The skin was a good
oeal lacerated. The wounds, however, healed kindly, and the broken
' Trmnf. Amer. Med. Assoc. Keport on Deformities after Fracture.
486 FRACTURES OF THE TIBIA AND FIBULA.
bones united in the usual time without any apparent deformitv; bot
the liral) continued swollen and painful, until finally suppuration took
place. After twelve years of great suffering, I amputated the leg near
its middle, from which time he made a speedy recovery. I found the
lower end of the tibia inflamed, softened, and expanded, and contain*
ing in its interior al)out three ounces of pus, but no sequestrum.
Anchylosis of the knee or ankle-joint may follow as a result of the
accident or of improper treatment; and at one or both of tUet^ joints
I have found more or less anchylosis at the end of nine months, one
year, six years, twenty-five, thirty, and forty years. Generally, how-
ever, it disappears in a few weeks, and seldom remains to any consid-
erable extent in the knee-joint after the dressings have been removed
two or three weeks; but an Irishman called upon me in 185^3, whuae
leg had been broken about three inches l)elow the knee-joint six yean
before. It was a simple fracture. A surgeon in Ireland had treated
the case. I found the limb shortened one inch and a half, the frag-
ments being overlap[>ed and displaced backwards at the |>oint of frac-
ture. The knee was also partly anchylosed. I could not learn what
the treatment had been.
In other cases, where no permanent anchylosis has followed, the
ankle-joint has been occasionally painful, and subject to swelliDgs,
after the lapse of many years.
After all that has been said as to the occasionally serious nature of
the consequences of these accidents, as shown in the shortening of the
limbs, in their deviations from their natural axes, in the stifl' anklet^
ulcers, and abscesses, it must be still admitted that in another point of
view these results are not. extraordinary, and mav hereafter continue
to be fairly anticipated in a certain proportion of cases, even under
the best management ; since it must l>e understood that more frarturei
of the leg are attended with serious complications than of any other
limb; and that while many produce death rapidly from the severity
of the shock, and very many are condemned at once to amputation,!
large number of those which are saved have been in that cx>ndition
which has rendered the a|)|>Iication of bandages or splints im|X)t!«>ihle
for many days. Indeed, not a few of these crooked limbs may still be
presented as real triumphs of the art of surgery, inasmuch as by con-
summate skill alone have they been saved.
Treatmait, — It is wholly impossible in a class of fractures whidi
present so great a variety in regard to form, seat, and complications,
to establish any universal system of practice; nevertheless it is ixiseiible
to declare certain general i)rinciples in reference* to a few well-rei'^ifij-
nized classes or varieties : and I shall deem it especially ini{K>rtant to
ra*ord my disapproval of certain plans of treatment which have from
time to time l)een suggestcnl and adopted.
It is seldom that I have found it necessary or a<eful to apply any
bandages directly to the skin, whatever form of apparatus nas been
employed, but in certain cases of com|K)und fractures, where dressings
have been applii'd which ncedcHl supiH)rt and prote(*tion, a bllndJ^^
has b(H.Mi of service. The roller, unless the patient is a child, wh<i«e
limb can be easily lifted and managed, is always objectionable; but
FRACTURES OF THE TIBIA AND FIBULA. 487
the many-tailed bandage, made of narrow strips of cloth, laid upon
each other, as we have already described in our general remarks upon
bmdages, etc., is occasionally useful.
Having made these preparations, we proceed to flex the leg to a
right angle with the thigh, and by the hands make extension and
counter-extension as much as the patient will bear, or as much as may
be necessaTy to restore the fragments to place, in case this restoration
IB found to be practicable. If the fracture is (compound, and the point
of bone protrudes through the skin, it is often difficult to replace it.
That is, we are unable to overcome the action of the muscles sufficiently
to make the limb of its natural length, and for this reason, mainly, we
ire unable to get the point of bone beneath the skin. If we cannot
then '*pet" the bone, or bring the ends into apposition, and this will
be the fact pretty often, we still have no apology generally for leaving
the bone outside of the skin. First, an attempt must be made to
fooomplish this reduction by pulling aside the skin with the fingei^s,
or with a blunt hook. This simple procedure has often succeeded
with me in a moment, when others have been trj'ing in vain to ac^com-
plish the same end by pulling upon the limb. If this fails, then the
skin should be cut sufficiently to allow the bone to retire, or if the
point is sharp, and especially if it is stripped of its periosteum, it may
be sawn or cut off. Resecting thus the end of an oblique fragment
does not generally affect in any degree the length of the limb, or inter-
fere with a prompt and j)erfect cure, but, on the contrary, it often is
advantageous in every point of view.
We are now prepared to apply the splints. Before, however, con-
sidering the character and form of the splints to be applied, it seems
proper to call attention again to the danger of ligation of the limb
from the tightness of the bandages, and esi)ecially from the use of a
bandage or roller placed beneath the splints and directly against the
dkin.
The larger size and irregular form of the bones of the leg, the small
amount of muscular tissue covering them, especially near the articula-
tions, the severity of the injuries to which they are liable, with their
remoteness from the centre of circulation — these circumstances alto-
gether, render them exceedingly cx|)osed to injury from the too great
or unequal pressure of splints or of bandages ; and it has often occurred
to myself, as it has to Dr. Norris, whose remarks upon this point we
have already quote<l, to find the skin vesicated, or even ulcerated and
sloughing, when the patients are first admitted to the hospital ; a con-
dition which, in nine cases out of ten, is due to the maladjustment of
the splints, or to the tightness of the bandages.
If bandages are used under the sjilints, and next to the skin, they
must be applied very moderately tight, and loosened or cut as the
swelling augments ; and, from the first day of treatment to the last,
the surgeon must be careful to loosen or tighten the dressings when
the c^wetling increases or subsides, just as the prudent boatman trims
his sails to the rising and falling breeze.
Dr. Krackowitzer presented to the New York Pathological Society,
June 10, 1863, a leg which he had amputated for gangrene occasioned
FBACTOB
. ANU FIBULA.
^^^^H unklojoiiit, which his medical attendant pronounced a fractare of [he
^^^^V Rhnla, and for which he applied only a tight bandt^. The child
^^^H aiiH'ered a good deal afVer the liandugc was applied, and the Ibllawing
^^^H morning the toes were blue, but the doc-tor pui<l no altoution to this
^^^H circumstance. The pain subr^ided on the third ilav, and on the fourth
^^^B the bandagea were renxived, and the limb found to Ik- giiiign-non:
^^^B The specimen showed that the 6bula was not broken, but that thiTtt
^^B was a fissure or crack in the lower part of the shaft of the tibia.*
^^H The following cn^e, which lias been communicated to me by Dr.
^^m Fuller, of Wyoming, N. Y^ with permission to make such use of it
^^B as I choose, is sufficiently pertinent for the instruction of otheni, and
^H derrerves a public record :
^H A mail, Ki. 71, fed fi-ont a tra^, striking upon his foot, August 27,
^B 185-5, producing a backward dislocation of both the tibia and fibula
^B ujwn the os calcis, and also a fracture of both bones of the leg a few
H inches above the ankle.
■ An empiric took cliai^ of this unfortunate man, and immediately
■ applied hUeral splints and a firm roller from the toe^ to the knee.
■ Notwithstanding the remonstrances and prayers of the patient to ha\x
■ the bundago loosened, it was kept on until the ninth dxy, when the
I dot^^tor cut the bandage npon the top of the foot, and it was finind
[ vesicated. Ignorant, nowever, as to the cause of this vesiinition, and
of the danger whicii it threatened, he omitted to loosen the reiBainder
_ of the bandages, and the limb was left in this i-onditiou until tlic
twenty-third day, when Dr. Fuller being called, and having remowil
all the dressings, found the internments covering tiie whole ftwt dtaJ
and dried down to the bones. The dislocations hud not bc<:-n niloml.
Soon after this the limb became (eilenmtoas, and on the '27tli of (hiobrr
the leg was amputated by Dr. Barrett, of Le Hoy, from whii-li lime
tlie patient recovered rapidly.
The fragments l>eing adjusted, two lateral splints of leallier, loof
enough to extend from near the knee-joint to tlie metaturso-phalnni^
articulations, and wide enough to nearly encircle the limb, are monltW
to the limb on each side, and secured in plat^v by succeiisivc turns iif
the roller. When the skin is delicate or tender, these should Iw tUf
derlaid with a thin sheet of cotton wadding or of |Mitent lint. A tuf
woollen cloth may answer the purpose equally well. .■\ rack is tbai
plaeed over the limb, such as will Ije seen figun-d for the ^usjenw^B
of the limb when dr^sed *vith plaster of Paris, and from tht* the '^
is suspended. The objects to be attained by tlie suajxiiision are tiii
fold : first, to avoid the danger of pressure u|>on the Iiecl, and
oiient ulceration ; second, to prevent that driving down of tlwupi
fragment uiHtn the lower which constantly ensues when the ftxri
u{Hin the bed or in a box which is immovable ; tliin), to nbi
movement of the fragments upon each other when the patient mi
or lies down in be<l. This movement, 1 observe, is peculiar. It
simply a motion of the fragments upon each other, as upon a pivfl
< Krackuwilur, Amcr. Mod. Time*, Nov. T, 18GS.
FRACTURES OF THE TIBIA AND FIBULA. 489
the point of fracture, which motion seldom interferes materially with
ecNQSolidation, but it is a rising and falling of the upper fragment, or
a motion to and from of the fragments, and also a riding motion ;
either of which latter movements necessarily delays or defeats bony
onion. It is because these motions are generally permitted to occur in
the usual modes of dressing these fractures, more than for any other
reasons, that union is so often delayed in the case of these bones. In
my own practice, when this plan of susj^ension is enforced, delay seldom
occurs, but nothing is more common than for me to meet with it when
other surgeons have had charge of the limb, and the suspension has
been omitted.
In suspending the limb, it is only necessary that the leg should float
clear of the bed ; and I think it worth while to say that when leather
is used for splints, a broad oval piece of leather or of some other firm
material should receive the limb in suspension, rather than pieces of
bandage, which soon become cords, and press unequally. To the sides
of these oval pieces bands are attached, and their ends tied over the
top of the rack. One must be placed under the knee and one under
the ankle.
If the fracture is above the middle of the leg, complete quietude of
the fragments can (mly be obtained by carrying the splints and the
bandages above the knee.
I have already, in my remarks on the treatment of fractures in
general, declared my acceptance of the so-called " immovable appa-
ratus" in the treatment of certain fractures of the leg below the knee,
and especially of the plaster of Paris dressings. In hospital practice,
where these dressings can be applied by experts, and where the limb
can be watched daily and hourly, most or all of the dangers incident
to this form of dressing may be avoided ; but even here I have occa-
sionally seen, from a little too mu(th delay in opening the dressings,
serious trouble ensue. Its most dev()t(Kl advocates, Seutin, Velpeau,
and others, have never denied the neccssitv of caution in its use. To-
day I hear of a surgeon in a neighboring State who has been prose-
cuted for damages in consequence of the death of the limb, caused, as
is alleged, by this form of dressing. On the other hand, when applied
judiciously, even immediately after the receipt of the injury, and
when carefully watched and opened freely on the first notice of danger,
it has, in my wards, and in the hands of my excellent house surgeons,
often served its purpose more completely than any other apparatus or
splints I have ever seen employed. It has steadied and supported all
pans of the limb more comi)letely, and permitted it to be handled
more freely, than anything else could do. In simple fractures patients
hive been permitted to walk about upon crutches after the third or
fourth day, and generally no harm has resulted. In one case, how-
ever, I believe this liberty caused a serious delay in the union ; and in
another an abscess resulted, which would have been avoided if he had
remained in bed.
But it is in the management of compound fractures of the leg that
I have of late seen the greatest advantage* in this mode of dressing;
and it was in precisely these cases that I formerly believed the immova-
82
490 FRACTURES OF THE TIBIA AND FIBULA.
ble apparatus most objectionable. I do not wish to retract anything
I have heretofore said as to its dangers, but I have not until lately
fully appreciated to what a degree these dangers might be overcome by
skill and attention.
The following careful description of the proper mode of applying
plaster of Paris bandages in fractures of the leg has been prepared at
my request by Dr. S. B. St. John, late house surgeon to Bellevue
Hospital. His large experience and his habits of accurate observation
render his statements peculiarly trustworthy.
"The materials necessary are, blanket, or cotton wadding, blanket
being preferable, and pla^iter of Paris bandages, which arc prepartnl by
rubbing dry plaster into the meshes of a l)andage of coarse texture,
and rolling it up so as to make it convenient of applicuition. (These
may be kept ready for use in tin c«ins.) The bones having been |>laced
in position, the leg is placed upon the blanket, which is cut an(J folded
neatly around it, and secured by a few pins. The blanket should ex-
tend from Uie base of the toes to the knee, or in case of fracture above
the middle, or of compound fracture at any point, a few inches above
the knee. The plaster bandages should then be immerseil in hot
water, to which a little salt has been added to hasten the setting, and
while in the water they may be gently kneaded to insure moistening
of every part. In about three minutes, or when bubbles of air ceai«
to rise from them, they will be ready for use, and should be taken out
as they are wanted, and gently scjueezed to get rid of su|xtHuous
water. They are then to be applied after the fashion of an onlinarjr
bandage, over the blanket, with just sufficient iirmne^N*^ to insure a
com|)lete fit. If, at any revolution of the bandage, the planter is seen
to be dry, it should be moistened by dipping the hand in water and
rubbing it over the dry surface. Extra turns of the bandage sh<mld
be tiiken at the places where it is necessary to secure extra strength to
the splint. Three or four bandages (six yanls long) are usually suffi-
cient to make a firm splint. The splint will usually be sufficiently
pliable just after its application to allow of rec^tificaticm of any faulty
position which may have occurred during its application. It should
then be kept in shajw by the pressure of the hands until it hanlcns,
which will be in from ten to thirty minutes, acc»ording to the fri*>hms!*
of the plaster and texture of the bandages used. If, for any n»:is«m,
it is desirable to cut the splint so as to admit of its removal, or tti nit
a fenestra through which to observe any part, this may bi^t Ih' d«»iM?
before the plaster becomes perfectly dry, say in fn)m two t4> five Imiirs
after its application, depending upon the quality and frt»shnc?vs t»f the
plaster. It will then cut like hard cheese, and a stout sharp knite
should be tisetl. In splitting a splint anteriorly, it is c^onvenient at tlio
same time to take out a piece about an inch wide, by making two
parallel cuts one inch apart, one on either side of the median line, ex-
tending nearly through to the blanket, and then by raising the strip ac
the upper edge, and cutting on either side alternately, the 80i*tio« may
be completed, and the central slip removed without danger of rutting
through the blanket and wounding the ptitient. The blanket may
then be cut with scissors and the splint sprung off to examine the limb.
FBACTUREB OP THE TIBIA AND FIBULA, 491
in". Wlien replaced, a bandage should be applied over it.
If it ehould be n««s9ary to cut a splint which bus already become
dry, and cuts with great difficulty, it may be softened with hot water,
applied by a sponge in the track of the proposed section for ten or
fifteen minutes.
"If it is necessary to cut such a. lai^e fenestra that only & small strip
of the splint would be left connecting its upper and lower portions, it
is better to adopt a different plan of atiplicatiou. For this it is neces-
eary to have a solution of plaster of Paris in water of the consistency
of cream. A piece of blanket is then cut long enough to reach from
the toes to the top of the proposed splint, and about fifteen inches wide.
This ifl to be thoroughly soaked in the solution, and folded several
times so as to be about two or three inclu'R wI<to when folded. This is
la be applied along that part of the limb which it is not necessary to
keep under observation (if convenient, along its posterior as]>ect), and
it is then to be secared in position by circular turns of the plaster
bandage above and below the iwrtion to be ieii ex|>(tsed. Whenever a
plaster apparatus extends above the knee, and It is proposed to sling
the 1^ from a cradle, the leg should be flexed slightly upon the thigh,
to that it may be swung horizontally. Any ))ortiou of a plaster splint
upoEed to the moisture of dischai^es or of water used in dressing,
aboald be carefully protected by oil silk and »)ttoii wadding.
"In cases where not much swelling is anticipate*!, blanket is prefer-
able to cotton wadding, as an elastic medium between the splint and
skin, because it is of more even thickness and retains its place better
when the splint is removed, but cotton answers better when much
swelling is anticipated, as being more elastic."
The accompanying illustration has also been made for me by Dr.
St. John, and furnishes a faithful picture of one of the many !^iniilar
rases which have been under treatment by this method at Bollevue
Hospital.
Plul«rorPmrIidKi«lDR, KU] suspeDsluD.
Dr. George A. Van Wagenen, while acting as house sui^con at
Bellevue, devised a most ingenious, simple, and effective apparatus
for EDspending the limb, which will be found illustrated In the ac-
company ins; woodcut.
"It consists of an efbow T of wood projecting over the foot of the
bed, from which the !c^ is suspendetl by two pieces of nibber tubing ;
492
FRACTURES OF THE TIBIA AND FIBDLA
one above the ankle, the other just belo^ the knee. The tubea 1
commoa groove<l iron pulleys or wheels at each end : those at
rolling on a. l&rae iron wire to allow motion toward the head or fo
the bed; those below, at rig)it angW to the otliers, holding the i
of rope in which the leg rotates; — this last being far the most iiu]
ant, allowing patient to tunt on either side. Motion on these tolli
accomplished with so liilk rtaistance that there is no pain.
"The upright of the elbow to go at the fi>ot of the lied shoali
long enongti to rest on the door, or any convenient post of the Itcdsl
and project about two feel above the level of the mattress, — the I
zontal piece long enough to reach nearly to the knee; pine { by 2 in
is heavy enough. The angle made by these pieces is braced, ai
strap of hoop-iron ontside makes it very strong. In the horisc
piece two slots are cut wide enough to allow the iron pulleys to
through, and of sufficient length to allow the patient to draw bin
up and down in bed. A ^ inch iron wire passes the whole lengt
this piece above the slots, steadied by small staples, so that it nw
withdrawn. On this the upper pulleys run. The wire shields i
above these slots are to prevent the bed-clothes from resting upon
rollers.
"The pulleys or wheels are fastened in the rubber tul)cs by null
a few turns of oop|)er wire around the iron screw of the jnilley. 1
is pushed into the tube and bound outside with fine wire.
"Ring^ of rope large enough to pass over the fi>ot are then
through the loner pulleys If the^te rings open, or the foot is slir
out ol them, the leg is taken down without any of the ap|iamtu» il
it, and the large wire may be with<lrawn and the leg lowered, with
pulleys and rings still attacluxl."'
There are a icw cases in which a very much better position of
fragments can be scc-ured by placing the patient under the ii
' Vin Wigsnen, H«d. Becord, April 1, 1878.
FHATTURES
R antesttietic, and by applying the dressing during complete antesthe-
' . But the surgeon needs to be warned of two things in this connec-
n : first, that just as much liarm can be dune to the soft parts by
feleDt wrenching and pushing when he is insensible as when he is
/conscious; second, that while the patient is passing under the
duence of an anesthetic he is liable to violent muscular spasms,
iiich may do serious injury.
n such few cases as demand or warrant a resort to permanent exten-
1 and con nter-es tens ion, a douhle-inclined plane furnishes a conve-
nient mode for its accomplishment; but it is only occasionally that, in
(ractnrcd of the leg, permanent extension and counter-extension can be
employed; an assertion which, however much it may excite surprise,
experience will prove true. If the fracture is near the middle of the
1^, quite remote from the points upon which the appliances for esten-
t'loa, etc., are to l>e made fast, and the infiammetioa is moderate, some-
thing may be done in this way; but when the point of fracture ap-
proaches the ankle-joint, as it actually docs in a great majority of cases,
a gaiter, made of any material whatever, if it has sufficient firmness to
overcome completelv the action of the muscles, will inevitably cause
congestion and swelling, accompanied sooner or later with great pain
and with ulcerations, and simply because the extension is made directly
upon parts already tender and inflamed fmm the accident itself; and
when wc add to this complete and violent ligation of the limb near the
scat of fracture, a similar ligation of tlie Hmb just below the knee, for
the purpose of making counter-extension, as is done in what is known
among American surgeons as "Hutchinson's splint,"' we are prepared
^ - JJ
k **> understand bow the worst consequences may ensue. I have (
h|*^ni, when this abominable ap()aratus had been used, a complete ring
^Hp ulreration below the knee, and another as complete around the foot
^^p4 ankle. The limb was twice girdled, and yet the surgetm thought
^^■1^ wtu performing a duty for the omission of which he would scarcely
^^Vtove b&!n n^rdcd as excusable.
nfBaegetf, bj JobnSyng Ooriey,^
i, p. IBl. Pbilidelphia,
494
FRACTURES OF THE TIBIA AND FIBUIiA.
Jarvis's adjuster, a still more mischievous, iuasmuch as it u
powerful iustrument, operating in a similar manner, has been
tive of like consequences ; but Jarvis's adjuster is liable to tl
tional objection that by its great weight it drags off the limb,
the toes outwards, an objection which no care or diligence can g
overcome.
I could wish that neither of these appliances would ever 8
impressed into the service of broken legs.
Neill, of Philadelphia, and others have sought to overcome
the difficulties in the way of making extension in fractures of 1
Fio. 226.
John Neiirs apparatus for fractures of the leg requiring extension and couuter-^xlti
by substituting adhesive plaster for the usual extending or <
extending bands.
Says Dr. Xeill : " For simple fractures of both bones of the
tended with shortening and deformity not easily overcome, tl
should be placed in a long fracture-box with sides extending
as the middle of the thigh, and a pillow should he used for com
" The counter-extension is made by strips of adhesive plas
inch and a half in breadth, secured on each side of the leg be
Fio. 227.
John NcillN apparatus for compound fractures of the leg.
knee, and al)ove the seat of fracture by narrower strijw of
applied circularly. The (mkI of the counter-exteiidin;^ strijw m
be 8einirc<l to holes in the up|H»r end of the s'n\v» of the fracti:
by which the line of the counter-extetmon w rendcral ii«ir(y
with the linib.
"The extension is also to ha made by adhesive strips, in
which is now well known and understo<Kl. The ends of the ex
bands may be fastene<l to the foot-board of the l)ox."*
1 Philadelphia Med. Exam., vol. xi, p. 680, 1866.
FRACTURES OF THE TIBIA AND FIBULA.
495
Dr. Neill further remarks: "In compound fractnres of the leg,
ahortening and deformity are often difficult to overcome, as is well
known to experienced surgeons. In snch cases we may wish to dress
the wounded soft parts, and, at the same time, maintain a certain
UQOunt of extension and counter-extension.
"This can be readily accomplished by having the sides of the frac-
tare-box sawed in two parts at the knee, so that the sides of the box
above the knee, fi-om the npper ends of which the eon nter-ex tension is
made, need not be disturbed during the ditssing, while that portion of
the side of the box corresiwnding to the leg may be opened at pleasure,
without diminishing tiie tension of the extending or counter-extending
liands."
In compound fractures of the leg. Dr. Gilbert recommends a modi-
fication of tlte common fracture-box. In this apparatus the foot-board
IB omitted, and a block for the reception of the frame of the tourniquet
18 substituted. Each side of the box consists of three separate seg-
ments. Of these the upper and lower are pci'mancntly screwed to the
botloro-board, and the central one is attache<l by hinges. By this
arnuifrement there is full access to the wound, which may be dressed
fiom day to day without disturbing the extension and con nter-ex ten-
sion, maintained by the permanently attached upper and lower seg-
nwnts.
The following woodcuts are intended to iilu^trate an apparatus
invented by R. O. Crandall, for the purpose of making permanent
4M
•:7 THi: TiaiA ASD FimCLA.
•fn-M-.T -111* 23iarr '.-r ii^a«*^T
jij
bj a gaiter, bol
whether he shftll
lor permaneot er*
rmlne, I am far froQ
Ijlu
to ynrv«at tbeir
•poo tbe
orer ft block of voxl nf'
of the koee.
conceding that tber will be fbond capable of overcoming the actioo of
the muscles vhere the ends of the fragments do not support each other.
Their mode of action is soefa that they can scarcely do more than to
hXeofly the limb, and if they operate upon the fragments at all in the
Fig. 231.
Posterior riev of the lower portion of CntDdall's apparatus.
direction of their axes, it must be only in the most inconsiderable de-
gree. The adhesive plasters are substituted for the circular knce-ban<|*
and the gaiters, with a view to avoid ligation; but in order todotht^
they mast not encircle the limb, but only be laid imrallel to its longai'*-
The leg of an adult, or that portion to which the adhesive plasters ^^n
be applied, supposing the fracture to be exactly at the centre, may i*
sixteen inches, that is, eight inches for extension and eight for Cl»unte^
exti'iision ; but when we employ the same means for extension in frac-
tures of the thigh, we find it n(»cessary to apply the stripes over the
whole of these sixtwn inches, the entire length of the leg, or ihevwill
not hold. It will be apparent also that we cannot use even the ei^rnt
inches which we have, for the pur|H)se of argument, allowed tbwe
gentl(»nu»n in fmctures of the leg. There must Ix? at It-iu^t a >j»3<*i' ^^
eight inches between the ends of the two op[)osing stri{]s in onlertbil
they may oiwrate at all uiM>n the fnigments; indiMnl, I do not U*lie^
that even then their influence would reach bevond the ^kiu to vhich
» ('rHmUn. Phil. M«h1. Journ.. vol iv. n 19.3. Jan. IS5«: a]«o TrmiiMC. of M*J.
>MOi'. of Southern and Central New York, I860, pp. SI, S2.
FBACTUBEB OF THE TIBIA AND FIBULA. 497
J were directly applied; but if » space of eight inches is left, only
ir remain for the strips at either end ; and this is an amount of ?ur&ce
lolly insufficient for our purpose. WImt, then, shall we do when the
icture is near one of the extremities of the bone? These gentlemen
SD to have forgotten, moreover, that the whole leg is tender, and that
e skin easily vesieates. In short, they have not seen tiie many points
difference between tlie application of these means in fractures of the
igh and leg, and which, while they allow ns to accomplish all that
tcould desire with the one, are of little or no use in the other. Wo
lU then always come to the same conclusion; whatever means we may
iploy to make ]^>erniancnt extension in fractures of the 1^, we must
Jier &il to accomplish all that we desire, or incur the hazards incident
complete and firm ligation of the limb; and if the preference is
ven to any form of apparatus to accomplish these ends, it must be to
toe form of the doubie~incline<l piano, by which we may at \eani avoid
;alion in the upper part of the limb, the counter-extension being made
UDst the under surface of the thigh while it is resting upon the thlgh-
ece; or to one of the long straight thigh-splinte, which will enable
to make the counter-extension from the thigh and perineum.
If a double-inclined plane is used, I prefer either a plain apparatus,
ch as we have already described as in use for fractures of the thigh,
DEtructed of boards, joined together by hinges opposite the knee, and
ith an upright footlxmnl, upon which a carefully arranged aud thick
ishion has been placed, or tne more elegant double-inolined plane of
iston.
Id using Liston's apparatus, it must not l>c inferred that the knee is
ways to be bent. The ap|>aratus is designed to be used occasionally
iBstraight splint; and there will be found many cases of fractures of
K 1^ in which the straight position will be most suitable: this is
specially true of such fractures as, occurring just below the knee-joint,
«vefhe line of fracture directed obliquely downwards and forwards,
lot there are many compound fractures which demand the same ex-
FrumMUUr.)
<K]ed position ; and in nearly all caves where this form of apparatus
Used as a double-inclineil plane, the lower end of the splint should
' elevated so that the heel shall not be much below the level of the
Me.
Bauer's wire splints, used also for side-splints, when they are formed
498 FBACTURES OF THE TIBIA AND FIBULA.
to fit the limb accurately, possess some advaDtages which must recom-
mend them to the attention of surgeoDS ; but neither these spliDts nor
any others, however accurately fitted, ought to be applied direc-tly to
the naked skin. They require always the interposition of a we/(-
padded lining.
Boxes are rarely useful except in certain compound fractures. Tbef
are heavy and awkward machines, which prevent the patient from
moving readily in betl ; or which, being fixed, if he does move, allow
the upper fragment only to descend, or to move upon the lower le •
fixo<1 point. If used at all, they ought generally to be suspended, or
made to move on a sus|>end«l railway. But, however, they are tt-
ranged, the limb is a great part of the time concealed from sight, fi
the suqjeon is prevented from making use of such means to ttdifj
' Btuer, BufTHlo Hetlical Journal, April, 186T, vol. sU.
FRACTURES OF THE TIBIA AKD PIBUI.A.
499
deviations in the line of the bone as lie would probably have otherwise
mployed.
The swing invented by Jamea Salter, of London, is consfrncted so
tt to allow not only a lateral motion, but also a more complete motion
m the direction of the axis of the limb, by which the danger of push-
Siltcfi crmdle. (Fnin
s^the fragments upon each other is obviated. This is accomplished
h (he rolling of two pulley-wheels upon a horizontal bar. The case
m which the leg rests may he made of metal or of wood, and the frame
of iron, for the sake of lightness and strength.
Dr. Hodgen, of St, Louis, siisjiends the Ixis over a pulley placed
IfMsversely, so that by drawing the rope to the right or to the left,
lie box may be turned upon citrier side.
Fracture-boxes, employed in the treatment of compound fractures
of the leg, are, in this country, sometimes filled with bran ; the bran
being closely packed npon all sideti so as to support the limb uniformly
ttd gently. This method of tn;ating compound fractures of the leg
was first suggested by J, Rhea Bar-
ton, of Philadelphia,' and has been fio. 23e.
mach used in the Pennsylvania Hos-
pital; and latterly it has been in-
troduced into the Bellevue and New
York City Hospitals. It possesses
the advantage of affording a perfect
protection against flies in the stim-
■ner season, and of absorbing the
matter as it escapes.
In using the "bran-box," the
Bides are firwt brought up into posi-
tion and made fast. A piece of muslin cloth, one yard in length by
> BBrlon, Amer, Journ. of Med. Scj,, vol. ivi, p. 81, and vol. lix, p. 616.
Fracture-boi, irltli
500
FRACTURES OF THE TIBl,
half a yard id breadth, is then laid upon the box, and into this the
bran is pouroJ, until it is about onc-fuurtli full. Tho braii ie then
distributed to as to fit the back of the leg, ami the limb is planed ia
position. After whi^h, additional bran is packed on either side of the
limb, until it is nearly or quit© enveloped; the wounds being Brafc:
covered by pieces of tint smeared with simple cerate. Finally, tha
upper portion of the muslin sack is fastened arouud the limb just above
the knee, to prevent the escape of the bran.
Whenever any portion of it becomes soiled by Itlowi or pus, it may
be dipped out with a spoon, and its place fiiipplied with fresh bma.
The support which it gives to the limb is also uniform withont l>ctiig
at any time excessive, and Dr. Coates states that the cscupe of blona
in rapid lufmorrhages has been known to incrca<^ the bulk of the bnn<
sufficiently to arrest the bleeding by it£ atxiumulated pressure.
In whatever position the leg is placed, and with many of the forms
of apparatus which we have ennmerated, it will be found neoeiwarv to
protect the limb from the weight of the bed-
clothes by some contrivance similar to thst
figureil in the accompanying drawing: or by*
rack, such as is represented for suspending
the leg when leather splints or the immovaHe
apjmratus is employed.
Malgaigne, wao declares tliat every snrKOik
wire ™jkftirfiw;ii.rBQf iFg. knows how impossible it is, in an immense
majority of cases, to overcome the pn^erfioa
of the superior fragment when the limb is placed in the pm-mitJ
position {over a double-inclined plane!, and who affirms thxt neithrt
Pott's position, nor Dupuytren's modification of it, will do rawliif wy
, jQ|||2|mi|apparaiuiror oblique rntttura* of the leK. i I'luu) Ualfmlfne.)
' better, nor, indeed, that Laugier's plan of outling the tendo Arhi'"*
les in this reai>ect any real advauta^, concludes iit lust to rW
to a now and really ingenious method, the value of which, also, I"
claims to have already i^Ily demonstrated. His appamtus oon**
simply of a steel Ifand of sufficient size to encircle I hnx*- fourths of**
limb, at the Uvo extremities of which are two hori/.<inlal miirti*
through which a band is passed, and which may be buckled u|x>n it*"
beiiind. The centre of the metallic arch, in front, is [tenelTatail *'^
a firm metallic screw, terminating in a very sharp point, and wliiclii>
moved by a flat tbumb-pieoe.
PBACTURES OF THE TIBIA AND FIBULA.
501
The limb being laid over a double-inclined plane, and the pads
being carefully adjusted, as we have already directed when si)eaking
of other forms of apparatus, and the lirab proix^rly extended, the
apparatus of Malgaigne is placed over the lirab, with the sharp point
of the screw resting upon the up{>er fragment, a few lines above the
Eoint of fracture; and at the same moment that this point is pressed
rnaly down to the bone, the fragments being held together by an
ttsistant, the strap is buckled as tightly as possible under the splint.
A few turns of the screw will now make its point penetrate more
deeply into the bone, and insure the most complete apposition of the
broken extremities. "This is accomplished," says Malgaigne, "with
very little pain to the patient;" and, as will be, seen, the steel arch
effectually prevents any ligation of the limb. I cannot say that the
plan receives my unqualified approval ; yet I have employed it to
idvantage in some cases of old ununited fractures.
Fig. 239.
Malgaign<>'9 apparatus applied. (From Malgaigne.)
Refracture and liescdion of Crooked Legs, — In some cases of extreme
Wornnty of the legs consequent upon badly united fractures, resection
ot the lK)nes has been practi(!eil with more or less success.
The first ciise of which I have seen any mention made, where the
bones were actually resected, is reported by Charles Parry, of Indian-
3pf)lis, Ind. A young man, rot. 15, having broken his leg near its
middle, the fragments united, from some cause, nearly at right angles
with each other. Some vears afterwards, on the 15th dav of January,
1838, Dr. Parry operated, by removing a wedge-shaped portion irom
both the tibia and fibula. The recovery was tedious, but satisfactory.*
Mr. Key, of London, made an operation of this kind upon a gentle-
man who had suffered a fracture of the right tibia from a musket-ball.
The limb was nearly useless, since he could only bring his toes to the
ground. Mr. Key operated in October, 1838, and when the report of
the caf»e was made, five months subsequently, the patient was doing
well.*
''parry, Amer. Journ. Med. 8ci., Au^j. 1H39, p. 334.
* Key, Amer. Juurn. Mod. Sci.| Aug. 1839, p. 339; from Guy's Hospital Kcportg,
April, 1889.
504
CTirRES OF THE TA
ture taken plaro posterior to the lateral ligaments, the detaehed fn^
ment ie liable to be drawn very far from the btHly of (he boue, eva
to the extent of four or five Juclies, and possibly tarther when the le^
is extended upon the thigh and the foot flexi'd upon the leg. Coi
atanre relates a case in which the tulwrosity, having been brokei
by a direct blow, was drawn up five inches.'
Fractures of the calcaneiim pro*luced by contraction of the sunit
muscles are generally simple, but thone whieh result from a crii4i(ii^
of the bone are more often compound. The «ime remark ie applicable
also to the other bones of the tarsus, the fractures of which, bciii^ ti
produi-ed by direct blows, are generally complicated with (^xtt-nial'
wutindid.
Si/infitnms. — All fractures of the bones of the tarsus demand es^teeial.
care in their diagnosis, since only a few of the usual signs of fnictofV
are in a majority of the cases presented. The explanation of this fact
will be found in the number, size, and strength of the bones of tb>
tarsus, and in their close and firm union by ligaments, by which th^
give to each other a mutual support, so that the fracture of a eingfai'
bone does not necessarily or usually result in displacement or delVtrtn*
ity, and even crepitus is with difficulty detectetl ; and when we toq-
fider, moreover, that the fracture is generally produced by greiit vio*
Ienc«, directly applied, in consequence of which the fixit in most aw*
becomes rapidly and euormnnsly swollen, we shall unden>tKnd (he InM
nature of the difficulties which are usually presente«i in thv way of an
accurate diagnosis.
Of all the usual signs of fracture, crepitus alone is pretty jp'nenill.f
present, but even this often fails l« tell ns whi<'h bone is brokwi, >D "
still more often does it fail to inform us as to the din?ction and txta
of the bony lesions.
If the whole or a portion of the tuberosity of the oalt^nenm isHfM*
rated by the action of the muscles, and the fragment is drawn apw>i™s
it may he discovered in its new position, and the heel will be flatt(
or sliort^ned, but no crepitus can be felt unless the fragments aroi(
brought in contact.
Treatment, — Not any of the fractures of the tarsal bone« in lb"
selves demand the use nf splints, and it is only when complicatnl wil^
a dislocation of the ankle and fracture of ihc liliuln that it is limp"
to employ apparatus of this si>rt ; certainly [he ex«-ptions tn this m
must lie very rare ; so that our practice in thest cuses will W. <»wi(iw
chiefly to the prevention and reduction of inflammalinn. The 1^1*
must tw plaoed in the most ca.-^y {tosilion, and cold water hitious >«<^'
nonsly applied. This will Ix.- the sum of the treatment deniio^
during tJie first few days after the I'eceipt of the injury in proialih •*'
oases of simple fracture, anil in many eases of compound traciuiv-
If single bones, or t'rjiginents of i^iugle l«ones, are displanil I" ^
\ eansiderable extent, and there is an external wound commuiiim"'
with the fracture, I have no doubt it would be host in all va»i I" ""
I ConiiNtiPi:, Amor. Journ. Med. ScL, vul v, |i. I'i-i, Nui. 1829, from Ik* XiO^
Med, and Hiirg. Kopurtur.
FRACTURES OF THE TARSAL BONES. 503
The calcaneiim is also occasionally broken by violent lateral pres-
sure, but much more often by a fall upon the foot, or rather upon the
heel. In some instances both heel-bones have been broken at the same
moment; but Malgaigne has collected eight cases of fracture of this
bone by muscular action, as in jumping upon the toes, the posterior
portion of the bone being thus violently acted upon by the tendo
Achiilis. South, in his Notes to Chelius, has mentioned two other
cases, one of which was seen by Lawrence, and has been reported in
the second volume of the Lancet, This person had received the injury
by jumping off a stage-coach. The fragment was found to be drawn
upwards slightly, but not so far as to prevent crepitus when the mus-
cles on the back of the leg were relaxed. The other example mentioned
hy South is a cabinet specimen cx)ntained in the museum of St. Bar-
tholomew's Hospital. The fracture had taken place just below the
attachment of the tendo Achiilis, but the upper fragment was not dis-
placed.^ Mr. Cooper mentions two other cases, both produced by vio-
lent efforts on the part of the patients to sustain themselves when fall-
ing. In one of these the fragment was immediately drawn up three
ji Dches.^
The other bones of the tarsus are generally broken by crushing
Cftceidents, such as the fall of heavy weights upon them, by the passage
of loaded vehicles, etc.
Pathology, — The astragalus often, indeed generally, escapes without
injury in those crushing accidents which break many or most of the
other bones of the foot, and, as we have seen, it is seldom broken
except when the patient has fallen upon the bottom of his foot ; but
»t the same moment, the foot being turned forcibly out or in, a dislo-
cation of the tibia takes place, and the fibula is broken. In nine of
the cases collected by Monahan, one or the other of these forms of
dislocation had occurred, in eight of which the dislocation was com-
pound. The direction of the fracture is found to vary greatly ; thus,
't has been found broken in its length antero-posteriorly, in its breadth
^r transversely, and in one instance it has been divided nearly hori-
zontally, so as to separate the upper face completely from the lower,
^metiraes it suffers a species of impaction, the fragments being actu-
^Uy driven into each other ; at other times, as iu one case related
^y Amesbury, the bone may be split without the occurrence of any
displacement.
The calcaneum also may be broken in any direction, and it is equally
y^ith the astragalus liable to impaction, by which its vertical diameter
*® sensibly diminished, while its transverse diameter is increased. If
^'^ fracture is a consequence of muscular action, the line of fracture is
^*Way8 posterior to the astragalus, and in some case^ only that portion
{^ broken off to which the tendo Achiilis has its attachments. It may
^ broken also vertically, directly underneath the astragalus, in which
^^ the lateral and interosseous ligaments will prevent anything more
^n a slight displacement of the posterior fragment. When the frac-
' South, Notes to Chelius's Surgery, vol. i, p. 639, Amer. ed.
• B. Cooper's ed. of Sir Aslley, Amer. ed., p. 811.
504 FRACTURES OF THE TARSAL BONES.
ture takes place posterior to the lateral ligaments, the detached frag-
ment is liable to be drawn very far from the body of the Inme, even
to the extent of four or five inches, and possibly farther when the leg
is extended upon the thigh and the foot flexed upon the \e^. Con-
stance relates a case in which the tuberosity, having been broken off
by a direct blow, was drawn up five inches^
Fractures of the calcancum produced by contraction of the soral
muscles are generally simple, but those which result from a enishing
of the bone are more often compound. The same remark is applicable
also to the other bones of the tarsus, the fractures of which, being only
produced by direct blows, are generally complicated with extermil
wounds.
Symptoms. — All fractures of the bones of the tarsus demand especial
care in their diagnosis, since only a few of the usual signs of fracture
are in a majority of the cases presente<l. The explanation of this faci
will be found in the number, size, and strength of the bones of the
tarsus, and in their close and firm union, by ligaments, by which they
give to each other a mutual support, so that the fracture of a single
bone does not necessarily or usually result in displacement or deform-
ity, and even crepitus is with difficulty detected ; and when we con-
sider, moreover, that the fracture is generally produt*ed by great vio-
lence, directly applied, in consequence of which the foot in most ca»ei
becomes rapidly and enormously swollen, we shall understand the true
nature of the difficulties which are usually presented in the way of an
accurate diagnosis.
Of all the usual signs of fracture, crepitus alone is pretty generally
present, but even this often fails to tell us which bone is broken, and
still more often does it fail to inform us as to the direction and extent
of the bonv lesions.
If the whole or a portion of the tuberosity of the calcaneum is sepa-
rated by the action of the muscles, and the fragment is dmwn upwanl»|
it may be discovered in its new jwsition, and the heel will lie flattened
or shortened, but no crepitus can be felt unless the fragments are again
brouijht in contact.
Treat iiumt, — Not any of the fractures of the tarsal bones in them-
selves demand the use of splints, and it is only when complicatetl with
a dislocation of the ankle and fracture of the fibula that it is pro|ier
to cm})lf>y apparatus of this sort ; certainly the exceptit>ns to this rule
must be very rare; so that our practice in these cases will be confined
chiefly to the prevention and reduction of inflammation. The limb
must be plactHl in the most easy position, and cold water lotions assid-
uously applied. This will be the sum of the treatment <Iomanded
during the first few days after the receipt of the injury in proUibly all
cases of simple fracture, and in many cases of compound fracture.
If single bones, or fragments of single Ixmes, are displacetl to any
considenible extent, and there is an external wound communicating
with the fnicture, I have no doubt it would be best in all cases to re-
' C«'n»«Hfiic, Amor. Journ. Med. Sci., vol. v, p. 2*J2, Nov. 1829, from iho MidUnd
Med. It lid Surg. Reporter.
FRACTURES OF THE TARSAL BONES. 505
move at once by dissection the projecting bone, even although it were
possible, or perliaps easy, to force it back again to its place, as has been
doDe saocessfuUy by Ashhurst, of Philadelphia.* The same rule I
would apply to examples of fracture uncomplicjited with any external
wound, if the fragments were very much displaced, and could not by
the application of moderate force be replaced, since the bone left to
prefect would prevent the patient from ever wearing a boot w ith com-
fort, and would entail as much weakness upon the limb as would be
likely to follow from its complete separation. But such cases as I
have last supposed are exceedingly rare ; indeed, I have never met
with a simple fracture of a tarsal bone accorapanie<l with displacement.
Norris has, however, reported a case of fracture of the astragalus
aooompanied with displacement of about one-half of the bone, but
without any lesion of the soft parts. This was in the person of a man
9bL 30, who was admitted into the Pennsylvania Hospital on the 26th
of Sept. 1831. "An hour previous to admission, while descending a
ladder, he slipped and fell in such a manner as to throw the entire
weight of his body upon the outer part of his left foot. Upon exami-
nation, the foot was found to be turned inwards and nearly immovable.
A slight depression existed immediately below the lower end of the
tibia, and there was a considerable hard and rounded projection on the
outer part of the foot, a little below and in front of the extremity of
the fibula. The skin covering this projection was reddened, but not
excoriated. There was no fracture of either bones of the leg."
These appearances led Drs. Norris and Barton, under whose care
the patient was placed, to regard the accident as a simple luxation of
the astragalus forwards and outwards ; and a short time after admission
efforts were made to reduce it. " This was done, after relaxing in as
great a degree as possible the muscles of the leg, by fixing the knee,
and having assistants to keep up extension, by seizing the heel and
froot part of the foot; at the same time the bone being pushed inwards
aod toward the joint by the surgeon. These efforts were continued
for a considerable time, but had no effect in changing the position of
the bone.
"Six hours afterwards Drs. Huston and Harris saw the patient in
consultation, when efforts were again made at reduction, which not
proving more effectual than in the fii-st trial, the excision of the bone
was determined on.
"The patient being properly placed, an incision was made through
the integuments, parallel with the course of the tendons, commencing
a short distance above the projection on the foot, and extending down
fitf enough to exj)ose fairly the astragalus and its torn ligaments. The
bone was then seized with forceps, and easily removed after the division
of a few ligamentous fibres that continued to connect it to the adjoin-
ing parts.
"Very little hemorrhage occurred, two small vessels only recjuiring
the ligature.
1 Aahhurst, Amer. Journ. Med. Sc'i., April, 18G2.
83
606 FRACTUKES OF THE TARSAL BONES.
"After removal it was discovered that about one-half of the surface
which plays in the lower end of the tibia had been fractured, and re-
mained firmly attached to the extremity of that bone, and as it was
judged that the efforts to remove this would be likely to produce more
injury to the joint than would arise from allowing it to remain^ no
attempt was made to extract it.
"The joint being carefully sponged out, the sides of the incisioo
were brought accurately together by means of sutures and adhesive
straps, after which simple dressings and a roller were applied, and the
foot, restored to its natural situation, placed in a fracture-box."
Subsequently that portion of the astragalus which was permitted to
remain, having become carious and loosened, was removed also.
The case continued to do badly; all the bones of the tarsus, and
even the lower ends of the tibia and fibula, becoming eventually cart*
ous; and on the 27 th of March, 1853, more than a year and a half
afl^r the receipt of the injury, the leg was amputated ; but no healthy
action ensued, and the patient soon died.*
The result of this case can scarcely be regarded as having settled any-
thing in reference to the value of the procedure which I have recom*
mended. For reasons which seemed satisfactory to the surgeons who
made the operation, only one-half of the broken bone was removed;
whether the result would have been different if the whole had been at
once taken away, we cannot now determine. I have related it, how-
ever, as the only example of a simple fracture with displacement which
I have been able to find upon record ; and in this case, several sur-
geons of merited distinction concurred in the opinion that the protrud-
ing fragment ought to be removed.
A fracture of the |K)sterior jwrtion of the calcaneum, especially when
it has been produced by muscular action, constitutes an exception to
fractures of the tarsal bones generally, and demands usually that appa-
ratus of some kind should be employed in its treatment.
In order to replace the posterior fragment when displaced, or to main-
tain it in apposition until a bony union is accomplished, it will he neces-
sary to shorten the gastrocnemii by flexing the leg ujx)n the thigh and
extending the foot upon the leg. But to retain the limb in this position
it will be expedient always to employ apparatus. A very simple con-
trivance, however, will generally answer all the indicatioas. A band-
age, pa^lded strap, or a stuffed collar may be fastened about the thigh
just above the knee, and made fast to the heel of a slipper by ata|»p
(Fig. 240). The apparatus is the same which has been recoraraeudeJ
for a rupture of the tendo Achillis.
In addition to this, the limb ought to be covered from the foot up-
wards as far as the knee with a snug roller, underneath which, on each
side of and above the detached fragment, ought to l)e placed suitahk
compresses, the object of the roller l)eing to diminish muscular i^w-
traction, and the compresses being intended to retain the detached
piece in contact with the main body of the bone. Some surgeons hav«
^ Norris, Amer. Journ. Med. Sci., vol. zx, p. 879.
PSAOTUBES OF THE HETATAKSAL BONES. 607
i it necessary to flex the leg upon the thigh ; but they have
themselves with extending the foot upon the leg, and con-
in this position by a splint
or gutta-percha laid along fio-mo.
of the 1^, ankle, and foot,
ther cases, the fragment has
little disposition to become ^t""^ ^ ^ i
as to render no precautious '^■' * ' '
nd necessary, except to im-
1 the patient complete quiet,
limb resting upon its outside
J, as in Pott's fracture of the
in as the inflammation has
ly subsided, passive motion
given to the ankle, in order
nt, as far as possible, the
is which is au almost con-
ilt of these accidents. In-
patient is fortunate who re-
iolerable use of Ills foot uf^er
! of many months; nor can
mred that the inflammation
E these bones and their dense
nvelopes for a long period,
it may not result in caries of
less of the tarsal bones, de-
finally anmulation of the
ive not intended to speak in
; of those severer accidents,
lied with comminution and extensive laceration, which forbid
of saving the foot, and for which immediate amputation is the
»er resource, but which constitute, in tact, the great majority of
actures of the tarsal bones.
CHAPTER XXXIV.
FRACTURES OF THE METATARSAL BONBS.
E bones can scarcely be broken except by direct blows, and the
ijority of their fractures are the results of severe crushing acci-
ich ax render amputation sooner or later necessary. Of thoee
.o not demand amputation, by far the largest proportion are
508 FRACTURES OF THE METATARSAL BONES.
compound fractures; of which class the following example will serve
as an illustration :
A man in the employ of one of the railroads which connect with
this city was run over by a loaded car on the 14th of June, 1856,
crushing his right arm so as to render its immediate amputation neces-
sary. I found also a compound comminuted fracture of the fourth
metatarsal bone of the right foot. Considerable haemorrhage occurred
from the wound, but this ceased spontaneously. Cool water dressings
were diligently applied, without splints or bandages, and although
some inflammation and suppuration ensued, the parts finally healed
over and the fragments united, with only a slight backward displace-
ment at the seat of fracture.
When only one bone is broken, the displacement is usually very
trivial ; but when several are broken, it may be considerable. Mal-
gaigne relates an example of this latter accident in which, the three
middle bones being broken by the wheel of a carriage, and the integu-
ments being badly torn and bruised, it was found impossible to retain
the fragments in place. The patient recovered, and was able to place
the foot well to the ground,, but the proximal fragments continued to
project upwards upon the top of the foot to such a degree as to require
a special shoe.
In a majority of cases the direction of the displacement is backwards
(upwards), especially when the middle metatarsal bones are the sqIk
jects of the fracture.
I have in my cabinet a second metatarsal bone broken obliqaelj
near its middle, with only a very slight displacement of the lower fraig^
ment backwards ; and also the cast of a bone which has united with to
enormous backward projection.
In one instance I have seen the metatarsal bone of the little toe cat
in two with an axe, and the fragments united in about thirty days, bat
with tlie lower fragments slightly displaced outwards.
Delamottc relates a case also in which the first four metatarsal bones
were cut off, and complete union was accomplished on the fortieth day;
at the end of tw^ months the patient walked without lameness.
Treatment. — If the fragments are not displaced, nothing is reqairrf
except that the foot shall be kept at rest, and the inflammation con-
trolled by suitable means.
In case, however, a displacement exists, it ought to be remedied, if
possible, since, if only very slight, it may become the source of a serions
annoyapcc. If the fragments project upwards, they interfere with the
wearing of a boot, and if they sink toward the sole, the skin beneath*
liable to remain constantly tender, and the patient may thus be «eri-
ously maimed for life.
In case the displac*ement is not due to the action of the muscles, ^^
only to the nature and direction of the force pro<lucing the fracture, of
to entanglement of the broken ends, and it is likely to cause anyofth^
inconveniences which I have mentioned if permitted to remain, it ^
be advisable at once to employ considerable force in the way of f^
sure, or to elevate the fragments through an opening previously Dtf»
FRACTURES OP THE PHALANGES OF THE TOES. 509
upon the dorsum of the foot, calling to our aid even the saw or the
bone-cutters, if necessary. After which the fragments may be retained
in place by carefully applied pasteboard splints and compresses.
CHAPTEE XXXV,
FRACTURES OF THE PHALANGES OF THE TOES.
If fractures of the other bones of the foot are generally of such a
character as to require immediate amputation, these fractures demand
this extreme resort still more often. Our experience, therefore, in the
treatment of fractures of the phalanges of the toes is extremely limited.
Lonsdale observes that it is not uncommon to find great irritation
arise after fracture of the great toe ; an inflammation extending along
the absorbents on the inside of the leg to the groin, causing abscesses
to form in different parts of the limb, and producing sometimes great
constitutional disturbance. An illustrative case has come under my
own observation at the Buffalo Hospital of the Sisters of Charity. The
patient, Morgan McMann, set. 18, was admitted Dec. 23, 1863, having
aeveral days before received an injury upon the great toe which con-
tused the flesh severely and broke the first phalanx. He was then
sufiering from severe pain in the foot and leg, and the absorbents were
inflamed quite to the groin. Poultices being applied to the foot and
eool lotions to the limb, the inflammation soon subsided, but not until
a portion of the toe had sloughed away. Eventually also it became
necessary to remove some portion of the phalanx, which had died ;
after which the wounds healed kindly.
When any of the smaller toes are broken, it will be found easier to
8iipport the fragments by a broad and long splint which shall cover
the whole sole of the foot and all the toes at the same time, than to
attempt to apply a splint to the broken toe alone. If, however, we
prefer this latter mode, a thin piece of gutta percha will be found alto-
gether the most convenient material for the purpose.
If the great toe is broken, its great breadth may prevent any dis-
placement, and a well-moulded gutta-percha splint will generally
aecure a perfect and rapid union.
GUNSHOT FBACT0RE8.
CHAPTER XXXVI.
GUNSHOT FRACTUREa.
Gunshot fractures have already been considered, more or less iai
detail, iu the several portions of this work, wherever it seemed l«
necessary to call especial attention to them. This chapter will be <
voted, therefore, to & brief rhuvU of my own observations and coo*
elusions in this department; to which will be added a few general
statistical statements, drawn chiefly from the published records of {^'
late WOT.
Causes. — Gunshot fractures are cawsed by a great variety of raiasil
such as musket and rifle balls, solid shot and shell, grape, canist
shrapnel, chain and bar shot, fragments of iron, stone, splinters of
wood, etc., etc. The only qualities which these mL^silcs jMissas tn
common is, that they are all projected by the elastic power of gun-
powder, and generally strike the mxly with great force ; and that thtrf
cause fractures by direct violence — seldom if ever by count«r-strokc.
Round, smooth balls frequently impinge upon hones without onm
I ing a fracture, for the reason that they are easily deflected ; aiii] tki
happens especially when they are not moving with great velocity.
Conical rifle-balls seldom fail to fracture the bones which lie in their-
direct course ; never, ]>erhaps, when, at ihe moment of contact, ll» batf
is moving with its average velocity. The [)eculiar deetructivi^HM of
this missile is due to its weight, momentum, and form.
Canister, grape, shrapnel, solid shot, sliells, chain and bar .•ihot,«e
still more destructive ; generally tearing the limbs from the bodyi"
such a manner as to rentier readjustment and restoration impomible.
PatJiology. — These fractures may be simple, compound, commiuai'd.
or complicatiKl ; and in addition to these common varieties of fnduiu
there is occasionally presented an example of simple " pcrforatiiW," «
mere penetration of the hone without fissure or otlicr fracture; »al
I itill more frequently are seen examples of perforation witli fi8siin&
I Probably ninety-nine per cent, of all gunshot fractures are bolll
compound and comminuted; the comminution being, in gCDcral, fi-
oessive.
As in gunshot wounds of the soft parte it has l>een genemDy ^
served that the point of entrance is more round, more smooth, w
somewhat smaller than the point of exit, and lliat tlie tiasna st*
little depressed at the entrance, while they are sliuhlly pmtruiW ^i
the exit, so also in gunshot fractures it will often lx» i'ound ihm ^
side of the bone on which the ball has entered, or u[>on which it if^
impinged, is less comminuted than the opposite side; and, if il i**
" perforation," that the opening is smaller upon the one side than vf*
the other ; Uiat the edges are slightly depreeeed upon the one aid^ ■>'
GUNSHOT FRACTURES. 511
elevated or protruded upon the other; and, finally, that numerous
small y as well as some large, fragments of bone have been carried into
that portion of the track of the wound which lies between the bone
and the point of exit of the missile.
When a ball fractures the shaft of a long bone, although the blow
may have been received three, four, or even six inches from an articu-
lation, the comminution or a single longitudinal fissure may sometimes
be found extending into the joint. These fissures or splittings of the
shaft often extend also a long distance up or down, without termina-
ting in the joint.
Perforations without fissure occur most often in the broad bones of
the pelvis, in the scapula, or in the spongy extremities of the long
bones. In the latter, however, it is exceedingly rare to find perfora-
tion without fissure.
Perforations with fissure are pretty common in the head of the hu-
merus and in the head of the tibia ; they occur also, but less oft:en, in
the lower ends of the femur and tibia, in the trochanteric portion of
the femur, and in the head of the femur. We wish to be understood
to say that fissures occur less often at the points last mentioned, simply
because perforations are there less common. It must be known that if
perforations do occur at these points, a splitting or fissure communi-
cating with the joints is almost inevitable. A misunderstanding here
would lead to a very fatal error in many cases.
Prognosis, — In general it may be stated that gunshot fractures of
the upper extremities do not demand amputation, and that similar in-
juries in the lower extremities do demand amputation.
This statement is very broad, and cannot be understood except by a
consideration of these accidents somewhat in detail. Thus :
Gunshot fractures of the clavicle, scapula, of the shaft of the hu-
merus, of the shafts of the radius and ulna, and of the carpal, meta-
carpal, and phalangeal bones, notwithstanding these bones have suffered
extensive comininution, do not usually demand amputation ; they will
in most cases eventually unite, and give to the patients tolerably useful
limbs. If, however, at the same time that the shaft of the humerus,
or of the radius and ulna, is thus broken, the large nervous trunks are
torn asunder, so that the extremity is cold and insensible, the limb
cannot probably be saved, nor, if it could be, would it be of any value.
Destruction of the main artery supplying the limb diminishes the
chance of its being saved, but does not, in the case of the upper ex-
tremities, necessarily demand amputation.
Penetration of the shoulder-joint by a musket or rifle ball, producing
a fracture of the head of the humerus or of the glenoid cavity of the
scapula, demands amputation when either the axillary artery or axil-
lary nerves are injured ; but resection can generally be practiced with
a reasonable chance of success when the arteries and nerves are un-
touched. Resection is also made successfully at the shoulder-joint in
some cases where larger missiles have traversed the joint, such as can-
ister, fragments of shell, etc.
Penetration of the elbow-joint by a large shot, or by a Mini6 rifle-
GUSSHOT FRACTURES.
ball, the missile fairly entering or traversing the joint, douiands ampu-
tation when the main arterial and nervous eupplies are cut off, andl
resection, generally, when both remain uninjured. Resection may bb
attempted at the elbow-joint, also, in some casea where, the nerve
supply remaining good, only one of the principal arterial trunks
cutoff.
Frequently a ball strikes the outer or inner condyle of the humenia,
makin)r but a small opening into the joint, and pniduclng only slighi
comminution, and in such coses we ouen save the limb with more o
less anchylosis, and without resection.
The remarks which we have made in reference to gunshot fractarea
of the elbow-joint apply, almost without quali 6 cation, to the i
accidents at the wrist-joint.
For gunshot wounds with fractnre of the carpal, metacarpal, andr
phalangeal bones we seldom practice either resection or amputation,
onle^ the soft parts are almost completely torn away.
The prognosis which, as we have now seen, is so favorable in tl»e
upper extremities, will be found very different iu the lower estremi-
ties ; indeed, it is almost reversed. Thus :
Gunshot fractures of the shaft of the thigh, of the shafts of the tibi^
and fibula, and of the tarsal bones, generally demand amputation;
to l)e more precise, gunshot fractures of the head and neck of the femnr
almost always terminate fatally under amputation or excision, iiiij
equally under treatment as fractures, that is, where an attempt is invJe
to save the limb without interference with the knife. The same wa-
dents in the upper third of the shaft of the femur are generally fiitsl;
but if the main artery and the principal nerves are uninjured, the lift
IB, in general, less hazarded by an attempt to save the limb than br
smpulation. In the middle third, under the same circumstances, tw
chances may be considered equal, as between amputation and the
attempt to save the limb by apparatus; in the lower third the nl
are in favor of amputation.
The above statements in relation to fractures of the femur are huti
mainly upon my own experience, and have been carefully coii«iileni]-
I have seen no resections of the knee-joint, and but few of the sluA
of the femur, after gunshot fractures, which have not toruiinalcd fatal!*:
and I am convinced that they should never be attempted in fnclnn*
of the thigh, unless it be that ease which prcsentji so Utile hope iaMT
direction, viz., gunshot fracture of the head or neck of the femur.
Gunshot fractures of the shafts of both tibia and fibula dwnw'
amputation where the comminution is extensive, or the pul«aiuB«f
the |ios1erior tibial artery is lost, or the foot is cold and immsibiB
"We do not mean to say that some limbs thus situated have not bcH
Mve<I, but only that the attempt to save such limbs gn-ally embufS*
the life of the patient, while amputation at or Itelow tlic knee is na-
tively safe.
Amputation is the only safe expedient in dcp penHmting i
of the tarsal bones produced by missiles of the size of inu»'
la^er. The only exceptions, which can safely l>c m«
where halls have opened partially and superficially theae a
GUNSHOT FRACTURES. 513
Resections at the ankle-joint are much more hazardous than arapu-
tatioDSy and scarcely to be preferred, in army practice, to attempts to
aave the foot without surgical interference.
TVeaiment. — While considering the prognosis in these accidents, I
have necessarily spoken of the treatment in certain cases; especially
with a view to the propriety of amputation or resection. It remains
only to speak briefly of the treatment of those cases in which we may
attempt to save the limb without resection, properly so called ; for we
must not forget that pretty often we find it necessary to remove small,
loofie fragments of bone by the finger, or by the aid of the knife, or to
resect sharp points with the saw or the bone-cutters, when we do not
practice " resection," in the sense in which this term is usually em-
ployed by surgical writers.
I shall take the liberty, in this connection, of reproducing what I
have written elsewhere in relation to gunshot fractures, since it com-
prises nearly all that seems necessary to be added upon this subject.^
" If an attempt is made to save a limb badly lacerated and broken,
certain conditions in the treatment are necessary to success.
"All projecting pieces of bone which cannot be easily replaced and
are not firmly attached to the soft parts, must be at once cut or sawn
away.
"All foreign substances, such as fragments of balls or other missiles,
pieces of cloth, wadding, dirt, etc., must be removed.
"Any portions of integument, fascia, or muscles, which are entangled
in the wound, and prevent a thorough exploration, or may obstruct
the free escape of blood or of matter, must be freely divided.
"Counter-openings must be made at once, or at an early period after
the formation of matter, to insure its easy escape.
"The limb must be placed in an easy position, and not confined by
tight bandages or forcibly extended by apparatus.
" The inflammation must be controlled by constitutional and local
means, and especially by the use of water lotions whenever their em-
ployment is practicable."
If joints are implicated seriously, and an attempt is still made to
save the limb, the joint surfaces must be laid freely open, so as to pre-
vent all possibility of the confinement of blood, serum, or pus ; and the
joint must be placed perfectly at rest, without adhesive strips, bandages,
or any apparatus which shall compress the limb or embarrass its circu-
lation.
I do not know that it is necessary to speak more particularly of the
treatment of gunshot fractures, unless it be to say that I still give the
preference, in fractures of the femur, to the straight position. In most
cases I have preferred my own apparatus, already described when
speaking of fractures of the thigh in general, with moderate extension;
and by moderate extension is to be understood such as may be effected
with from five to ten pounds.
* TreiitiM on Military Surgery, by Frank Hastings Hamilton. 1 vol.,8vo. Pub-
lished by Baillidre Brothers. New York, 1861 ; also enlarged ed. of same work in
1866.
GUNSHOT FBACTUBBa.
A movable canvas, such as is shown in the accompanying woodcut,
witb a hole in tlie centre, and reinforced by an atlditional piece tk
canvas where the weight of the hips rests, will enable the surgeon t«
move his patient and clean the bed when necessary. Tlie standsid
which supports the pulley can be received in a slot in the frame.
An apparatus similar to this was used, during our late war, in the
I^incoln General Hospital at Washington.
I have also used, with the movable canvas, and upon an onlinut
bed, Hodgen's apparalus, or "cradle," as he terms it^antl have ftiuH
it cxoce<lingly uwt'iil, and much preferable to any form of double-in-
clined plane, whether KUi<pended or not. The cradle is Rimply a skel^
ton-box, of the length of the thigh and leg, made of light 8tri{M of wood.
GUNSHOT FRACTURES.
515
Across the two upper bars are laid, transversely, cloth bands, upon
vhich the limb is laid at full length.^
Fio. 248.
Fio. 244.
Hodgen'B apparatus for gunshot fractures of the thigh.
Of gunshot fractures of the femur many hundreds, probably many
thousands, during and since the close of our civil war, have come under
my observation ; but of these, only 92 have been made the subject of
especial record. Of this number, 75 were fractures of the shaft of the
femur; 9 being fractures of the upper third ; 36 of the middle third;
and 30 of the lower third. Nearly all of these fractures were caused
by the conical rifle-ball. They were treated in various Federal and
Coofederate hospitals by a great variety of methods, and under a variety
(^circumstances, which latter were sometimes favorable and sometimes
anfavorable. The results may, therefore, be regarded as furnishing a
fiiir basis for conclusions as to what may reasonably be expected in army
surgery, or during the progress of a great war. I have a strong con-
viction, however, that if in an equal number of cases the straight po-
sition, with moderate extension, were to be employed, and the circum-
stances were as favorable as are usually found in civil hospitals, the
results would be considerably better than are here shown. Indeed, my
own recorded cases show, in a marked degree, the advantages of the
straight position, with slight extension, over the double-inclined planes.
In a number of these cases, while the limb was flexed, the shortening
and bending were excessive, and the substitution of Buck's apparatus,
Hodgen's, or my own, has made at once a great improvement in both
regards, besides contributing manifestly to the comfort of the patients.
The average shortening in those fractures of the shaft of the femur,
1 Hodgen, Treatise on Military Surg., by the author, p. 408.
516 GUNSHOT FRACTURES.
which were measured by myself, was, in the upper third, two inches
and one-eighth ; in the middle third, two inches and one-quarter ; and
in the lower third, a h'ttle more than one inch and a half. In the
upper third three were shortened two inches or more; the greatest
shortening being three inches and one-quarter. In the middle third,
twenty were shortened two inches or more, six three inches or more,
two four and a half, and one five inches. In the lower third, two were
shortened two inches or more ; the greatest shortening being two inchea
and three-quarters.
In a large proportion of the cases the thigh was bent at the point af
fracture, the bend being in most cases outwards, or to the fibular siifc
of the limb. Where N. R. Smith's suspension apparatus was used, the
bend was usually backwards, while in most of the cases treated in tlie
straight position, with moderate extension, the limb was nearly or quite
straight.
It is somewhat remarkable that in this table of ninety-two case
there are only three examples of union delayed beyond four mooths,
and one of these patients was evidently about to die. In a pretty large
proportion of cases the union was not delayed much beyond the usual
period of union for a simple fracture, although the limb might be
much shortened and crooked, and still discharging pus, with frag-
ments of bone occasionally.
Among the cases which have come under my especial notice are a
few of peculiar interest, and which deserve to be particularly mentiooei
Limb Lengthened, — Melchior Bri^tel, private 12th N. Y. Volunteen,
was wounded in June, 1862, at the battle of White Oak Swamp, Va.,
by the fragment of a shell, which struck the left leg three inches above
the condyles. He was taken to Richmond as a prisoner, and about a
month later he was exchanged and sent within our lines. Januair 1,
1864, I found him in the United States General Hospital at Newark,
imder the charge of Surgeon Taylor. The wound was still dischar^
ing matter occasionally, and several fragments of bone had been re-
moved. Splints were not applied until after his exchange. No exten-
sion was ever employed. At the end of four months he began to walk
about with crutches.
On measuring I found this limb lengthened half an inch, andtlA
measurement was confirmed by Surgeon Taylor and others. There w»
no anchylosis at the knee-joint.
It is doubtful whether, in this case, the shaft was broken acnw ••
tirely ; if it was, probably no displacement ever occurred. Theaw*
reasonable supposition is that the fragment of shell entered the booe|
and that it \\*as in the bone at the time of my last examination, aid
that, in conseouence of its presence, the bony structure had beeo**
hypenemic, ana had undergone hypertrophy in the directicm of tbeaxi
of the limb.
Perforating and Penetrating Wounds of the Fnnur. — JaoMS & Mi^
sey, of 16th N. Y. Volunteers, was wounded at Gaines's Mill, June W
1862, probably by a round ball. The ball entered the right Btt»*«J
behind, passing entirely through the right trochant^*; a finger f»
be thrust through the round, smooth hole in the btme. When I V
GUNSHOT FRACTURES. 517
him, three months after the accident, at Baltimore, under the care of
Surgeon Hasson, the wound was still discharging pus, but in no other
way was the injury causing either local or general disturbance.
At the same time, also, my attention was called to the case of Henry
Voger, 20th Mass. Volunteers, who was woundeil June 30th, 1862, at
the battle of White Oak Swamp, Va. A ball had entered the lower
end of the femur, near the joint, in front, but did not pass through,
and had not, up to this time, been found. Three months had passed
since the injury was received, and the wound was now entirely closed,
the knee-joint being anchylosed; but in other respects the condition of
the limb was almost normal. At no time was there much inflamma-
tion of the soft parts in the neighborhood of the injured structures.
Sergeant Lewis Monell, of the 119th N. Y. Volunteers, was wounded
July 1st, 1863, by a ball, which entered on the outside of the left thigh,
within one inch of the lower end of the femur, passing forwards, and
emerging in front above the patella. Four months after the accident
I found him at the Fifty-first Street United States General Hospital,
New York City. Several fragments of bone had escaped ; the lirnb
was bent to an acute angle, and pus was still discharging from the
wound. There was no effusion into the joint, and his ultimate recov-
ery seemed to be assured.
H. O. C. was a private in the French army in the Crimea, when he
was wounded in his left leg by a ball which passed through the bone
from before backwards just above the patella. Synovia with pus dis-
chai^ed for several months, and three small fragments of bone escaped.
In seven months the wound became permanently closed. When 1 ex-
amined the limb in 1864 the joint was a little deformed, and slightly
anchylosed, but in other respects sound.
These examples of recovery after gunshot injuries of the femur in
the vicinity of the knee-joint, must be understood to constitute rare ex-
ceptions to the rule. In most cases such perforations have been accom-
pfUiied with longitudinal fissures involving the joint, as is illustrated in
JFig. 1 of this volume ; and attempts to save the limbs have resulted
fa the loss of the lives of the sufferers.
Fracture from Duelling Pistol — Rex^overy without Lamencm, — In
tile somewhat famous duel fought between J. C. Breckenridge and
I^^rank Leavenworth, on Navy Island, June 7th, 1855, with duelling
pistols, at ten paces, Breckenbridgc was shot in the calf of the leg, and
•Leavenworth through both thighs. After Leavenworth fell he Wiis
^^^rried in a small boat to a point known as Fort Schlosser on the
-^Qierican side of the Niagara River, and placed in a wooden cabin, the
^^y tenement in the place. I was at once summoned, but did not
''^^h there until the following day. Drs. Grimes, Church, and Ware
^^te already present. We found that the bullet had entered his right
f*^igh about eight inches above the knee, and passed through the limb
?^ front of the bone. The ball then entered the left thigh a little
father back and a little lower down, striking the femur and breaking
^* ^bout five or six inches above its lower end. Here the ball was ar-
reted, probably being deflected and becoming lodged in the flesh, and
* ^ras never found ; nor did it ever afterwards cause any trouble.
I visited Jjeavenworth, in consultation with Drs. Ware and Churd^,
once or twice each week until his recovery was complete. During tbft.
first few days no apparatus was applied, but the broken limb was sup-
ported by junks, and both limbs were kept cool and moist with evapo-
rating lotions. On the eighth day a long side-splint vras applied
(Boyer's), with a perineal band for counter-extension, and a scrc\T (ot
extension. The amount of extension was varied from day to day, bnl
it was never more than could be comfortably borne. Still later short
aide or coaptation splints were applied. At the end of eight weeks tl»
long splint or extending apparatns was removed, and a few days after,
the coaptation splints. Eleven weeks after the accident he vaB on^
crutches. The femur was then found shortened half an inch, and pep>
fectly straight.
Mr. Ijcavenworth survived this injury many years, and altbongh h
led a very active lite, he never suflered any inconvenience from t'
wounds in either limb, and his gait was jierfcct.
It is probable that in this case there was no comminution of the booe;
and I think the same thing hu.^ happened under my observation eevenl
times, where the femur has been broken by a round ball, or by a coni-
cal ball whose force was nearly expended, A conical ball at shorl
range, when it strikes the shaft of the femur fairly, tan never tailw
cause extensive comminution.
MissHen remaining in the Bone. — Lieu tenant Cham plain (subsequentJj
Commodore) was wounded by a bullet, in 1813, during a sortie trani
Fort Erie, on the Niagara frontier. The ball entered about the micMfc
of his thigh and buried itself in the bone. Subsequently Dr. Williani
Gibson, Bf Philadelphia, and still later, Dr. Natnan Smith, of 'St*
Haven, attempted the removal of the ball, but without success.
During alt of his long and atlive life his limb continued to give him
serious trouble at intervals, and I was several times called to open »!*■
scesses which had suddenly formed, but I was never able to finii'li*
ball. The limb was firm, somewhat shortened, and strongly roUlw
outwards at the point of fracture,
I-ieutenant Charles Paysnn, aid-d&K^mp to General Devino, ■»
wounded by the fragment of a shell while leading a charge upoul
portion of the enemies lines at the battle of Cold Harbor, Va., Jw
lat, 1864.
The missile entereil about the middle of the left thigh, breaking «•"
comminuting the bone. Surgeon Rice, of the 2oth Miiii8. Volaale*^
removed on the same day one fragment of bono about two inch*"
length by half an inch in breadth, but the piece of shell eculd oott"
found. On the third day he was taken to ChesujHaikc Hospital, iiar
Fortress Monroe. Subsequently the surgeon in charge rcniovuJ »i"
a saw portions of both fragments.
October 24th, nearly five months after the receipt uf the injmj'.I
was summoned to the hospital to sec LicutonHnt Paywin in ajnul*
tion, I found the limb suspended in Smith's anterior ^plinr, lb*'"'
separated ends of the broken femur pointing Imckwanls nt an anjlf"
45°, and nearly projecting from the wound. This is the position iW
GUNSHOT FRACTUKES. 619
I have seen the fragments take in very many, probably in a majority,
of the gunshot fractures of the shaft of the femur treated by this ap-
paratus; and which vicious position the surgeon had in vain sought to
prevent in the case of Lieutenant Pay son.
Having removed three or four detached fragments of dead bone, we
laid the limb in a straight position upon a Hodgen's splint or cradle,
while permanent extension was made with a weight and pulley secured
lo the leg by adhesive strips. The amount of extension employed was
eight pounds. The fragments were now in line, and the patient de-
dared that he was much more comfortable.
March 31st, 1865, five months after this change in the mode of
dressing had been adopted he was brought to New York greatly im-
proved in health, the bone firmly united, with a slight outward bend
tt the seat of fracture, and shortened six and a half inches, and with
tlmost complete anchylosis of the knee-joint.
From this time Lieutenant Payson remained constantly under my
diSTgie for two or three years, when at length the wound became per-
manently closed, and his health was completely re-established. In the
meanwhile, however, after his return to New York, the original wound
discharged more or less constantly, and occasionally abscesses of con-
siderable size were formed which had to be opened. On the 8th of
November, 1865, seventeen months after the wound was received, it
was my good fortune to detect the position of the fragment of shell
which had caused all this trouble. I had searched for it many times
before, but on this -occasion a N6laton's probe disclosed an iron-rust
mark by which I was guided to its bed in the centre of the bone, and
from which it was at once removed.
As supplementary to this chapter, it seems proper to add a brief
rifumi of the statistics of the late civil war, drawn from the reports
of the Surgeon -General, made in 1865 and in 1867.*
Of 4167 gunshot wounds of the face, 1579 were accompanied with
fractures of the facial bones. Of these latter, 107 died, and 891 re-
<^vered. The remainder are undetermined. Secondary haemorrhage
ttsaid to have been the most frequent cause of death.
Of 187 examples of gunshot injuries of the spine (not including
those in which the chest or abdomen was penetrated), 180 died. Six
tf those reported as having recovered were examples of fracture of the
tiunsverse or spinous processes. The seventh is that of a soldier
'bounded at Chickamauga, September 20th, 1863, by a musket-ball,
Which fractured the spinous process of the fourth lumbar vertebra, and
Penetrated the vertebral canal. The ball and fragments of bone were
^tracted, and one year after he was reported i\s "likely to recover."
Of 359 gunshot wounds of the pelvis (not including those in which
Uie abdominal cavity was penetrated), 77 died, and 97 recovered. In
the remainder the result is not ascertained. In 256 cases the ilium
^lone was injured; in 19, the ischium alone; in 12, the pubes; in 32,
Ibe sacrum ; and in 40 cases the lesions extended to two or more por-
tions of the innominata. Pyteraia was a frequent cause of death.
* Circular No. 6, Surgeon-GenerHl's Office; also Circular No. 7.
GUNSHOT FRACTUHES.
Of 1689 gtinahot frat^iires of the humerus, 436 died, and 1253 re- M
covered. Nine hundred and ninety-six of these 1689 cases were treated _^H
by amputation or resection, with a mortality of 21 per cent. Id 693 ^^^
cases the conservative treatment was adopted, witli a mortality of 30^;^ ,'
per cent.
Of 68 cases in which attempts were made to save the timb aft<r gi"'"-^--
shot injury of the hip-joiut, without resection, alt died. (I have aeti^.^_
two cases of successful treatment of these accidents by tlie conservativ -fc "^'
plan, and others have been reixirted.) *
Fifty-three amputations at tlie hip-joint, made by siirgmns in tl- ^hu
Federal and Confederate armien, iucluding also reamputations, ^. —
seven succe^ful results. The fate of two is uncertain.
Sixty-three excisions at the same joint, made by Federal and Coufer^^^j
eratc surgeons, furnished five successful cases.
Three hundred and thirty cases of gunshot fracture of tJie upf>y
third of the shaft of the femur, in which neither amputation uor ns^^..
tion was practiced, gave a mortality of 71.81. Thirty-two casis ,'„
which amputation was made gave a mortality of 7o j)er cent. TH-enrr-
two in which resection was made, gave amortality of 81.18. (Welwit
rejected three cases given in the report as cured. Two of these were
resections of die head, and one was merely a "rounding off of sliivji
edges.")
Two hundred and ttiirty-two cases of gunshot fractures of the mid-
dle third, treated without amputation or resection, gave a morlalily v(
55,46. Ninety-three treated by amputation gave a mortality of 54.83,
Fifteen treated by resection gave a mortality of 86.C6.
One hundred and seventy -three gunshot ft-actures of the lowerlliiii
treated without amputation or resection, gave a mortality of ^'-'i^
Two hundred and forty-three amputated — mortality 46.09. Two i*
sected — both die*I,
Of 308 gunshot wounds of the knee-joint, with or without frarunt
treatfid without amputation or resection, 258 died — mortality 93.'^
Of the 50 which recovered there were, however, only six or ciflit '"
which the testimony is unequivocal that the joint was opened. Of' "
amputated, 331 dieil— mortality 73.23. Of 10 resecU-d, 9 dii *
tality 90 [)er cent.
Of 696 gunshot fractures of tlie leg, 169, or 24 per cent.
No analyses have been made of fractures of the smaller \xint3.
It is much to be regretted tliat in these comparative analystB of ll*
treatment of gunshot fractures, except in the case of the hi|»-joiDl,l?
the three methods, it is not stated whether the ampulalionek or (W
tions were primary or secondary. In all secondary amputation:' i^
resections, which, for aught that ap))Gars, may have constitnlid > lu*
jority of the whole number, the conservative treatment had fjcciim*
and ha^l failed, and the deatlis which liilluwed ought in ju^in lu 1*
chargeil to consi'rvalism, and not to the openition. As the reportsw*
stand, they arc of little or of no imiwrtance in dotvnuining ihc rtJmt
value of conservative and o|>enitive treatment.
From the reporls of the Cunfiilernte artny, as published in tlieO*
/edetaU Otateii Medtaal JouriuU, we learu liuil of 221 aw« oC
'"SO
GUN8H0T PRACTUBE8.
hetares of the thigh, treated without amputation or resection, 105
Mud 116 recovered. The shortest period of recovery was 41 days;
it longest, 255 days ; the average, 104 days. The shortest period of
Ganihnt rrulureof Ihlgh.
Front ilflw. (Aulhor'i col-
JW termination waa one day; the longest, 185 days; average, 52
"^ Greatest shortening, five inches; least, half an inch; average,
<w inch and nine-tenths.'
or 507 amputations for gunshot fractures of the thigh, 250 recov-
^hmond Hcd. Jouro., Feb. I8ti6, from Confedomto States Med. Journal.
'lUd., Jtnuar;, 1866, p. 62.
PART II.
DISLOCATIONS.
DISLOCATIONS.
CHAPTER I.
GENERAL CONSIDERATIONS.
i 1. General Division and Nomenclature.
A DISLOCATION IS the displacement of one bone from another at its
\sce of natural articulation.
Dislocations may be divided into accidental or traumatic, sponta-
eoos or pathologic, and congenital.
Our remarks upon the etiology, pathology, symptomatology, prog-
>si8, and treatment of these injuries must be considered as applicable
^ly to accidental or traumatic dislocations, unless the fact is in any
^«e otherwise stated.
Accidental dislocations are those in which the bones have suffered
^placement in consequence of the application of a sudden force ; and
»^ns have divided these accidents into Complete and Partial,
niple, Compound and Complicated, Recent and Ancient, Primitive
^d Consecutive.
^ complete dislocation is one in which no portions of the articular
Waces remain in contact.
-A partial dislocation is one in which the articular surfaces are not
riipletely removed from each other.
^ simple dislocation is that form of the accident in which the bone
Sonly slid from its articulation, and is accompanied with the least
^only an average amount of injury to the soft parts or to the bones
facent to the joint.
-A compound dislocation implies that the articulating surface of the
Oe has been thrust through the flesh and skin ; or that in some other
J^ a wound has been made which communicates with the joint.
Complicated dislocation is a term em])loyed by some writers to
*ignate a condition wholly differing from a comjiound dislocation,
in some cases, a condition of extra complication. Thus, a simple
'location may be complicated with a fracture, or with the laceration
^n important bloodvessel, etc. ; and a compound dislocation may be
^plicated in the same way, and with the addition, perhaps, of exten-
'^ laceration and destruction of integument, muscles, nerves, etc.
-A recent luxation, has taken place within a period of a few days, or,
\\ t
PART IL
DISLOCATIONS.
^ \
P A E T II.
DISLOCATIONS.
I
1
PART IL
DISLOCATIONS.
IV
DISLOCATIONS.
CHAPTEE I.
GENERAL CONSIDERATIONS.
{ 1. Oeneral Division and Nomenclature.
A DISLOCATION IS the displacement of one bone from another at its
plaice of natural articulation.
Dislocations may be divided into accidental or traumatic, sponta-
iic^ous or pathologic, and congenital.
Our remarks upon the etiology, pathology, symptomatology, prog-
nosis, and treatment of these injuries must be considered as applicable
^JTiiy to accidental or traumatic dislocations, unless the fact is in any
^^^^5e otherwise stated.
^ Accidental dislocations are those in which the bones have suffered
displacement in consequence of the application of a sudden force; and
^^rgeons have divided these accidents into Complete and Partial,
Simple, Compound and Complicated, Recent and Ancient, Primitive
^^d Consecutive.
-A complete dislocation is one in which no portions of the articular
®^i*faces remain in contact.
-A partial dislocation is one in which the articular surfaces are not
^^^iipletely removed from each other.
^ -A simple dislocation is that form of the accident in which the bone
^^s only slid from its articulation, and is accompanied with the least
^•* ^only an average amount of injury to the soft parts or to the bones
^MJ^Mient to the joint.
1^ ^ compound dislocation implies that the articulating surface of the
^^Oe has been thrust through the flesh and skin ; or that in some other
^^y a wound has been made which communicates with the joint.
^ 0>mplicated dislocation is a term employed by some writers to
^^*»ignate a condition wholly differing from a compound dislocation,
^^» in some cases, a condition of extra complication. Thus, a simple
i^location may be complicate with a fracture, or with the laceration
* %n important bloodvessel, etc. ; and a compound dislocation may be
^?*tiplicated in the same way, and with the addition, perhaps, of exten-
laoeration and destruction of integument, muscles, nerves, etc.
A recent luxation, has taken place within a period of a few days, or,
526 GENERAL CONSIDERATIONS.
at most, of a few weeks ; and an ancient luxation has existed during a
longer period. The exact point of time at which a dislocation shall be
called recent or ancient is not fully determined by surgeons, and the
application of these terms is therefore always somewhat arbitrary.
A primitive luxation is a luxation in which the bone remains nearly
or precisely in the position into which it was at first thrown ; while a
secondary or consecutive luxation is one in which the bone has subse-
quently, in consequence of the action of the muscles, or from unsuc-
cessful efforts at reduction, or from some other cause, changed its pos^i-
tion sufficiently to entitle the accident to a new designation. Thus a
primitive dislocation upon the ischiatic notch may become a secondary
dislocation upon the dorsum ilii, or the reverse.
i 2. Oeneral Predisposing Causes.
Age, — According to Malgaigne, whose conclusions are based upon
an analysis of six hundred and forty-three cases, dislocations are venr
rare in infancy, only one having occurred under five years ; but the
frequency increases gradually up to the fifteenth year, from this j)eriod
more rapidly up to the sixty-fifth year, and from this time onward
again dislocations become more rare. He has mentioned none afier
the ninetieth year; and the period of greatest frequency is between the
thirtieth and sixty-fiflh year. To this middle period belong four
hundred and seven of the whole number.
The inference from this analysis may be thus briefly stated : age, as
a predisposing cause, is most active in middle life, less active in ad-
vanced life, and least active of all in early life.
It is proper, however, to observe that while such statistics may be
relied ujwn as indicating the relative frequency of these accident* at
different periods of life, they cannot be regarded as determining abso-
lutely the value of age alone as a prcKlisposing cjiuse, sini-e the diirct
or exciting causes may be more active at one |)eriod than another, and
in some measure these latter causes may be, and doubtless are, respon-
sible for such results.
Conditution and Coyulitiou of ihe Mxu^la^ and Ligamentit. — It may
be stateil as a general fact that persons of feeble constitutions, and
whose muscular systems are much weakened, suffer dislocation from
slighter causes than those who are in health, and whose muscular sys-
tems arc firm and vigorous: and that a relaxation of the ligaments
which surround a joint, however this may have been oci'asione*!, pre-
disposes to disl(K»ation. Thus, a paralyzcxl and atrophic<l limb is pre-
disposed to luxation ; a joint in which the <.*a|xsule has beix^mo stretrbed
by effusicms, or by violent extension, or weakened by lat*eration fn>m a
previous dislocation, or by ulceration, or if in any other way the artic-
ulation is deprived of these natural protections, we nee<l scarcely say,
it is thereby rendered more liable to luxation.
Ball and socket joints, other things being equal, are more liable to
displacement than ginglymoid ; hut then much more depends u|K>n the
relative exjwsure of the joint than upon its anatomical structupp, «>
tliat the elbow is much more frequently dislocated than the hip; the
GENERAL SYMPTOMS. 527
shoulder-joint, however, being, from its position and extent of motion,
peculiarly exposed, and being also a ball and socket joint, is, of all
others, most liable to dislocation.
i 3. Direct or Exciting Causes.
These may be classed under two general heads, namely, external vio-
lence and muscular action.
External violence operates either directly or indirec^tly. When a
person falls upon the knee and dislocates the head of the femur, the
force is said to have acted indirectly, and this is by far the most fre-
quent mode of dislocation ; but when the blow is received upon the
upper end of the humerus, and its head is sent into the axilla, it is
said to have l>een dislocated by direct violence.
Muscular action produces a dislocation slowly, as in some cases of
chronic rheumatism, and then it is called a spontaneous or pathologic
dislocation; or suddenly, as in the violent spasmodic contractions
which accompany convulsions; or sometimes by the mere voluntary
effort of the muscles; and both of these latter are true accidental luxa-
tions.
It is very probable that external force can seldom be regarded as
the sole cause of a dislocation, but that, in a large majority of cases,
muscular action consenting with the shock, performs an important role
in the history of the accident. The limb being driven obliquely across
its socket by the external violence, is seized by the stretched and ex-
cited muscles with such vigor as to contribute not a little to the unfor-
tunate result. Thus it will be found that the same force which is ade-
quate to the production of a dislocation in the living and healthy
subject is wholly insuflBcient to accomplish the same in the dead; and
a man who is fully intoxicated seldom suffers a dislocation.
i 4. Oeneral Symptoms.
As fractures are characterized by preternatural mobility and crepi-
tus, to which may be generally added the circumstance that when
Induced the fragments will not remain in place without external sup-
port, so, on the other hand, dislocations arc characterized by preter-
oatnral rigidity, an absence of crepitus, and by the fact that when
reduce<l the bone does not generally require support to maintain it in
position.
These three are the usual, and they may be termed the common,
signs of distinction between fractures and dislocations, but no one of
them can be alone depended upon as positively diagnostic. Generally,
when a bone has been dislocate^l, we shall find the limb in a certain
position, which is uniform for all dislocations of the same character,
and almost immovably fixed ; but when the ligaments and muscles
about the joint have been extensively torn, or the whole body is still
suffering under the shock, or in any other circumstances where the
power of the muscles is weakened, this rigidity may give place to ex-
treme mobility.
&EXERA1. COSs;
True crepitus does not exist without fraoture, but is not atwavs
present in fractures, and there is often a senratlun produced iu tne
rubbing and chufing of dislocaled bonea which very niucb rosi-mblce
certain kinds uf crepitus, and by tlie inexpericnce<l has been often mi»-
takon for it. I allude to the subdued rasping sound or 8onsation
which is found generally oti the secoud or third day, and sometimes
earlier, and which ia the result of fibrinous effusions, or, perhaps, in
some instances, of the mere rubbing of firmly ct>nipreesHi liguinvntous
and cartilaginous surfaces upon each other. The txepitus of ik rws-nt
fracture can be scarcely confounded with this oK'Miure sensation, uriitss
it is in some cases of incomplete fracture, or of a fracture sitHat«J re-
mote from tiic surface, as in the case of the hip ; but a fracture whioh
is a few days old, whose surface haa become softened by inflammation ^
and more or less covered with lymph, and, when the rigidity is great, ^
may sometimes deceive the most experienced surgentn, shj exactly will it .^^^
be found to imitate the sensations produ(»d by the chafing of au ii
iiamed joint, or of closely approximated tibrous surfaces.
I have said that a true crepitus does not exist without a fractuTt
but then a very minute fracture, such as the detachment of a scab
bone by the tearing away of a tendon or of a ligament, may prwlor^
crepitus; or even the sejwiration of a piece of cartilage may nuffici
expose the bone to determine the presence of this phenomenon. Thi
are, however, no longer examples of simple dislocation.
Nor are the two inverse proiKeitions, in rcliition to tlic retention
the bones in place, invariable in their appH<«tion. A bn>kpn bur
well reduced, does not always manifest a tendency to displuccmrot,
does a dislocated limb, when restored to its socket, in all comts maint^n
jsition without support.
The other general signs of dislocation are pain, swelling, ami dis-
coloration. The pain is generally more intense in dislocations than in
fractures, the expanded end of the hone resting often upon one (ir mon
\arge! nerves, which usually, with the arteries, appn<ach very ni«rtlif
joints, this pressure being also greatly increase"! Iiv the extreme terormi
of the muscles. Not unfrMiuently numbness and temiximry [mralj'"'*
of the whole limb are the consequences. In other cases* the [tain i* dm
solely to the pressure u|>on the muscles ortollie tension uf the nioscK
or, )>erhaps, to the tension of the uutoru ligaments and mjiMile.
Generally the limb is shortened, but in a fewcnitesit isfiHindslii^liUJ
lengthened, while the natural axis of the bone with itM soeket isaltw*
changed. If examined early, and before the Bujwrvention of swiJli"^'
the joint end of the displaced bone may l»e felt in its unnatunl p^
tion, and a corresponding depression may be discovered in the giiuafi"'
of the articulation, especially if the bones are superficial.
i 5. Pathology.
The dissection of recent disloi -111 ions produei'd by external >
shnwiii the capsular ligaments more or lei's torn, and al»o a nipiui^fl
e of the lateral and other short liganient.s, with a c»niple(c nilitV
cases of some of the tendons which immediately sunvaiidff
t,i»«v
PATHOLOGY. 529
joint, or of those which are attached to the capsule : the muscles, nerves,
arteries, etc., through which the bone in its passage has passed, or upon
which it is found resting, being also contused, stretched, or torn
asunder. i
This description, however, does not apply to dislocations produced
by muscular action alone, in a majority of which cases the capsule is
only stretched, and not torn, and no lesions of other structures are
necessarily present.
If the dislocation remains unreduced, the margins of the old socket,
in the case of enarthrodial articulations, become gradually depressed,
while the concavity of the socket is filling in with a fibrous or bony
tissue, until at length the whole of this portion of the joint apparatus
b nearly or entirely obliterated. This process is generally very slow,
and may not be consummated until after the lapse of many years.
At the same time, but with much greater rapidity, the head of the
bone in its new position, and the soft or hard parts upon which it rests,
are undergoing certain changes to adapt them to their new relations,
and calculated in some measure to restore the limb to its normal func-
tions. If the head of the bone rests upon muscle, the cellular and
fibrous tissues which enter into the composition of the muscle become
condensed and thickened, forming a shallow or elongated cup, whose
mai^ins are attached to the neck or shaft of the bone, and whose walls
are lubricated with synovia. If it rests upon bone, by a process of
interstitial absorption a true socket is formed, sometimes dee}> and
sometimes shallow, whose edges, receiving additional ossific depositions,
become lifteil so as to form a rim. At the same time the head of the
bone is undergoing corresponding changes, to adapt itself to the newly
formed socket ; it is flattened or otherwise changed in form, and in the
progress of this change its natural secreting and cartilaginous surfaces
are gradually removed, a porcelaneous deposit taking its place. The
same kind of hard, polished, ivory-like deposit is found also in those
portions of the new socket which have been es|)ecially expo6(»d to pres-
sure and friction. Instead of the eburnatiou, an imperfect fibro-serous
surfece or synovial capsule may be formed.
I have in my cabinet an example of ancient luxation of the hip-joint
in which the head of the femur, having rested upon the dorsum ilii, has
formed a nearly flat but smooth surface — a kind of elevated plateau;
in other cases I have seen the margins of the new socket so elevated as
to rest against the neck of the femur, and completely lock it in.
Consenting with these changes, and in consequence partly of the dis-
use of the limb, the muscle, and even the bones sometimes suffer a
gradual atropliy. In some measure these alterations may be due also
to the pressure of the dislocated bone upon arterial and nervous trunks,
W which their functions become j)artially or comj)letely annihilated,
and their structure even may be wholly obliterated. In consequence
also of the inflammation which immediately results, we ought not to
omit to notice that the trunk of a large artery sometimes becomes
finnly adherent to the capsule or periosteum of a displaceil bone, and
rt8 reduction is attended with imminent danger of laceration and of a
CONSIDERATIONS.
fatal hsemorrhage. Humeroas instances of this grave accideot, e»|
clally In attempts to reduce old disloeations of the fihuulder-joiut, i
upon record,
i 8. General Prognosis.
We shall study tlie prognosis of these aocideiits to better adrantags
when we come to speak of the individual bones and their various foraiR
of dislocation; but it is proper to state in this place, generally, thi^
very few joints, having been once completely displaced from that
sockets by external violence, are ever so completely restored as not tt
leave some traces of the accident for many years, if not for the whula
of the subsequent life of the patient, either in the portinl limitatiun o
their motions, or in the diminished size and power of the muMJeea
the limbs, or in tlie presence of an occasional arthritic pain : the deent
and permanence of tlicse sequences depending upon the joint whitA il
the subject of the displacement, tlie extent of the original injury, iJic
length of time it has remained unredui'cd, the means employed in ro
reduction, tlie health and condition of the patient, with so many other
contingent circumstances as to preclude the idea of a eiiniplete specifi-
cation.
If the bone is not reduced, a permanent maiming is inevitable; but
it is surprising how much time and the intelligent processt* of natatt
can eventully accomplish toward a restoration of the natiirul fumSi'MH,
especially when aide<t by a good constitution and judicious Imimeot.
If the symmetry of form and grace of motion arc never replaail, tb«
value of the limb, for all the prarticul purposes of life, is not uafn-
quently completely re-established.
I 7. General Treatment.
The first indication of treatment is to reduce the bone. W*haier«
delays may be pro[>er or justifiable in certain cases of fracture,
delays are never to be argued in eases of dishK'ution. The BoooertlM
redoction is accomplished the iM-tter. For this purp<jse we rasoit tt
once to such manipulations or mechanical contriv«n»fS as tlie latun"?
the case demands; and if these fail, or if at tlio tiret (hey nre dwmol
insuflicient, we uivoke the aid of constitutional means, or such i
calculated to diminish the power and antagonism of the niuscl's.
Many dislocations may be reduced promptly by inHiii)»ulnli()H i
which mode is always to be preferred when it will prow suffioliait, i*
the reasons that it is generally the least painful to the jNilii-nt, aiul tbt
least apt to inflict additional iujurj- upon the mnseles and ligainvotr-
A person wholly nnacouaintcd witli anatomy or anrjjery maywiw
sioually succeed in reducing a dislocated limb: indeed it frequwll.'
hapjtens that the patient himself, by mere accident in g4-lting upurii
lying down, accomplishes tho reduction ; and even in a very lar^pi ■►
jority of cases, force and perscvcninca will finally sncoceii by whooa^
ever they may be employed ; but the oliscrving student of siuparinB
soon discover the difference between acvideni and brute ibroe uo '^
GENERAL TREATMENT. 531
one handy and intelligent manipulation on the other. The charlatan
bone-setter does not often allow himself to fail, unless the courage of
his patient gives out, or he ignorantly supposes the reduction to be
effected when it is not; but his success, achieved through great and
unnecessary suffering, is often obtained, also, at the expense of the limb.
While the surgeon, whose knowledge of anatomy enables him to under-
stand in what direction the muscles are offering resistance, and through
what ligaments the head of the bone must be guided, lifts the limb
gently in his hands, and the bone seeks its socket promptly and with-
out disturbance, as if it needed only the opportunity that it might
demonstrate its willingness to return.
We must understand not only what muscles and ligaments antag-
onize the reduction, if we would be most successful, but also what
muscles, by being provoked to contraction, will themselves aid in the
ledaction. In short, to become expert bone-setters in the department
of dislocations, one must possess a complete knowledge of the physiog-
nomy or the external aspect of joints, acquired only by repeated and
careful examinations, he must be familiar with the anatomy and func-
tions of the muscles, he must understand thoroughly the ligaments, he
most have experience, tact, and fertility of resource.
Without these qualifications a man will do better never to under-
take to treat dislocations, since he is constantly liable to mistake frac-
tures for dislocations, and dislocations for fractures ; he will submit a
sprained wrist to violent extension, under the conviction that the joint
k displaced ; he will mistake natural projections for deformities, and
fiul to recognize the real deformity when it actually exists ; he will
leave bones unreduced, fully believing that they are reduced ; and he
will, all in all, within a few years, accomplish vastly more evil than
be can ever do good. Let a man practice any other branch of surgery
if he will, without experience or scientific knowledge, but he must
not attempt to reduce dislocated bones. The most learned and the
most skilful we shall find falling into error, embarrassed by the un-
oartainty of the diagnasis, or successfully resisted by the power of the
oppoeing agents; what then can be exj)ected of those who are both
ignorant and inexperienced, but failures and disasters?
As a means of disarming the muscles, or of placing them off their
guard, we often practice successfully the diversion of the mind of the
patient. At the very moment that the limb is moved or extension is
naade, a question is addressed to him, or he may be suddenly surprised
by some unex})ected intelligence.
Extension and counter-extension, made with our own hands or with
the hands of assistants, constitute the second resort where manipula-
tion alone has failed. The surgeon seizing upon the limb firmly with
bi8 hands, makes the extension, while the assistants make the connter-
ntension ; or, instead of grasping the limb directly, the operator may
'isefor this purpose circular and longitudinal bandages, or the bandage
or handkerchief tied in the form of the clove-hitch. Extension is thus
tpplied in connection with manipulation, aided, perhaps, by direct
pressure upon the head of the displaced bone. Failing in this, we
employ some one of the various mechanical contrivances which, while
532
GENERAL COKSi DEBAT10N3.
they are capable of exerting much more power, poesess also the ira-
portflnt advantage of operating gradually and steaaily, by which mode
the resistance of the muscles is always more
^'°- **'■ speedily and more completely overcome.
For this purpose surgeons emplov gener-
ally, in the case of the large limtK?, the com-
pound pulleys, or the simple rope windlo^
which latter is thus described by Dr. Gilbert,
of Philadelphia: "Place the patient, and
adjust the extending and counter-extending
bauds as for the pulleys ; then procure ao
ordinary l>ecl-cord or a wash-line, tie the emls
together and again double it upon itself, pa«
it through the extending tji|>ea or towels,
doubling the whole oucc more, aud fasten the
distal end, consisting of four loops of ro|>e, to
a window-sill, door-sill, or staple, so that the
cords are drawn mo<lerately tight ; finally,
pass a stick through the centre of the double
rope, then by revolving the stick as an axis
or double lever, the power is produced pre-
cisely as it should be in such vases, viz., slow*
ly, steadily, and continuously." ;
doTe-hitcii, (FmmErichseD.) Jarvis's adjuster, althougli very complex, j
n esses some advantages over tlie pnlleys, j|
; to the preference in a few cases. -5
Among the constitutional means, ether and chloroform occupy the '■
first rank ; indeed they are, at the present day, almost the only meaiu
of this class to which surgeons resort, and their value in this point
Conlpoimii pullc
of view can scarcely be over-estimated. Only when some untwal
circumstantfe or condition of the ])aticnt forbade the use of an anv-
thetic, would the surgeon return to the ancient practice of blwdii^
ad deli(juinm, of prostrating the system with antimony, or totheiw
of those vastly less efficient agents, opium an«l the warm bath.
DOUBLE OB BILATERAL DISLOCATION.
CHAPTER II.
[. DISLOCATIONS OF TUE LOWER JAW (TEMPORO-MAXILLARY).
P
I ha.
There are two pr]ncii>al forms of this dislocation, namely, the
Hil>le or Ijilateral dislocation, and the ^ing:1e or unilateral ; in both of
hich the direction of the displacement is forwards. To these there
I been added one example of an outward displacement accompanied
ith a fracture.'
I 1. Doable or Bilateral Dislocation.
This form of dislocation of the lower jaw is much the most frequent,
ing met with in about two out of every three cases. It apjiears also
occur oftener in women than in men, and usually between the twen-
;h and thirtieth year of life. In infancy and extreme old age it is
»edingly rare; yet Sir Astley Cooper mentions a case in which
two boys" being at play, one had an apple tlinist into his mouth,
iduciug a double dislocation ; and Mlilatoii saw the same accident in
old man of .seventy-two years, who was toothless,
Thie comparative immunity in youth and old age has been ascribed
to certain peculiarities in the form of the jaw at these periods of life,
K&laton attributes Its more frequent occurrence in middle life to the
great length and strong anterior inclination of the coronoid process.
In a majority of cases the direct or immediate cause has seemed to
be muscular action alone. Malgaigne found thie cause to prevail in
twenty-five out of forty cases; and of the twenty-five cases fifteen
were occasioned by gaping, five by convulsions, four by vomiting, and
one by rage. lir, Physick, of Philadelphia, found both condyles dis-
located iu a woman in conse(|UDncc of the violent gesticulation of her
jaw while scolding her husband. But in a more remarkable case still,
this surgeon found the jaw dislocated after recovery from a profuse
salivation, and of the cause of which, or the time of its occurrence, the
patient, a young girl, could give no account. Dr. Physick made sev-
eral ineffectual attempts at reduction, and only succeeded at last after
had made her completely intoxicated with ardent spirits.'
Dp. E, Andrews, of Michigan, found both eondylee dislocated by a
ibelia emetic. The patient had often taken these emetics before, and
had frequently experienced a sensation " of catching " at the joint, but
the jaw had always until this time resumed its position spontaneously.^
Among the causes from outward violence, the introduction of some
' Bolin-I. Jnurnil de Cbir., 1844.
■ Phj'ick, Dor»e<r'« ElcmenUof Siirgory, vol. i, p. 202. FbiladQlpbiR, 1
* An'draw*, Fanlnmlu Jaum. Med., toL Hi, p. 101. 1S56.
534 DISLOCATIONS OP THE LDWEB JAW.
foreign body into the mouth, and the extraction of teeth, occupy the
most important place. In fifteen cases seven were from the former
and six from the latter cause.
My former pupil, Dr. A. W. Gilbert, has related a case which came
under his own observation, produced by a similar cause. During his
apprenticeship with Dr. Parsons, a dentist, he was requested to insert
a set of teeth for a young man residing in Cattaraugus Co., N. Y., and
while opening hia mouth to take an impression of his gums, he dislo-
cated " both condyles forwards, under the zygomatic arches ;" bat so
perfectly were the muscles relaxed, that he immediately reduced theiOi
without the least difficulty, by placing his thumbs as far back as pos-
sible upon the molar teeth, depressing the back part of the jaw, and
at the same moment elevating the chin.^
Prof James Webster, of Rochester, N. Y., dislocated the jaw of a
lady while attempting to pry out a root of one of the molars.
Pathology, — In order that we may better understand the patboloey
of this accident, it will be proper to say a few words in relation to tb
anatomy of the temporo-maxillary articulation and the other parts
concerned in the dislocation now under consideration.
The articulation is formed by the condyloid process of the inferior
maxilla and the glenoid fossa of the temporal bone, in front of which
fossa, and at the root of the zygomatic arch, is a slight elevation, called
the articular eminence. Between the joint surfaces, both of which are
covered with cartilage of incrustation, is placed an interarticular car*
tilage, which divides the joint into two cavities, one corresponding to
the condyle of the inferior maxilla, and the other to the glenoid fosBSy
each of which is furnished with a distinct synovial membrane.
Properly there is but one ligament — namely, the external lateral—
which {)asses from the outer surface of the articular eminence to the
corresponding surface of the neck of the condyle. What is called the
internal lateral ligament arises from the apex of the spinous process of
the sphenoid bone, and is inserted into the margin of the dental fore*
men, and has therefore no immediate connection with the articulatioii)
although it tends to strengthen the joint. The same is true of the
stylo-maxillary ligaments.
The lower jaw is drawn upwards, or closed upon the upper jaw, by
the action of the temporal, masseter, and internal pterygoid musdei;
it is drawn downwards by the action of the digastricus, mylo-hyoideo8|
and genio-hyoglossus muscles ; forw*ards by a few fibres of the maaseter
and by the external pterygoid muscles ; and laterally by the alternate
action of the external and internal pterygoid muscles.
When the mouth is open to its utmost extent, the maxillary condyle
rises upon the articular eminence until it rests upon its very summit
Indeed, it is probable that in most persons it advances rather in froot
of the centre of the eminence; so that in order to become actually
dislocated it only needs that the capsule shall be somewhat relaxed, or
that it shall actually give way in front, when the condyles slide for-
1 Gilbert, TbesU on Dislocation of the Inf. Max. Umvertity of Buflalo, 1S5IL
DOUBLE OR ^ILATEBAL DISLOC ATIOTT.
wards and occupy a position directly in front instead of behind this
le dlglaCRllon of lbs Inrsrlor miilllii.
It is easy to comprehend how the combined action of the two external
pterygoid muscles, with a portion of the fibres of the nia^^seter, may
ikme produce the dielocation when the mouth is wide open, and espe*
dally when, in consequence of a slight blow upon the chin, the anterior
portion of the capsule becomes
Mcerated ; for it must be noticed ^'"^ ^^■
that the ascending ramus, with
its i»oloDged oon<fyloid process,
eoDsHtnteB a lever of the first
kind, ID which the temporal
mnscle, attached to the coronoid
pmceas, the masseter, and even
tbe mastoid process, constitute
' &e fblcrum, the anterior portion
of the capsule, the weight, and
Ae force acting against the front
of the chin, the power.
In this position of the condyle,
drawn upwards and forwards by
Ibe action of the pterygoid and
temporal muscles, the chin descends toward the neck, and the coronoid
pcooess rests gainst the back of the superior maxilla, or against the
malar bone at the point of its junction with the upper maxillary. The
temporal, masseter, and internal pterygoid muscles are very much upon
tbe stretch, if not more or less lacerated.
Symptoms. — The month is widely open and the jaw nearly immov-
able. It has been noticed generally that, by pressure, the chin may
be slightly depressed, but that, owing probably to the pressure of the
eoronoid process against the body of the upper maxilla, or against the
malar bone, it is generally impossible to elevate the jaw in any degree
whatever.
The jaw is also slightly advanced ; a depression, covering a consid-
oible space, exists between the auditory canal and the posterior mar-
gin of the condyle. A slight fulness is observed in the temporal fossa,
tod also upon the side of the cheek in the region of the masseter muscle.
Ordinarily the patient suffers considerable pain, but not always,
fiom the pressure of the condyles upon the branches of the temporal
Derrea. There is a constant flowing of the saliva from the mouth; the
patient is unable to articulate, and even deglutition is performed with
great difficulty.
Pntgntms. — When the dislocation remains unreduced, the lower jaw
gndoally approximates the upper, and its anterior projection sensibly
flimiobhes, the saliva ceases to dribble from the month, deglutition
and speech are restored, mastication is iierformed with considerable
ease, and, in short, the patient comes at length to experience no great
inconvenience from the displacement.
Robert Smith relates the case of a woman whose lower jaw was dis-
located during an epileptic convulsion. She was at the time in one of
536
DISLOCATIONS OP THE LOWEH JAW
tlie metropolitan liospitals, but the accident was not iioti«;d hy dw
surgeons, and it reoiained ever afterwards unreduced. At the end of
a year i^hc could close the lips per-
u,„ «» fectly, but was able to open the moalh
only to a limited extent; the teeth ol
the lower jaw remained advanced, the
involuntary flow of saliva had ceasei^
and the faculty of speech had bm
regained.' In Professor Webstert
case, to which I have before referrw^
although the jaw was immediate^
and easily reduced, after the lajM ,
of several years, when I saw tbt
lady, she still complained that it hut
her whenever she ate, and thai ^
often felt the condyles slip in then '
sockets.
Reduction has been accompli^
by Physick in the case already rclstd
after the lapse of several weeks; Sir
Astley Cooper reduced a double dis-
location after a month and fivedsj^
which had been overlooked by thi
Double diiiocntioii or ih« Inferior miiiiii. gui^oH lu attendance;* and DonoTU
sureeeded after ninety-five days,'
Treaimeni. — Reduction may generally be accomplished with easeii
cast'ii of recent luxation, in the following manner: The juitieDt belDj
seated upon the floor with his head between the knees of the opermtor,
a couple of pieces of iwrk, gutta-]>ercha, or pine wood are placed M
far back between the molars as ])ossible, when the surgeon ee\mf
u|>on the chin draws it steadily upwards, taking care not to draw it
forwards at the same time, since by this movement he would re«il
the action of the muscles which naturally tend to restore it to pl»«
whenever the condyloid proc-esses are lifteil duFficiently from the lygo-
matic fosstc. Many surgeons prefer to sit or stand in front of m
patient, and depress the condyles by means of the thumbs placed insiih
of the month and upon the tojis of the molars. If the thumbs u*
used in this way, it would be well to protect them with a pieceof
leather, or to slip them off from the teeth suddenly when the oondyl*
are gliding into their places, as the muscles sometimes close the Dwatk
with sufticieiit violence to bruise severely anything which might il
this moment be intcrjiosc*! between the teeth.
The method practiced by Ravnton, of simply lifting the chin grad»*
ally and forcibly toward the upper jaw, was essentially the taToe, bol
far less efticient ; for although he placed nothing between the niolu*
to serve as a fulcrum, the backmost teeth themselves must in mum
' Sir A»ili>y Cuoppr, i
' D..n..v»n, Amer Ji
Uv lib, 1642.
tures «nd Di.loc«tinri. Dublin, 1854, p. 288.
>>»lnc- and Fne., Amer. cd., p. 816.
. Mod. Sci., Oct. 1842, p 470; from Dublin M*d rrMh
SINGLE OR UNILATERAL DISLOCATIONS. 537
d^ree perform this service whenever the lower jaw being dislocated
and drawn upwards, the chin is forcibly approximated toward the
upper.
In other cases it has been found necessary first to disengage the
ooronoid process, by depressing the chin gently, and then pressing
backwards in the direction of the articulation ; a method which would
certainly deserve a trial in case of the failure of that first described.
This was the method practiced by Hippocrates.
A more effectual expedient, however, consists in reducing one side
at a time; taking good care always that the side first reduced is not
reluxated while the attempt is being made to reduce the other, a thing
which happened in one of the cases treated by Sir Astley Cooper, and
has happened many times in the practice of other surgeons.
Finally, if all other expedients fail, we ought not to hesitate to
resort to aniesthetics, nor indeed could any objection exist to their em-
ployment at any period of the treatment, were it not that in a large
majority of cases the reduction is effected so easily and promptly as to
render their employment wholly unnecessary.
Afler the reduction is accomplished, it will be a matter of wise pre-
oaation to sustain the jaw by a double-headed bandage passed under
the chin, and secured upon the top of the head, so as to prevent the
mouth from being accidentally opened too far, especially during sleep,
since experience has shown that a tendency to a reproduction of the
dislocation remains for some time. It will be prudent to continue
these measures of protection for at least one week ; after which the
danger of anchylosis should be borne in mind, and the extent of pas-
sive motion should be gradually and cautiously increased. In illus-
tration of this tendency to reluxation, Malgaigne refers to the case
mentioned by Put^gnat of a woman whose jaw for many years became
loxated at least once a month ; but she was always able to reduce it
beraelf.
2 2. Single or Unilateral Dislocations.
The causes of this accident are in general the same as those which
pfoduce double dislocations, and it occurs most often in middle life.
Tartra has seen one exceptional example in a child only fifteen months
old, and Levison saw a case in an old man who had lost all his teeth.^
Symptoms. — ^The mouth is open, but not so widely as in double dis-
location; the jaw is nearly immovable; the teeth are advanced; the
oondyloid process can be felt in front of the articular eminence, leav-
ing a depression in its natural situation, and the coronoid process is
more prominent than in the bilateral dislocation.
It will be remembered that we have already pointed out an impor-
tant diagnostic mark between a fracture of the neck of the condyloid
pfixesR and a dislocation of one condyle. In the latter the chin in-
clines to the opposite side, while in the former it falls toward the side
Upon which the accident has occurred. According to Hey, this lateral
> Levison, Boston Med. and Surfi;. Journ., vol. zzxiv, 1S46, p. 3S8, from London
Xjftncet.
538 DISLOCATIONS OF THE LOWER JAW.
deviation of the chin is not always present in dislocations; and Robert
Smith mentions one case in which the surgeon was misled by thi^ cir-
cumstance so far as to attempt a reduction upon the left side when tht
dislocation was upon the right.
Treatment, — The same rules of treatment which we have established
for dislocations of both condyles will be applicable to the single dislch
cations, with only such modifications as will be naturally suggested to
the surgeon.
In the case mentioned by Levison, the dislocation was constant!/
recurring upon the left side ; and it was especially liable to happai
when just awakening from sleep. " He would then pull his jaw, pitai
it backwards, when, after about half an hour's work, bang it seemed
to go, and all was right again." This old gentleman was finally w- ,
lieved of these annoyances by a band fastened under the chin. la
such a case, an apparatus constructed after the same plan as my lower*
jaw fracture apparatus might perhaps serve a useful purpose.
2 3. Conditions of the Jaw simulating Luxations.
There is a condition of the temporo-maxillary articulation called by
Sir Astley Cooper " subluxation of the jaw," in which it is assuinea
that the condyles slip before the anterior margins of the interarticohr
cartilages, and thus for the time render the jaw immovable. No posi-
tive evidence, however, has ever been presented, either by Sir Astky
or others that any such derangement of the joint apparatus does actu-
ally take place, the opinion being based, not upon dissections, but ool?
upon the symptoms which are known to accompany the accident, ft
is Quite probable that this explanation of the phenomenon in questioa
is the true one, yet it is not impossible that, in some rare cases it has no
relation whatever to the interarticular cartilages, but that it indicatei
a true subluxation of the inferior maxilla upon the zygomatic emi-
nences.
It occurs mostly in young people, and in those of a feeble or scrofu-
lous diathesis. Relaxation of the capsule, ligaments, and miisicla
about the joint may, therefore, be reganled as the principal predisipni-
ing cause. The exciting causes are generally yawning, or biting upoB
some very hard substance.
The symptoms are a sudden arrest of the motions of the jaw, witk
the mouth about half open, the arrest of motion being accom|ianifd or
preceded generally with a sensation of slipping in one of the articnii"
tions. The chin is slightly inclined to the opposite side. The condyle
may be felt somewhat advanced in its socket, and while it remaiitf !>
this position the patient experiences some pain.
In most cases the condyle resumes its place spontaneously, or after t
slight lateral motion of t)ie jaw; but at other times it requires wme
little manual force to replace it J
I have myself, during several years of ray early life, while pumiinf
my studies at college, experienced this accident many times. It vn
f ecu liar ly prone to occur in the morning, and it became necessan* th«t
should eat with some care at my first meal. Sometimes the locking
rCONDITIONS OF THE JAW SIMULATING LUXATIONS, 539
of the jaw was upoD the right ami sometimes upon the left side; it was
always slightly painful. Generally the condyle was made to fall into
place by a volnntary lateral motion of the jaw, but occasionally I was ■
obliged lo press gently against the chin with my hand. I never adopted
any measures to remove the pretlisposition, but as I became older the
annoyance gradually ceased,
Benevoli, in a dissertation published at Florence, Italy, in the year
1747, describes another condition very analogous to this which we have
now described, but which evidently depended u|jou a contraction of the
miisoles. A priest having opened his mouth very widely in gaping,
found himselt unable to clone it. A sui^eon who was called diagnos-
ticated a dislocation of the jaw, and attempted to reduce it, but failing,
Benevoli was called, who obsejving "that the jaw was not absolutely
immovable, that the articulations were not separated, and that the chin
did not incline outwards or toward the sternum," concluded that it waa
only a contraction of the depressing muscles. He therefore prescribed
fomentations and oily unctions. The same night the temfioral muscles
had acquired the size of a couple of e^s, from contraction, but the
next day the patient could shut his mouth, and by the following day
the tumefaction of the temporal muscles had also disappeared, and the
restoration of the functions of the mouth was complete.
Malgaigne, to whom I am indebte<l tor the above case, relates two
others, one in the person of the surgeon Mothe, and the other in a
yonng man who was suffering from paralysis and spasmodic contrac-
tions of the muscles. Mothe observes that it had occurred to him very
often, and that it still continued to happen sometimes, that when he
gaped pretty widely, the genio-hyoid and mylo-hyoid muscles'con-
tracteil with so much force as to render it impossible for hira to close
hb mouth ; these muscles being thus in a s^ate of cramp, their bellies
became hard under the chin, and so painful that he was obliged imme'-
diately to press upwards against the under surface of the chin in order
to oppose their action. This condition would last from one to three
minutes, and was relieved, generally, by frictions made with the hand
over the contracted muscles. Sometimes he actually believed that the
lower jaw was dislocated, although the result always convinced him
that it was not.
Treatment. — In most or all of the oases of this peculiar derangement
I the temporo-maxillary articulation, which have come under ray
', a spontaneous cure has been soon effected. It will be proper,
^^ /er, in all cases, to instruct the patient to avoid using the jaw in a
manner to produce the sensation of slipping; and if the general health
ia impaired, to adopt suitable measures to improve his condition. Cold
water affusions to the side of the face and jaw would seem also to be
iBures, and I have generally recommended their u£e, ^
DI8L0CAT10NG Of THE 8P1ME.
CHAPTER III.
DISLOCATIONS OF TUE SPINK.
Dei.pech and Abernethy denied the possibility of a dislooatioii
the spine, either in tJie cei'vieal, dorsal, or lumbar region, withuat l!
concurrence of a fracture.
Says Sir Astley Cooper: "I have never witnessed a separatinn of
one vertebra frum another through the intervertebral substance, wilfaont
fracture of the articniar processes ; or, if those processes reinnin nn-
bnilten, without a fracture through the bodies of the vertebra." Hi
would not, however, be understood to deny the possibility of a diBloca*
tion of the cervical vertebrae, their articular processes being plaoed nnwe
obliquely than those of the other vertebne.
The accident is, no doubt, exceedingly rare, at least without the wm-
plication of a fracture, and it is not improbable that the actual Dumber
is smaller than the reported examples would indit^ate. Those vIm
make aulo|)sies do not always perform their duties with that euct
fidelity which might be necessary to determine so nice a poinl as t
fravtureofan oblique process, and it is quite likely that the cirfuui^lince
may have been overlooked in some cases ; but a eonsidemble numbtf
of well-autheulicated examples of simple dislocations of cervical
brie have accumulated within the last fifty years. The reported
pies of simple dislocations of the other vertebra are not so numenol^
nor as well attested.
The causes are in general the same with those which produce fne-
tnres of the vertebne, such as falls upon the head, feet, or book, ud
violent flexions of the spine backwards or to the one side or tin* otliff.
Several examples are recorded of "spontaneous" dislocations, tfat
result of some morbid chaiigts in the bones or in the ligameiita of tk
spinal column; which accidents seem to belong more properly W ge"-
eral treatises upon surgery.
The symptoms, also, partake of the same general charaetn- vil^
fractures; the accident being accompanied with more or less oimplM
paralysis of those portions of the bmly which receive their uern*
supply from below the point at which the dislocation has occwrJ;
the spinal column presenting at the seat of displacement an anpilK
projection or some form of irregularity ; and the distortion l>e)ii|; i^
tended with {Miin, especially when an attempt ia made U> taovt it*
body.
In very many ca'?es the symptom.i are so nearly like those pmmtM
in a case of fracture, that the diagnosis is rendered excee<lingly dilBalt
The presence or aW-nee of crepitus may aid in the diagnosis, anil t*
it is well understood that this symptom is nlleu ulisent in simple d*^
tures, and that it may be present in all those examples of dislooJi*
DISIiOCATIONS OF THE LUMBAR VERTEBRiE. 641
which are aocompanied with a fracture of an oblique process, or of any
other portion of the vertebrae, which class of examples constitutes a
large majority of the whole number.
There is usually present, however, in the dislocation, whether partial
or complete, a peculiar fixedness or rigidity of the spine, which serves
to distinguish this accident from a fracture of the spine as plainly as
the preternatural rigidity of the limb in dislocations of the long bones,
serves to distinguish these accidents from fractures of the same bones.
The head or upper portion of the spinal column is bent forwards, or
hickwards, or more commonly to one side, and in this position it re-
Buuiis immovably fixed until the reduction is accomplished. Some-
times, also, the sui^eon may feel distinctly the lateral deviation of the
S|HDon8 process, and, in the neck, the transverse processes become an
HDportant guide in the diagnosis.
After these few general remarks, I shall proceed to speak of disloca-
tions of the spine in the same order in which I have treated of fractures
of the spine.
2 1. Dislocations of the Lnmbar Vertebrse.
Sir Astley Cooper plainly intimates that he does not believe a dislo-
Otion can occur in either the dorsal or lumbar region without the
ooDcurrence of a fracture, and Boyer affirms positively that it is "en-
tirely impossible."
Without wishitig ourselves to insist upon the actual impossibility of
these accidents, we are prepared to affirm that no well-authenticated
ose has yet been reported ; at least of a complete dislocation, unac-
oompanied with a fracture of the articulating apophyses. We can
even conceive it possible that a lumbar vertebra may be dislocated
fcrwards or backwards, and that a dorsal vertebra may be dislocated
klerally, without a fracture ; yet we hardly think either of these events
Cbable. What we urge, however, is that no evidence appears to be
[iished that such a dislocation has actually occurred.
Cloqaet mentions the case of a " tiler" who fell from the roof of a
iioiise backwards, and dislocated one of the lumbar vertebrae. This
Datient lived many years after the accident, and at the autopsy it was
mild that the second lumbar vertebra had been luxated to the right
by a movement of rotation about the left articular process, the two
oblique processes of the left side preserving their connection, while
thoee of the right were separated quite half an inch. The right verte-
bcml plate was broken, and the canal of the vertebra was thus thrown
Ofpen and widened.^
Dupuytren says that a man was crushed by the falling of a bank of
earth upon his loins, when in the act of bending forwards. On the
third day he was brought to H6tel Dieu, when it was observed that
his lower extremities wiere completely paralyzed ; and that there ex-
isted in the upper part of the lumbar region a hard tumor, by pressure
upon which a crepitus was manifest. A second tumor could be dis-
' Cloquet, Malgaigne, from Journ. des Difformit^s de Mnison , torn, i, p. 453.
642 DISLOCATIONS OF THE SPINE.
tinctly felt in front through the abdominal parietes, and the length of
the spine was evidently diminished. This man died on the sixtlh daj
from a gradual asphyxia. When the body was examined it was fouod
that the last dorsal and first lumbar vertebrae had been pushed for-
wards more than one inch, lacerating the spinal marrow, breaking tbe
transverse and oblique processes of the last dorsal and first two lumbtr
vertebrse, and tearing off a small fragment of the body of one of the
vertebrsB where the intervertebral substance adhered to it*
These are all the cases of dislocation of the lumbar vertebrtt of
which I am able to find any record. Both were accompanied with
fractures. In neither case was any attempt made to reduce the disk^
cations. In the second, it is scarcely probable that any means couU
have been employed which would have succeeded in restoring the
bones to their places ; nor is it probable that if the bones had been re-
stored to place, the patient would have survived the accident a day
longer, probably not so long. The cord was greatly lacerated, aod
the diaphragm torn up and displaced, rendering a recovery almost im-
possible.
In the first example, where the dislocation was less complete, aod
the complications less grave, could reduction have offered any reason-
able chance for relief? By extension, combined with a movement of
rotation in a direction opposite to that in which the displacement bid
taken place, it is possible that a reduction might have been accom-
plished. The attempt certainly would have been justifiable ; but since
the man lived "many years without ,the reduction, it is doubtful
whether the result of a reduction would have been more fortunate.
i 2. Dislocations of the Dorsal Vertebrae.
Malgaigne enumerates twelve examples of dislocations of the dond
vertebrae. I have found reported by American surgeons, at dates too
recent to have been included in his analysis, two other examples; but
of this number only three are claimed to have been simple dislocatioDS,
unaccompanied with fracture. One of the fourteen was a dislocatico
of the fifth dorsal vertebra upon the sixth, one of the eighth, two of
the ninth, five of the eleventh, and five of the twelfth ; the relative
frequency of their occurrence in the different vertebra* corresponding
with the observation of Weber, as to the points of the spinal marrow
which allow of the greatest freeilom of motion, and are conseqoeotif
most liable to di8l<K»ations. The direction of the displacement in ten
cases was observeil to be six times forwards, twice backwards, and
twice to the (me side.
Two of those which wore unaccompanied with fracture, occorring
respectively in the tenth and sixth dorsal vertebne, were example «
a dislocation forwards, and the third, belonging to the ninth vertebra,
was a dislocation backwards. A lateral luxation without fracture hi«
not been recorded. It is worthy of remark, also, that these three exsni'
4
1
> Dnpuytren, Injuries and Dis. of Boncw, Syd. ed., p. 340.
DISLOCATIONS OP THE DORSAL VERTEBRA. 543
tics, being all which our science up to this moment possesses, have
appened in the experience of the same surgeon.*
A moment's consfderation of the anatomy of these processes will
render it apparent that even a partial luxation forwards without a frac-
toreof the oblique apophyses is impossible, and that in the direction
backwards the luxation can only occur to the extent of about one-
quarter of an inch, constituting only a species of articular diastasis,
without breaking off the articulating apophyses of the lower corre-
S coding vertebra. The first two examples, therefore, notwithstanding
ey have been receiveil without question by Malgaigne, I shall un-
hesitatingly reject. The third, which alone carries evidence of its
liaving been correctly reported, and which was only a partial disloca-
tion, Ls related as follows : " A mason having fallen from a height in
anch a manner as that the lower part of his back struck upon the angle
of the upper step of a ladder, died on the following day. After death
it was observed that the spinous processes of the dorsal vertebrse were
prominent down to the tenth ; and that the tenth process with all of the
processes below were depressed. It was also noticed that this depres-
sion, very marked when the trunk was thrown backwards, gradually
diminished and finally disappeared altogether when the body was bent
forwards. On removing the soft parts it was found that the ligaments
were extensively torn asunder and detached, so as to permit the articu-
lating apophyses of the tenth vertebra to be carried into contact with
the back of the ninth. The spinal marrow had undergone no visible
tlteration."*
Malgaigne thinks he has once observed the same thing on a living
sabject, and that by simply bending the body forwards he accomplished
the recluction and effected a perfect cure, except that a slight curvature
remained at the point of injury.
Among the cases reported as having been complicated with fracture,
the following example, reported by Dr. Graves, of New Hampshire, to
Dr. Parker, of this city, possesses unusual interest :
On the second day of January, 1852, a man, set. 25, was struck on
the back while in a stooping posture by a falling mass of timber, causing
a dislocation of the last dorsal upon the first lumbar vertebra. His
lower extremities were completely paralyzed, and priapism continued
for several hours. The surgeon determined to make an attempt at re-
duction, and for this purpose he placed the patient upon his face, and
secured a folded sheet under his armpits and another around his hips,
directing four strong men to make extension and counter-extension by
these sheets. Chloroform was administered, and when the patient was
completely under its influence the extending and counter-extending
forces were applied, and in a few minutes the vertebrae glided into place
with a distinct bony crepitus. The restoration of the line of the ver-
tebral column was found to be nearly but not quite perfect.
On the sixteenth day he began to have slight sensations in his feet,
and at the end of six or eight weeks he was able to control the evacu-
* Melchiori, Gaz. Medica, stati SHrdi, 1850. * Mclchiori, loc. cit.
544 DISLOCATIONS OF THE SPINE.
ations from the bladder and rectum. Several months later he had
recovered so completely as to walk with only the aid of a cane.*
I know of only one similar case. Rudiger has published an aocoani
of a dislocation obliquely backwards and to the right side, which
occurred at the same point in the spinal column. The subject was a
musketeer, who had been struck upon his back by a falling wall whidi
he was endeavoring to pull down. Kudiger laid him upon his belly,
and by the assistance of others he was able, but not without causing
pain, to reduce the bones. Immediately, however, when the extensioo
was discontinued, the action of the muscles caused the displacement to
recur. The surgeon then directed four men to make extension, while
another man retained the bones in place by pressing upon them with
his hands. After several hours this method of pressure was replaced
by a board underlaid with compresses and sustaining a weight of more
than fifty livres. On the following day it was found sufficient to bind
compresses over the projecting bone, and in this condition the patient
remained fifteen days; during all of which time he lay upon his bellr
with his shoulders more elevated than his pelvis. On the twentieth
day he could lie upon his back, and in about six weeks he was so oooi*
pletely restored as to be able to pursue his trade as before!* Thia is
certainly a very extraordinary case, whether considered in refereooe to
the means employed to restore the bones to place, or to its results;
and if the statements are to be received at all, it must be with some
hesitation and allowance.
On the other hand, we are able to present at least one example ia
which, although no reduction has been accomplished, the patient has
survived the accident many years ; yet it must be admitted that his
recovery is far from having been as complete as in the two cases just
mentioned.
Joseph Stocks, set. 11, in the spring of 1826, was crushed under the
body of an ox-cart in such a manner as to produce a dislocation of the
last dorsal from the first lumbar vertebra, causing immediately aImo4
complete paralysis of all the parts below. This young man was ^eeo
by Dr. Swan, of Springfield, Mass., in the summer of 1834, at which
time he was occupied as a portrait-painter. His lower extremities
remained paralyzed and of the same size as at the time of the receipt
of the injury. He was unable to sit erect, owing to the mobility of
the spine at the seat of dislocation, and he had therefore lain constantl;
u|X)n his side. The upper portion of his body was well developed, and
his intellectual faculties were of a high order.'
It is not, however, with a life of per{)etual deformity tliat the two
examples of reduction already described are to l)e contrasted. A ra»ult
so fortunate as this, where the bones remained unreduced, is uniooe;
in all the other cases re{)orted the patients died miserably after period*
ranging from a few days to one year or a little more.
Charles Bell has related the case of an infant who was run over br i
» GruvM, N. Y. Journ. Med., March, 1862, p. 190
' Rudi|;or, Journ. de Cliir. de Desnult, lom. iii, p. 09.
• 6wMn, Boat. Med. and Surg. Journ., vol. iiii, p. 102, March, 1*40.
OF THE SIX LOWER CERVICAL VERTEBRA. 545
a fliligence, and who died thirteen months after the accident. On
eiamiDation after death, the last dorsal vertebra was found to be
completely luxated backwards and to the left, upon the first lumbar
vertebra.*
With these facts before us, I think we cannot hesitate, when the
oatare of the accident is fully made out, and especially when the dis-
locatioD has occurred in the lower dorsal vertebrae, to attempt the
Rduction by forcible extension, united with judicious lateral motion,
or with a certain amount of direct pressure upon the projecting spines.
i 3. Dislocations of the Six Lower Cervical Vertebrse.
It is much more common to meet with simple luxations of the ver-
tebrae of the neck uncomplicated with fractures, than of either of the
other vertebral divisions. This is doubtless owing to the greater extent
of motion which their articulating surfaces enjoy.
They may be dislocated forwards or backwards. The forward lux-
ition may be complete or incomplete; with both sides equally advanced
("bilateraP' of Malgaigne), or one of the articulating apophyses may
be dislocated forwards, holding the opposite apophysis in its place
("unilateral" of Malgaigne).
Schranth' has collected twenty-four examples of luxation of the
cervical vertebrse, of which four are recorded as dislocations forwards,
two back, and six to the one side or the other. Three of this number
were dislocations of the atlas, two were disclocations of the second
vertebra, five of the fourth, two of the fifth, two of the sixth, and one
of the seventh. In the other cases the seat was not stated.
Malgaigne has brought together forty -five examples ; of which
twenty-one were complete forward luxations, nine incomplete forward
luxations, nine unilateral and forwards, and four were backward lux-
ations. Three were dislocations of the second vertebra upon the third,
four were dislocations of the third vertebra, ten of the fourth, eleven
of the fifth, fifteen of the sixth, and two of the seventh.
The bilateral fonvard luxations are generally caused by a fall upon
the top and back of the head, or upon the top of the head while the
neck is very much flexed forwards. The unilateral is caused generally
by a direct blow upon the back of the neck, the blow being probably
directed somewhat to one side or the other. The number of backward
luxations which have been reported are too few to enable us to indicate
very accurately the general causes, but it seems probable that they are
most often occasioned by a fall upon the fore and top i)art of the head,
received while the neck is bent forcibly back.
In dislocations of the cervical vertebrae forwards the head is usually
depressed toward the sternum, in dislocations backwards the head is
thrown back, and in unilateral dislocations the head is turned over
one of the shoulders. Neither of these malpositions of the head is
oniformly present in these several dislocations, and indeed not un-
' ChiiHes Bell, on Injuries of the Spine, 1824.
' Schmnth, Amer. Journ. Med. Sci., May, 1848, from Archiv. fUr Phys. Heil-
kunde.
546 DISLOCATIONS OF THE SPINE.
frequently, especially in case the system is greatly shocked by the
accident, the head and neck assume a preternatural mobility, and may
be turned easily in any direction.
The spinous process, unless the patient is very fleshy or consider-
able swelling has supervened, can easily be felt, and its deviations to
the right or to the left, forwards or backwards, furnish us with the
most valuable and important sign of the dislocation. Even the trans-
verse processes may be felt sometimes, especially in the upper part of
the neck, with sufficient distinctness to render them useful in the
diagnosis.
To these circumstances we may add paralysis of the body below the
seat of injury, with pain and swelling at the point of dislocation. Id
some cases also the patient has himself distinctly felt a cracking or
sudden giving way in the neck at the moment of the accident
Prognosis,— The complete bilateral luxations, whether back wards or
forwards, have in most cases terminated fatally within a short time,
generally within forty -eight hours. Unilateral Irxations are less speed?
in their results, but when the dislocation remains unreduced, death
generally takes place in a month or two. Lente relates a case of in-
complete dislocation of the fifth cervical vertebra backwards, unaccom-
panied with fracture, which accident the patient survived five days.*
A patient of Roux's lived eight days; but in the case of a second
patient mentioned by I^nte, with a complete luxation, w*ithout fmo
ture, of the fifth vertebra, the patient survived the injury only two
hours.'
On the other hand, occasional examples are presented of partial or
complete recovery with the luxation unreduced.
Horner, of Philadelphia, presented to the class of medical students
of the University of Pennsylvania, in 1 842, a lad, set. 10, who had fallen
a distance of twenty feet, alighting upon his head. He was found
senseless and motionless, with his head bent under his body. Ho
gradually recovered from the shock, but his neck was stiff, distorted,
and motionless, his face being inclined downwards to the right side.
Two days after, his " common and accurate perceptions returned, bat
he was affected for some time with tingling and numbness in his left
arm." When presented to the class the transverse processes, from the
fifth upwards, were about half an inch in front of those l)elow, showing
that the left oblique process of the fourth was dislocated forward!
upon the fifth. The rotary motions of the neck could now be exe-
cuted to some extent, but much more freely to the right than to the
left. Professor Horner refuse<l to make any attempt to reduce the
dislocation.'
Dr. Purple, of New York, has reported a case of what was called a
dislocation of the fifth and sixth cervical vertebrae, producing complete
paralysis of the lower part of the body, in which the patient 8urvi\fd
the accident many years ; but his lower extremities were so useless and
cumbci*some as to induce him, in the year 1851, six years after the
> Lento, New York Journ. Med., Mny, 1850, p. 284. > LenUi, ibid , p 397.
' Horner, Amer. Journ. Med. Sci., April, 1843, from Med. ExMin.
OF THE SIX LOWER CERVICAL VERTEBRiE. 547
injury had been received, to submit to the amputation of both at the
hip-joint. In 1852, having become v^ry intemperate, he died, but no
intopsj was obtained, so that the exact character of the injury was
never ascertained.^ Sanson, of Paris, has reported also a case which
came under his observation at H6tel Dieu, of dislocation of the ^Hhird
cervical vertebra backwards," from which, although unreduced, the
patient partially recovered. The character of this accident was not
much better determined ; for, although he felt a severe and sharp pain
•tthe moment of the injury, which was greatly aggravated by motion,
and his head was bent forwards and to the left, " the chin being fixed
on the upper part of the sternum," there was no paralysis of either the
motor or sentient nerves. Aft^r the lapse of about four months he left;
the hospital, still unable to lift his chin more than four inches from the
sternum ; after which he resumed his usual occupations, suffering no
further inconvenience than what was occasioned by the unnatural
position of his head.' Notwithstanding the authoritative testimony
of Sanson that this was a dislocation backwards, one cannot avoid the
oonclusion that it was either a unilateral subluxation, or perhaps a
mere diastasis of the articulation, or else that it was an example of
q»rain of the muscles, and consequent contraction of one set, or paralysis
oil the opposing set of muscles. It is certain that.it was not a complete
luxation ; nor, since there was no paralysis of the body below the point
of injury, can it be properly made use of as an argument for non-inter-
ference where such paralysis docs actually exist.
Let us see now what encouragement an attempt at reduction may
oJfer, in a case which presents so little ground of hope where the re-
daction is not accomplished.
Dr. Spencer, of Ticonderoga, N. Y., relates that a man, ajt. 50, fell
backwaitls from a board fence, striking upon the superior and ante-
rior portion of his head, dislocating the second from the third vertebra
of the neck. His head was thrown back so far as to prevent his seeing
his own body, and all below the injury was completely paralyzed.
Repeated attempts were made to reduce the dislocation, *^ but the trans-
▼eree processes had become so interlocked that every effort proved
abortive," and he died forty-eight hours after the injury was received.*
Gaitskill also attempted reduction in a case of dislocation of the seventh
cervical vertebra, but failed.* Boyer failed in two cases. It is related
by Petit Radel, that a young patient at La Charity expired in the
hands of the surgeons, upon such an attempt being made a few days
after the accident;' and Dupuytren says " the reduction of these dislo-
cations is very dangerous, and we have often known an individual
perish from the compression or elongation of the spinal marrow which
always attends these attempts."
Dr. Shuck, of Vienna, relates that a man, set. 24, while engaged at
his work on December 5th, 1838, twisted his head suddenly round, in
' Purple, New York Journ. Med., May. 18.".8, p. 819.
' Sanson, Anier. Journ. Med. Sci., Feb 183f), p. 514; from Gaz. des Hopitaux.
• Spencer, Boston Mod. and Surg. Journ., vol. xv, No. 11.
• O^iUkill, Ifondon Repository, vol. xv, p. *282.
• Petit Radel, Note to Boyer, Malad. Chir., vol. v, p. 118.
548 DISLOCATIONS OF THE SPIKE.
consequence of one of his companions roaring into his ear, when he in* ;
stautly felt something give way in his neck, and found it impossible to j
move his head. Next morning his head was turned to the right and |
bent down toward the shoulder. Every attempt to move his head
caused great pain. He complained of weakness in his right arm, but
all the other functions of his body were perfect. An attempt was im*
mediately made to reduce the dislocation by lifting him by the head|
but without success. On December 7th, the weakness and nomboeii
of the right arm had increased, and the attempt to reduce the booci
was renewed. The patient was laid horizontally upon a bed, and ex-
tension made from the chin and occiput while counter-extensioo wai
made from the shoulders. The force thus employed was gradually in-
creased until the patient and assistant felt a snap as of two bones meei>
ing, when it was found that the head was restored to its natural posi-
tion, and the power of moving it had returned. The next day his am
was more powerless than before, and on the following day he had vcr*
tigo, but these symptoms soon yielded to copious bleedings, and he kA
the hospital cured on the 13th.*
Dr. Hickerman, of Ohio, has reported also, in the Ohio Medied
Journal, a case of dislocation of one of the cervical vertebrae, the origi-
nal account of whicK I have not seen, but only an abridged statement
published in the Buffalo Medical Journal, By exploring the pharynx
a prominence was felt opposite the junction of the fourth and fifth cer-
vical vertebra; and the action of the heart was barely perceptible.
Seizing the patient's head under his left arm, Dr. Hickerman in thii
manner made traction, while with the index finger of the right hand
in the patient's throat, he made firm pressure obliquely upwanis, back-
wards, and to the left ; after continuing the pressure for about forty or
fifty seconds, the part against which the finger was placed gradoally
yet quickly receded in the direction in which the pressure was made^
and instantly, as quickly indeed as the act could be possibly executedi
the patient opened her eyes, and natural respiration was established.
She then also immediately became conscious of what was transpirinf
about her, and signified by signs, for she was yet unable to speak, thai
she had suffered pain in the epigastrium. Complete recovery took
place.'
Schranth received under his care a patient who had a luxation of tht
" right transverse apophysis " of the fourth cervical vertebra, withoot
lesion of the spinal marrow, which he reduced on the seventh day.
The first attempt was unsuccessful ; but the second, made with mat
caution, by the aid of four assistants, three of whom pulled the ncnd
upwards while the fourth pressed with his whole weight upon the
shoulders, was completely successful. During the time that ttie tm»*
tion was being made, the head was occasionally rotated slightly and
moved laterally, and at the same moment the surgeon pushed firmlv
against the displaced apophysis. The reduction was attended with
'^ various distinct crackings in the neck," which were loud enough to
1 Sbuck, Amer. Journ. Med. Sci., July, 1S41. p. 207.
' Hickcrmiin, Buf. Med. Journ., vol z, p. TCfS, April, 1866.
OF THE SIX LOWER CERVICAL, VERTEBRA. 549
be heard. After some days of repose he resumed his occupation, do
rtiffness remainiDg in the movements of the neck.^
I^. Cdward Maxson, of Geneva, N. Y., was called, on the 28th of
OcL 1856, to see a child about nine years old, who had met with a
amilar accident about forty hours before, namely, a dislocation of the
light articulating apophysis of the fifth or sixth cervical vertebra, occa-
aoned by suddenly turning her head around while at play. She at
fifBl oom plained only of pain and inability to straighten the neck; but
whatever moved she became faint and irritable. A short time before
the SQi^eon was called, the mother had, in attempting to move her in
bed, turned the face a little more to the lefl, when a severe convulsion
immediately ensued. On examining the neck. Dr. Maxson discovered
the displacement of the transverse process. Having advised the parents
of the danger necessarily incident to an attempt at replacement, and of
the probable consequences of its being permitted to remain as it was,
Aqr consented that the trial should be made. "I grasped the head,"
■ays Dr. Maxson, "with both hands, and proceeded according to De-
auilt's method, only I first carried or turned the face very gently a little
farther toward the left shoulder, to, if possible, disengage the process;
then lifline or extending the head, I turned the face very gently toward
the right shoulder, when the difficulty was at once overcome, and she
exclaimed: *I can move my eyes.' Her countenance soon acquired a
BMire natural appearance; the faintness passed otF; she rested quietly
through the night; had no return of the difficulty, and needed only an
emollient anodyne to soothe the irritation and slight swelling which
remained at the point of injury."^
Rust/ Wood, of this city,^ and others, have seen and reported simi-
lar cases attended with like success.
So fiur the cases of successful reduction which we have descril)ed are
examples of dislocation of only one of the articulating apophyses,
and they are sufficiently numerous to establish the value of the prac-
tice. We have now to relate a case in itself unique, namely, a suc-
CBBsfuI reduction of a dislocation of the fifth cervical vertebra, in which
both apophyses appear to have been thrown forwards. It occurred
in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y., and will be
best understood by a reproduction of his own published account of the
"E, K., the subject of this accident, was a laboring man, thirty
years of age, tall and muscular, but not fat, with a neck longer than
the average among men of equal height. On the evening of the 2d of
October he became intoxicated ; was brought home insensible, and did
not recover from the combined effects of the shock and his libations
antil the following morning, when he was supposed by his wife to be
laboring under oold and a stiff neck. She made some domestic appli-
cations to the affected part, and administerc<l a dose of cathartic medi-
cine. When it was thought sufficient time had elapsed without ob-
* Schranth, Amor. Journ Mod. Sci., Mhv, 1848.
" Maxson, BufTalo Med. Jnurn., Jan. 1857, p. 476.
* Rust, Cheliup, note l>y 8niilh.
* Wood, New York Journ. Med., Jan. 1857, p. 13.
560
DISLOCATIONS OF THE SPINE.
tainiog relief, lie was Been by Dr. Potter, of this city, and afienrj
by Br. Cullen, both of whom recognized a condition which was
only very unusual, but one which they had never before obeer%'ed.
was then requested to examine the cose, which I did on (he ninth da;
after the acoident. With some aasistsince and great personal effort. h_^
waa able to get out of bed, moving very slowly and cautiously. D^^
siring to expectorate, he was obliged to get down on his hands ai^^
knees, which he accomplished with the same deliberation. \Vh^^
9eat«i ill a chair, the head was thniwn back and permanently fixe^:*
the face turned upwards witli an anxious expression. The anter^-
portion of the neck, bulging forwards, was strongly convex, rcnderij
the larynx very prominent. The integuments of this region were toe*
ceedingly tense and intolerant of pressure. The posterior |M>rIion of
the neck exhibited a sharp, sudden angle at the junction of the filih
and sixth cervical vertebra:, around which the integuments lay in
folds. It was difficult to reach the bottom of this anele even witb
strong pressure of the fingers, and of course the regular line formed I7
the projecting spinous processes was abruptly lost. He complaincila
intense and constant pain at this [mint, which was neither re!icv«i nw
aggravated by pressure. With difficulty he swallowed small quin-
tities of liquifl, pausing after each effort, and could not be indiiitd 10
take solid food, since the first attempt to do so aft#r the awidcnt wu
followed by violent paroxysms of coughing and choking. His breatb
ing was olwtructed and somewliat laiwred, being unable fully to da*
the bronchia of their secretion. This, however, seemed mlher n
effect of the tejise condition of the soft parts of the iie<"k, limn thi
result of pressure upon the spinal cord, since he presented no evidem*
of paralysis, either of motion or sensation, in parts below the n«k.
The stemo-oleido- mastoid muscles of both sides were felt quitosoftuM
relaxed.
"But one ctmclusion could be formed upon this slate of fect%W
wit: that the oblioue processes of both sides were completely it^
cated. The markcn rigidity of the head seemed to precluue the prn^
bility of fracture through the vertebral bodies, and although the or*
lape might be separaleti anteriorly, yet the lK>dy not pressing backwani
Bufficiently to produce paraiysia of the cord, it waa hoped rliat th* p*
terior vertebral ligament remained uninjured; it was, therefore,
mined to make an effort at reduction on the following day. In
tion to those originally conneolc<l with the cast', I am umlcr oblipwi**
to Dra. Ingraham, Turner, Palmedo, G. D, Ayres, an<l n miinwrrf
other medical gentlemen, who were present by invitation, all of wW
confirmed the diagnosis, and rendered eflGcient services.
" The patient was placed upon a strong table, in a rrcumbeol p^
tion, with a pillow resting under the shoulders, the hciid being wp*
ported by the hand during the administration of chloroform, of whi*
an ounce was given before anesthesia ensued. Counler-eitewi*
being made by two folded sheets placed obliquely acrms the shonH*
and properly held, the head was graspeil by one hand placed una*
the chin, the other over the occiput, and by steadily and firmly it**-
ing the head directly backwards, and then upwanla, an attemp"*
DISLOCATIONB OF TH£ ATLAS.
651
at reduction, but fiiiled for want of suflicient power. Dr. Ingra-
was then re(|uested to place his hands immediately over my own
e same position as before, and steady traction was again made in
nrae direction. Our united strength was required in drawing
lead backwards and upwards to
dge the superior oblique processes Fin. vf\.
their abnormal position. When
was felt to be yielding by Dr.
en (who kept one hand constantly
le seat of dislocation), Dr. Potter
iirected to place his hands under
iwn, still in position, and assist in
png the head forwards; at the
: time the chest was depressed
rd the table. The bones were
nctly felt to slip inio their places;
line of the spine was instantly re-
d, the head and neck assuming
DBtural position and aspect. As
as the patient became conscious,
[pressed himself ignorant of what
taken place, but free froni pain,
in his own language, 'all right.'
andage was arranged to support
head and keep it bent forwards,
lad an anodyne for two nights fol-
rag, after which no further treat-
l was necessary, and at the end of
«eek he had complete control over anb ccnicii Terubn.
novemeots of the head and neck.
md the debility and emaciation immediately depen<lent ujKin
racted fasting and loss of rest, he has experienced no uneasiness
: the operation. His appetite is now good, and all the funoti(ms
MTU their duty normally. In a subsequent inquiry, to determine,
wsible, the cause of the accident, he states that he distinctly
llects going into a store in Atlantic Street, near the ferry, and
! having angry words with an acquaintance; that he left the store,
was proceeding'Up the street (which is here a rather steep ascent),
1 he was violently struck from behind, over the lower portion
le neck. He likewise remeinbera falling forwards, and striking
ut some object, but docs not know what it was, nor what took
! until the following morning." '
i 4. SUlo cations of the Atla*.
ii^eons have met with several forms of displacement between the
and axis. First, a forced inclination forwards of the atlas upon
izis ; in consequence of which the body or anterior arch of the
is made to recede from the odontoid process, and the transverse
> AyrM, Mew Turk Journ Med., Jan. 1857, p. 9.
al dIalDCtCiOD atUia
552 DISLOCATIONS OF THE SPINE.
ligament glides upwards without breaking, so that the extremity of
the odontoid process comes to occupy a position underneath or behind
the ligament, and thus presses upon the cord. It is apparent also thii^
this form of displacement cannot occur without a rupture of the ver-
tical ligaments which bind the transverse ligaments to the axis, nor
without a separation of the atlas from the axis posteriorly and a rap-
ture of the posterior atlo-axoidean ligament. Second, a similar incli-
nation of the atlas, accompanied with a rupture of the transverse and
superior vertical ligaments, in consequence of which also the odontoid
process is allowed to fall upon the cord. Third, the atlas in the same
position, with the odontoid process broken at its base. Fourth, the
atlas displaced directly forwards or backwards ; and fifth, a displace-
ment of only one articular process in a dire<:tion forwards.
We have already, when speaking of fractures of the atlas, or of tiie
atlas and axis together, called attention to several examples of thil
form of the dislocation which is accompanied with a fracture of tbe
odontoid process. The other forms of dislocation are characterised
by so few symptoms peculiar to themselves, or which can be r^anlcd
as diagnostic and not already sufficiently studied in connection with
other dislocations of the neck, that we shall not deem it necessan' to
do more than remind our readers, that if permitted to remain unre-
duced a speedy and fatal issue is inevitable, and to point them tot
couple of examples of recovery, after re<l notion has been fortunately
accomplished ; for both of >vhich I am indebted to Malgaigne. The*
may alone suffice to show that Dupuy tren was in error when he declared
that such accidents were wholly beyond the resources of our art.
An old man received upon his head a bundle of hay cast from tbe
top of a wagon. He fell with his head bent forwards so that his cbia
touched the top of the sternum, and in this position it remained
immovably fixed ; all the other portions of his body preserve<l their
natural functions. A surgeon, who was indeed the father of Mal-
gaigne, being called, assured the patient, that unless he could give bin
relief he certainly would die; but that inasmuch as the attempt might
itself prove fatal, he ought at once to put in order his affairs. Accord-
ingly the man partook of the sacrament ; then the surgeon seat«l him
u})on the ground, and placing himself at his back with his knees
resting upon his shoulders for the purpose of making counter-exteo-
sion, and with a towel brought over his own shoulders and under the
chin of the patient for extension, he proceeded to act upon the neck ib
the direction of the axis of the spine. The efforts were long and pain*
ful ; but at last, while the heaid was lifted as far as possible, it ^ns \
suddenly drawn backwards, and immediately it resumed its natural |
direction. Absolute quietude was enjoined, and the patient recovers ^
in a short time and without any accident.
This patient was seen two years after by the younger Malgaigne •'
which time no trace of the amdent remained, except an iuijwssibihty
of turning the head to the right or to the left.
The other example is related by Ehrlich, but in this case the dido"
cation was backwards. A young man, let. 16, while carrj'inp a sack
of flour up a ladder, fell backwanls, and the sack falling over upon bi»
fSLOCATIONS OF THE RIBS FROM THE VERTEBRAE. 553
5 and head came to the ground before him. He was found lying
,h his h(>ad thrown back and to the right, the head resting upon the
pala of this side, but having so completely lost its " solidity " that
itJi own weight it would &ll from one side to the other. On the
«it and left side of the neck there existed a prominence supposed
be formed by the atlas; the patient was unconscious; the pulse was
ircely perceptible, and the whole body was suflering under paralysis.
brlich directed the shoulders to be held by one assistant, and the
ad to be drawn upon by another, while he pressed with his own
indfl forcibly upon the displaced atlas from behind. After several
oitless attempts, the reduction took place, accompanied with a sound
stinctly audible to all of the assistants ; the head resumed its posi-
9D firmly, and the arms began to move. The head was afterwards
aintained in place by a bandage. The cure proceeded rapidly, and
ier a time no trace of the injury remained but a disagreeable tension
I the nape of the neck whenever he moved his head briskly to the
ae side or the other.*
1 5. Dislocations of the Head npon the Atlas, or Occipito-Atloidean
Dislocations.
Lassus, Palletta, and Bouisson' have each reported one example of
bis dislocation. In neither case was the dislocation complete, but death
ecarretl speedily in every instance. Dariste exhibited t^ the Anatomi-
il Society of Paris, in 1838, a specimen of incomplete luxation of the
ocipito-atloidean articulation, with stretching of the transverse liga-
lent. The patient from whom the specimen was taken having lived
lore than a year after the accident, when he died from a tubercle in
lie brain.^
CHAPTER IV.
DISLOCATIONS OF THE RIBS.
The ribs may be separated from the bodies of the vertebrae, from the
cartilages of the ribs, and from each other. The cartilages of the ribs
may also be separated from the sternum.
{ L DislocatioiiB of the Elba from the Vertebrae fVertebro-ooatal).
The heads of the ribs are joined to the bodies of the vertebrae by
strong ligaments. The articulations are ginglymoid, admitting of mo-
tion chiefly in the direction of the axis of the spine. The mobility
* Xalgaigne, Ehrlich, MalgMi^ne, op. nt.. torn, ii, p. 834.
' Liiit»u», Palletta, B<>ui»8on, Mal^aiirne, op cit., p B20.
• Daritte, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives G6n., May,
86
K dually increasps as we proceed from tbe first rib downwards to tl^
;, Each joint is furnished with a papsule. '
The necks ami tubercles are also iinili^d to the transverse pro
by ligaments, and the articulations are fnrnished with synovial caa
Bule».
I am not aware that any ejiaiuplea have ever been reported of disl
cations of the ribs from the transverse pronesses.
Kxamples nf dislocation of the heads of the rihs have heen nieniioii
by Ambrose Par6, Bransby Cooper, Alcock, Donnie, Henkel, tCenne^
Buttet, and some others ; but most of these reputed Leases have not bu^
the test of a eritiiial analysiH, and while Vidal (de Cassis) is in dn^
whether the claims of even one have beeu fully established, Bo^
denies absolutely its possibility. We see no reason, however, to qiKstMti^
the authenticity of several of these examples.
The case mentioned by Bransby Cooper, although very briefly
rated, leaves no room for doubt as to its real character. "Mr. Wel>-
atcr, surgeon at St. Albans, when examiuing the body of a |iatient wbo
had die<i of fever, found the head of the seventh rib thrown niw
front of the corresponding vertebra, and there aDchyio(*ed. Lpon in-
quiry, Mr. Webster learn«i that this gentleman, several yenrs bcfoM,
had been thrown from his horse across a pate, for which accident b«
had been subjected to the treatment usually followed in fractun^oribe
ribs, and there is every reason to believe that it wa." at (his tim« (be
diitloeation occurred.'"
These accidents seem to have been generally occnsinnctl by a fallflt
a blow upon the back, and (he dislocation has l>ecn accompanid, iu)f
ally, with a fracture of some other rib, or of the transverse or s[Hnooi
processes of the corresponding verfebne. The head of the ril> tio
always been found to be displaced inwards. Tbe lower n[«, inclii^
ing the false and floating, are those which have been most frwiiwntly
displaced.
It would be difficult, if not impossible, during the life of the paliflit,
to make a positive diagnosis, since the symptoms resemble so clmrff
those which accompany a fracture of the rib near it? posterior ext«niil|^
The nature of the accident prodncing the dinlocalion, the depnwio^
mobility, and pain, are equally indicative of a fracture; while tie lailuiv
to detect crepitus might easily be explained by the ibicknewoflln
muscular walls at this point, or by the riding, or by other diapli*
meniB of the broken fragments.
Chelius speaks of a pe<'uliar "rustling." perwived wlien tho twfr
and ribs are move<l by the surgeon or by the patient himitrir, mm
which is different from the sensation produced by emphysema nr fiw
ture.
The treatment ought to be the same which would \)c adopt<-d inW
the rib was broken. Replacement of the dislocate*! l>on« mik<t heif
garded as impossible; and it only remains that we insure (]ui«i«Bf
as possible in this portion of the chest, and coml>at the fnin and inlha-
mation by suitable remedies. The circular bandage, however iW"
' Wetwli^r, B. Cuoper'i ed. of Sir Attlejr Cooper, Am«r. ad., p. 4fiS
DISLOCATIONS OF THE CARTILAGES OF THE RIBS.
555
mended in these casRS by Sir Astley Ccw>per, could only be serviceable
ill dislocations of those ribs which huve an attachment to the eternum|
the fluutin^ ribs, which have been iimiid dislocated quite us often as
either of the olhers, could derive no support from circular pressure, or
from anv other mechanical contrivance.
The carliliifje of the first rib han no proper articulation at either ex-
tremity, hut the remaining six upper ribs, where they join the sternum,
are furnished with synovial capsules. In old age these articulations
^^^erally di.sappear, yet not always.
^^m Charles Bell observes : " A young man playing the dumb-bells and
^Hpowing his arms liehind him, feels something give way on the chest ;
^1^(1 one of the cartilages of the ribs has startal and .stands prominent.
To reduce it, we make the patient draw a full inspiration, and with the
fingers knead the projecting cartilage into its place. We apply a com-
press and bandage, but the luxation is with diiScuIty retaine<l."
Itavaton, Manzotti, and Mouteggia have each, according to Mal-
pnigne, reported one example of traumatic dislocation ; in all of which
the cartilages were thrown forwards in advance of the sternum.
; When treating of fracture of the sternum, I have related one case,
[k>eh has come under my own observation, of dislocation of three or
ibr cartilages at the name time.
iDr. Samuel D. Flagg, of St. Paul, Minn., relates as follows:
■** During the evening of June 29th, 1871, a girl, set. 10, while
rith several children, ran violently against the corner of an
idinary deal table. It is .stated that the child was faint and breathed
h difficulty for a short time, but soon returned to play. No swell-
iftp or other evidence of injury was observeil by her friends.
" On the let July, about forty-eight hours after receiving the injury,
while exercising somewhat violently, she complained of sudden pain at
B left costo-sternal articulation and a sensation of something having
^nn way. Soon afterwards I saw the child for the first time, and
(nnd a slight non-crepitant swelling at the latter point, and the ster-
3 eJitreraity of the cartilage of the fourth rib displaced forward, its
tenor surfat* being very nearly on a plane with the anterior surface
r the sternum. A minute fragment of bone, unconnected with the
ir cartilage, was noticed, which I took to be a fragment chipped
«ff from the margin of the articular depression on the edge of the ster-
num. Neither pain nor embarrassefl respiration were notably promi-
nent; crepitus could be detected, but not very distinctly; preternatural
' 'lity was very evident.'"
y pressure alone restoration has generally been effected, the cartilage
"ning its position suddenly and with a sound. The reduction may,
rtheless, he facilitated by bending the trunk backwards, or by
ting the patient to make a full inspiration.
' Flagg, Nortbwustern Med. and Sur^. Jour., Aug. 1871.
556 DISLOCATIONS OP THE HIB8.
To maintaJD the reduction hafi been found more diffieiilt, and Sfl
Aatley directs that "a long piece of wetted pastelioard should be piaf^
in the amree of three of the ribs and their cartilages, the injureil r"
being iu the centre ; this dries upon the chest, takes the exact form '
the parts, prevents motion, and affords the same support ai' a )'pl)
upon a fi-actured limb. A flannel roller is to be applied over 1^
splint, and a system of depletion pursueil, to prevent iuflammution
the thoracic viscera." Instead of the pasteboard, we might use eii1
felt, sole-leather, or gutta-percha.
The patients spoken of by Ravaton and Manzotti were both ax
in about one month.
Mr. Bransby Cooper says that a baker's boy applied for relief,
Guy's Hospital, who was the subject of displacement of the mrtila^n
of the fiflh and sixth ribs from their junction with the slernnm, tiro-
duced partly by the constant action of the pectoral muscles in kiieaarn,
bread, but principally by his defective conetitution. Mr, Cooper stuto
to the Iwy the necessity of changing hia occupation, and advised liii
to go into the country ; but an he was unable lo do eo, little hojK
entertained of his recovery.'
J 3, Dislocation of one Cartilage upon Another.
The cartilages on the sixth, seventh, and eighth ribs are fiimishci
at their lower borders with a true arthrodial joint, by which they«tii>
ulate with the corresjKinding cartilages. This arrnogcment aoraetinM
extends to the fifth and ninth ribs.
A displawment oF these articulations may take place when one ft*
upon his back, striking upon some projecting body, so that the
suddenly thrown forwards ; in consequence of which the upper
of the lower cartilage is depressed and entangle<l behind the 1"»*
margin of the upper. The inferior cartilage is, therefore, the one whidk
is displaced rather than the superior, although this latter Iteing iomB
Srominent by the pressure of the other from behind, sei-ms nione W !•
isplaced. Boyer, Martin, and Malgaigne have each reported one '
ample.
It is probable that the contraction of the pectoral and abdomio"
muscles has a chief agency in the production of these dislocatiattf.iw
that they are not solely or directly due to the shock of the accident
The treatment consists in pressing firmly upwards and hacli«rff
against the interior margin of the upper, or overlapping rib, *» • "
disengage it from the lower, when by its own ehisticity It wil) IW
ita natural position. Tlie reduction might also be aided by a fuU
spiral ion,
DISLOCATIONS OF THE CLAVICLE. 557
CHAPTER V.
DISLOCATIONS OF THE CLAVICLE.
Of 50 dislocations of the clavicle observed by me, 9 belonged to the
sternal end and 41 to the acromial. Of those belonging to tlie sternal
ad, 7 were dislocations forwards, forwards and upwards, or forwards
ind downwards, and 2 were upwards. I have never met with a dis-
keadon backwards. Of the acromial dislocations the whole number
were dislocations upwards, or upwards and outwards.
i 1. Stemo-Clavicular.
(a.) Dislocation Forwards at the Sternal End.
Causes, — This accident is generally caused by a fall upon the point
of the shoulder, in consequence of which the sternal end of the clav-
ide is driven forcibly inwards and forwards. It is probable, also,
tkal the blow which produces the dislocation is received rather upon
4e anterior and outer face than exactly upon the extremity of the
shoulder. A sudden effort of the muscles, as in the attempt to balance
I weight upon the head, or to throw the shoulders backwards when
Under drill, has been known also to produce this dislocation. In one
aoiinple it was occasioned by placing the knee against the spine and
Inwing the shoulders forcibly back. Various other accidents, the
shilosophy of whose agency is not so easily explained, are said to have
^foduced the same result; but it is not improbable that in many of
these cases the precise manner in which the injury was received has
not been correctly understood or reported.
Mr. Fergusson has once seen this displacement in a newly-born in-
hnt, which had happened during birth. It could be replaced with
nse, but immediately slipped out again when left to itself. "Nothing
was done; a new joint formed, and the child afterwards possessed as
much power in the one arm as in the other."^
Symptoms. — The head of the bone, unless the person is exceedingly
hi, or great swelling has supervened, can be distinctly felt and seen in
front of the sternum ; the corresponding shoulder falls a little back;
the head inclines also sometimes to the same side; the movements of
the arm are embarrassed, and accompanied almost always with an acute
pain at the point of dislocation. The clavicular portion of the sterno-
cleido-mastoid muscle presents an unusually sharp and projecting out-
* Fergusson, System of Practical Surgery, Amer. od., 1863, p. 203.
568 DISLOCATIONS OP THE CLAVICLE.
line, and tt careful measurement indicates, if thedisloeation is complete,
a sensible approach to the acromioa
Fio. 252. process toward the (•entre of the iner
num. If now the sur^>n places liii
knee against the spine, and draws the
shoulders back, the projection of the
clavicle in front diminishes or dL-vf^
{tears ; if he carries the sh<>ui<Ier up,
it dcM'cnds; and if he dejire^ses toe
shoulder, it ascends.
The simplicity and uniformilj irf
the 8yni|»toms which usually cbanfr ;
teriM this accident will genenllf
prevent the possibility of a misiakt; i
but Pinel mentions the ease of a mu .
niiiuotionor theiteraiicudrorwirdi. wtio, having presented himself at ooe (
of the hospitals of Paris, sulferiiig a^ \
der this dislocation, the surgeou-in-chief thought it a tumor of the
bone, and advised the application of a plaster; and, on the other hand, <
a patient presented himself to Velpeiin, who had been treated for a di»-
Iw^tinn, when the bone was only expanded by disease.
I Imve my.self also seen a fracture so near the sternal endof thebooe
as not to be easily distinguished from a dislocation.
Paihology. — In complete anterior luxation of the clavicle, theoip-
eutar ligament suffers a complete disruption, and also the anteriorwitk
the posterior sterno-clavioular ligaments. The rhomboid and inteiv-
tieufar ligaments suffer more or loss, according to the extentof thf di»*
placement. The interartieular cartilage may retain its atta<'hmeiit to
the sternum, or it may l>e cnrried forwards with the clavicle. The
head of the bone lies imiuediatety underneath the skin and in front
of the sternum; and generally it is tound to have dewvnded a liiilc
upon its anterior surface. Kichorund saw a (»se in which the sivrntl
extremity of the bone was placed three inches below the lop uf tl»
stenuitii.
Wherever the bone lies it ••arries with it the clavicular fasck-uiu* of
the sterno-cleido-mHstoitl muscle.
Deafment. — Not one of the seven forward dishicatinns of ihecUvi-
cle at the sternal end seen by me has been completely re<hiced, m if
reduced they have not lx?en retained in place. In the (ollowini!"*
ample the reduction, although faithfully attempted, was never mwo-
plishetl.
Mr. II., of Buffalo, fet. 45, wa.« thrown by a horse, suffering >t thf
same moment a frntturc of the leg and a forward dislwation of the \A
clavicle at its sternal end.
Prof. Janitsu P. White, with whom I was in consultation, made"*'"
ernl attempts to reduce the drxlotation by placing the knee agaiwiil>f
sjiino and ]iulling the shonhler forcibly Iwick, and the twme effortf "«»
re|>e)ttcil bv myself, but without accomplishing the reduction. We il"'
endeavored to reduc<! it by praising directly upon (he projecting bt*"
DISLOCATION FORWARDS AT THE STERNAL END. 559
nd by placing a pad ih the axilla, using the arm as a lever^ as recom-
oended by Desault, and with no better result.
This patient was tolerably muscular, but while we were manipulat-
ing he was very much enfeebled by the shock of the accident.
Finding that it was impossible to reduce the dislocation by any mod-
erate amount of force, and believing that if we were to succeeil we could
not retain the bone in place, and the more especially because his left
ride was so much bruised that he could not bear an axillary pad or
baadagcs of any kind, we desisted from any further attempts.
Two years later I examined the shoulder and found the clavicle still
unreduced, and its position unchanged. When he carries the shoulder
ibrwards or backwards, there is a corresponding motion at the sternal
end of the clavicle. The arm is not quite as strong as the other, and
te freedom of motion is slightly impaired.
I have also in my museum the east of a case of complete forward
lislocation at this point; which accident occurred in a lad twelve years
W, who had fallen into a cellar on the 20th of Aug. 1856. The late
Jr. Lewis and Dr. Dayton, both excellent surgeons, had examined the
,nn, and dressings had been applied with a view to maintain the re-
luction ; but on the fifth day after the accident I found the bone dis-
>laoed ; nor do I think reduction was ever afterwards maintained.
A lad was brought into the BuJfalo Hospital of the Sisters of Charity,
with a dislocation of the same character, on the 25th of Sept. 1858,
irho had been run over by a wagon on the same day. Dr. E. P.
Smith, one of the surgeons of the hospital, attempted faithfully to re-
duce it, but was unable to do so. Five days after, I found the bone
out and quite movable. All apparatus having been removed, we laid
him upon his back in bed, and kept him in this position three weeks.
He was then dismissed with no change in the appearance of the bone,
but he could move the arm as well as before the accident.
Other surgeons have not met with, or at letist they have not men-
tioned, anv cjises in which the reduction of this disloc^ition was attended
with difficulty, nor am I prepared to explain the difficulty which was
experiences! in my own (Mr. H.), and in Dr. E. P. Smith's case.
Probably they ought to l)e regarded as exceptions to the general rule.
But most surgeons have testified to the difficulty of retaining it in place
when reduction has been fairly accomplished. Chelius says, " there
commonly remains more or less deformity,." and Malgaigne says that
"it is difficult and rare to cure it without deformity."
Nevertheless, Desault (or, rather, his pupil Bichat, who has published
Ms lectures), who always speaks very confidently of his ability to re-
tain either broken or dislocated bones in their places, says that he
"almost always ol)taine<l complete success" with his apparatus. It
is remarkable, however, that of the three examples furnished by Bichat
tocoufirm this statement, all of which were treated by Desault himself,
one recovered after a long time with a " very perceptible protuberance
ifl front of the sternum, one with a "very slight protuberance," and
in the other the "swelling was almost gone" on the twentieth day, and
^are left in doubt as to whether the reduction was any more complete
560
DISLOCATIONS OF THE CLAVICLE.
than in either of the other cases.' Rkiherand and Guprsant siiw*«l«-
no better with Desault'a dressings.'
Other surgeons liave made similar claims for their own forms of a«
paratus, but experience still continues to show that a complete rvlts
tion of the dislocated bone in seldom to be expected.
Sir Afltlcy Cooper recommends au apparatus, tlie coiistrnction sut
application of which are illustrated b; the accompanyiug sketch, the i:a
ject of which istodrawthe»hu^
ders back, and at the same tici
by the aid of two pads or cushi<^
in the axillie, to carry the she*,
ders outwards. Tho clresTiiu ^j
thcD completed by placing (^
arm in a sling. He Bdvisei^
however, that in some way f/A
retrt pressure should be nude
Upon the projecting point uT
bone.
Velpeau objecte to any pIiD
which will draw the shoukkn
bai^k ; but, on the coDtmrj, be
thinks that theshouldeif ehuuld
be kept slightly forwards, «»
to diminish the tendency of tJic
sternal end of the clavicli' »
escape in this direction.
Until further obscrvalioM
Imve dclermined the reUti't
value of these and of maoT
8irA»ii,f, co.,pLVs»ri,Brj.iui,fordWo«iddci.iicia. othcr proccsscs, It will U' Mil
to adopt no tixe<l m)eofarli«i
but, having reduced the bone by either placing the knee upon the^'i*
and drawing the shoulders \mck, or by making use of the humena "
B lever, we recommend that the surgeon shall seek to maintain it »
place by such means as the ex[>eriment shall pnivu arc nust enci^wAL
Among these means, direct pressure npon the sternal end of the ciavirf«i
the sling, and perfect quietude of the uiiist-lcs of the arm through tk'
I Hid of bandages, are no doubt of the greatest im)>orianoe, and can HeW»"
I be omitted. If then we find that a position of the shoulders mow*
less forwanls or backwards best maintains the apposition, this poaiW""
whatever it is, ought to be continued.
Id order to be successful, sufficient time must elapse for the In"
ligaments to become firmly reunitml, during which the reduotinn nitrt
be constant; since every time the bone eiwnpi«, the whole work ■
repair has to be recommenced as from the beginning. Tothi^mJ*'
least four or six weeks arc necessarj', and sometimes the period "'
be lengthened far beyond these limits ; so tliat it may ufU-n bwonr*
n». b.v Xhv. Bk-hat, Ptiihd^ ed., im P »
OP THE STERNAL END OF CLAVICLE UPWARDS. 561
grave point of inquiry whether the long confinement of the limb will
not entail more serious consequences than have ever been known to
arise from leaving the bone displaced. In no case seen by me has the
function of the arm been seriously impaired by the displacement.
(b.) Dislocation of the Sternal End of the Clavicle
Upwards.
Malgaigne has collected four undoubted examples of this dislocation,
tod I have been unable to find a report of any other except the very
extraordinar)' case described by Dr. Rochester, at the September meet-
ing of the Buffalo Medical Association, and which case, through the
coortesy of Dr. Rochester, I was permitted to see several times.^
Jerry McAuliffe, set. 44, on the 28th of August, 1858, while seated
upon a load of wood, was caught under the bar of a gateway and
violently crushed, the right shoulder being forced downwards and a
little backwards. Dr. Rochester saw him very soon after the accident.
Oq examination, it was found that the sternal extremity of the right
davicle was thrown upwards so far as to rest upon the front of the
thyroid cartilage, occasioning considerable pain, difficulty of respira-
tion, and loss of speech. Reduction was easily effix^ted, and a retentive
apparatus was immediately applied, consisting of a gutta-]>ercha splint,
moulded to the clavicle and ribs, and retained in place with adhesive
plaster. Suitable bandages, a sling, etc., were also employed to main-
tain complete rest.
Notwithstanding all the care employed, the bone again became dis-
placed, and when, near four months after the accident, this man came
before the class of medical students at the Hospital of the Sisters of
Charity, we found the sternal end of the clavicle carried upwards half
in inch, and across toward the opposite side also about half an inch,
tod projecting somewhat in front. It was fixed in this position by
ligaments which allowe<l it to move much more freely than natural,
but which would not permit any great displacement. The correspond-
ing shoulder was slightly depressed. McAuliffe said that he felt no
inconvenience or abatement of strength in the arm except when he
attempted to lift weights above his head.
In April, 1870, I met with a similar case in a woman fifty years of
age, which had been caused by a fall upon the shoulders nine weeks
before, and which had been overlooked by her surgeon in the first in-
stance. When seen by me it was immovably fixed in its new i)osition.
The accident seems to have been produced, in all the cases, so far
as can be ascertained, by a force operating upon the end and top of
the shoulder; in consequence of which the head of the clavicle is
poshed and at the same time lifted, as it were, from its socket, tearing
not only its capsule with the ligaments which immediately invest the
capsule, but also in some instances the costo-clavicular ligament w^ith
some fibres of the subclavian muscle. The sternal end of the clavicle
is found riding upon the top of the sternum, its head being placed
between the sternal fasciculus of the sterno-cleido-mastoid muscle on
> Rochester, Buffalo Med. Journ., vol. xiv, p. 262.
562
DISLOCATIONS OF THE CLAVrci.E.
the one band, and the sterno-hyoid muscle oii the other. In oneuf tl
cases seen by Malgaig;ne the head had traversed in this dircctioa con
pletely the intra-clavinilar space, and lay behind the sternal portion
the opposite »temo-cleido- mastoid muscle.
The symptoms are, a depression of ibe shoulder, with an elevnti-
of the sternal end of the clavicle so as to increase sensibly the f\m
between it and the first rib. The clavicle also encroitrliWi more
less upon the supra -sterna I fossa, occasioning a oorrespondiug dinu«
ution uf the siia™ between the end of the shoulder and the centre^
the sternum. The sternal portion of one or both of the stemo-cleL^
mastoid niusoles may also be seen raised and rendered leiise by '
pressure of the head of the bone from behind.
Reduction has been found easy, but Malgaigne thinks a perfMl
retention impossible, at least it does nut seem to have bt^n uaMm-
plished in any of the cases reported. In no case did the dispboeiiient
seriously impair the functions of the arm.
The same apparatus to which we sliall give the prcfi^renee incMi
of dislocation upwards of the acromial end of the clavicle, at leaU villi
only such slight modifications as the pccnliaritiee of the ease will art-
urally suggest, will be suitable for this accident. The shmililer nnrt
be lifted by a sling, while the sternal end of the clavicle ia nrwed
downwards by a pad and bandages ; and all the muscles of tno «•
and chest, so far iis is consistent with respiration am) comfort, muitbe
maintained in a state of perfect reut until the ligamcnte havi! heoia*
reunited.
(c.) Dislocations of the Sternal emd of the CuiVictf
Backwards.
The first case upon record of this kind of accident, caused br W"
lence, was published by Pellieux, in 18;)4, in the Itenu Mimui'l
until which time its existence had been generally denied. Ja ik
Ijomton and Edinburgh Jo\u~nal of Mediatl Sotmee for Octolier, IMl.
several cases are mentioned.
OP THE STERNAL END OP CLAVICLE UPWARDS. 563
Two forms of the accident have been described, one in which the
»d of the clavicle is driven backwards and a little downwards; and
lother in which it is displaced directly backwards, or backwards and
little upwards. In both of these classes, the end of the l>one falls
iwards toward the opposite clavicle, and occupies a space in the
dlular tissue back of the sterno-hyoid and sterno-thyroid muscles,
nd io front of the oesophagus ; the trachea, if reached at all, being
irobably thrust to the opposite side.
' The examples in which it has been found below the top of the
temum are much the most numerous ; indeed, it is probable that the
ther form is only a secondary displacement, occasioned by the action
f the fibres of the sterno-cleido-mastoid muscle.
Cauaea. — Of the eleven examples mentioned by Malgaigne, four
rere ocaisioned by direct blows, and most of the remainder by crush-
Qg accidents, as by powerful lateral compression of the shoulders.
One of the cases produced by a direct blow was accompanied with
A external wound, and is the only instance of a compound dislocation
f this kind upon record. The man was admitted into St. Thomas's
iloepital in Sept. 1835, and, according to his own account, the sharp
ud of a pickaxe had been driven through the flesh against the bone,
rhe sternal end of the clavicle was found to be displaced backwards,
ind with the finger thrust into the wound on the front of the chest, it
!Ould be distinctly felt resting upon the side and front of the trachea,
irhere it interfered somewhat with respiration and deglutition. He
wd a great desire to cough, with a sensation of pressure on his wind-
ripe, which was greatly incre^ised when his head was thrown back.
There was also a slight emphysema in the region below the collar-bone
ind over the top of the sternum. The shoulder having been brought
nek with stra{)s attached to a back-board, the lK>ne readily resumed
ts place. The elbow was then brought forwards and bound to the
lide, and the wound being closed with adhesive plaster, he was put to
)ed with the shoulders much raised. No unfavorable symptoms fol-
owed, and in three weeks he left his bed. Three weeks later he left
he hospital with the sternal end of the bone still falling a little back-
rards, and rather more movable than natural.*
The following example, related by Morel-Laval I6e, will illustrate
htt class in which the dislocation results from an indirect blow, or
rom a crushing accident.
Lemoine, seventeen years old, had his right shoulder violently pressed
igainst a wall by a carriage. He experienced at the moment some pain
It the bottom of his neck, and a great sensation of suffocation, which
lasted for more than a quarter of an hour. The dyspnoea gradually
Milieided, but the motion of the right arm not returning, he, on the
eighth day after the accident, entered La Charity. On examination,
tfc two shoulders were found to be on the same level, but the right one
wag nearer the median line. The internal extremity of the clavicle was
half concealed behind the sternum. On depressing the shoulder, the
inner end of the clavicle arose and disengaged itself from behind the
1 South, note to Chelius's Surgery, Amer. ed., vol. ii, p. 218.
564 DISLOCATIONS OF THE CLAVICLE.
sternum ; but reduction was effected by elevating the shoulder, while at
the same time it was carried outwards and backwards. Desauit's
bandage was then applied, but as it became loosened, Velpeau's was
substituted, which kept the bone completely in position until the
eighteenth day, when the patient was lost sight of.^
Symptoms, — The most constant symptoms are, the absence of the
head of the bone from its socket, and its complete or partial disappear-
ance behind the sternum, an approach of the corres|K)nding shoulder to
the median line, an inclination of the head to the opposite side, elevi-
tion of the shoulder, pain at the bottom of the neck, impairment of tbe
motions of the arm, sometimes difficulty in respiration and in degluti-
tion, partial arrest in the circulation of the arm from pressure upon the
subclavian artery, and a slight projection of the acromial end of the
clavicle, noticed twice by Morel-Laval I6e.
It has not generally been found difficult to reduce this dislocation,
nor, when reduced, is it so liable to again become displa<^e<l as are the
dislocations forwards; yet in only a few instances has the restoration
been so complete as not to leave some deformity.
In order to the reduction, the shoulder must be carried generally up-
wards, outwards, and backwards, and it may then be best maintained
in position by laying the patient on his back upon an elevated cushion,
as practiced by Tyrrell in the case related by South. To this may be
added such other measures, differing but little from those employed in
other dislocations of the clavicle, as are necessary to insure complete
rest to the muscles. Of course, no pads or bands across the clavicle
can be of any service in this case.
As in the other cases of dislocation at this point, the patients have
generally recovered nearly the full use of their arms, even in oue or
two instances in which the reduction has never been accomplished.
2 2. Acromio-Clavicular.
(a.) Dislocation of the Acromial End of the Clavicle
Upwards.
Of all the dislocations of the clavicle, this form is most frequent. I
have met with it either as a partial or complete luxation forty -one tinges.
The youngest subject wa.s seven years of age, and the oldest sixty-three.
All but two were males.
Causes, — It is produced generally by a fall u|)on the extremitj'oflbe
shoulder. Twice the blow has been received rather upon the back tbiD
upon the extremity, and once it was occasioned by the fall of a board
dire<'tly ujK)n the top of the shoulder, and once by a bolt thrust dirertly
up from under the clavicle.
St/mptoms, — When the di*^l(X^ation is complete, the clavicle not only
is lifted from its articular facet to the extent of the breadth of the bone,
but it is pushed more or less outwards over the top of the acromioo
process; generally less than half an inch, but I have once seen it riding
* Morel-LavHlIfeo, Amer. Journ. Med. Sci , vol. ixix, p, 22», 1842; from 0^
OF THE ACROMIAL END OF CLAVICLE UPWARDS. 565
•
process to the extent of three-quarters of an inch. In this last ex-
ple, the case of James Moran, a strong, healthy laboring man, the
vicle was easily reduced, and it always went into place with a, sensi-
I click; but although every possible care was taken to retain it in
ice by bandages, compresses, an axillary pad, and a sling, yet it was
t accomplished, and on the third day he removed all the dressings,
d refused to have them reapplied.
1 have usually found the shoulder slightly depressed; and in one in-
mce, where it is probable the deltoid muscle had suflered some injury,
5 elbow hung away from the body, and any attempts to lay it against
2 Bide produced an acute pain in the shoulder.^ It has been noticed
10, in most cases, that the clavicular portion of the trapezius muscle
peared lifted and tense, especially when the neck was straight.
Inability to raise the arm to a right angle with the body is a general
t not constant symptom. In two instancies, where the displacement
18 only moderate, the patients were at first and for some time aftcr-
irds unable to lift the arm in any degree from the side. In one ex-
iple, a lady sixty years of age had fallen upon her shoulder and pro-
ced a disloc-ation upwards, but she had not consulted a surgeon until
B called upon me, five months after the accident. The clavicle was
en raised from its socket about half an inch, but it could be easily
eased back to its place, the reduction being attended with a grating
nsation, a circumstance which I have not noticed in any other instance,
le was not even then able to raise her arm to her head, nor had she
en able to do so since the accident occurred.
In all the motions of the arm and shoulder, the clavicle is seen to
ove more freely than natural immediately under the skin, and these
otions are usually attended with some pain at the point of dislocation.
This accident has been sometimes mistaken for a dislocation of the
imerus, but unless the siiouMer is already greatly swollen, the error
not likely to happen. If the point of the acromion process can be
ade out, it will be easy to determine, by sliding the finger along its
ine, whether the clavicle is displaced or not, and by these means to
ttle the question of its complicity in the accident. The question as
whether the shoulder is dislocated or not may be more difficult of
lution, as we shall hereafter have occasion again to observe.
Pathology. — Generally there exists simply a rupture of the ligaments
^mediately investing the joint, so that the clavicle rises from its socket
ily alx)ut half an inch, more or less, according to its diameter, and is
rricd outwards just sufficiently far to allow it to rest upon the upper
iigin of the acromial articulation. In at least twenty-nine of the
868 seen by me this has been the position of the acromial end of the
ivicle, and for its complete reduction nothing more has been required
an to press with moderate force upon the upper and outer end of the
ne.
In eight cases I have found the bone not only thus lifted in its
cket, but also driven over upon the acromion process from half to
* Report on Dislocntions, by the author. Transac of New York State Med. Soc,
156, p. 19.
5G6
DISLOCATIONS OF THE CLAVICLE.
three-quarters of nn inch ; and in odg instance, that of a gentlemaDf
Mr. B., who was injured in a railroad accident, the acromial end of tlia
clavicle waa displaced outtvards half an inch and backwards tbre»-
quarters of an inch, while the sternal end also was considerably lifted
in its socket and slightly sent inwards. The shoulder fell forwanli
and the coracoid process was one inch nearer the sternum than tbt
same process upon the opposite side. In such cases more or less of tin
fibres of the coraco-clavicular ligament must have suffered a disrup-
tion ; indeed, without a rupture of its external fasciculus, which anato-
mists have called the trajiezoid ligaweut, such a dislocation cannot laka
place,
Prognosiit. — It is impossible for rac to say what has Ijeen the urreise
result in all the cases which I have seen, but my notes furnish unlj
two cases of perfect retention afler a complete dislocation at thia point.
One of these, David Thomas, aged alxiut twenty-five yeani, fell t^
ways upon the ground, striking upon the extremity, and, ns he thinfcN
1 a little upon the f«p of the shoulder. I found the clavicle dtslfWOi^
upwards and outwards, m that it overlapped the acromion pnK«8 h*f
an inch. It was easily replaced, and having applied my own »H*"
ratus for broken collar-liones, with the addition of a hand acww* tk
' shoulder and under the elbow to keep the clavicle down, I fonnii iJal
I had succeeded in retaining the bone in place. This drtwiiajt**
oontinued until the forty-second day, when, on being removen, It*
I davicle was seen to be elosely confined upon ite articulation ; ami •»*
^a lapse of two years it still retains its position so completely tW
difference can be detected between the opposite nrtieulatiotu*.
In the case of Moran, already mentioned, whose clavicle overfiipf*
the acromion process three-quarters of an inch, and who llirevroff '"'
dressings at the end of three days, the same degree of displatvnHiil U'
OF THE ACROMIAL END OP CLAVICLE UPWARDS. 567
1 at the end of two years; the scapular end of the clavicle moving
ly in every direction under the skin according as tlie arm was moved.
lifting, he says, the strength of his arm is undiminished until he
es the weight nearly to a level with his shoulders, and from this
it upwards he can lift but little. For a laboring man it amounts to
rious maiming. I liave seen the same loss of power in the arm to
e bodies above the head in at least two or three of the examples of
complete luxation, continuing after the lapse of several years; but
the majority of cases, although the bone does not remain reduced,
patients have recovered eventually the complete use of the arm in
itever position it may be placed.
The case to which I have already referred as having been caused by
olt thrust upwards under the clavicle, will furnish the best illustra-
I of this general principle. James O'Brien, 1st U. S. Artillery,
\ injured in September, 1862, by being run over by a horse-car.
5oJt, three-quarters of an inch in diameter, was driven through the
n on the anterior margin of the left axilla, breaking the first rib,
ering the coraco-clavicular ligaments, and forcing the clavicle up-
rdfl from its socket. No attempt at reduction was ever made. When
a by me one year after the accident, the outer end of the clavicle
5 lifted directly up two inches from the acromion process, to which
ras united only by a long and slender ligament. He was not con-
)U8 of any loss of power or limitation of motion in the injured arm.
my request, my son, then in the U. S. service, instituted a series of
»eriments to test the relative strength of the two arms, and with the
lowing result: First with the right arm, and then with the left, he
ed fi-om the ground fifty -six pounds and three ounces, and sustained
3 weight above his head thirty seconds, with his arms fully extended,
th his right arm extended at full length, at right angles with his
ly, he sustained twenty-five pounds for fifteen second^. With the
: arm he sustained the same weight, in the same position, seventeen
onds.^
Treatment, — When the bone simply rises upon its socket, the reduc-
1 is always easily accomplished by pressing firmly upon its extremity
h the fingers ; but if, at the same time, it has been carried outwards,
outwards and backwards, the reduction is only accomplished by
ling the shoulders backwards, or by placing a pad in the axilla,
ng the arm as a lever, or by lifting the arm by the elbow and at the
le time pressing the clavicle down ; and it will sometimes require
application of all or several of these procedures at the same moment,
some cases the complete reduction has only been effected when the
ient has been brought under the influence of an anaesthetic,
is to the maintenance of the bone in its socket for a length of time
Beient to insure a firm union of the broken tissues, this will be found
fSjB more difficult, and, in a great majority of cases, absolutely im-
fiible. Nearly all surgeons who have written upon this subject have
de the same observation ; and if occasionally a new apparatus in the
ndfi of a clever surgeon has seemed to promise better results, the
> Am. Med. Times, Oct. 24, 1868.
668 DISLOCATIONS OF THE CLAVICLE.
same apparatus in the hands of other equally clever surgeons, aod
under circumstances equally favorable, lias been found almwt mn-
Btantly to fail; and we nave been cotnjwiled again to exercise anew our
ingenuity, and to seek for new resonrc.^i', or to abandon thu eSurtli
despair.
Dr. Folts, of Boston, believed that he had found in Bartlett's Hfipe-
ratus for broken clavicles, modified by the application of a shiiuldW-
Strap, the infallible remedy for this one of the many sad defects in our
art. The most important part of this dressing, according to Dr. Folia,
is the compress placed upon the upper and outer end of the clavicl^
and the bandage or strap passed over the compress and under the point
of the elbitw to maintain it in position.'
Dr. Folts is no doubt correct in regarding this strap as an importtot
if not tlie essential pait of the apparatus; and it is surprising that If
Sir Astiey Cooper, as well as by many other experienced suiyeoiM, io
value should have been overlooked. The chief obstacle to the rriMi-
tton of the bone in place Is the powerful action of the trapcKiue, whidi
constantly tends to elevate the outer end of the boue. In some mwson
this may be resisted by elevating very forcibly the shoulder, or br in-
clining the head, but both of these positions are extremely fatipiinfi
and will not be long endured. The bandage or strap, adjusted i
manner which Dr. Folts has recommended, is the only nican^ iif i
teracling the action of the trapezius, upon which any sulistjintial nji-
an(« can be placed; but the principle has long been understood >nd
Eracticed upon, Bradaor's tourniquet, or Petit's, 6ecure<l by a ntnf
rought under the point of the ell>ow, Boyer's double shouider-elrin
and Desault's third bandage, all aimed at the accomplishuienl <:^ tot
same purpose; yet Boyer and Desault found all these contrivance^
in a majority of cases. Mayor employ«l a dressing oon.'^iructvd with!
strap to buckle over the dislocated clavicle, but N?laIoii baa seen H*
apparatus h\\ also, when applied in his own wards.
The experient* of Dr. Folts at the time of his reimrt did not cit™
beyond three cases, and the apparatus had been completely succmW
in only two of the three. Ournwu experience is sufficient to shuttW
it will be ibund occasionally, but liy no means constantly, succc
We have already mentioned two cases in which we suwevdwl pcrfadf
by this mode, but iu several others which seemed equally favombkW
have met with partial or complete failures.
The practical difficulties arc, the sensibility and tmnsequcnt JnabifilT
sometimes of the point of the elbow to l>ear the requisite prtMnn, ■*
the even greater sensibility of the skin over the lop of the clavicle; t^*
tendency of the bandage to slide ofl' from the shoulder and also)"b^
come displaced from the end of the elbow; the gradual relaxalioo"
the bandages, which, when existing even in the nift^t inconsidt«^
degree, is sufficient sometimes to allow the bone to slip out fniia M
shallow socket; the im[iossihility of fixing the scapula, upon wrl)Mrii>'
mobility as well as upon the immobility of the claviclv the retfot**
> FulU, BcMt. Had. and Surg. Joiirn , vA. lill, p. 250.
OP THE ACROMIAL END OP CLAVICLE UPWARDS. 669
Mii]?or'«
lepends; and, finally, the great length of timcrequiBite to unit* firmly
the ligaments, if indeed they ever again become actually united.
The hand can be prevented in
tome measure from gliding ofi' p,^ ^j,
from the clavicle by a coiinter-
tnad attached to a collar u|>on
the opposite shoulder, but not
without causing some pain and
gjving rise to excoriations gener-
tUy in the opposite axilla; and,
in a d^ree, all the other difiB-
calties may be met by patience
■nd ingenuity, but unfortunately
the Bmallest failure in any one
of these numerous indications
insures a defeat.
The axillary pad employed as
tfulerura upon which extension
may be made is equally as dan-
gerous here as in fractures, and I
00 not think it ought ever to be
used for this purpose, but only
la a means of moderate support
ud retention; indeed it would
be well, perhaps, if it were dis- »ubio i;uuuij-ins-™»puiaiK. j
euded altogether.
The case of Mr. B., already quote<l, with a dislocation outwards and
backwards, aflbrds not only an illuslration of tlio inel!icicni-y of either
the shoulder-strap or the axillary (lad in eertiiin cast's, but also, it
Hems to me, of the mischief which may result from their too diligent
^iplication ; for 1 cannot persuade mywelf but that most of the maim-
ing in this case was due to the apjtaratus rather than to the original
ucident.
This gentleman was injured on the lOlh of November, 1855. A
(ling with an axillary pad and bunduge.s was immediately appliotl. I
Mw him on the seventeenth day. The displacement was tlxni Kueh as
1 have described, but I did not observe any i>araly8l9 or emaciation of
the limb. Having notiwd that the clavicle fell into its socket when
he lay upon his back in \ie>\, at my suggestion all the dressings except
the sling, were remnvetl, and the patient was laid upon bis back in
bed, with instructions to continue in this position, if (lossiblc, until the
enre was completed ; hut atler a few days I received a communicutiou
from his physician, stating that, owing to a troublesome cough, he had
found it impossible to maintain this position. His residence was forty
or fifty miles from town, and I sent bim one of my dressings for broken
ColUr-bones with instructi<ms as to its use ; directing es|)ec'i.ally that n
thoiilder-strap should l)e U!^ to keep the clavicle down.
The dressing was applied and continuetl six weeks, and on being
teooved, the elbow, wrist, and fiuger-joiuts were found to i>e stifL
The whole arm was emaciated and almost powerless. One year later
there was no improvement in the condition of the arm; every joint
from tlie shonlJer down wa» almost completely anchyloeed, the miucles
were greatly wasted, and the hand trembled constantly.
These reeulte, it eeems to me, were dne to too long and ton ti^ht lianil-
aging of the arm, and especially to the pressure of the axillary pn<i. 1
do not state this positively, but th'iB is my belief.
Is it worth while, then, to incur rhe dangers of too long confinemeat
and of excessive bendaging for the purpose of attaining the alwan un-
certain result of maintaining the bone in its Bucket? We certainly
may be |>ermitted to make the attempt within certain reasonable limit?;
and es)H?cinlIy if the patient m a female and the avoidanee of deforniiiy
is a point of serious cunsidcration ; but never without keeping amMmtlT
in mind the possibility of a jiernianent iinchvloais and jiaralvsis of the
limb.
(b.) DlBIXX^ATION OF THE ACROMIAL EnD OF THE CLAVUXE
Downwards,
This form of dislocation is exceedingly rare, only three vrelJ-antheft-
ticated cases having been placed upon record, one of which wiu W(fl
and dissected by Melle in 1766, the second was met with by FlwiT
in 1816, and the third is des<Tibed by Tournel.
Caii«e. — So far as we lan asrertain, it has been jiroducwl only Iw'
force which has acted directly upon the top of the claviolc. In the
case mentioned by Tournel, a horse had trod npon the shoulder; ind
in the example recorded by Melle, the accident occurred in a child mi
years old, from an attempt to support a great weight upon tlje top li
the collar-bone. In this last example Ihe humerus was disUicaleil »1»,
and both dislocations had remained unrwluccd many years wbeatkt
patient was seen by Melle.
This force acting directly upon the top of tlie clavicle would Mtt
dislocate the bone, except by Smt breaking down the eitracoid pncMi
if it did not happen sometimes that at the same moment the lowerai^
of the scapula was thrown outwanls, in Huch a manner as to dtMW
slightly the eoracoid process, and thus to permit the outer end of U»
clavicle to fall below the level of the acromion process,
'Si/mptmiia and I'aiholotjy. — This dislocation, whether it hw he»,
ftrotluceil artificially u|Jon the dead subjcL-t or amdentally up"
iving, has always been found tu be accompanied with a coi
rupture of the acromio-clavicular llgameuts not only, but aim
coraco-acromial and coraco^lavicular ligaments; the outer vxia
of the bone resting between the acromion process and the oipsule of I
ahonlder-joint, and a little (wsteriur to the articulating raoet
originally reoeived the clavicle.
The superior angle of the scapula approaches the body tilighU.'. •■■
its inferior angle is thrown outwards. A marked deprcMioo exi**
the point of dislocation, accompanied with a vharp pain, iixHW*
es[)ecially when an attempt is made to move the arm. The [MtKnl *
unable t^) liH the arm voluntarily, but it can be moved pntiy ftv^f
;nd of the clavicle under coracoid process. 571
the direction forwards and backwards by the hands of the surgeon :
laction is much more dii&cult.
I^eatment — Reduction is easily accomplished. At least, in the only
0 examples upon the living subject in which the attempt has been
ide, it was effected promptly by drawing the shoulders gently out-
rds and backwards; nor has it been found any moi*e difficult to
intaio it in position when once replaced. When the scapula is re-
red to its natural |H)sition, and its lower angle approaches again the
eof the body, a reluxation becomes impossible; since the coracoid
loeas now effectually prevents that descent of the clavicle upon which
displacement always depends. It is only necessary, therefore, to
are the scapula at its base and lower angle snugly to the body, by a
xmI bond and compress, and all the indications of treatment are com-
itely fulfilled.
(c) Dislocation op the Acromial End of the Clavicle
UNDER the CORAa)ID PROCESS.
Pinjoa met with one example of this singular dislocation,^ and
xlemeFy or Mayenne, has recorded five more,^ and these constitute the
lole number which are at this day known to science.
Cause. — Age and a consequent relaxation of the ligaments seem to
HBtitute a predisposing cause, since of the six recorded examples four
w between the ages of sixty-seven and seventy-one, and the other
o were adults. In all the cases, also, the dislocation was the result
a fall upon the shoulder.
The symptoms which have been said to characterize this accident are
in and a very marked depression at the point of displacement, with
sorresponding projection of the acromion and coracoid processes ; a
pid inclination outwards and downwards of the line of the clavicle,
outer extremity being felt in the axilla; the corresponding shoulder
pressed and inclined forwards ; freedom of motion in all directions
oqjt inwards and upwards ; the lower angle of the scapula thrown
twards and backwards ; to which Morel-Laval 1^ has added an actual
crease of space betw^n the acromion process and the sternum.
DrtfMtment. — Godemer reduced all the examples which came under
» notice easily, by directing an assistant to pull the arm backwards
d outwards while he himself seized upon the clavicle with his fingers,
d disengaged it from under the process; but Pi njou, after many
brtB by the same method, tailed completely, and the patient having
h him, the clavicle was reduced the next day by an empiric. Vidal
e Cassis) recommends that instead of pulling the arm outwards, by
kidi procedure the pectoralis major is made to antagonize the surgeon,
« elbow shall be brought down to the side, and kept there by the
ft hand, while the right hand, placed in the axilla, shall pull the
yper end of the humerus outwards, converting the arm into a lever of
* Pinjnu, Joiirn. de M6d. de Lyon, Juillel, 1842, from Vidal (de Cassis).
' Godemor. Kecueil d*>!* travaux de la Soc. Med. d'Indre et Loire, 1S43, from
the third kind. This prowss, I confess, seems to Ix- much the matt
rational.
Finally, having given the history of these cases as they have ln«i
reported, we shall scarcely have performed our duty as a faithful writer
if we do not state frankly that we entertain a aa^picioa tlist both ilw
gentlemen who have rejiorted these curious ejtamples have enttrloiiirti
us with fitbulous or imaginary stories; and especially do iheM' «iis|it-
cions rest upon the posea repiirteil by Godemcr, who in five years «aff
five cases, e&ch presenting throughnnt the same class of synijuons, ih»
same facility of reduction, aocomplished by the same means, and thtyt
with the same perfect result.
If to these singular coincidences we add the fact that only one ntiitf
sui^:eon has ever claimed to have met with the a^ident, and if »*
notice the actual iiniitomicjil difficulties which Mand in the nay of in
occuri'cnce, such esiiwially as the complete occlusion of the suimira-
coidean space by the tendons and mu-sclcs which pass from iii* cxlfun-
ity toward the chest uud arm, we shall lind a tiiir apolog_v f'jr
degree of skepticism.
(d.) Dislocation of the Clavicle at both Evm,
SIMULTANEODSLY.
On the 26th of January, 1863, Dr. North, of Brooklyn, N. Y- if«
called to see a lad fourteen years of age, who had hecu tJiruwn wlih
violence backwards from a stool upon which he was sitting, sinking
the buck of his lefl shoulder againtit the floor. Dr. North foiiDcl hi*
suffering severely from pain, and with some difficulty of breathing
The shoulder *vas depressed and thn»wn forwards. The Memal hm1«
the clavicle, turned forwards, formed' an abrupt, ronnded promini-Mtl
the acromial end, turned forwards also, presented its longest diarumr
toward the surface, and rested al>ove the acromion pn)caai ; wliile lb«
central portion seemed depressed or thrown Itack, an iippeanmoc «lu*
was caused by the rotation of the clavicle upon its axis.
Reduction was accomplished by throwing the shouldeni fat^^^
backwards, and at the same time prci^ing with 'the thiimlis iiimb iM
two extremitira in such a manner as to reverse the rotation, as fi>IW»;'
pressing at the acromial end liackwards and downwanU, mid at tl*
8t«nml end backwards and upwanis. TIic restoration was i»itn|)l«t
and the Ixmcs were retained in place by com|irp«ses and udhwivf i»l>"
ters, with the aid of Day's " neck yoke." At the viu\ of three Wb
the dressings were removed ; and when last seen hy im surgeon "tbd*
was but little, if any, trace of the accident remaining." It ii* (^
opinion of Dr. North that the rotation was cauifed bv Ihe artiw of"*
pectoralis major and deltoid after the <lislocaiiun took plu(«.'
Erichsen says that Rieherand and ^[o^el-IJavaIk■e have each repofW
oue example of double dislomtiun of the clavicle.
Dr. Stanley Hayncs, of Malvern Link, has reported tho on' ~
maiutng case of which I have been able to find a reoord.
DISLOCATIONS OF THE SHOULDER. 573
" A girl, aged 13, rapidly growing, of lax tissues, and of a consurap-
'e &mily, out who had always had good health, while washing the
ck of her neck with her left hand, one morning in September, felt
nething give way in the shoulder of the same side. I found dislo-
lion forwards of the sternal end of the clavicle and partial luxation
»ward8 of the acromial one. There was very little pain. Both ex-
ADities of the bone were easily replaced by drawing the shoulder
ckwards and downwards, but the double deformity was reproduced
mediately the shoulder was liberated. A pad was applied under a
ore-of-S bandage over the sternal end, and the arm was placed in a
Dg as a temporary measure. To a strap, fastening round the chest,
strap bearing a truss-pad was attached in such a manner that the pad
pt the sternal end of the clavicle reduced, the other end of the strap
ssing over the shoulder and diagonally across the back to the hori-
Dtal strap: the wearing of a sling kept the acromial end in it8 natural
eition. The patient soon afterwards returned to school at a distance,
le is now at home, and I have found the sling has been discontinued
me time, that the straps have stretched and are useless, and that the
ids of the bone are as mobile as, but not more than, they were when
first saw the patient, but that the sternal end does not become luxated
aless the arm is raised, when it nearly always starts forwards."^
CHAPTER VI.
DISLOCATIONS OP THE SHOULDER (SCAPULO-HUMERAL).
Owing to the great exposure and the peculiar anatomical structure
f the shoulder-joint, its structure having reference mainly to freedom
f motion rather than to firmness and security in the articulation, dis-
Kstions of the humerus are very common.
Writers have not been agreed as to the precise anatomical relations
fthese dislocations, nor as to the nomenclature. Velpeau, Malgaigne,
Tidal (de Cassis), Skey, and Sir Astlcy Cooper have each adopted ex-
hnations and classifications peculiar to themselves. With the arrange-
lent established by this latter surgeon, English and American students
re the most familiar; and believing that it is more simple, and quite
8 appropriate as either of the others, I shall adopt it as the basis of
oy own descriptions.
I shall have occasion, however, to dissent from the opinions and
etchings of this distinguished surgeon, as to the exact seat and rela-
ioM of the head of the humerus in some of these dislocations.
According to Sir Astley Cooper, there are three complete luxations
f the shoufder ; namely, downwards, forwards, and backwards.
1 The Britibh Medical Journal, Jan. 27th, 1872.
ONS OF THE SHOULDER.
i 1. Dislocation of the Shoulder Downwards (Subglenoid).
This 18 usually oalleil u tlislociitioii into the axilla ; ihe head of*
bone resting rather upon the inner side of the inferior border of
Ecapnia, near the base of that triangular anrface whu^h is found h^li
the glenoid fossa.
Sinoe in both the other complete dislocations of the shonlcicr, thg
head of the humerus, in order to eseape from its socket, roust be nistb
to descend more or less downwards, we shall regard this dislocaiioi
the type of all the others, and shall make it the subject of especial
consideration as well aa of reference when speaking of the other form
of dislooalion.
CkiTUKS. — The most frequent cause of this accident is n blow rtwinul
directly upon the up[>er end and onter surface of the humerus. 1 1»«
found ihe arm disloealed iiilo the axilla by this cause twenty-one time';
five timeK by a fail u|ion the extended hand ; three time« by a fall D)«n
the elbow ; and in theae hitter eases the arm was pi-obably carried a«iy
from the body at the moment of the receipt of the injury.
In all the alvive examples the shoulder has been dislocated by lU
simple force of the blow, or with only slight aid from miisoiilar actioo;
but in a considerable number of eases the bone is displaced alnx*
wholly by the action of the muscles, the arm having been pri'vioudj
violently aMucted; and [lerhaps in some cases the capsule wing Wm
before the resistance of the overstrained muscles has ac(K)mplisheii tin
displacement. Thus, in three instances I have known the dislixaOna
to result from holding on to the reins after being thrown from a <«-
riage; in two cases the patients have fallen through a hat^-hwav lo^
been caught and snH[>ended by the arms ; once a woman met wilK thk
accident by holding on to a pump-handle when she had slipped im
&tlen upon the ice. A few years sim« I examined the arm of aS«i»
woman, Maria Norr^an, who was then sixty-five years old, and wbot
humerus had been dislocated into the axilla seventeen years bifo'^
where it still remained. Her own arawunt of the accident w*i, iW
she WHS returning from the Jura Mountains, near Neufchatel, with i
load of hay upon her head. She hail carrit^ it u long way withmr
hands held upwards, without once stopping to rest, and when at Ici^
she threw down the load at her door, the right shoulder wa<> disiootoL
The arm soon became very painful, and swollen to the fingera* ea^i
but she was too remote from, and too |)oor to employ, a surgooa. ^
tailor, who used to do the minor surgery of the neighborhood, bW >*
three or four times, but the dislocation was not recognised until owij
months after,
A Mrs. Hui
she had
I informed me that when she was f
ulsion, 1
, ,nd that her attendants in trjiitg toluJd I*
upon her bed, actually pulle<l the shoulder out of joint. After lb*'*
at^^'ident the dislocation was not re|>eated for four years, but ainatbM
it had oct^'urred from very slight causes many times. SA\v van io |*
habit of reducing it herself by placing a ball lu the axilla au<l o^if
the arm as a lever.
ILOOATION OF THE SHOULDER DOWNWAEDS. 575
iman repnrte the cane of a saiktr on hoard an American brig,
abject to a dislocation into the axilla from very slight causes,
Ally if he bent his l>ody far over to raise anything. He
by pulling horizontally, remove the head of the bone from
It was reduced easily, and he experienced no pain either in
ion or dislocation, nor, indeed, during the displacement.^
iy. — In this accident the head of the bone is made to press
t capsule below and immediately in front of the long hea<I of
, until the ca}>sule gives way, and continuing to descend in
lirection it is finally arrested by the triangular snrface of the
Ige of the acapnia immediately below the glenoid fossa,
the pressure of the tendon of the triceps behind, it occupies
also a little in advance of the (centre of this triangle, or rather
iterior edge, so that it rests more or less upon the belly of the
ris muscle.
sule is generally torn quite extensively, especially below and
ad the tendon of the long head of the biceps may be broken
' detached completely
isertion ; the irupra-
uscle is stretched or
the infra-spinatus,
ris, and coraco-bra-
put upon the stretch ;
Lpnlaris being also
completely torn from
lent to the head of
IS, and in either case,
)rn or merely rom-
d stretched, the cir-
lerve, which runs
>wer margin, is sub-
re injury ; the deltoid
ileo placed in a con-
treme tension ; while
najor and minor in
; are subjected to but
^'
: rases a portion or
of the greater tuber-
npletely detached, and the fragment displaced by the action
icleti inserted into it.
ase the axillary artery has been ruptured. The patient had
■n dowu by a runaway horse, and was taken to Jervis Street
liondon. On the tenth day Sui^eon O'Reilly tied the sub-
eiy, and the patient recovered after the loss of two fingers
jefas and gangrene,'
jre or less rapidity, after the occurrence of the dislocation, if
576
S1,0<.'ATI0N8 OP THE SHOUI.DE
1
the bone remaias UDrednewI, various changes lake place in the arm-
toniical relatione and structure of the [mrts. The following is a brief
account of the conditiou in which the parb« were found in the anxct
an old man, wliose hislorj' is unknown. The diaeection was madcbj
my assistant Dr. Frank Deems, at the Bellevife dead honse. The
head of tlie humerus was in front of the socket, below the coracoid |ifO-
cess, lying upon the anterior surface of the neck of the scapula. A
new socket was formed in the hone at this point, mostly cartilaginutu,
and a fibrous capsule inclosed the head of the humerus. The niargint
of the old siKiket were removed, and the socket was filled with fibroo
tissue. The axillnry nerves and artery were not injured or eomnnswH.
The biceps tendon was not torn. All the muscles about the snouldcr
were atrophied.
Sympbma. — A palpable depression immediately under tJie extrpinit/
of the acromion proce.os, more distinct in children, in very old md in
thin people, than in adults of middle life or than in fat or niwculir
people, but never absent eompletely, unless the shoulder is very idik'Ii
swullen; the elbow carried out from the bud v three or four illohe^
DiilurallDD of Ibi ghoulilcr dawnwirdi 1nu> tb« Kiilla. (SubclnwU.)
Hometimcs a little backwards, and the line of its axis directed W***
the axilla ; the outer surface of the arm presenting two planee incli"*
towanl each other, and meeting at the point of insertion of thcilflW''
muscle; the head of the humerus felt in the axilla, particularly *l*
the elbow is carried away from the body : numbness of the arm, an'W
panied generally with pain, especially when any sttcmpE is mail''''
press the elbow against the side; rigidity with inability to mofcil"
DISLOCATION OP THE SHOULDER DOWNWARDS. 577
imi freely in any direction, but especially inwards ; allowing, however,
rf pretty free passive motion, but not permitting the elbow to touch
4e body without great pain, which pain is occasioned mostly by the
f«8ure of the humerus upon the axillary plexus; under no circum-
Moe can the hand be placed upon the opposite shoulder while at the
tme moment the elbow touches the thorax ; the head of the patient,
id sometimes the whole body, inclined toward the injured arm; the
ID lengthened from half an inch to an inch ; a chafing or friction
and is not unfrequently present, especially if the bone has l>een some
lys dislocated ; but Mr. Lawrence mentions a case in which there was
distinct crepitus, yet there was no fracture; Dr. Hays saw a similar
ae in Wills Hospital, Philadelphia, in a woman sixty years old, whose
TO had been dislocated forwards eight weeks.^ Other surgeons have
laled like examples, but it is probable that in all these cases there
KB been an exposure of the bone at or near the edge of the glenoid
«Ba, by the partial detachment of its ligamentous margin, or some
ortion of the head has become divested of its cartilaginous covering.
For a more complete differential diagnosis, see chapter on fractures of
be humerus.)
Decisive as these signs usually are of the true nature of the accident,
ases will every now and then occur in which the diagnasis will be
ittended with great difficulty, and especially if a few hours have been
emitted to elapse since the occurrence of the injury, so that consider-
ible effusions of blood and of lymph may have taken place; while at a
itill later period, when the swelling has subsided, the diagnosis again
becomes easy. " At this latter period," says Sir Astley Cooper, " it is
iatsui^eons of the metropolis are usually consulted ; and if we detect
i dislocation which has been overlooked, it is our duty in candor to
Jtate to the patient that the difficulty of detecting the nature of the
Joeident is exceedingly diminished by the cessation of inflammation,
uid the absence of tumefaction.''
It has never happened to me to have seen a case of dislocation into
ne axilla which I have not easily recognized, but in my report to the
W York State Medical Society, already referred to, I have related
«ro cases which were not recognized by the patients themselves, and
0 surgeon was called until afler several days or weeks, and three cases
» which empirics having been employed they failed to detect the dis-
Kiation; and since the date of the report, I have met with many simi-
^r examples which had not been recognized by intelligent surgeons.
Ithough, therefore, I am prepared to admit the justness of the obser-
ationa made by Sir Astley Cooper, I think that if the case is seen
ithin an hour or two after the accident, its nature may be generally
^ermined promptly by the surgeon of experience; but upon this sub-
*tl have already spoken very fully in the chapter on fractures of the
nmerus; and from the examples and opinions which I have there pre-
ented it will be inferred that it is much more (iommon to mistake a
f^cture for a dislocation, than a dislocation for a fracture, an observa-
* Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv, p. 236, May, 1839.
578
DISLOCATIONS OF THE SHOPLDER.
^
tton which in equally as applicable to dislocatiotiH fonvards as to the
form of d isldcatlon now under con^ideralinn.
Prrypume. — If the force which displacei) the bone w^s not grwt. or
if the shoulder-joint has not suffered anv injury from the ai^^ridcnt il«etf
beyond the mere rnptiire of the capsule and a moderate? strainini; rf
the mnscles, and if the dislocation has been early and easily reduced,
tho patient is immediately atlcr the rcdnction able to move thr arm
freely in at) directions ; very little swelling follows, and in a short time
a perfect re^-toration of all the functions of the limb is Hctvuuplisliul,
It cannot, however, always be inferred from the d^ree of vinlena
employed in the production of the dislocation, nor from the abaeiHvar
presence of swelling, how much injury the tendons, muscles, and nen»
have suffered, since the same causes proihice gi-cater lesions in one p<T-
eon than in another, and the amount of swelling may depend itponllie
accidental rupture of an nnimportant bloodvessel, or upon some pwu-
liarity in the constitution of the patient predisposing to serou^i, fibriHiii,
or sanguineous effusions.
To whatever cause we raay find occasion to attribute th« rceolt, it
will nevertheless be observed, that, in a great majority of cMei,t]»i
limb is not restored to all its original strength and freedom of ni'»tioii
until after the lapse of some mouths; and the shoulder does nut reaumt
ita perfect form and symmetry until a much later j>eri<>d ; ocrasiooJ
pains, especially aller exerciiiie of thenuiscles, and in certain oondirinnt
of the weather, are present also at irregular intervals and for indefinite
periods of time. Opposite and more favorable terminatioDS niuslbt
r^^rded as exceptions to the rule.
Where the reduction has been made within a few hmirs, I haw
found the shoulder affected with muscular anchyloois with Toait or
less weakness of the arm af^r a la[Kie of from a few days to one or lw»
years.
A lalwrer, jet. 41, had dislocated his right shoulder into the Kill".
Dr. H., an intelligent young surgeon, reduce<l the bone e«Hily with \m
hands alone, while the patient was still nncoascious from the shnrJt n
the injury. After six weeks he t'alled upon me, accompanied liv hi*
Burgeon, thinking that it was not properly reduced because thi> arm
was still painful, and he could not move it freely. The boocw*,
however, well in its socket. One year later I examined this man, ■»>
found some anchylosis remaining in the shoulder-joint.
James Rogers, rot. 39, fell while running, and struck n)K>u hi»nel>>
afaoulder. Dr. Eastman, Professor of Anatomy in the Buffalo W«l''«l
College, re<1uced the dislocation four hours after the 0(rcunva(Y, in
the following manner: The patient being seated in a cliair, Ur. 1^9^
man placed hie knee in the axilla and manipulated, while oneasntiri
8np|iorted the acromion process, and another pulled downwards iip<*
the forearm. The time oix?upied in tho reduction was about !••
minutes, and the Ixme finally resumed \lR position with a snap audiblt
to all the persons in the room. For some mouths after, and it 1^
period when I was invited to see him, the muscles alxiut the shoakti^
were rigid, and the motions of the joint embarrassed ; but at tlie nn
of two years, Dr. Eastniau informed me that the Joint had become free
Bud the arm as useful as liefiire, except that he cnnid not throw a stone.
Ill anuiher case, a gentleman residing in an adjoining eouuty, ast.
42, was thrown from his rurriai^e, falling forwards upon his hands.
The dislo(»tion was rediit-ed promptly, hy placing the heel in the
iicinH,:tnd within fil\een minutes after it had occurred. Three months
ifter this the patient eonsnited me on aeconnt of the immobility of
Lhe shoulder-joint, and because several 8ui^;eoDS had expressed a
loubt whether it was properly reduced. The anchylosis was then so
xiniplet« that the humerus could not be moved separately from the
tcapiila, but there was nu displacement. This gentleman again called
jpon ma at the end of four years, and I then found the arm nearly
rei^tored to its original condition, bnt it was not quite so strung as
tieibre. He experienced also "curious" sensations in his arm and
iiaud occasionally. The anchyltwia had continued with very little
mprovement about two years, after which it had been gradually dis-
ippearing.
J need scarcely aay that in those examples in which the reduction
>f the bone has been delayed beyond a few hours, or for several days
)r weeks, the continuance of the anchylosis has been more persistent ;
jct in no case which has come under my observation, unless the bone
itill remained unreduced, has the anchylosis been permanent. For
Jiis reason I am disposed to think that muscular, rather than fibrous
ir ligamcntoDs anchylosis, is the cause, generally, of the immobility
if the joint. I have certainly never in any instance met with a true
miiy anchylosis as a consequence of a shoulder dislocation. The an-
iiylosis in question seems to be a result simply of laceration or more
fCiieralty iif a severe strain of the mus<'tilar fibres, resulting in in-
laraioation and a contraction of these fibres; and its occurrence in
ny particular case may therefore !» justly attributable either to the
Kiflition of the bone when it is dislocated, to the force of the blow
rhicb has produced the dislocation, or to the violence applied in the
tlempti^ at reduction.
Paralysis and wasting of the musolea of the arm, either with or
rithout muscular conlraction and rigidity, are also observed in a cer-
lin nundter of coses. Especially has it been noticed that the deltoid
inscle is liable to atrophy; and in their attempts to explain the fre-
uency of its occurrence in this latter muscle, surgeons liave generally
efrrrwJ to a proltahle rupture of the circumflex nerve, a circumstance
thich tiie autopsies show does occasionally take place; or t<J a mere
tret^hing of this nerve; yet it is quite as fair to presume that in
lany cases it is due solely to the greater injury which the deltoid
luscle has sustained by the unnatural position of the head of the
one during the continuance of the dislocation, for, with the exception
if the supra -spin at us, it is placeil more upon the stretch than any other,
Kor is it improbable that in some cases it is due to the mere force of
W blow which, having been received dlrtK-tly upon the top of the
thouldcr, has contused the muscle. In short, any of the causes which
Duty determine in the deltoid inflammation and con^tsqueut rigidity,
t tiually result in desuetude and consequent atrophy.
CATIONB OP THE SHOULDER.
In quite a number of cases my attention has lieen called to a remark-
able fulness just in front of the liead of the bone, which has continuetl
sometime) for many months and even years alter the reduction hu
been eSectcd, the patients having in xeveral ca.«e» applied to me to
know whether this did not indicate that the bone was not in its socket,
especially as it has been usually attended with some stitfnestt in tb*
joint. Not unfrc<iuently I have been told that sui^i>ns who liid
noticed this fulness, thought the bone was not rt-duced ; and in one in-
stance I am informed that a jury returned a verdict against the sui^n,
where there was no other evidence of malpractice than this fulness wiilt
some anchylosis, but which, in the opinion of th<«e gentlemen, wu
conclusive evidence that the Iwnf was riot properly set. The deception
is also often the more complete from the tact that there may nvl i
corresponding depression underneath the acromion process, bcliiml.
It may be present where but little force has been used, either in the
production of the dislocation, or in its reduction. I have seen it in*
girl, only fourteen years of age, who had dislocateii her left shiHildff
into the axilla, by a fall npon a slippery sidewalk. I reduced th«
bone, assisted by i)r. George Burwoll, within half an hour after tJ*
accident. Dr. Burweil held upon the acromion process while I liM
the arm to a right angle with the body, and pulled gently, futi ik
reduction was at once accomplished ; but we immediately noticed lh«l
the head of the bone seemed to press forwards in the socket so *• W
resemble what Sir Aetley Cooper has described as a partial forward
luxation. There was also a corresponding depression liehind. Catr^
ing the elbow back rendered the projection more decided, but bringiuf
it forwards would not make it entirely disapjiear.
In other instances much more difficulty has been experienced, W
more force has Ixwn employed in the rednetion. \ man wei^inj
two hundred pounds, and forty-one years of age, residing at Bstli, io
Steuben Co., fcU from a load of hay in May, 1853, striking np»n tht
top and front of the left shoulder. It was immediately asccrtaiixd
that he had dislocated his arm Into the axilla, and bntkcn his It^. A
youne surgeon attemptwi within a few mltiutes to rwluoe the dt«lo«-
tion, but feiled; and about two hours later it was re<lu<!0<) by ftDrth*
surgeon, with the aid of chloroform and Jarvis's adjuster. Fouryoi*
after the accident had occurred, this gentleman came to me aofoo-
panleti by the surgeon who had made the reduction, in oons«HHiiif
of its having lH?en intimated by some medical men that it was n**
properly reducetl. The arm was not as strong as the other; »«•
ancliylosis existed at the shoulder-ioint; hut especially il was notim
that there still remained a remarkable fulness in front, as if the Uui
of the bone was pressed forwards. By no manipulation or p<wtii«
could this fulness be made to disitppear, yet the bone was plainlf
enough in its BO<!ket.
This phenomenon is probably due in some csircb to a niptnrpnf tk»
supraspinatus muscle, and the oonseqnent prcpimdcrating action "f tfc»
antagonizing muscles, or to the laceration of the capsule, hut bm^
often, I imagine, to a rupture or to a displacement of the long b<wl<*
DISLOCATION OF THE SHOULDER DOWNWARDS. 579
oyearSy Dr. E^tnian informed me that the joint had become free
he arm as useful as before, except that he could not throw a stone.
another case, a gentleman residing in an adjoining county, tet.
as thrown from his carriage, falling forwards upon his hands,
iislocation was reduced promptly, by placing the heel in the
,atid within fifteen minutes after it had occurred. Three months
this the patient consulted me on account of the immobility of
loiihler-joint, and because several surgeons had expressed a
whether it was properly reduced. The anchylosis was then so
ete that the humerus could not be moved separately from the
la, but there was no displacement. This gentleman again called
me at the end of four years, and I theu found the arm nearly
dd to its original condition, but it was not quite so strong as
. He experienced also ''curious" sensations in his arm and
occasionally. The anchylosis had continued with very little
vement about two years, after which it had been gradually dis-
ring.
leed scarcely say that in those examples in which the reduction
i bone has been delayed beyond a few hours, or for several days
iks, the continuance of the anchylosis has been more persistent ;
I no case which has come under my obi^ervation, unless the bone
remained unreduced, has the anchylosis been permanent. For
eason I am disposed to think that muscular, rather than fibrous
amentous anchylosis, is the cause, generally, of the immobility
I joint. I have a^rtainly never in any instance met with a true
anchylosis as a consequence of a shoulder dislocation. The an-
lis in qut»stion seems to bo a result simply of laceration or more
illy of a severe strain of the muscular fibres, resulting in in-
lation and a contraction of these fibres; and its occurrence in
articular case may therefore 1x3 justly attributable either to the
)n of the bone when it is dislocated, to the force of the blow
has produced the dislocation, or to the violence applied in the
pts at reduction.
alysis and wasting of the muscles of the arm, either with or
lit muscular contraction and rigidity, are also ol)served in a cer-
uml)er of cases. Especially has it been noticed that the deltoid
e is liable to atrophy; and in their attempts to explain the fre-
y of its occurrence in this latter muscle, surgeons have generally
ad to a probable rupture of the circumflex nerve, a circumstance
the autopsies show does o(?<Misionally take place; or to a mere
ling of this nerve; yet it is quite as fair to presume that in
eases it is due solely to the greater injury which the deltoid
8 has sustained by the unnatural position of the head of the
iuring the continuance of the dislocation, for, with the exception
supra-spinatus, it is place<l more upon the stretch than any other.
$ it improbable that in some ciises it is due to the mere force of
low which, having been receivwl directly uiK)n the top of the
kr, has contused the muscle. In short, any of the causes which
letermine in the deltoid inflammation and consequent rigidity,
finally result in desuetude and consequent atrophy.
580 DISLOCATIONS OF THE SHOULDEH.
In quite a number of cases my attention has lieen nailed to a remark"
able fulnsas just in front of the head of the bone, which has continiK^i
aonietimes for many months and even years atler the reduction hai
been eifeotetl, the patients having in several cmbcs applied to me U
know whether this did not indiraite that the bone was not in i'tsenck«^
especially as it has been usually attended with .some stiffnes io tlit
joint. Not unfreqnently I have been told that surgeons who had
noticed this fulness, thought the bone was not reduced ; and in oiieis-
stancelam informed that a jury returned a verdict against tliesnrgroe)
where there was no other evidence of malpractice than this fulness wilfc
flome anchylosis, but which, in the opinion of these gentlemen, vm
conclusive evidence that the bone was not properly set. The det»[iiwfl
is also often the more complete from the fact that there mav fx\sit-
corresponding depression underneath the acromion process, behind.
It may be present where bnt little force has been used, either In tbi
production of the dislocation, or in itt reduction, I have seen i
girl, only fourteen years of age, who had dislocated her letV 9hmil<ls
into the axilla, by a fall upon a slippery sidewalk. I reduced tJ*
bone, assisted by Dr. George Burwell, within half an hour aftw t!*'
accident. Dr. Burwell held upon the acromion process while I lilW
the arm to a right angle with the body, and pulled gently, and tlx
reduction was at once necomplisheti ; but we immediately notictd thil
the head of the bone seemed to press forwards in the s<)cket so w »
resemble what Sir Astley Cooper has described as a {lartial ftirtrarf'
luxation. There was also a corresponding depression behind. Cinj*
ing the elbow back rendered the projection more decided, but brtngiof
it forwards would not make it entirely disappear.
In other instances much more difficulty has been experienced, ■M'
more force has been employed in the reduction. A tnun wtHj^iiV
two hundred pounds, and forty-one years of a<;e, residing At BmIi,'
Steuben Co., fell from a load of hay in May, 1853, striking upon tk
top and front of the left shoulder. It was immediately asMfttinIt
that he had dislocated his arm into the axilla, and broken his leg. i
young surgeon attempted within a few minutes to redm* the diskK*-
Uon, but failed; and about two hours later it waa reduced bv aiiotlur
surgeon, with the aid of chloroform and Jarvis's adjuster. F(»tir
after the accident had occurred, this gentleman (^mc to me artW"
panied by the surgeon who had made the re<luction, in conswuww*
of its having l«?en intimated by some medical men that it wa» V*
property rednced. The arm was not as strong as the other: »"*
ancnylosis existed at the shoulder-joint ; but espivially it was OfHtiai
that there still remained a remarkable futnms in front, as if the iMa
of the bone was pressed forwards. By no manipulation or pnntiS;
ooidd this fiilness be made to disappear, yet the bone wm plaiiiT
enough in its socket.
This phenomenon is prolwbly <lue in some fwca to a rupture of !*•
»upratpinatus muscle, and the consequent preponderating suTtiou of l»*
antagonizing muscles, or to the laceration of the capsule, but w^
often, I imagine, to a rupture or to a displacement of tbo long haw"
DISLOCATION OF THE SHOULDER DOWNWARDS. 681
biceps, a circumstance to which I shall more particularly allude
JT the subject of " partial dislocations."
Diong the results of this dislocation must be placed a tendency to
[ation, which, although it may not often be made manifest by its
J occurrence, owing |)erha})H to the prudence of the surgeon, yet
OS take place in a sufficient number of cases to establish its peculiar
ity. Indeed, we need only consider how imperfect is the proteo-
igainst this accident, when once the capsule has been torn, to ap-
EUe this observation. Examples of spontaneous luxation, or of
ion of the shoulder from very trivial causes, after it has once been
edf may be found in the experience of almost every surgeon. I
myself met with several persons who have had repeated luxations
a slight cause, and in some instances, where the patients were
ct to epilepsy, the luxations have occurred whenever the convul-
retumed.
gentleman residing at Toronto, Canada West, had a dislocation
te right shoulder into the axilla when he was quite a child, and
oeident was renewed when twenty-nine years old by falling from
Tiage head foremost, with his right arm extendeil and uplifted.
5 then, until he calleil u|K)n me, a perio<l of al)out six years, he
been constantly subject to the same dislocation ; and he cannot
his arm high above his shoulders without pnxlucing a subluxa-
the head of the humerus resting upon the outer margin of the
r and anterior edge of the glenoid fossa, but by rotating the arm
ards it immediately resumes its place. I found the whole limb
lly developed, and he said it was quite as strong, as the opposite
•
liave alremly mentioned the case of Mrs. Hunn, whose arm had
dislocated more than twenty times in the last 6ve years; and I
mber a lad, Pat Dolan, aged nineteen years, whose left arm was
cated by falling from the masthead of a vessel, and hanging by
and. No attempt wiis made to reduce it until fourteen hours after
oeident, at which time it was set by two German doctors, but not
they had pulle<l upon it three hours. Four months after, it was
I dislocated by the slipping of an oar while he was rowing a boat,
rgeon having failed this time to bring it into place, I succeeded
ly, and witliout the aid of an antesthetic, by raising the arm di-
r upwards in the line of the bo<ly, while my foot was pressed u[>on
op of the scapula. Many other similar examples have come under
lotice.
e have referred more than once to the occasional difficulty of
losis in this as well as in many other shoulder accidents ; and I
alluded to five cases in which the dislocation was not recognized,
jone of them had been seen by a surgeon. Other writers have,
iver, mentioned many examples of unreduced dislocations of the
Ider, for which surgeons of skill and experience were responsible.
ve myself met with these cases quite often. For example, I have
two dislocations of the humerus into the axilla, both of which
been seen and examined by New York hospital surgeons within a
hours after the receipt of the injury, but the nature of the accident
had not been rect^ntzed. One of these I reduced at Bellevue Ho*pil
on the seventh day, and one on the tenth. There waB also preseai
to me, at the Charily Hospital (Blackwell's Island), in mj service,
axillary dislocatinn of twenty years' standing, which a surgenn
immediately after the receipt of the injury and failed to recognize,
other cases the dislocation has been dearly made out, but the siifL
has been unable to reduce the bone, It has been my fortune to suc(<eei
in several instances where others have made a fair trial and have failt^
but the following case leaves me no opportunity to boast the superiorinr
of my own skill above that of my confreres.
Mary Kanally, ret. 43, a laige, liit, laboring woman, was adniittnl
into the Buffalo Hospital of the Sisters of Charity, with a dislomtiiNI
of the right humerus into the axilla, which had oceurred tu-elve lim
before. This is the same woman of whom I have before spi>ken
having produced the dislocation by a fall while holding u)>on the
handle of a pump.
Drs. Lockwood andBaker, of Buffalo, were first calle<],andattein|ilal
reduction. They made extension and counter-extension in every w»-
Bible direction, and for a long time, but to no pnrjHise. She was ini
sent to the hospital. Without attempting to describe minutely iht
various modes of extension and manipulation which I emplnveil. I
will briefly state that, having placed her i-ompletely under the inftu*
ence of ciilorofbrm, the manipulations were made nssiduonelr diirintf
one hour, without succeJis. On the following morning she was him
freely from the opposite arm, and chloroform again Rdniintsterfd; *t-
tension being made, in the presence of Prof. Charles A. Lee and othtf
gentlemen, with Jarvis's adjuster. After more than an hour, the i-flmrt
was again suspended. On the following day we made a third attempt,
the patient being completely under the influence of eblon)f"rm. but
with no better success. The chloroform produced a condition apprnadi*
ing apoplexy, and it was not again used. On the tenth day, masui
by Prof, James P. White and other sni^eons, we applied the i-ommunj
pulleys, moving the arm in various directious. Twice we thougal iJ
reduction was accomplished, but as often as we proceeded to exaiaiit
it attentively we found it was not. If it did ever pass into ihewdM
it was immediately diflplaeed.
The woman after this refiised to submit to any further attempts, »
she soon left the hospital, nor have I seen or licanl from her mikt.
Sir Aelley Cooper has thus destTibed the ap|)caranecf> prraentvdu
dissection of a disloeation wliieh had been long unreduntl : "TbetKii
of the bone altered in its form ; the surface towards the «^palal<Bf
flattened. A complete capsular ligament surrounding the head of iv
OS humeri. The glenoid cavity entirely filleii by ligHinentun? mittiri
in which were suspended small portions of Ihiuc, whirh vrvn iif 0'*
formation, as no jmrtion of the scapula or humerus wtw broken. \ »**
cavity formed for the head of the ns humeri on the inferior cmu^
the scapula ; but this was shallow, like that from whieh the hoarW
eecapetl."
When the dislocation into the axilla remains uiire<iui'«l, the w«<^
quencee are always auflSciently grave, but they ditfer very much ia^
DISLOCATION OF TH£ SHOULDER DOWNWABDfl. 583
, in character, and in persistence, according as the arm has remained
iger or shorter time unreduced, and according to the presence or
loe of complications. These condi-
will be best illustrated by a refer- fiq.mo.
to examples.
m.S., a German, tet. 51, fell down
bt of steps while intoxicated, pro-
)g a dislocation of the left arm into
xilla. Eleven hours afler the ac-
t lie was received into the Buffalo
lital of the Sisters of Charity. No
ipt had been made to reduce the
The reduction was effected by
If with tolerable ease, by extend-
.he arm perpendicularly above the
. while my foot pressed upon the
if the scapula. The head of the
9118 could be plainly felt in the
1, approaching the socket, until it
»I to be directly over it, when, on the >houlder dowDwiidi. (Fnm sir A.
log the arm, it was found to be Cooper.)
cd. After the reduction the patient
I DOt raise the arm more than eight inches from the body. The
n, hand, and forearm were almost paralyzed. Three weeks later,
be left tlie hospital, his arm had improved, but he could not flex
ngers.
rs. G., set. 70, fell down a flight of steps and dislocated her arm
he axilla. She did not suspect the nature of the injury, and no
on was called. I was consulted one week after the accident, at
1 time she was suffering great pain from the pressure of the head
e bone upon the axillary nerves. We first attempted to reduce
one by resting the knee in the axilla while she was sitting, but
wt success. We then placed her in bed, and with my knee in
lilla, the acromion process being supported by the hands of an
ftnl, we restored the bone ader a few moments of pretty firm ex-
m downwards and outwards. Afler the reduction she could not
her arm, but the pain was much abated. One month later the
Tmained very weak. She could not raise it more than six inches
■d her head, but I could raise it to a right angle with the body
ut causing pain. The whole hand felt numb, and was occasion-
jaioful. The deltoid muscle was slightly atrophied. There was
t, slight flatness under the acromion process behind, and on the
side, with a corresponding fulness in front.
try Ann Hosier, tet. 47, was admitted to the hospital with a dis-
on of tbe right humerus into the axilla. The arm had been dis-
•d three weeks, in consequence of a fall upon the up[>er and outer
)f the shoulder. Au empiric, who saw it fifteen minutes after the
uid when the arm was not swollen, said it was not dislocated.
le fiflfa day a Catholic clergyman discovered that it was out, and
pted to reduce it, but was not successful. When she caine under
684 DISLOCATIONS OF THE SHOULDER.
my notice the arm was lengthened about one-quarter or one-half of
inch, and hung out from the body in a condition of almost compti
paralysis. There was very little swelling about the shoulder or nn
and the head of tlie bone eouldbe distinctly felt in the axilla. T!
rtient being rendered partially insensible by chloroform, I plaewi
el in the axilla, and by pulling moderately about thirty ^eoonde i
direction slightly outwards from the line of the body, the bone
reduced. Seven days after the reduction she left the hospital, the i
being yet quite useless, though not grmtly swollen. There was si^o
striking fulness in front of the head of the bone.
Wm. Gardner, of Painted Tost, N. Y., set. 75, dislocated the rigftt
humerus into the axilla, twenty years before I saw him, by falling upui
his hands with his arms extended. I found the arm weak and
phied, so that he could raise it hut slightly outwards from his side
he WHS unable to move it forwards much beyond the line of bia hody,
but he could carry it back quite freely. The whole hand wa
condition of partial insensibilitv.
I have before mentioned the case of Maris Norrigan, the Sin«
woman, whose arm had been distocnted dowtiwanls Bcvcnteen ynri.
The deltoid muscle has become greatly wastetl ; the head of the Ujue
can lie ielt oltscurely in the axilla; the arm is shorteneil iK-rceptiU)'
the elliow hangs freely against the side; the little and ring fingwa»»
numb, and also one-half of the forearm ; ibe whole hand and arm an
weak and atrophied ; she complains also occasionally of a troubieMaw
sensation of formication over the arm and hand ; she canuot stnigfaRo
her fingers perfectly ; the elbow may be raised from the side to a r^
angle with the body, but she cannot raise it herself more than one fool;
she carries it back a little morp freely than forwards.
In compound disloi^tions the prognosis must always tx: rt^anlcd
exceedingly grave. In the only example which has mnw under mr
notice, the circumstances attending which 1 shall hereatli-r mwicion ia
the general chapter devoted to compound dislocationH, ihe (laiient dioi
from sloughing of the axillary artery. Mr. Scon has, however,"-
ported a case, in a boy fourteen years of age, who recovered r>{Hd]/
afVer the reduction was effected, and in thirteen months his ana n*
nearly as useful as before.'
JVeatrnftU. — The principles of treatment in tliis dislocation art vvj
' simple and easy to be comprehended. I speak now of recoil unroo*
plicated caseo of dislocation into the axilla ; and, notwithstandtH); tht
various and sometimes almost contradictory views which surgvuDM kivi
entertained as to the l)est and most ratiimul niiKlcs of prn^^lun, 1
1 continue to affirm that the laws which ari' in govern the rnliictioo is
a great majority of cases are eKtablishod and indixpuliiblc,
j Observe now the obvious anatomical facl», and then consider ll*
inevitable inferences.
The capsule is torn, generally extensively, along the inner aad !«»•*
margins of the socket. The head of the bone is lodgwl belaul^
I, i> eiA, Aug. 16«T,fr«BlkiUii»
DISLOCATION OP THE SHOULDER DOWNWARDS. 585
^ghtly ID advance of its natural position, in consequence of which the
jXHDte of origin and insertion of the deltoid muscle and the supra-
ipmatus are separated somewhat and their fibres rendered tense, inso-
niich that the arm is abducted and actually lengthened.
At first, and in the most simple cases, these are the only muscles
rhich are in a state of extreme tension, but after the lapse of a few
ours, or of a few days, nearly all the other muscles about the joint,
lost of which were originally only in a condition of moderate exten-
on, and some of which were rather relaxed than extended, sympathize
ith those which are suffering the most, and a general contraction and
igidity ensue, increased also at the last by the supervention of inflam-
ittion and its consequences.
What, from these simple premises, must be the obvious practical
eductions ?
That in the simplest forms of the dislocation the most rational mode
f reduction will be to elevate the arm sufficiently to relax the over-
trained deltoid and supraspinatus muscles, which bind the head of
be bone in its new position, and to pull gently in the same direction,
n order to overcome the moderate resistance offered by several other
Qoscles, but whose tension caimot be relieved by the same manoeuvre.
Failing in this, that we shall increase the relaxation of the first
Mmed muscles, by pulling at a right angle with the body, or even
lireetly upwards : and meanwhile, as we carry the arm more and more
ipwards, we shall operate more powerfully against the resistance of the
Mber muscles.
If in all these modifications of the same procedure, we keep the arm
I little back of the axis of the body, we shall accomplish the indica-
iioDs tlie most perfectly.
Such are the conclusions which must be drawn from the anatomical,
}r,asMr. Pott would call it, the "physiological,'* argument; and which
KBumes as its basis that the muscles constitute the sole or the main
)li8tacle to the return of the bone to its socket. If any surgeon main-
Iwns that the premise is unsound, and that the restoration of the head
jf the bone is opposed by the untorn fibres of the capsules or by any
Jther important circumstance than the action of the muscles (we speak
>f ordinary cases), we shall content ourselves by referring him again
io the extensive laceration which this capsule generally suffers, and
^the constrained and almost uniform position of the arm, as a suffi-
cient reply to his objection.
It must not be forgotten that in all these modes of extension, for with
nearly all of them some slight degree of extension is found necessary,
hfite must be afforded some point of resistance beyond the bone; and
hie it is really which has constituted one of the greatest impediments
0 reduction. It is not that the muscles are in such an extraordinary
tate of extension or rigidity that they must be operated against with
itat force ; it is not that the margin of the glenoid fossa is an elevated
arrier, like the margin of the acetabulum, over which the bone must
e lifted before it can fall into its socket ; but the explanation of the
iiEculty so often experienced in producing effective extension and
Mmter-extension is to be sought for mainly in the fact that the scapula,
88
DISLOCATIONS OP THE SHOULDEH.
upon which the humerus rests, is movable, being held to the body tiy
little else than mii»!les, which, in fact, bind the scapula rourh leaa
firmly to the body than tlie muscles of the shoulder now hind the
scapula to the arm ; while at the same time the scapula itself presents
very few points against which a counter-es ten ding force can be properly
and efficiently applied.
Occasionally it will be only necessary to elevate the arra to an a«il«
angle, or to a right angle with the body, when, the resistance of llie
deltoid and supraspinatns being overcome, the hone will at oii« re-
sume its place. In several Instances which have come under my notiM
Qothing more has been necessary ; and where it can be done, ihc Icut
possible pain and iujury are inflicted, It is the method, therefore,
which in nil recent aXses I have fii-st tried and would wish l« rewrni-
mend. By it I have more than once succeeded when other and more
violent efforts have failed.
At other times it will be necessary to add to this simple inanipola-
tion only a moderate degree ol' extension, such as the hands of tlM
Burgeon can make, without the application of direct counter-extennon
except what is eSect«d by the weignt and resistance of the body.
Dr. John T. Darby, Professor of Surgitnl Anatomy in the Uni^tf
sity, city of New York, informs me that he has been very suoceEeful in
reducing dislocations of the shoulder, by adopting a rule similar to itul
which we have laid down in reducing dislocations of ihe thigh, nainrlf,
to carry the arm only in those directions in which it meets with the
least resistance. He lias found that, in most cases, he can cany lh«
arm np to nearly or qnite a perpendicular, by humoring the artion rf
the muscles; and tJiat in this position the reduction is easily eflcfwA
I have no doubt that the principle, as stated by Professor Darby, i>
Bouad, and that in nearly all dislocations the same may be ajifilinl
successfully, whenever we depend upon manipulation alone.
If, however, the bone refuse to move, we shall then lie obliged M
consider upon what point and by what means we can bt«l apply ■
counter-extending force. Ample experience has taught tnc ihat tiw
extremity of the acromion process is the only available point when "C
are making the extension in a line below a right angle, or in a lint
downwai-dsmorcor less approaching the axis of the body. It baslMS'
supposed that the counter-ex tens inn could b(> made in tlie axilla agiin!*
the inferior margin of the scapula; but several obstacles are prcfcnteJ
to the successful application of force at this point. The axillary fpw
is narrow and deep, so that even with the ingenious contrivaotv ''
placing first a ball of yarn in the axilla, and uiwn ihis the hwl «(0*
operator, it will be found excwilingly dillicult to enter the axilla mtfc-
out at the same time pressing with considerable force against iU lD■l^
cular margins; but to press ujion the pectoralls major and latLtnanv
dorsi is to neutralize our own efforts. If, Imwever, the licci or Ibe W!
docs press fairly into the axilla, it will not find the scnpnla rwuhly, Ix"
it must impinge first upon the head of the humenis, which vt alwiy*
little to the inner side of the scapula. If it ever is ma«h- (» n»A
actually the inferior border of (he scuptila, and I do not think it ii, ti#
efieot must be still only to tilt the scapula ii{>on itself by thruwui^ bus
DISLOCATION OP THE HUMERUS DOWNWARDS. 587
Jb lower angle, and not to separate the glenoid cavity or its upper and
aMerior margin from the head of the humerus.
Vbitever success, therefore, may have attended this mode of prac-
6^ either in my own hands or in the hands of other surgeons, must
ktfttribed not to the counter-extension thus ciTected, but simply to
tie operation of the heel as a wedge, which, by insinuating itself be-
Veen the body and the head of the bone, has thrust it outwards and
pwards into its socket ; or to its having acted as a fulcrum upon which
le bnmerus has operated as a lever.
It is to the extremity of the acromion process, then, that we must
jply our counter-extension when we are employing this mode of ex-
DBion. The fingers or hands of a faithful assistant may answer the
irpoee, or having removed his boot, the operator may often press
icoessfully with the ball of his foot, and the more he carries the arm
itwards, the more secure will be his seat upon the process ; or we
ay adopt some of the contrivances for securing the process which
ive been suggested by other surgeons; such as a band crossing the
loolder, and made fast to a counter-band, which passes through the
mpit and against the side of the body. Dr. Physick, of Philadelphia,
doced a dislocation in this way as early as the year 1790, in the case
^a patient admitted to St. George's Hospital, in London, while he
M a student of medicine, and he subsequently taught the same in
R lectures. Physick directed that an assistant should pre&s firmly
piost the process with the palm of his hand. Dorsey and Hays
fprove of the same method,* and perhaps a majority of American
T[)ns regarded it favorably,
we pull directly outwards, at a right angle with the body, we
Miy still continue to press upon the acromion process with the foot ;
rwe may perhaps trust to the method of making counter-extension,
Psfc suggested by Nathan Smith, of New Haven, and 8ul)sequently
ioommended by his son. Prof. Nathan R. Smith, of Baltimore. Says
W. N. R. Smith :' " What surgeon of experience has not encountered
»e difficulty which almost always occurs in fixing the scapula?" and
e then proceeds to give what seems to him the most effectual mode
'rendering the scapula immovable, namely, to make the counter-
^teosion from the opposite wrist. By this method the trapezii are
tnroked to contraction, and the scapula of the injured side is drawn
mly toward the spine and the opposite scapula. In illustration of
e value of this procedure he relates the case of a gentleman who
d snfTered a dislocation of his left shoulder, and upon whom an un-
ooessful attempt at reduction had already been made by a respectable
rgeon. Dr. Smith being called, proceeded as follows : Two gentle-
si made counter-extension from the opposite wTist, while Dr. Smith
d Dr. Knapp made extension from the wrist of the injured side, at
Bt pulling it downwards^ but gradually raising it to the horizontal
' Pbyi^ick, Amer. Journ. Med. Sci., vol. xix, p. 386, Feb. 1837. Dorsey's Ele-
nu of Surgery, toI. i, p. 214. Philadelphia, 1813.
' Smith's Med. and Surg. Memoirs, Baltimore, 1831, p. 337 ; also, Amer. Journ.
^. 8ci., July, 1861 ; also, American Med. Times, Nov. 9, 1861 ; paper by Stephen
^ers, M.D.
588
DISLOCATIONS OF THE BHOULDER.
direction, and then gently depressing the wrist. On the effort beis
steadily continued for two or three minutes, the bone was observed
slip easily into its place.
But no position places the scapula so completely under our conts
as that in which the arm is carried almost directly upwards, and ■
foot is placed upon tlie top of the scapula. By this method we may s«
ceed generally when every other expedient has failed, yet it b painf^
and I cannot hut think that it increases the laceration of the a\K^-
and that, even when employed in recent cases, it does Bometimes wriw* ,
injury fo the muscles about the joint. In Lister's case of rupiuwtf
the axillary artery, and in Agnew'scaae of rupture of the axillarjTM.
both of which will again be referred to in conncl^tion with ancimt Jifl<^
cations, the accidents occurred when the arm waii drawn upwanls. 1*
Mothe was the first to recommend this method,' but as oarly a» lln^.f*
1764, Charles White, of Manchester, made fast a set of piilW* in '^
ceiling, and, placing a band around the wrLit of the disloc.tti^i orni, If
drew the patient up until the whole body was suspended. No ])n«u*'
DISLOCATION OF THE
EROS DOWNWABDS.
veref, was made npon the scapula from above, which is no doubt
moet essential part of the pn>oess.' By La Mothe's plan, Jobert
Deeded after twenty-three days when all the usual methods had
ed.' Sometimes this procedure ia modified by placing the hand of
operator against the top of the scapula, ai ifi shown in the accom-
ijiag drawing (Fig. 262) ; and I have several times succeeded in this
r after other measures have failed.
La Uoths-i msthod, modified.
k gentle movement backwards or forwards, a slight rotation of the
t>, or suddenly dropping the arm toward the body, diverting the
Mion of the patient, are Httle tricks of the operator, which now
then prove successful.
Sir AMxj Coopei** mstbod of mppi jlog
r Astler Cooper thus describes his method of applying the heel to
ixUla (Fig. 263) :
'- Wbitfl, Amer. Journ. Ued. Sci., Not. 1836, from Med. Ota. And Inquiriet,
1, p. ITS, London, 1764.
Ud., Tol. xxiil, p. 287, Not. 1838.
690
DISLOCATIONS OF THE BHOULDEQ.
"The patient should be placed in the recumbent posture, upon
table or sofa, near to the edge of which he is to be brought ; the ;
geoR then binds a M'etted roller around the arm immediately above
elbow, upon which he ties a handkerchief; then he separates the
tient's elbow from his side, and, with one foot resting apon the fli
he places the heel of his other foot in the axilla, receiving the heai-
the OS humeri upon it, whilst he is himself in the sitting posture f,
the patient's side. He then draws the arm by means of the handle^,-:
chief, steadily, for three or four minutes, when, under common circa m,
stances, the head of the boue is easily replaced; but if more foire ^
required, the handkerchief may bi
rw.iu. changed for a long towel, by whiti
several persons may poll, the 9U^
peon's heel still remaining in the oi-
ilia. I generally bend the furetns
nearly at right angles with the «
humeri, because it relaxes the biwps,
and consequently dimioisfaeB its tt-
sislance."
He was also accustomed in some
cases to reduce the dislocation b*
substituting the knee for the Im
Placing the patient upon a lowch»ir,
the axilla is laid over the knee of tb«
operator, and while one hand ^tn^ft
the acromion process and scaptdi, ike
other presses downwards upon th»
lower end of the humerus (Fig. 2611.
If some hours or days have dapwd
since the occurrence of the dl'li***
tiou, it will be necessary to rosort to
chloroform or ether for the purpi*
of paralyzing the muscles, as well »
with the view of preventing pain; and it may be necessary, in additiuo,
to resort to pulleys, or ta some similar jtermnncnt mode of ealeiwi<*>
The same measures also sometimes become necessary in ver^ noal
cases, es])ecial]y in muscular subjcd».
In employing the pulleys we generally operate, not exactly la a
with the axis of the Ixxly, nor at more than a right angle, but bd*
an angle of 45° aiid a right angle.
Mr. Skey has suggested a plan by which we may combine the p
ciple of the heel in the axilla with the pulleys, but which plan wwlil,
in my judgment, be very much improved by a co untcr-cx tenth ii)[ ("^
applied to the acromion process. I ought to say, however, that Mr.
Sltey prefers that the scapula should not be fixed, believing thai (••
reduction is much more easily effected when the glenoid cavi^ isilt«»i
downwards in the act of making the extension.
With all respect for the opinion of this distingiiisheal surfpion.**
cannot precisely agree with him; and while we would lie iUs|"i«^'"
recommend in some coses a trial of his method of applying the [HilhfS
DISLOCATIOH OF THE HUUEBUS D0WNWABD8. 591
vould, at the same time, or certainly in the event of ita failure, add
! acromial support, and especiaHy would we advise that the arm
mid be more abducted. The following is Mr. Skey's method, as
Kribed by himself:
"There is no reason why, in veiy muscular subjects, or in old dis-
ntioDs, the same principle may not be applied conjointly with the
IrDD kDob employed bj Biej, lutud of the fa«el.
Kof pnlleya. For the purpose of retaining this admirable because
nt efficient principle, I employ a well-padded iron knob, which may
imwnt the heel, from which there extend laterally two strong straight
'anches of the same metal, each ending iu a bulb or ring of about
nr inches in length, the office of which b designed to keep the mar-
neof the axilla as free from pressure as possible." The iron knob
to be pressed well up into the axilla and attached to cords fastened
a staple; the patient lying upon his back or inclined a little to the
ponite side. The arm is then to be drawn downwards by the pulleys,
K Dearly as possible parallel to, and in contact with, the body."'
Id this way Mr. Slcey says that he has succeeded in reducing a
St many dislocations, whether occurring in very muscular men, or
tetBome days', or weeks', or even months' duration ; and he thinks
/>^
^
9
^
-..^3
^
w
K^
#^*^p^
^
w
Skef'i melbod or miklns ei
>D ind counter-cxtentlon irith
e plan especially applicable to cases which require long and persistent
tension.
Ur. Skey and many other surgeons prefer to make the extension
Ha tiie hand. I have succeeded as well, and it has seemed to be less
in&l to my patients, when I have followed the practice of Sir Astley,
■ Skey, Operative Surgery, Amer. ed., p. 93.
592 DISLOCATIONS OP THE SHO0LDEB.
and made the extension from the arm. Sir Asdey always made t
extension more or less out from the line of the body, and genera."!^
almost at a rig:ht angle when using the pulleys, the sntpula beiii^ n
fast bv "a girt buckled on the top of the acromion," or by a s
cloth (Fig. 267).
sir Aillcj Cooppr'i uioJb o[ makfpg eileniton wiili pullojj.
The instrument invented by Dr. Jarvis, of Portland, Conn., tailed
the adjuster, useless and even mischievous as we have found it In in
application to the treatment of fractures, possesses considerable tnenl
as an apparatus for reducing old dislocations, especially of the shooM*
The principal advantage which may be claimed for it is, that "hill
the forces are being applied the limb may be moved pret^ ^'^X ^
all directions; thus enabling us to employ rotation at the santetiai
that tlie extension is made. We may also lifl or depress, itddnot tt.
abduct the limb without relaxing the extension. In the htikdi ^
Americau surgeons it has occasionally been successful when olhw iww*
have failed. Dr. Jarvis has related a case presented at the Muni
Haspital, at Mobile, Alabama, of forty-two days' stAnding, vtbidi hi
reduced on the second attempt, at\er other means had titiled ;' ami I^«
May, of Washington, reduced a similar dislocation at the eiMiofii»
weeks, by tlie same appanttus, without, however, having prcvioo^y
resorted to any other means,'
I have myself used the apparatus occasionally, both in my hwpit*!
and private practice, and can epeak favorably of ita operation.
I must not omit to mention the practice adopt«d by Viot H. H.
Smith, of Philadelphia, according to whom nearly all dislotatioiii of
the shoulder, of a recent date, may be promptly and easily reduced of
DISLOCATION OF THE HUMERUS DOWNWARDS. 593
anipulation alone. His method consists, first, in flexing the forearm
xm the arm, while, at the same moment, the elbow is lifted from the
)dy ; second, in rotating the humerus upwards and outwards, employ-
ig the forearm as a lever ; and third, in reversing this last movement,
bat is, rotating the humerus downwards and inwards while at the
arae moment the elbow is carried again to the side.^
When the dislocation is into the axilla, this manoeuvre will gener-
lUy succeed; but if the head of the humerus has slipped forwards, even
only sufficient to engage itself slightly under the tendons of the coraco-
brachialis and biceps, the outward rotation of the humerus will inevi-
tably thrust the head further forwards, and fasten it more certainly
Tuademeath these tendons ; while the rotation of the humerus in the
opposite direction will alone often be sufficient to carry the head directly
into the socket.
Ancient Luxations, — Finally, I ought to speak somewhat more in
il of the manner of procedure and of the principles involved in the
redaction of old dislocations, or of dislocations requiring the interposi-
tion of mechanical appliances ; especially with a view to the more com-
plete exposition of my own practice in these cases.
If the dislocation is recent, but reduction is found impossible with-
i>ut the aid of mechanical apparatus, the difficulty will be understood
to consist mainly, if not altogether, in the resistance offered by the mus-
fe. If, in a few exceptional cases, the capsule, or an untorn tendon,
* the margin of the glenoid fossa, present themselves as obstacles,
bey must still be considered as unusual and extraordiary impediments,
^e existence of which may be regarded rather as possible than prob-
Almost our sole purpose, then, it will be understood, in all recent
ises requiring mechanical appliances, and in some ancient cases, is to
ireroome the contraction of the muscles.
We prefer always to place the patient upon a mattress laid upon the
jot; two silk handkerchiefs, or two pieces of a cotton roller, are then
id along the radial and ulnar sides of the humerus, and over the
liddle 01 these, immediately above the condyles, a wetted roller is
>plied, its end being made fast with a needle and thread rather than
ith a pin. The upjier ends of the longitudinal strips, or of the hand-
erchie&, are now turned down and tied to the opposite ends, thus con-
erting them both into lateral loops. For the purpose of making coun-
T-extension, a sheet is passed around the body under the axilla, and
lade fast to a staple; while an intelligent assistant is to manage the
caimla with his naked hands, either by pulling with his fingers placed
inder the process, or by pushing with the palm of his hand and ball
•f his thumb. The pulleys, secured to a staple exactly opposite to that
Aich holds the counter-extending band, are made ready, but not for
lie present attached to the arm.
As soon as the patient is placed completely under the influence of an
UMBBthetic, the operator is ready to proceed with the reduction. It is
>&y maxim never to attempt to accomplish by complicated and violent
1 H. H. Smith, Gross's Surg., ed. of 1868, p. 162.
591 DISLOCATIONS OF THE SHOULDER.
measures what may be done as well by more simple and gentle means.
I think it, proper, therefore, to make several attorapts at reduction b;
raanipulittion alone, aided now by the anEe^thetio, the extendiog and
counter-extending bands, etc., before resorting to the pulleys. Seating
himself upon the mattress, with his boots drawn, the iJurgeoD.ihouM
bend the forearm to a right angle with the arm, and planting ooe lii-el
in the axilla, with one hand he should seize upon the loops at the elbnw,
and with the other steady the hand and forearm of the patient, while
he proceeds to make firm traction for a few seconds in fne linenf iht
body, or only a little out from this line. Failing in this, he may <iir«»
the assistant to seize upon the scapula, and make counter-extension j
still notxuccecding, he may change his foot from the axilla to the mo
mion process and pull directly outwards at a right angle with the body,
or he may swing himself gradually around until he comes to be abovt
the head of the patient, and the foot presses firmly u|)un the top oTttx
acapnia ; now descending again in the same direction, he wilt very \mh-
ably find the linih reduced, or capable of being reduced easily, b>' oper-
ating upon it as a lever by laying it across the body while at the mom
moment it is rotated slightly inwards.
If still the reduction is not accomplished, the pulle)'s must at once
be put in requisition. The sheet pa^ed around the chest and fasltntd
to a staple, is only a means of supporting the bo<Iy and rendering it
more st<»dy ; as a means of counter-extension its value is incoiuiilw^
able. To make fast the scapula, we must still rely mainly ujhio tb«
naked hands of strong men, or upon a strap drawn firmly acnwlJii
process and held in place by an assistant.
Whenever we employ extension without the aid of aniwthftiis,*
sometimes we are compelled to do, it must be constantly Ixtme in niix)
that it is proposed to conquer the muscles by fiitiguing them, and thil
this cannot be done by a force suddenly applied, however grcil it mif
be, but only by gentle, steady, and long-oon tinned extension, T*
muscles, when attacked oiienly and vigorously, resist, and will suffi*
laceration rather than yield, while, on Uie other hand, nn insidioitf bol
persevering approach seldom fails to end in their defeat. The same i»
true, but in a much less degree, when the patient is insensible fram in-
fest lies la.
The forearm is again flexed, and the arm carried out to a right UH(i*
with the body, the pullej-s secured to the loops, and the assistant t^«
hold npon the process, while the sui^eon draws gently upon tbenv*
attached to the pulleys; as soon as everything is moderately im^ ut
is to desist for a few moments. Again the ro]>e is drawn npon gentl*i
and again the progress of the extension is sufli»ended. In this waylln
operator is to pi-oceed during half an hour, or two hours, as the natnit
of the case may demand ; occasionally rotating the humerus, ami ««*•
sionally lifltng its head toward the socket. Meanwhile, it is ntAs-
stood that the principal counter-extension is made by the awistaaK'
who must relieve earJi other, at the acromion process. The sh«* j"
the axilla, or rather against the side of the chest, has some vniaf ■■
this respect when the arm is at a right angle with the body, b"'''
itself it cannot control the scapula, only aa it holds the body to iihiA
1
DISLOCATION OF THE HUMERUS DOWNWARDS. 595
le scapula is attached. Much, therefore, as we may regret the incon-
aiieDce of makiug counter-extension by hands alone, experience and
tttomy alike must teach that here it is the only mode. If these dis-
eatious are reduced often by other methods, as no doubt they are,
en it is only an evidence that in these examples little or no counter-
tension was necessary.
Sometimes the dislocation is not reduced when the extension is given
», but if then a resort is promptly made to some one of the simple
eihods already described, while the muscles are still exhausted, it
;f often happens that the reduction is easily accomplished,
t will be prudent in all cases, in order to prevent a reluxation,
liether the dislocation is recent or ancient, as soon as its reduction is
»sted, to place the arm in a sling and secure the elbow to the side by
few tarns of a roller. I do not think the axillary pad necessary, and
am afraid it has sometimes done as much mischief as the dislocation
elf.
The following example will illustrate the variety of expedients to
hich we are obliged sometimes to resort before our efforts prove suc-
mM:
Thomas Leeding, of Niagara Co., N. Y., «t. 62, a laborer, and a
loscolar man, dislocated his right arm into the axilla, by jumping
om the cars when they were in full motion. The blow was received
pon the shoulder. An intelligent country surgeon, assisted by several
her persons, attempted reduction within an hour after the accident,
Qt &iled, and as the patient had some distance to travel, he was not
itmght under my notice until eighteen hours had elapsed. We first
Immistered chloroform, and then, while an assistant held firmly upon
le acromion process, I pulled in the line of the body, then outwards,
id finally upwards, but to no purpose. Having then applied Jarvis's
adjuster," and after the arm had been kept extended at a right angle
ith the body fifteen minutes, we removed the apparatus, and found
tebone in its place.
John Harrington, rot. 50, a very large and powerful man, fell, while
toxicated, and dislocated his left humerus into the axilla. No sur-
on was called until the tenth day, when he first consulted Dr. Dud-
7f who at once brought him to me. Without delay we applied the
illeys, and placing the arm at a right angle with the body, we made
tension fifteen minutes; occasionally also rotating the arm. We
m removed the pulleys, and while an assistant held upon the aero-
CD process, with my heel in the axilla, I made extension in the line
tlie axis of the bony, then outwards, and finally upwards with my
tt upon the top of the scapula. I next seated my patient in a chair,
i drew his arm and axilla forcibly over my knee. The bone was
t yet reduced ; I therefore bled him twenty-four ounces, or until
rtud syncope was induced, and proceeded to repeat most of these
Messes, but with no better result. At this moment I determined to
^sulpharic ether, which had just been introduced, as an ansesthetic,
d while he was completely under its influence the pulleys were again
plied, and the extension continued for some time, and until the rope
%
596
nrsi.ocATioNS of the shuulder.
broke. He was then again placod in a chair, an<] the axilla brought
over my knee, when in a moDient the reduction was accomplished.
Julia McKuight, set. 39, admitted to wan! 28, Bellevue, in Novem-
ber, 1866, with a dislocation of the humerus into the asilla, which had
existed seven weeks and one day. The deltoid was much wasted and
the hand somewhat numb. Before the class of medical studenta, the
patient being under the influence of ether, the reduction was effetled;
lint not iiutil various methods of manipulation and extension had beni
tried and had failed. Having Anally carried the arm directly upwsnli
— La Mothe's method — and in this position employed extension, the
arm was again bnmght down and with moderate manipulation th* re-
duction was eflected. The return of the bone was sudden, and was
accompanied with a slight grating sensation ; it was observed also, ihit
a hard bony projection was left in the axilla, which was no doubt the
margin of a new socket. The head of the humerus could be iiiiinly
seen and felt in its socket, rendering it certain that we had not brokM
the surgical neck of the humerus.
John Bowles, of Buffalo, aged 4fi years, an Irish laborer, tolertblj'
muscular, but spare. Bowles tell down a flight of stairs, and di^lontra
his left humerus into the axilla. The shoulder became much swi^lln.
and was very ])ainful, but he did not suspect a dislocation and did wA
consult a surgeon. Eight weeks after the accident he applies! to ma
There were preeent the usual signs of this dislocation, but the arm «i!
by careful measurement one inch and a half longer than the other.
The reduction was accomplished on the same day, in preecnce c(
Drs. Lee, "Webster, Coventry, Ford, and Jewett. The time occnpifll
in the reduction was about two hours. An attempt was first iwl
with the hcet in the axilla and with violent rotation and extcnsloo.
The same plan was repeated with the aid of ether, which was adiiuni**
tercd freely. Jarvis's adjuster was now applied, with no result, cio^
that, either in consequence of the force employed by the adjiist«T, or a
consequence of the Iree use of ether, or of both, he became convot*"
violently, which was accompanied by frothing at the mouth nikd oths
grave symptoms. The adjuster was removed, and the exhibition *
ether discontinued. As soon as the convulsions ceased, and befin
consciousness had returned, extension, rotation, etc., were again aiit
by hands. Finally, after all extension was relinquished, pTarinf; of
knee in the axilla, I rechiced the bone by a very slight rotary Kti"*
upon the arm; the bone was at once plainly in its socket, but tbi
unusual length of the limbi^ntinue<l, being one inch and a haff lon^
though it could be shortened to the same length as the other by limif
the elbow. A pad was placed in the axilla, and the arm secured *™
a sling and roller. The nest day the arm remained in plaiv, hoi B
was now only one inch longer than the Other. At the end of a (**■
night It was only three-quarters of an inch longer, and ci>uld hf *
duced to the same length by lifting; the pain and swelling alwullh*
shoulder, which never were great, were subsiding, and the patient ••
dismissed.
However skilfully our efforts may be directed, they will be fi»™
occasiooally to fail ; either owing to adhesions which have taken pbo
DISLOCATION OF THE HUMERUS DOWNWARDS. 597
een the head of the bone, or rather its capsule, and the ailjacent
)DSf muscles, etc., to some extraordinary position of the head and
of the bone in its relation to ligamentous or tendinous structures,
filling up of the glenoid fossa, or to some other cause not fully
lined. Such failures have happened not only in the hands of
"ant and unskilful surgeons, destitute of appliances, but also in the
8 of those who are the most expert, and who are the most com-
ly provided with all the necessary apparatus. Indeed, if the truth
known, it would probably be found that the number of failures
the sixth or eighth week has been greater than the successes. The
ds of surgery, however, furnish a great many examples of ancient
cations of the humerus reduced after periods ranging from one
th to six, or even longer. Dieffenbach has been able to accom-
1 the reduction of a forward dislocation afi«r two years, but not
he had cut the tendons of the pectoral is major, latissimus dorsi,
major, and teres minor, and had divided the ligaments surround-
he new joint.*
would be unjust to the young surgeon not to call especial atten-
to the numerous examples of serious and even fatal accidents
h have followed upon the attempts to reduce ancient luxations at
joint.
upture of the Axillary Artery. — The late George C. Black man, of
innati, a distinguished surgeon, having met with one of these un-
inate accidents in his own practice, has had the candor to make a
ic statement of the case and of the circumstances which attended
In a letter to the editor of the Western Lancet, published in the
ember number for 1866, he writes as follows :
A.bout the 10th ult., aided by yourself, I succeeded in reducing by
ipulation, without the pulleys, a dislocation into the axilla, of
^ days' standing. The reduction was accomplished in a very few
iteSy under the influence of chloroform and ether, and the next
ling the patient left for the country, in a comfortable condition.
B that I have received no tidings from him. Encouraged by the
It in this case, another patient, himself a physician, a tall, athletic
, and about fifty years of age, decided to submit to the same manip-
on, although his arm had been dislocated for about sixteen weeks,
dislocation was downwards and inwards, and about the tenth week
nsuccessful attempt, by another surgeon, had been made with the
^8, to which the force of six men was applied for two and a half
•8. The patient being under the influence of chloroform and ether,
1 by yourself, Drs. Fries, Gary, Graham, and Kauffman, I com-
oed by manipulations, adducting, rotating, abducting, and elevat-
the arm. These eflbrts had been made for about ten minutes, and
least possible violence employed, when a tumefaction appeared in
pectoral r^ion, which in a few minutes attained a considerable
Supposing that the axillary artery was ruptured, as no pulse
d be felt at the wrist, a ligature was immediately applied to the
MefTenbach, Boat. Med. and Surg. Journ., vol. xxii, p. 882, from Ifedicin.
tog.
598 DISLOCATIONS OF THE SHODLDEE.
vessel at the upper part of its course. The operation was performed
about 10 o'clock a.m., and mmpression of the pectoral r^ion madeliy
means of a sponge and broad roller. On romoving this the neit
morning, the tumefaction had nearly disappeared. The patient con-
tinued comfortable, and about nine days after the application of the
ligature I was compelled to leave the city on a profeasional visit U
Indiana. I left on Friday afternoon and returned on Monday morn-
ing, at which time I lcarne<l that my patient had died on Sundiy
morning, from htcmorrhagc at the seat of ligature."
The following is a risnmi of similar accidents which have froni time
to time occurred in the practice of other sui^eons.
Rupture of the Axillary Artery. — Deaault twice observed, afler at-
tempts to retluce old luxations of the shoulder, " tumeiirg ofriemin.''
It is quite probable, however, that in each case the tumor was caii»d
by the rupture of a bloodvessel, and probably an artery.'
Pelletan, also, attempting to rednce a lunation of four months' stand-
ing, thought he produced a tiimcur atrienne, but it being opened Un
patirat bled to death."
Malgaigne, attempting to reduce a dislocation of sixty-eight dsyi^
standing, was surprised by a sudden tumefaction in the axilla, and uo
the shoulder, which cause<l so murh alarm at. to indui^ htm to (iti>con-
tinu« his efR>rts. Ire was applied, and the hseniorrbage, whith lie
thought came from muscular branches, was arrested.' Vcrduc sa»
the axillary artery ruptured in the same manner, in conscquowe of
which the patient died.* J. L. Petit, Dupuytrcn, Delpcch, and Ne!-
aton, met with similar cases. C. Bell reports an example of ruirtnrl
of the artery with extensive laceration of the muscles, and which
manded immediate amputation. Dclpcch ruptured the artery, and hit
patient died immediately.* Flanbert was more fortunate, the effiwi
blood being absorbed after a few days.' John C, Warren, of Boston,
tied the subclavian arterj' to arrest the progress of an cnormon.'* aneo-
rtsmal tumor in tlie axilla, caused by tlie reduction of a rei*nl di«lof»-
tion.' Gibson, of Philadelphia, lost two patients from rupture of the
, artery in attempting to reduce old luxations of the humerus.* and iM
relates another fatal case occumng in the practice of David, of Btweo-
Ijeudet, of Rouen, lost a patient in this way in 1824. In this bitKt
case, and in both the cases occurring in the practice of Gib«oii, lh«*'
was a fracture, also, of the lower margin of the glenoid cavity. W-
lender rujtturetl the artery in an attempt to reduce a dislocation at M
weeks.' Mr. Lister lately met with the same accident.'*
In addition to these lesions of arteries and veins caused bv aUeafU
* Halgnignn, op- ciL, |> H
■ DcBHUli, Juiirn. ile Chir, t. iv, p. SOI.
' PelletBD, Chir. Clin., t. ii, p. Bnl.
« Virduc. Uti«rHt. de In Chir., 1698, t. i, p. Gfi9.
> Mnlgnignp, cip cit , p. IG2.
* MSmi.irci' "iir plusicurs iw de LuiMinnc-*. ete. HipiTtoire il'AnkL rtd" P*TS
18'JT,0I)< .1. Fn{irt-n°'-!<'^f injurv t<> Ihi- AxilUryor Rrnrliial V»iRti or NttM
• Wnrri.n, \i.mt. .Ii-.ii ii Mcd.'Soi.. Vol, x\. N. S , I8<(1.
' (Jilij-.ii, Ki.in.i.r.-. nf s,i.«., y.<\. i,,.. P24. 4tlied.
•St l(ririli.>l l[<>-|>. Il<'p., IR'I'i, vnl ii, p. 96.
» Utd. Time, Niid G-L7,., !'\-b. 1, 1878.
DISLOCATION OP THE HUMERUS DOWNWARDS. 599
duction of dislocated shoulders, in both recent and ancient cases,
3 are several examples recorded of sudden death when no such
DS were disclosed in the autopsy. In the case reported by Lisfranc
b was ascribed to cerebral congestion. MM. Lenoir and Larrey
' to cases, also, of lesions of the brachial plexus, causing paralysis,
hese were recent cases, and the reduction was easily accomplished.*
upture of the AxUlury Vein, — Froriep attempted the reduction of
shoulder in a woman, set. 36, the dislocation having existed twenty
. The axillary vein was torn entirely across, and death ensued in
oar and a half.^
rofessor D. H. Agnew, of the University of Pennsylvania, ruj>-
i the axillary vein while attempting to reduce a dislocation of six
IB. The woman-, aet. 60, had a subcoracoid dislocation, and while
inn was lifted and extension made according to La Mothe's n>ethod,
7em was ruptured, causing a very large tumor covering the entire
St. Compresses and bandages were at once applied and continued
everal weeks, the case resulting in a complete cure, but with the
I unreduced.^
uptu^re of Artery and Vein. — Platner mentions a case of rupture
oth artery and vein, in which death ensued from subsequent rup-
of the aac.
harles Bell reports a case in which the artery was ruptured, at the
Castle Infirmary, and the parts adjacent so much injured that
«diate amputation became necessary. It seems quite probable
^ore that the vein was also torn, but this is not stated.^
ijury to Axillary Nerves. — Very many accidents of this kind have-
lened from time to time, some of which have been reported by
ibert, Malgaigne, Lenoir, Larrey, and others.
tmhion of the Arm. — Guerin tore the arm completely from the
^, in an attempt to reduce a dislocation of three months' standing,
woman 63 years of age.*
iflamnuUion, etc. — Mr. Hutchinson, of London, reported in 1866
inflammation, suppuration, and death had resulted from an at-
»t made to reduce an old dislocation of the humerus, under his own
rvation.*
racture of the Humenis. — In the following case an attempt to r«^
an ancient dislocation of the humerus occasioned a fracture- of the
teal neck.
'artha Hogan, aet. 70, of Brooklyn, N. Y., was admitted into the
g Island College Hospital during the spring of ISGOk The dislo-
»D had existed six weeks, and was snbcoracoid. On the day of
ission an attempt was made to reduce it, both by Dr. Johnson and
slf^ without an anaesthetic, in which we both failed. I then gave
jisfranc, Lenoir. Larrey, Bui. de la Soc. Chir., i, i.
/eraltete, Luxationem, etc. Weimar, 1834, p. 36.
*hiladeU>bia Med. Times, Aug. 16, 1873.
ce I>e Forest Willard's excellent summary of these and other cases^in Phila.
Times, Aut?. 16, 1878.
». Cooper's First Lines, vol. ii, p. 4f)6. Amer. Journ. Med. Sci., 182S, p. 186.
iOod. Heap. Reports^ vol. ii. (See Cincinnati Journ. Med., Aug. 1866, p. 861.)
%
600
DISLOCATION
her ether, and iiow discovered that she had a fracture of the ncond
and third ribs ou the aame side. The fractures were ununited. While
maDipuIating, pulling the arm ^utly and rotating, the Buigieal ueck
of the humerus gave way. She did not survive the injmy many davi,
and the autoptiy confirmed tills diagnotiis.
lu December, 1874, Dr. Stephen Smith, of Bellevue, met with lit
same accident in attempting to reduce a suhglenoid dislocation nf e^ht
weeks' standing, before the class of medical studeolH. The patient, t
man aged about 40, was under the influence of ether. Maiiij)iilitti<a
and extension had been freely employed in variouf; directions, but ihe
fracture took place when, at my suggRstion, extension was for a mo-
ment relinquished, and while Dr. Smith was rotating the humtntf
with the elbow at a right angle with the body.
In December, 1865, Rosanna Casey, jet, 32, was admitted to B«i!levM
with a Bubcoracoid dislocation of the left shoulder. The aoirideiit oc-
curred sis weeks before. On admiasion, one of the house surgeoot
attem|)tcd reduction, and, as I am iuformed, fractured the stiqricil
neck of the humerus. Af^er which, Dec. 9th, 1 attempted reducliiio
bctcirc the class, tlie patient being under the intluence of ether, bat
without success.
Summary of Accidents. — Ru|(tnre of an artery, nineteen cases ; tnori
of which were known to lie ruptures of the axillary artery, Calletiilw,
Lister, and Blaekman tied the axillary, and the patients alt iitd-
The subclavian was tied by Warren sut«essfuily. Gibw>n also titil the
Hub(?lavian, but his patient died. N^laton did the same, and the rwnit
IB not stated.
Rupture of vein alone, two cases, Froriep's patient died ; Apu"*'*
patient was saved.
Rupture of artery and vein, probably two eases. Platncr** pntiKil
died. In Bell's case the result is not stated, except that aniputatko
■was practiced.
Avulsion of arm, one case. Patient died.
Of the whole number, t^venty-four, fifteen terminated fatally, tlini
are uncertain, and six recovered.
Of fractures of the neck of the humerus I have reported three tmtk
In neither of these was the reduction accomplished. My own patidt
died, but probably uot in consequence of any injury suSered b tb*
attempt at reduction.
Norris has reported three cases of ancient <lislocnttoti into the ueSk,
treated at the Feunsylvania Hospital; one, of four tvcek«' stUHtiaft
was reduced in thirty seconds by the aid of pulleys; thcMwood, wb»
had existed seven weeks, was reduced by tlic same means iu about <«•
hour; and the third, dislocated ten weeks, was left nnrtxluivd •*■■
extension and counter-extension had Iieco made for an hour, la ti*
second case, however, suppuration occurred in or abitut the joint, mi,
on the tenth day, the abscess was opened, giving exit to a large ■in\xiii
of pus. He lefl the hospital with the parts about the shonMcroill
much hardened and stiff.'
> Nnrrli, Amer. Jau
i,p. 2L
DISLOCATION WITH FRACTURE. 601
Dislocation^ with Fracture of the Humerus near its Upper End.
We have thuB far omitted to speak of the treatment of dislocations
the humerus accompanied with fracture near its upper end. The
ler writers, almost without an exception, agree in declaring the re-
ction of these dislocations impossible, until the fracture had united,
nd, BO late as the year 1828, we have the report of a (use treated in
is manner by a surgeon in Massjichusetts. Dr. Warren, of Boston,
iDself reduced the dislocation at the end of four weeks, when the
icture was found to have united.*
But since the introduction of antesthetics immediate attempts at
inction have more often proved successful ; and in no case can the
rgeon excuse himself for having omitted to make the effort.
Kichet rejyorts an example of this kind in a man sixty -eight years
age, in whom the dislcnation was complicated with a fracture of the
X!Kof the humerus. The attempt was not made until the fourth
ly, when it proved successful without extension. The fracture was
terwards adjusted and consolidated, so that he recovered the complete
« of his arm.'
At a meeting of the New York Academy of Medicine, in May,
855, Dr. Watson refwrted a case of fracture of the humerus near its
ead, complicates! with a dislocation into the axilla. The patient was
robust man, passed the middle age, and had received the injury by
blow on the shoulder from a steam-engine. He was very much pros-
ated at the time of being admitted into the hospital, and the exami-
ition was not made until the following morning. The arm was then
•ond lying close to the side, but in other respects it presented the
«ial signs of a dislocation. Ether was immeiliately administered;
id while extension and counter-extension were applicMl, and a sweep-
g motion given to the arm, drawing it from the bcnly, firm pressure
ith the fingers was made in the axilla, forcing the head toward the
cket, and the btme slipped into its position.^
In the Transactions of the American Medical Association, I have re-
tried a case of sup|)<)sed dislocation, accompanied with a fracture,
lich I succeeded in reducing on the eighth day.*
I have, however, twice failed in attempts to reduce similar disloca-
►n«. The first patient, John Riley, tet. 49, was admitted to Bel lev ue
w^pital, March 29th, 1864, having received the injury two days
fore^ The dislocation wius sulK'oracoid, and the humerus wa^ broken
its surgical neck. Having place<l him under the influence of ether,
sbted l)y Dr. Stephen Smith and several other surgecms of the hos-
tal, I attempted to re<luce the dishxratetl bone, but after a trial, pro-
ngieil through one hour or more, the effort wjus abandoned.
The second case was m a man aged about 40 years, who was admitted
* B«*»t<)n Mi»d. and Surg. Journ., No. 1, 1828; hIso, Amor. Journ. Mod Sci.,
»1 W, p. 2M3.
• Kicnet, Amer. Journ. Med. Sci., vol. xii, new ser., p. 293, from Bulletin do
b^ran.
• Miatson. Amer. Journ. Med. Sci., vol. xvi, new ser., p. 888,
* Op. cit., vol. ix, p. 93.
89
1
602 DI8LOCATIOSS OF TUB SHOULDER.
tu fiellovue Hospital in July, 1864, with a di»^locatioii of the head of
the humerus Ibrwartls, nnd a fracture of the surgical neck, of four weeks'
standinj;. A surgeon had attempted reduction immediately aftcrtbe
receipt of the injury, but had failed. We found the fra<?ture still on-
united, and placing him under the influence of ether, we tried tititli-
fully, by pushing and pulHu^, and by various other manteuvref, la
reduce the dislocation, but without success.
The fractures united in both cases promptly, and attempts were sub-
Bemiently made to reduce the dislocation, but to no pur|K>se.
lu neither of the three cases of fracture of the surgical neck of tbt
humerus, reported in the preceding pages as having l)een eauswlhy
efforts to reduce dislocations, were the dtslocatioua subsequently
duccd.
Examples have been recorde<l by sui^etms in which the redurtioa.
has bc*u accomplished immediately, and without much difliculn, ti^
simple pre.'iisure upon the head of the bone, while the patient was undtf^
the influence of an antestJietic, and without the aid of exteusina; li
deed, it is quite doubtful whether extension in these cases is of as
service. If, however, the surgeon were to fiiil by pressure alone,
would be proper to employ extension and niunipulatiun.' In thccvM
of a failure by these means, the (^ase ought to be treated as a frai-lur
and the earliest period aOcr the union of the fragments should I
seized upon to accomplish the n-duction of the dislocation. The oca
sional ^^uccess of the older surgeons by this method is saflicicnt I
warrant the attempt.
The treatment of compound dislocations of this joint will bcdi
cussed in a separate chapter devoted to the general cvtrisidcntioa i
compound dislocations of all the joints counctUed with tlie long bqne
I 8. Dislocation of the Hnmems Forwards. (Snbooraooid aid
Subclavicalar.j
Ont*es. — The causes of tlii;- di.slocalion are the same with thot
which pnxluoe dislocation downwards into the axilla, cxii-pt tliat it
more likely to (xtiur in a fall U]ion the elbow or u(>on the hainl <«lia
the line of the axis of the arm and forearm is thrown b<-lunil the lioljr.
If it is the result of a direct blow, the impulse has u!>uully bwai (f.
ceived rather upon the back tlian upon the outer side of tlie hnddF
the humerus; or the upper end of the bone having been origiul^.
thrown directly downwards uiwn the inferior edge of the scftptila,nff
have been made to assume the position forwards, IwDuath the podoi*.
muscle, in consequence of the peculiar action of the muscles, orortli^
position of the arm in an attempt to risi-. By this latter mod* 4
explanation the dislocation forwards is consecutive only upon a i" '
cation downwards.
In several instances which have come under my notice the di»h«^
tion has been due to muscular action alone. In one cxanipk tiii
I, Amer. Janrn. M<d. 8el., Jn iM
DISLOCATION OF THE HUMERUS FORWARDS. 603
adon occuiTf?d frequently in consequence of epileptic convulsions.
lis was in the person of a lad, tet. 18, of a slender frame and feeble
iscles. When the dislocation had taken place, he was frequently
le to reduce it himself; sometimes he was obliged to call upon a sur-
ra, and at other times he left it out a day or two, or until it became
lueed spontaneously. This spontaneous reduction generally took
loe at night, during sleep. At the time he called upon me the bone
1 been out two days, and he could not reduce it. I administered
oroform, and then made repeated and prolonged efforts at reduc-
Q, adopting all the usual modes of manipulation, but without resort-
; to mechanical appliances. The father now refused to allow me to
)ceed, and he was taken home with the bone unreduced. The fol-
nng day he called at my office, to say that during the night, while
eep, and, he thinks, while turning over in bed, the bone suddenly
mroed its place.
Dr. Edward L. Pardee, of this city has recently met with a case of
nultaneous dislocation of both shoulders, in a man aet. 38, caused by
all from a carriage, hLs arms being extended in front of him, and
e force of the concussion being rc*cei ved upon hLs hands. Both of the
^locations were subcoracoid ; and, aided by Dr. Glover C. Arnold,
ey were easily reduced.
Surgical writers occasionally refer to similar exam pi (»s, but the
iraber of cases of double dislocation on record is small. Most of those
corded have happened when the arms were extendeil in front of the
dy, as in Dr. Pardee's case just cited ; and the dislocations were gen-
illy subcoracoid.
Paihfdogy. — Omitting for the present to speak of partial luxations,
5 existence of which, as a form of traumatic dislocation, we are pre-
red to question, we shall proceed at once to describe the anatomical
ations and the various lesions which generally accompany a complete
cation forwards.
Of these we shall observe two principal varieties, differing mainly in
■ degree or extent of the displacement.
rhus we may find the head of the humerits resting beneath the cora-
\ process, having the conjoined tendon of the short head of the biceps
I of the coraco-brachialis lying up<m its anterior surface, while its
terior and outer surface rests upon the venter of the scapula in front
tbe glenoid fossa; in which position it has usually thrust up, to a
ater or less extent, the belly of the subscapular muscle.
Mr Astley Cooper, Fergusson, and others, when mentioning this form
dislocation, call it a "dislocation into the axilla;" by Boyer it Ls
led a "primary luxati(m forwards." Dr. Wood, of New York, has
orted an example, accompanied with a fracture of the neck of the
nerus, which he has named " dislo<*ation under the subscapularis
ficle." The drawing which accompanied the report, made from the
opsy, sufficiently shows that it was a dislocation of the same charac-
as that which we are now describing.* Dr. Parker has called at-
tion to a similar case, an account of which was first given in Reese's
» Wood, New York Journ. of Med., May, 1860, p. 282.
604 DISLOCATIONS OF THE SHOULDER.
edition of Cooper's Surgical DKtionary. The head of the humenis
reposeil in the "siibseapiilar fiissa.'" By M&lgai^e, Vidal (lie Ciis?isl,
and others, this is ealled a HulK'ora<-oid dislocation, a terra whicij.as
being more distinetive aJid appropriiite than either of the othere, 1^1
choose Ut itdopt.
In the se<'ond variety, the head, having escaped from underneath the
coraeoid pnx'ew, is made to ajiprimeh nearer tn the stemiUD, w » to
apply itself more or less closely to the inferior e<ige of the cltviclt
In which case the head and neck will \ic placed Eiehtnd the pctTtiniii
minor, and also behind the short head of the biceps and coraoo-ltrauhi*
alis ; or Ijctween these Heveral inti&clcs on the one hand, iind the errm*
tue mugnus, covering the second and third vWts, on the other hanil.
Upon the Hupearaiiees which a(^um]iatiy this more advimoed liinii </
dislocation writers have generally based their descriptions, liiagma^
treatment, etc., of forward luxations.
In either form of the accident, the deltoid, with the sapra- und inft
Bpinattis, is greatly stretched, and tlie two latter somelimt^ lorn; ll
eabscaputaris is displat^d upwards and backwards, while itt* teailon
in some inslaneeti completely wri'nched from the head of the hunnfiit
Mr. Ericliseii has seen the lesser luberele itself completely bmkfTi
in two examples of this accident which he has been permilti'd xe-n-
amine after death.' Occasionally the axillary nervi-s are rfflrrinlfo**
wards with the head of the bone; and in this caw the pain nroJus^
by their being thus pressed upon is even greater than in diidimBi"^
into the axilla.
In this accident, as in dislocation downwards, the lon|{ head of tk
biceps i." sometimes broken ; the circumflex nerve may ix- ounUBMl"
ruptured, and the capsule is generally toni very exioiuuvely.
' P»^k^^, New Ycirk Jmirn. <.f MpcI., M«rcl.. I85i, p. I8T.
■ BrlthMR, ikicncs and Art iit Surgttrj', :M Am«r. rd., |i. M
DIBLOCATIOK OF THE HUMERUS FORWARDS. 605
iptoBW. — If the dislocation is subclavicular (Fig. 26!)), a depres-
xists under the outer end of the acromion process, extending also
aeath its mjsterior niai^in ; the elbow hangs away from the body,
little backwards ; the axis of the limb Is much changed, being
Q inwards in the direi^^tion of the middle of the clavicle, the whole
Dclining modemtely to the same side ; there is also more or leas
ity to move the arm, especially in a direction forwards or out-
; a fuloeas is seen underneath the clavicle, and to the sternal side
coracoid process, occasioned by the head of the humerus, the
noving with the shaft. To these we may add the common sign
dislocations of the humerus, mentioned by Dugas, viz., the im-
ility of placing; the hand upon the opposite shoulder while at the
noment the cIdow is made to touch the front of the chest.
Jie di8locati<Ai is forwards, but subcoracoid, the head of the bone
e found below this process and deep in the anterior margin of the
ry fossa. It cannot, therefore, be so distinctly felt ; but the other
are the same as in tlic dislocation forwards under the clavicle.
•ffitoina. — While on the one hand experience has shown that the
py nerves and artery are less liable to suffer serious and perma-
njury than in dislocation downwards, and that the capsule, with
adiaous and muscular tissues about the joint, are no more liable
eration — on the other hand, the difficulty of reduction has been
increased, and consequently a largo number of examples, in pro-
in to the actual number which occnr, have been left unreduced.
, Norris relates a case which the surgeon who was first called sup-
to be a mere contusion, but which, on being admitted to the
606 DISLOCATIONS OP THE SnOULDER.
Pennsylvania Hoapital, three months after the accident, was found to
be a dislocation forwards under the clavicle The arm was almoat
useless. Dr. Norris made extension and counter-extension with mm-
pound pulleys nearly an hour, but to no purpose ; and finally, ai the
request of the patient, the attempt wae given over.'
Treaimenl. — The same rules of treatment which we have estabMi^
in relation to dislocations into the axilla will be found to I>e appliobli
to this dislocation, with the exoeption that the extension will rwvf lo
be made generally at first somewhat in a line backwards from the Ixidy,
and that our efforte will frequently have to be continual with more
perseverance, although with lews fear of injury, in t^nsetjucne* of sup-
posed adhesions between the artery and the adjacent tissues. The ex-
tension also must always Ik^ made downwards and outwnnis, if the dis-
location is subclavicular, until the head of the bone has esni)>Hl froa
beneath the coracoid process ; we may then pull directly irtitwards or
even upwards, while at the same moment pressure is made willi i1m
hand ujion the head of the bone in the direction of the socket, hw) tk
arm is rotated inwanls.
If the dislocation is subcoracoid, our motles of priM^dure n»i
scarcely vary in any respect from those which wc have reoommmdHi
for dislocations into the axilla.
The plan adopted in the f<)]lowing case has I>een found sufficient la
several examples of subcoracoid dislocation.
Mr. McA., of Buffalo, »t. 73, moflerately muscular, fell thnnigli ■
trai>-door, striking npou his right elbow, and dislouiting the hutiifna
forwanls. Within two hours after the accident, I found the hmdrf"
the bone resting under the coracoid proce^ia, where it could bedistincllf
felt and seen. There was a marked drprpssion under the acromioi
process, and ihc arm was carried out from the l)ody and sH^htlr l«tt.
He had not suffered much pain. The patient was seated in a ch '
and while Dr. Lemon, who was at that time my pupil, supgxtned
acromion process, I pushetl the head of tlie humerus outwards to>
the socket with mv left hand, while with my right I pulled :
upon the arm in the direction of the axis of the Ijody. A(Ut
twenty seconds it slid suddenly into its plaw with an audible pna]>.
Simple manipulation alone will also lie found suflicicnt in nu
cases of subclavicular dislocation.
A German, Simeon Orennos, ret. 21, fell unon an icy sidewalk, i
dislocated his right humerus under the clavicle. We found him sb
an hour after the accident sitting with his head inclined tn bis rigti
side, and supporting his elbow with his left liand. A marked ikfir*
sion existed under the outer end of the acromion process, and Jivtai
of the usual fulness there was a flatness under the prociess behintL TV
elbow was carried out from the Ixuly, and very slightly backwinlt
While Dr. Boardman supported the acromion process I liftr! l'
elbow from the side, carrying it 6rst upwardo and bni-kn-ards, and tb
forwards, making thus a short detour with the arm, aiK) wbai I
B wa« nearly completed the bone slid into its aook«t wWii
DISLOCATION OP THE HUMERUS FORWARDS. 607
fit snap. No extension was used, and no more force was employed
I was sufficient to lift and rotate the arm. He was not at the tirae
le reduction faint nor were his muscles relaxed from any other cause,
[ore than once I have accomplished the reduction by extension
e directly upwards, as in the following example,
gentleman, forty-five years of age, had his left shoulder dislocated
ards under the clavicle in a railroad collision, on the 8th of Octo-
1858. A young surgeon had been making extension in various
J for half an hour, when, by placing my foot upon the top of the
ula and drawing the arm directly upwards, 1 accomplished the
ction immediately and without much eflTort. Six months after the
lent, I found the deltoid muscle considerably wasted, and he was
unable to raise his arm to a right angle with the body.
have in this way also reduced a dislocation which had existed
Qteen days, the nature of the accident having been misunderstood
he attending surgeon. The man was twenty-three years old, and
* muscular. The dislocation had been produced by a severe blow
ved directly upon the shoulder, and the arm was still considerably
len and very tender. The reduction was accomplished in a few
ids while the patient was under the influence of chloroform, but
ly hands alone, aided only by the pressure of the foot upon the top
le scapula. The method adopted successfully in both of the pre-
3g cases, namely, pulling directly upwards, ought generally to be
idered a last resort, inasmuch as it especially exposes the axillary
7, vein, and nerves to injury.
I December, 1857, Dr. White, of Buffalo, and myself, reduced a
lavicular dislocation of the right shoulder, which had existed sixty
I, in a man sixty -eight years of age. The surgeon who first saw
nan thought it was only a sprain or a severe bruise. When he
^ to Buffalo, the whole limb was enormously swollen, and neither
White nor myself had much expectation of accomplishing a re-
ion without a resort to pulleys and anaesthetics. He was, however,
ed upon the floor, and after extension made for about half an hour,
Qg which time we had pulled the arm in various directions, up-
Is, outwards, and downwards, I at last succeeded while my heel
placed in the axilla, and while the limb was undergoing a slight
ion. No anaesthetic was employed.
r. M. C. Cuykendall, of Bucyrus, Ohio, informs me that he has
itly reduced a subclavicular dislocation on the sixty-fourth day, in
in 62 years old, by the following method: "As a last resort I
ned the pulleys to the arm above the ellx^w, making the counter-
ision with Skey's knob in the axilla, flexed the arm and made ex-
on downwards and forwards ; and when well extended I moved
iody under the pulley ropes, so as to bring the arm forcibly across
breast; then, keeping up the extension, I had Dr. Richey place
;nee upon the top of the scapula, and lock his fingers around the
jr, while I placed my knee against the elbow and locked my
rs around the top of the scapula, and directing the extension re-
;d, we forced the bone upwards and outwards to its socket ;" ad-
»ns were felt to give way, and the restoration of the bone was
1 to be complete.
608 DISLOCATIONS OF THE SUOULDER.
It will be undorBtood that this method did not succeed uutil alW
repeated and long-continued efforts had been made by other mi'lhwLt,
euch as pulling down, {mlling out, and pulling directly up. Dr. Cuy-
kendiill informs ine that this is the seccinil time he hjis succeetid in
"completing" the reduction of old dislocations of the shoulder bytbia
These several cases are mentioned that the surgeon may iindcratiDii
how impo.Bsible it is always to ci^tablish absolute and invariable nils
of procedure which shall be applicable to every accident of this diar^
acter. The method which will su<'ceed readily in one case mavEul
completely in another, although belonging to the same class, and m*
apparently differing in its anatomical relations. Before relinq:ii»liing
the attempt, we ought to have put into requisition all the exp«li<iitt
which the experience of other surgeons has shown to be worthy of a tri»L
During the year 1865, two ancient snbcurHtnid dislocations c
under my observation at BelJcvue Hospital. One of t]tv«« vase
tlie person of Janips Thompson, tet, 49, had existed two ywtrs or ni
He was employed atxiut the hospital as a carpenter, and has a Kileri"
biy useful arm. The second, in the person of Rosanna Ca»w-, irt, 33,
had existed six weeks when she was admitted. A'arious attempts bai
been made to reduce the dislocation before admission. During tbi
week following her admission, an attempt wai« made at reduction bf
Dr. Verona, an intelligent house sni^eon, subsequently by Dr. Jani*
K. Wood, and at the end of three months the attempt was madebf
myself, before the class of medical students, the patient \mwg etA
time under the influence of an anaesthetic. She was finally dlschaifii
with the lione still unreduced.
Mary Coffl«, set. 46, was admitted also to the Charily IToepitat, >
Feb. 1864, with the same dislocation, which had existed six inoiilhli
having been mistaken at first for a fracture. I found her arm M
from swelling or paralysis, and moving quite freely in it« new fiocb(%
and declined to make any attempt at reduction.
July 28, 1873, an Irishman, almut 40 year* of age, was adtniltid I
St. Francis's Hospital with a subcomcoid dislocation of the humcnix
eight or nine weeks' standing. The surgeon who first saw him iKrlirm
that he reduced the dislocation, but several weeks later he found iiw
again out of place, and he tried incSV-ctnally to reduce it. Mj" «
efforts, continued for au hour or more, wore equally UD&ucw<»sfliL
The two following cases are recorded in order that they ni«T ifli
trate the apparent inutility' of a successful reduction in miiu« ouws.
William F. Disbrow, of Bridgeport, Conn., receive<l a ^iilnnnwii
dislocation of the right arm, in cvnsequenoe of a violent aud din
blow. May 9th, 1870. Dr. George Lewis, of Bridgeport, a v«y i*-
telligent surgeon, reduced the dislocation within half an boar, it*
patient being under the influeuce of ether. The rest»rati<in of i^
Ixine was complete, and attended with an audible sound. The Ui
was subsequently very painful, and at the end of three weela Hl
Diabrow consulted a "natural bone-setter," who maaipoUtuI tl*
limb violently, and perhaps dislocated it. July Stth. 1H70, oK*"
weeks alkr the original aocideut, I found the buuv uuroduoed, and ■■
DISLOCATION OF THE HUMERUS BACKWARDS. 609
the presence of a number of medical gentlemen at Charity Hospital,
effected reduction. The patient was anaesthetized, and the reduction
VIS accomplished only after considerable extension and manipulation
kad been practiced ; the return of the bone to its socket Ix^ing accom-
puiied with a grating sensation. A thick pad was then placed in the
ixilla, and the arm and forearm secured across the front of the chest,
tfr. Disbrow remained under observation for some time ; but it was
lOon evident that the head of the bone was gradually receding from
he socket, and that he was not to have a very useful limb.
Jan. 10th, 1875, Leonard Ball, set. 40, was thrown from a carriage
It Norwich, Conn., causing a subcoracoid dislocation of the left arm.
Five days later Dr. Patrick Cassidy, of Norwich, reduced the disloca-
ion, the reduction being accompanied with a grating sensation. Four
lays later Dr. Cassidy found the arm again dislocated, and he again
reduced it. Feb. 11th, thirty-two days after the original accident, the
inn was examined by myself and other visiting surgeons at Bellevue.
Some of tlie gentleman doubted whether it might not be a fracture of
he surgical neck of the scapula. In my opinion it was a dislocation.
)n the same day, before the class, and under ether, I effected reduc-
i<m by manipulation, very little extension being employed. The arm
ras, however, manipulated in various directions, and considerable
dhesions were torn before success was attained, the bone returning to
18 socket suddenly, and with a grating sensation, while the heel was
a the axilla, and I was pulling moderately upon the arm. No one
oabted the fact of reduction ; the arm was now done up as in the
(receding case, and the patient remanded to his ward.
A few days later I found the head of the bone had receded from its
ocket, and was evidently tending to assume the position in which I
irst saw it ; and the motions of the joint were very limited. He was
Ii8char|ged from the hospital after two or three weeks, and I have not
een him since.
It is quite probable that among the successful cases of reduction of
Id dislocations of the shoulder, reported from time to time, many
«ve completed their history in a similar manner. Possibly there
lay have been in each of these examples a fracture of the inner lip of
be glenoid cavity, a condition which has been verified in several
Dtopsies of old shoulder dislocations.
The rapid changes which often take place in the socket, and in the
ondition of the adjacent tissues, may also account for the difficulty
rhichwe often experience in reducing these dislocations, and of retain-
3r them in place after reduction. In Professor Lister's case, already
erred to, at the end of seven Aveeks there was a complete socket
brmed, smooth, cartilaginous, and partly bony ; and strong fibrous
lands had formed between the coracoid process, the surgical neck of
he humerus, and the axillary artery, containing a spiculum of bone.
{ 3. Dislocation of the Humerns Backwards. (Snbspinons.)
This form of dislocation has been seldom met with. Only two
cases, according to Sir Astley Cooper, occurred in Guy's Hospital in
610
orRl-DCATIONS OF THE SHOnLDEK.
thirty-eight years; but in the last edition of Sir Aatley Confti't
treatise on FVa-chires mid DUlocatioTW, edited by Bransbv f/ooper, nini
caseH are meiitioneit.' Sedillot,' Malgaigne, Desclaux,* Van Biiren,
W. Parker," Lepelletier,* Trowbridge/ Pbyaick, Snyder,* Slephm
Smith, and myself, have each seen one example. Exaraples havenlfO
been seen by Dupiiylren, Aruolt, Best, Lcvacher, Berard, Fizeait, Vel-
peau, Fergusaon, Kirkbride,* and by Rogers."
Dr. Stephen Smith's case was seen by myself ten days after (he ac-
cident, by courtesy ofDr, Smith. The patient, John Creswell, at. U,
fell down a flight of stairs Sept. 11, 1871, striking on the front of hit
shoulder. A surgeon, who saw him a few honrs after, thought it iM
simply a bruise. Sept. 21, he was an inmate of Bellcvuc Hu^ptt^
The head of the humerus eould be distinctly seen in its new jKsilinti,
and there was a marked depression under the acromion proc'ess, ftijiwi-
ally in front. The elbow hung very slightly from the ImkIv, «ud
seamely more ffirwards than the opposite ellww. He eonld i-nrryit
forwards pretty freelv, and a little out, but he could not (arry it liact
He suffered very tittle ])ain, and there was no swelling of the arm
hand. On the following day Dr. Smith redneed the dislocatioii easily,
by pulling the arm forwards, an<l at the same time pushing upon tit
head from behind. Dr. Smith informs me, however, that the boot
became displaced on the following day ; but that it was easily reduwd,
and afterwards remained in plave.
CausrH. — One of the patients mentioned in Mr. Cooper's book hil
bis shoulder dislocated backwards in an epileptic convulsion ; not* Itil
fallen u|h>u his shoulder; another met with the accident while pu^faiog
A jierson violently with the arm elevated ; and a fourth, seen by OJoj",
was " pulled down by a calf which be was driving, a cord havmg liffl
tied to one of the calf's legs, and being held fast by the man'H liand.'
My own patient, Frederick Kretner, had his arm caught in TnacliinaT
on the Nth of January, 1860, The dislocation was di;icovered whwl
was preparing to amputate the arm soon after the accident o«iirr^
Descliuix's patient fell from a height with his arm in front nf him. I>
the case seen by Dr. Parker, of New York, a woman, let. (10, hud ftl^
forwards and struck upon the outside of her elbow, arm, and xhimW*
No attempt was made to re<hice it until the fourteenth (hiy, hIw"^
having for some time called the attention of any surgeon to itn a***
tion, Trowbridge's iwlient wa." thrown from a horse, striking oo ll*
palm of his hand.
Pathnhffij. — Mr. Cooper has given us a careful account of ti« fr
Acction in the case of Mr, Complin, already alluded to, whose
DISLOCATION OF THE HUMERUA BACKWABDS. 611
n dislocated by muscular spasm. This gentleman was fifty-two
re of age, aod had been subject to epileptic fits, in one of which the
iilder was dislocated. Many attempts were made to reduce it, but
longh it seemed to be easily drawn into its socket by extension
ely, yet, as soon as the force oeased, the head of the bone slipped
in upon the dorsum soapulce, and in this situation it was finally per-
[cd to remain until his death, whirh did not take place until five
rs after. In the meantime he was able to move the limb but very
htly, so that his arm was almost useless.
Ir. Cooper, to whom the arm was sent after death, found the head
ie bone resting under the spine of the scapula, and against the pne-
)r edge of the glenoid fossa, where it had Jbrmed a slight depression,
the head itself had become somewhat changed in form by absorp-
. The tendon of the subscapularis muscle and the internal portion
he capsular ligament were torn at the p«»int where the muscle was
rted, but the greater portion of the capsule remained, having been
Bed back by the head of the bone. The supraspinatus was stretched,
le ihe infraspinatus and teres minor were relaxed. The long head
he biceps was elongated, but not ruptured. The glenoid fossa was
jh and irregular upon its surface, tlje cartilage being absorbed,
'he fact that the bone would not remain in place when reduced, was
lained by the rupture of the subscapularis, and the consequent loss
ntagonism to the action of the infraspinatus and teres minor.'
Iieaoconipanyingdrawing is a copy of that furnished by Mr. Cooper,
llustrate the position occupied by the bone.
ought to mention that this case has been regarded by Vidal (de
iis), Malgaigne, and others, as only subacromial, and as a variety
he dislocation backwards, differing from that in which the licad
he bone occupies a position under-
,h the spine. But as I can see no dif- *^'^"'
nee except in the degree or extent
be displacement, I prefer not to re-
I the distinction made by these snr-
18.
^ptomg. — The signs of this accident
a projection under the spine of the
ula, produced by the heati of the
!, the head being obedient to the
ioDS of the arm ; a corresponding de-
sion in front and under the outer ex-
i\W of the acromion process; a wide
e between the head of the bone and
ooracoid process, into which the
ere may be pushed deeply ; the axis
W shaft of the humerus directed up- Sahapinoui diiioaUan.
ie and outwanis toward a point pos-
rr to the glenoid fossa. The forearm is usually carried forwards
«8the chest, and the humerus rotated inwards, unless the subecapu-
' Sir Aetloy Cooper, op. cit., p. 8M.
612
OCATIOSS OP THE SHOULDER.
laris iiiiiscle is torn. Immobility existe, but tlie motions of the arm
nru not getifrally eo much imjiaired as in either of the other disloca-
tions; and finally, aa in all other dislocatious of the hanirru», tW buntl
cannot be laid upon the opposite shoulder while the elbow tou<rht» tli«
front or side of the chest. In Piirker's case the elbow was tlirtiwn
outwards, although the arm was carried very much across the cliwL
lu Smith's case the arm was nearly vertiral, Deaclaux's patient held
hie hand upon his head, with his arm horizontally across his Ixxly.
Usually the diagnosis will he easily made; in my own and Sniith'«
case the position of the head of the bone was easily recognised, but Sir
Astley relates one case in which, on the morning following the acci-
dent, a surgeon was unable to discover the dietlocation, and ou ihr
seventeenth day Bransby Cooper faile<l to make the diagnosis); nor,
indeed, on the twenty-third day did Sir Aetley himself determine ttut
it was a dislocation, until he had unexpectedly reduced it while manipu-
lating upon the arm. In a second example, Sir Astley at Bret believed
it to ue a fracture, but a more careful examination showed it to liri
dislocation backwards. In this instance the limb could not lie ratstcd
outwards, as the subscapularis was not torn, and eontiuuc<l to offer
sistauce when the arm was moved in this direction ; he was also suStf-
ing much more pain thnn did the other patients, owing, as 8ir AmW
thinks, to pressure ujtnn the articular nerves. In the caso of Mr. Col*
linsoQ, also mentioned by Mr. Cooper, a surgeon, who saw the pUienl
immediately after the accident, felled to discover the true nature of tb«
injury; and Trowbridge's patient had snScred a dislociitioD sevoil
weeks before the nature of the accident was fully determined,
ProffnosU. — The red uctiou has always been sooner or lat*rii««in-
plished, except in one instance ; in this case we have seen that the ana
never recovered any considerable degree of usefulness. Mr. CoUinami
arm, reduced on the second day, yeas restored to all of its fuiKiioni
within one month. Dr. Parkers patient had nearly recovi'red the mm*
Slete use of her arm at the end of four weeks, although it was not »
uced until it had been out fourteen days. Sedillot sucoeeded lu trdtii^
iDg the dislocation in the case of his patient, at the end of one year
fif^n days. Lepelletier, after forty-five days. Trowbridge, oft*
forty days ; and in this latter case we arc informed that the arm «*
restored to usefiiliiefia.
Tirabnent. — In the first «Lse mentioned by Sir Astley Cooper, "d*
bandages were app1ic<l in the same inunner as if the head of the ha-
morus hod been in the axilla, and the extension was tnaile in the mom
direction as in that accident" (downwards and a little outwanbt. !>
]ef** than five minutes the bone slipped into its socket with a lond
The second case was treated successfully in the same way. Mr, DuM
also having: failed to reduce by pulling upwards, finally suMtxilei ^
pnllin^at the wrist downwards and forwards, while an nsi^ixtant |>ieW
the head of the bone toward the socket; tlie heel was not plurrd in ill*
axilla, which Mr. Bransby Cno|>er thinks would have only nWm-
the re<luction. Smith sueoeeded by a similar mmiccuvn^. Mr. Ki*
also tailed to accomplish reduelion while currying thi> arm att"VB
and backwards, but when the patient had become faint, by placwg l^
PARTIAL DISLOCATIONS OF THE HUMERUS. 613
ieel in the axilla and pulling downwards a minute or two, the bone
was reduced. Vidal (de Cassis) recommends the same plan, namely,
that we shall pull in the direction in which we find the limb; Trow-
bridge employed the pulleys successfully, the extension being made
lownwards and forwards; while Dr. Parker succeeded equally well
rith his patient, by " pulling the arm outwards, downwards, and
lightly forwards." Counter-extension was at the same time made by
sheet in the axilla, and the head of the humerus was pushed toward
ie socket by the hand. In Mr. Collinson\s case, the scapula was
ipported by a towel, while "gradual extension of the limb was made
irectly outwards, and then the arm being moved slowly forwards,
le head of the bone was distinctly heard to snap into its socket.''
lie time occupied was not more than two or three minutes. Rogers
loceeded by N. R. Smith's method. Sir Astley, liowever, seems to
ive the preference to the method which succeeded so happily in the
ase of Mr. G., while he was still manipulating with a view to determine
be character of the accident. "I readily reduced the bone," he re-
larksy "by raising the hand and arm, and by turning the hand back-
rards behind the head." In one other instance, having failed to re-
lace it by slight extension outward.s, he raised the arm perpendicularly,
t the same time force<l it backwards behind the patient's head, and
he reduction was promptly effected. In the case of Kretner, I first
Lttempted reduction by pressure dinx^tly upon the head of the humerus;
>at failing, I proceeded to pull the arm with moderate force outwards
ind downwards, which proc^edurewas attended with immediate success.
rhe patient was under the influence of chloroform.
After the reduction, a compress should \ye placed against the head
of the bone, and underneath the spine of the scapula, and this should
be secured in its place by several turns of a roller. The forearm ought
also to be placed in a sling, with the elbow thrown a little Imck of the
centre of the body, so as to direct the head of the humenis forwards.
2 4. Partial Dislocations of the Humerus.
Sir Astley Cooper has related in his treatise two cases of supposed
iocomplete luxation of the head of the humerus forwards; and in con-
liniiation of his views he hits added an account of the ap|>earan(*es pre-
sented on dissection in the IkkIv of a subject brought into the rooms of
3t Thomas's Hospital. Bransby Cooper, in his edition of the same
irork, furnishes the report of a similar case which came under the ob-
Kfvation of Mr. Douglass, of (ilasgow. Hargrave and Dupuytren have
awh reported one example of this s|)ecies of dislocation, in which its
existence was said to Ix* cc>nfirme<l by dissection.
Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and
many others, have admitte<l its possibility ; Malgaigne, however, only
admits its existence when the capsule remains entire.
Without intending to discuss wary much at length the value of these
opinions, I shall content myself with dec^laring that the existence of
tois or of any other form of partial luxation of the shoulder-joint, as a
614 DISLOCATIONS OP THE f
1
traumatic accideut, hue not up to this moment been fairly csitabliaheii ;
and that the anatomiml tttructiire of the joint renders its occurrence
escewliugly improbable, if not abeolutety impossible.
The only example mentioned by Sir Astley Cooper, in which a dis-
section was made, showed that tlie long head of the bic«ps had Iwo
ruptured, and that the capsule waft toni, while the head of the humerus
was resting under the coracoid process. We shall have no diffimiltv,
therefore, in assigning it to its proper jilace as a complete subcoraciiil
dislocation. In Mr. Hat^jave's case, also, the tendon of the \ittv^
was torn; while Dnpuytren omits to mention what was thi- actml fart
in relation to this tendon in the ca^e seen by him, but it h dislitmly
stated tliat the head of the lx>ne rested upon the ribs. Mr. Hnrgrarv
seems, therefore, to have described a case of rupture of the long liaJ
of the bice[>8, and it is probable that Dnpuytren, who knew nothing of
the previous history of the subject, has given us a faithful accoum da
pathological dislocation, a result of disease, and not of a direct injur)*.
If the head of the humerus is driven from its socket by vioUiK«,
and remains thus displaced, it is, wo assume, a complete luxHtiim;
since it is only by having placed the semi-diameter of the head of tht
bone ontside of the margin of the glenoid fossa tliat it i%n be mnAt far
one moment to retain its abnormal position. To accomplish this atnMint
of displacement upwards, or upwards and forwnnfs, or directly forwanli,
tlie acromion or the coracoid process must be broken ; while its uocw
rence in any other direction must involve at least a most exlraofdiraiT
extension, if not an actual laceration, of the caftsule. If weadmitimti
Malgalgne, that occasionally the capsule has been found cnpabli; of sudi
extraordinary extension without actual rupture, wc still are luiwillinr
to r^ard this a.s a fair example of a jiartial dislocation, siniie the hew,
of the l>onp no longer moves in its socket, being at no point in actnd'
contact with the articular surliice of the glenoid fn^^ia. It is essc-utiil^
a complete dislocation, according to all the admitted delinitioa%gf tha'
term.
It is quite probable that a majority of these aceideutm wereexamplai
of rupture or of displacement of the teudon of the long head of «be
biceps, the effect of which, as Mr. John G. Smith' and Mr. Sodeu'hm
shown by a number of dissections, is to allow the head of the huiuenv
Cto be drawn upwards and forwards in its so<:kct, until it is arrwHJ bj
the two processes, and by the coraco-acromial ligament. Say Mr.
Boden, " To enable the bone to muintnin its equilibrium, it i* nwwetiT
ttuit the cajtsular muscles should exactly count«rhuliini'e each adut',
and as there is no muscle from the rilw to the humerus to »niagoni>
the upper capsular muscles " (l)iat is, ti> draw the head of iIjc hoina»
downwards), "it is suggested that this office is performed bythuM^
gular course of the long tendon of the biceps, wnich, by pati^ny <>vtf
the head of the bone, when the muscle is put in action, teiidi tolhror
the head downwards and backwards; it follows, iherefon;, lh>l,tkt
PARTIAL DISLOCATIONS OF THE HUMERUS,
615
on being removed, the head of the bone would rise upwards and
ards."
ie drawing (Fig. 272) represents the case of displaeement of the
m of the biceps seen by Mr. Soden, and of which he had been per-
id to make a dissection.'
»ave myself frequently observed, and I have before, when speak-
f the prc^nosis or results of dislocations, called attention to the
that the head of the humerus
times remains for a long time
the reduction has been elfected
;ly atlvanced in its socket, so as
0 to a suspicion that it is not
■rly reduced. Quite recently I
been consultetl in the case of a
l)OUt fourteen years of age, who
been subjected to the pulleys
Jr four consecutive hours to ac-
luh a more complete reduction,
e same thing, also, has been
■d by me occasionally where
boalder had been subjected to
lent wrench, but no actual dis-
oa had ever occurred. In either
the explanation is perhaps the Diipiirsmentoribciongheuiuriiicbinpii.
, the long head of the biceps has
broken or displaced ; or, when it follows a dislocation, some of the
Ics inserted into the greater tuberosity have been torn from their
bments. I mean to say that in these circumstances we may tind
Scient and perhaps the most frequent explanation ; yet it is quite
ible that, in a considerable number of eases, the laceration of the
lie, and the action of the muscles, are alone concerned in the pro-
on of this phenomenon. I have seen one example in the person
r. Craig, of Brooklyn, in which the tcn<lon of the biceps suddenly
led its position after the lapse of several days, and the prominence
i head of the humerus at once disainK'ared.
fred Mercer, of Syracuse, N. Y,, in a very interesting paper on
same subject, relates several examples of forward displacement
injuries to the shoulder-joint, one of which, as being exceedingly
lent, I shall take the liberty of qnoting.
irs. B,, a well-developed woman, of fniT habit, aged tifty-six, seven
since was thrown from a carriage, dislocating her right shoulder,
1 was reduced a short time after the accident, but the shoulder
painful, and tender to the touch, and almost useless for monthe
She oould carry the arm forwards and backwards, but conid
nise it from the side, or carry the hand behind her, or raise it to
lesd, for fourteen months. She has gradually gained better use of
f, cd., p. 266; nlso, Sir Aetley Coiiper, edited by
6H5
DISLOfATrONS OP THE SHOULDER.
her arm, but now, July, 1858, she cannot raise her elbow from
side more than half-way to a Iiorizonlal position without assistani
but with assistance, the arm may be carried into any position
pain or resistance. Measurement shows no appreciable difTer
the size or length of the nrin, or size of the shoulder; but the point a/
the shniildor is still tender to the touch, is prominent in front, and eor-
respondiogly flattened behind. The head of the hamerua appear? n
rcMt against the outside of the roracoid process, hut the fulness ofliabil
obscures the diagnosis, oomi>ared with the other cases. Several lioctow,
at different times, have examined the shoulder ; some have said it
not nro[jerIy reduced, and advised a suit for malpractice.
"I examined the shoulder again in Novemlx-r last; it prraentwl th*
same general appearance, although the patient n-as mucli thinner in
flesh from recent sickness. Some six weeks previous to this cxaniinir
tion, in a sudden and thoughtless efli>rt to raise the arm above llii; liwd,
the muscles unexpectedly obeyed the will ; since which time she Hm
had perfect use of it, though the deformit}' still remains. She tiliakt
she felt or heard a snap when the arm went up, bnt it was foilownl 1^
no pain, soreness, or swelling."'
There can be uo doubt, we think, that in this ease, at least, tlicile-
formity and maiming were due in a great mc^isure to a displofomad
of the long hea<l of the biceps.'
If a displacement of the tendon necessarily causes a displacement at
the head of the humerus, it might seem proper t« infer that a ni]itiift
of the rendoii would do the same. The only example of rupture of the
tendon which has come under my observation does uot mnfimi tliii
opinion.
James Wallace, let. 46, a sailor, and a man of remarkable mnwnl*
development, while pushing a swing with his arms extended fell
thing snap in his right arm, and the arm at once became powirlissi
The sensation of snapping was at a )Hiint about four and a half in^
below the acromion process. The pain was like that caused hy )iilliii{
s nerve ; on the following day there was an extt-nsivc ccchrmosi* o**
the upper end of the humerus, and the bcllv of the biceps was full »»
flabby.
Wallace was examined by me at Bellevne in March, 1875, sb""^
eight months after the injury was received. The l>elly of the bifrp
ahortened upon itself, and made a very remarkable ]>rnmincmTOiil*«
fniut of the arm, but he could not render it firm by coutniciiiHi, H*
can flex the forearm slowly but not ^^ainst any con.-<iderahltf resL'lw*-
The head of the humerus is not advanced in the sockets I cvn M •!•
tendon of the biceps in its groove, and infer thai the ruptarc
place Dear its insertion into the muscle.
DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 617
CHAPTEE VII.
DISLOCATIONS OF THE HEAD OF THE RADIUS (HUMERO-
RADIAL).
I HAVE met with twenty-six examples of traumatic dislocation of
the head of the radius ; of which nineteen were dislocated forwards,
0r forwards and outwards, and only four backwards: or, rejecting
those cases which were complicated with fracture, I have recorded
ten cases of simple forward luxation, and two of simple backward
Inxation. My experience, therefore, does not correspond with the
experience of Boyer, Velpeau, Vidal (de Cassis), Chelius, B. Cooper,
Gutiirie, Gibson, and some others, who declare that the dislocation
backwards is the more frequent of the two. Indeed, I ought to say
of both of the examples of backward luxation of the radius which
have come under my notice, and which I have marked as simple, that
they were ancient luxations, and I am not entirely certain, therefore,
that they had not been originally complicated with a fracture, although
at the time of my examination they presented no such evidence. I
have seen one congenital dislocation of the head of the radius outwards
ftnd forwards, which I will describe more particularly in the chapter on
congenital dislocations.
i 1. Dislocations of the Head of the Radius Forwards.
Causes, — A fall upon the elbow, the blow being received directly
upon the posterior face of the head of the radius; a fall upon the hand
nith the forearm extended and pronated ; extreme pronation of the
forearm ; or, according to Denuc6, a blow upon the inside of the elbow,
irhich is equivalent to a violent adduction of the forearm.
In children, and especially in those of a strumous habit, whose liga-
ments are feeble, a subluxation forwards, or even a complete luxation,
ia occasionally produced by being lifted suddenly from the floor by the
band, or by an attempt to sustain the child when he is about to fall. I
bave seen examples of this dislocation produced in this way. Batch-
dder,^ Sylvester,* Goyrand,* and many other surgeons, have mentioned
limilar cases. In the case of Lydia Merton, four years old, brought
k> me in May, 1868, the dislocation was caused by holding on by the
hands after having fallen from a swing.
Dr. Krackowizer related to the New York Academy, in 1856, a
of complete dislocation forwards, produced, as was supposed, in
* New York Journ. Med., May, 1866, p. 888.
* Amer. Journ. Med. Sci., vol. xxxi, p. 206, Jan. 1848.
* Ibid., vol. xxxii, p. 228, July, 1843.
40
618 DISLOCATIONS OF THE HEAD OF THE BADIU8.
the act of turning the child in delivery. The arm was ecchymoeeO,
and the dislocation was veir distinct.'
Pathological Anatomy. — The head of the radius is carried for^'ards
upon the humerus, and generally a little outwards. In the case of
Lydia Merton, already mentioned, the head of the radius, on the ninet}-
fourtti day after the accidcrit, was nearly in the centre of the huraerm.
Tlie anterior and external lateral ligaments, with the annular, are io
most cases more or less broken. Sometimes the anterior and ext«i>il
lateral are alone broken, the annular ligament being then sufficieiitlj
stretched to allow of the complete dishjoation ; or the anterior aod
annular having given way, the external lateral may remain intact.
Symptoms. — The head of the radius can in general be distinctly felt
in its new situation, rotating under the finger when the hand is pro-
nated and supinated ; we may sometimes also recognize a depreR^oo
corresponding to its natural situation, behind and below the little head
uf the humerus. The external border of the forearm is slightly short-
Ilod of ndtiu :
cned, and the arm inclines unnaturally outwards. The tendon of tbf
biceps is relaxed. The foreiirm is generally pronated, jiometime' i'"
in a position midway between supination and pronation, but I h*"
never mvn it supinated. I have |)artieularly noticed this lacl in ""^
' Krackowizor, Now York Journ. Hed., March, 18-JT, p. 201
DISLOCATIONS OP HEAD OP RADIUS FORWARDS. 619
put made to the New York State Medical Society iii 1855 ; and
aac^, who has also examined these cases carefully^ affirms that it is
Horn supinated, notwithstanding the general statements of surgeons
contrary,
e arm is usually a little flexed, and (ftinnot be perfectly extended
t causing pain. In some cases, especially when the dislocation
i|. existed for a considemble length of time, the arm is capable of
Prome and unnatural extension. This was the case with Lydia
iprton. There is usually preternatural lateral motion ; but, except in
I cases, the forearm cannot be flexed upon the arm beyond a right
Ihrognosis. — Denuc^ says : "The reduction is often impossible; more
ifoently still, difficult to maintain." In proof of which he refers to
h observations of Danyau and Robert. In the case of recent luxa-
m related by Robert, it was found impossible to maintain a reduc-
VI which he thought he had several times accomplished, and he
Sieved that the difficulty consisted in a portion of the torn annular
punent having become entangled between the head of the radius and
le condyle of the humerus.^
Sir Astley Cooper was unable to accomplish the reduction in two
BOeDt cases; and of the six cases which came under his immediate ob-
Wation, only two were ever reduced. In Bransby Cooper's edition
f Sir Astley's work, other similar examples of non-reduction are
jjinted.
', ICalgaigne says that in a collection of twenty-five cases which he
lis made, the accident was unrecognized or neglected in six, and in-
rftectual efforts at reduction had been made in eleven ; so that only
^^t of the whole number were reduced.
I have myself met with six of these simple dislocations which were
not reduced, three of which, however, had not been recognized, and no
■ttempts at reduction had ever been made; one had been treated by an
BDpiric, Sweet, a "natural bone-setter," but without success; one had
woi reduced, but it had become reluxated, and in the remaining ex-
■oiple I was myself unable to reduce the dislocation on the seventh day.
The following are brief notes of four of these cases :
A young man, aet. 23, presented himself at my office, to whom the
locident had occurred about one year before. The surgeon who was
fiiBt calle<l did not recognize the dislocation, and no attempt had ever
been made to replace the bones. The forearm was forcibly pronated
ind could not be supinated, but he could extend it completely, and flex
it somewhat beyond a right angle. It was strong, and nearly as useful
M before.
H. H. B., set. 6 ; dislocation produced by a fall upon the elbow.
The surgeon who was called did not detect the nature of the injury.
Eighteen years after, I found the head of the radius lying in front of
4e old socket, having formed a new socket, in which it moved freely.
Rom the elbow to the hand the arm inclined outwards, or to the
ndial side; pronation and supination were perfect. He could flex the
> M^moire sur les Luxations du Coude, par Paul Denuc^. Paris, 1854.
620 DISLOCATIONS OF THE HEAD OF THE RADIUS,
arm to an acute angle, hut not so completely as the other. The arm
was as strong as the other, but it was frequently hurt hv lifting,
Ira E. Irish, set. 12. "Sweet" was at first employed, but failed to
reduce it. Thirty-nine years after, when Mr. Irish was fifty-one y«ii»
old, I examined the arm. He conld not fler the forearm upon the arm
beyond a right angle ; and when the attempt was made, the railiol
strtiok against the humerus. Complete supination v/as impossibia
The anil was as strong as the other, except in raising a wright alxnt
his head, Occasionally he was annoyed with slight pains in this limtb
Urias Ijett, a colored Iwirlwr of Buffalo, aged forty-eight yeare, WM
thrown from a carriage, profhicing dislocation of the right radium, and
severely bruising the elbow-joint. He drove a couple of spirited lioi
sevei-al miles after the accident, and did not see Dr. K., a highly so-
comptished young surgeon, until six hours had elapsed. The «lw*
was then much swollen, and exquisitely tender, and Lett wonid nri
permit much if any examination, to enable Dr. K. to determine hil
condition. The Doctor applied simple dressings, and the next day ifr
quested me to see him. The whole arm wa-s then swollen and teitdir,
and very little eKamtnatinn was admissible. The dressings WH
therefore, not completely removed, but only laid open sufficiently
enable us to see the joint. We suspected a forward luxation of tbt
head of the radius, but could not positively determine the point — llw
patient not permitting any kind or degree of manipulation. We de-
cided, therefore, to wait a few days until the inflammation had son*
what abated, and then, if the existence of a dislocation was Ascerlainfd,
to attcmjit its reduction. On the seventh day the swelling luid mett-
urably subsided, and the diagnosis be<«me satisfactory. We immedi-
ately placed him under the complete influence of chloroform, and msdl
long-continued and violent efforts at reduction, but without succnfc
Severe inflammation again followed these efforts, and Lett would nrv*
consent to another trial. After four years, I find the bone srill out
He can tlex the forearm upon the arm almost as far as he ran llic op-
posite limb; he can carry it nearly to his mouth, the head of int
radius sliding off upon the outer face of the humerus, and not n
plumply against it; indeed, the radius seems to, have t)een gradasIlT
pusheil outwarils as well as forwards. The hand is forcibly pronatm,
and cannot l>e supinated. The attempt to supine produces a cliokb
the neighborho<xl of the head of the melius, as if it struck againM
bone. The arm is as strong as the other, and not wasted. Bt>li*
constantly pursued his oocuiMition as a barber, after only a few ««■»
confinement.
If the dislocation is accompanied with a frai'turc of the ulna, dbI*
the fracture is transverse or incomplete, reduction is not gvnendly v-
compli.shed. When speaking of fractui-es of the shaft tif the nil*'
have related several examples illustrative of this remark. Nor™ h*
made the same observation.' I have, however, throe times mrt •"'■
this accident thus complicate*! in children, in the treatment of whi^>
much better result has been obtained. In the firat exaDiple,k bdi("
' Norrb, Amer. Juurn. H«d. Soi., vgl. xxxi, p. SI.
DISLOCATION OP HEAD OF RADIUS FORWARDS. 621
oioe years had broken the uhia in its upper third and dislocated the
radius for^v-ards. Dr. White, of Buffalo, and myself were in imme-
fiate attendance. Both the fracture and disUxjation were easily re-
looed, and in a few weeks the limb was sound and perfect, except that
alight fulness remained in front of the head of the radius, and this
mtinued for several years. In the second example, a lad, of the same
56 as the other, was treated by Dr. Austin Fh'nt and myself. We
diiced both the fracture and the dislocation by extending the arm
om the wrist, while at the same moment pressure was made upon the
sad of the radius from before backwards. A right-angled splint was
spiled and continued during a period of four weeks, being removed
illy for the purpose of giving to the joint gentle, passive motion, etc.
fter this the arm was i>ermitted to straighten gradually, and at the
id of a month more the joint was moving freely, and with no degi'ee
:* displacement at the point of fracture or dislocation.
It is quite probable that in each of the above cases the separation
'as not complete, although crepitus was distinct, and the displacement
f the broken ends was very marked. In the following case the frac-
ire was certainly incomplete :
Elizabeth Carmody, aet. 4, was brought to me, August 6, 1851, with
. fraetore of the ulna, two inches below its upper end, the fragments
»eing inclined backwards, while the radius was dislocatetl forwards.
loth bones were easily replaced, and the functions of the arm were
lOOD completely restored.*
Where the restoration has been promptly effected and maintained
steadily, the motions of the joint are soon restored ; but in one case
the head of the radius has been found to play very freely and loosely
after the lapse of two years, and in others it has remained slightly
prominent in front, as if it was a little in advance of its socket.
Treatment. — Extension and counter-extension should be made in the
direction in which we already find the limb, namely, with the forearm
slightly bent upon the arm, while at the same moment the surgeon
should seize the elbow with his hands, and press the head of the melius
iMck with his two thumbs.
Other methods will often succeed ; but by this we relax the biceps,
ind put the parts in the best position to accomplish the reduction easily
ud promptly. Sir Astley directed to supine the forearm while the
xtension was being made from the hand, but Denuc6 prefers that the
orearm should be in a position of pronation.
AAer the reduction is effected it is never safe to straighten the arm
ompletely at once, nor indeed for some weeks; not until the ligaments
ttive been sufficiently restored to resist the action of the bicejw. The
inn must therefore be flexed and placed in a sling, or, if the radius is
iisposed to become reluxated, a right-angled splint ought to be placed
tpon the back of the arm and forearm, and, by the aid of a compress
tnd roller, an attempt should be made to retain it in place.
Nor will it be found safe at any period to compel the arm by force
^ This ciise was erroneously reported to the New York State Medical Society as
in example of fracture of the radius, with dislocation.
622 DISLOCATIONS OF TRE HEAD OF THE BADIT^
to resume the straight position, since this bone, when it has once ijwn
dif'locatef], will for a long time be liable to luxation.
A boy, aged almnt four years, was presented at my clinic hy.liil
father, having a forward dislocation of the head of the mdius. Th»
dislocation had existed several months. The father's ptirpwae in tiring-
ing the ohild was to ascertain whether he could not claim damajrcs for
malpractice. The accountwhich he gave was as follows: Th« siir^ma
called it a diRlocation forwards, and pretended to rednce it. A right-
angled splint waa applied with a roller. At the end of three wwla
the father removed the splint, bnt ilid not discover anything out nf
place. Finding, however, that the elbow was stiff, he took measuitf
to straighten It forcibly. In a few days he discovered the head i>l' the
bone fiiit of place, and so it hasremainod ever since.
I explaineit to him that there wa.** much reason to suppose tliat the
sui^eori ha'l properly reduced the dislocation, and that he had himsdf
reproducetl the accident, by straightening the arm, through llir tteXiot
of the biccfis upon the upper end of the radius. The fhUicr ilecliDcd
any further surgical interlcrence, and do prosecution has followed.
The late Dr. Butchelder, of this city, in a very excellent pajier f*
dislocations of the head of the radius, has descril)ed a method of reduo
tion sufigeated to him first by Dr. Goodhne, of Chester, Vermont, snil
which he had himself found more successful than any other meihmi;
indeed, he says it never fails, yet he does not inform us in prwwlf
how many cases he had made the trial. The plan suggested bv l>f.
Goodhue consists essentially in first making extension fnim thelaml,
and pressing at the same time downwards and backwards ujki
head of the radius until it has desi'cndwl to a level with the articuUftif
surface of the humerus. As soon as this is accomplished, the furwtna
is to be stifldenly tlcxed upon the arm in such a dinx-tinn as that tlw
hand shall pass outside of the shoulder; at the same moment, al^i, ibt
pressure must be continued vigorously upon the heiid of the nidiii*.'
{ 3. Sislooation of the Head of the Badina Baokwardi.
Denucf' has collected fourteen examples of this Uixation ; but M»i*
gaigne, who rejects a iH>rtion of the ca.'^es, and adds one or two nwnj
admits only twelve. In addition to those mentioned by thcs*' !•*,
writers, I have found recorded, or incidentally noticed, one by MiS
one by Bransby Cooiier," one by Lawrence,' one by Liston,' iw of
Case,' two hy Gibson,' one by Parker,* three by Markoe,* autl W lli«»
> Ooudhue, S<^m York Journ. ot Med., Uny, 181>a, ji. 388.
• May, Sir Aitlev Cuoper on DU1oL'Hti<>nii, etc , by B Cuoper, op. (4t-,^4n^
• B Coiiper, ibid., p 404. ' Idiwrcnco, PlrrioV Hj^item of Sargci;, f.*
' Liitim, Practii-nl Surgery, p, 88,
• C'HPe, Am«r. Journ. of Med (ki., »ol. »i, p, 864, from llili So. of P«nri«»
Med. QhKIIo.
~ UibiiKn, InsUlut» and Prat-'tice of Sureerr, 6th nd., vol. i, n. 879^
> Ptth'-T, N<<w York Journ, of Mvd., MKrub, IB'oi, p. 188.
■ Markw. ibid., M»y. IS&G. p. OSH.
DISLOCATION OF HEAD OF RADIUS BACKWARDS. 623
Biy own observations have added four more, in all twenty-eight sup-
Msed examples.
Of the examples brought under my own notice I have already in
ie preceding section affirmed that two of them were accompanied
ith fracture, and I am not entirely certain but that they all were.
Earkoe, of New York, whom we have mentioned as having reported
ree cases, found in each case a fracture of the internal condyle of the
imenis, and, after an examination of a number of the reported ex-
iples, he does not find any evidence that this dislocation ever occurs
a siniple uncomplicated accident. I am unable to complete the
itical analysis which Dr. Markoe has undertaken ; yet 1 confess that,
for as I have been able to do so, the testimony strongly confirms hi.s
•Dclasion. While I am preimrecl to admit the possibility of the lux-
ion without either a fracture of the lower end of the humerus or of
le alna, I have found no written account of any case, nor have I seen
1 example, which was absolutely conclusive.
The example reported by Parker as having occurred in the practice
FN. K. Freeman, of this city, is one of the few which seems to admit
f but very little doubt.
In July, 1850, Dr. Freeman was called to see a gentleman, aet. 37,
fho was seriously injured by jumping from the railroad cars while
he? were in motion, and found a backward luxation of the head of
he radius of the right arm. " The symptoms," says Dr. Freeman,
'were marked ; the hand and forearm were prone, and the attempt to
flace them in the supine position caused great pain ; while the head of
the radius formed a considerable projection posterior to the external
owidyle of the humerus, where the (»avity on its extremity could be
ItstiDctly felt. Assisted by Dr. Walsh, of Fordham, who firmly
nisped the humerus, I was enabled to reduce it by extending the
H)rearm and flexing it upon the arm, at the same time pronating the
hand, and pressing forwards the head of the radius with my thumb.
After the re<luction was effected, I requested Dr. Walsh to examine it;
when, upon slight extension being made upon the forearm, with supi-
nation of the hand, the bone was again dislocattKl. I immediately re-
luceil it in the same manner as before, and directed the patient to keep
the forearm flexed and the hand prone, and, laying it upon a pillow,
ipply cold water. He complained of severe pain for two days, which
dually subsided, and on the fourth day he was able to move and
extend the forearm."
Causes. — A direct blow upon the front and upper part of the radius ;
i&ll uj)on the elbow, or upon the hand; a violent effort to supinate
the forearm while it is grasped and held firmly in a state of pronation ;
probably, also, sometimes it is occasioned by a twisting of the arm in
nmcliinery, etc.
Pathological Anatomy. — In the only example of which a dissection
has been made, reported by Sir Astley Cooper, " the coronary ligament
was found to be torn through at its forepart, and the oblique had given
^y. The capsular ligament was partially torn, and the head would
have receded much more, had it not been supported by the fascia which
fiends over the muscles of the forearm." The head of the radius
624 DIRLOCATIONH <
AD OP THE RADIUS.
was thrown behind the external condyle of the humerus, and rather la
the outer side. This was an ancient luxation found in the disse-tinp-
room of St. Thomas's Hospital, and the accom[>anying drawing ia
copied from the sketch made at the time.
If the luxation is not complete, as occasionally happens vrhh iJiil-
dren, the annular ligament may not be torn.
Symptoms. — The head of the bone ia felt rotating behind the outa
com^yle, and a depression exists corresponding to it« original poeition.
The forearm is slightly flexed and prone; anJ
the whole arm 19 deflectc<l outwanb from the
ellmw downwards; flexion and extetifiion are diffi-
cult, while supination is impossible.
JVcuiiiKnt. — Most sui^eons Iiave agreed tilt
while extension and counter-extension are being
mode, the forearm should be forcibly supinatcu.
At the same time, also, the head of the radiu
murit be strongly pushed tiirwards. Martin iw-
onimende to extend forcibly, and then suddeulj
flex the arm, in a manner very suuilar Ui the plu
rnxnnmended by Batehelder in dislocations for-
wards. In Dr. Freeman's case, just (jnoted, tia
reduction was effct^ted while the forearm was pro-
natcd, and supination seemed to throw it igvo
out of place.
A('<\)rdiug to Markoe, where the accident ii
complicated with a fracture of the inner cooiItI^
when the reduction is aecomplisbcd the >ns
should be place<l in a position about Icn dvgnS
fiiiuotwii »f iiie heHd at '^^ tliau a right angle, and supported by a •{■lilt
Uis maiut i...'kini(di. with bandages, etc.
If the dislocation is simple, however, I can
no objections to its being nearly or nuite extended, since in Ihia ditk^
cation the action of the hiL'eps would only tend to retain the haiti
the radius in place.
I 3. Dislocation of the Head of the Radios Oatwardi.
Deniic«5 has collected four examples of this ai-cident, unaffompuit^
with a fracture, and he proceeds to speak of it as u distinct form «
dislocation. In two of the examples, however, mentioned by kini,il
was consecutive upon a forward luxation, and I have several tiM
seen the head of the radius very much incline<] outwards in wbal u*
projwrly termed forward dislocations. For these reasons it tn not v«^
plain to me that wc ought to consider this Of a distinct form *•( pn*
mary dislocation, but rather as a consecutive luxation, or at 1nfl>*
only a miKlifu^tion of the forward or hackwanl luxation. Indeed,!
think the radius never will be found thrown directly outwanb, Ixi'
always in a direction inclining forwards or luu-hwards.
Parker, of this city, mentions a case which came under hi» at^^
in a child four years old, who, six weeks before, had fallea duira ewB
DISLOCATIONS OP UPPER END OP ULNA BACKWARDS. 625
€t
beckwardly, with the right arm twisted behind the back, in such a
poeition that the whole weight of her body came upon her arm." No
attempt was ever made to reduce the bone, and the head of the radius
oontinued to project externally. By pressure it was easily reduced,
but became immediately displaced when the forearm was either flexed
or extended. The motions of the joint were completely restored. Dr.
Parker recommended no treatment.^
CHAPTER VIII.
DISLOCATIONS OF THE UPPER END OP THE ULNA (HUMERO-
ULNAR).
Dislocation Backwards.
This accident, the existence of which, as a simple luxation, is placed
beyond doubt, has nevertheless been described so variously, and oflen
indefinitely, that it is impossible to declare its history, except in a few
pointB, with any degree of accuracy. No doubt many of the cases
which have been reported were examples only of a subluxation of both
radius and ulna backwards. In other cases, the radius or the external
condyle of the humerus being broken, the ulna has been actually dis-
placed, not only backwards, but upwards ; indeed, it is very certain
that without either a luxation of the radius, or a fracture with displace-
ment of the external condyle of the humerus, or a fracture or bending
of the radius, an upward displacement of the ulna, to the degree repre-
sented by the reporters of these cases, could never have occurred. The
example mentioned by Sir Astley Cooper, and of which a dissection
was made, is plainly a case of subluxation of both bones ; or if the lux-
ation of the ulna may be regarde<l as having been complete, the head
of the radius was also displaced more or less upwards from its original
socket, a new socket, Sir Astley himself informs us, having been formed
for its reception, upon the external condyle. But this is the only ex-
anoiple, the actual condition of which has been proven by an autopsy.
Nevertheless, it seems probable that a simple luxation or subluxa-
tion of the ulna backwards may occur without either of the above-
mentioned complications, and that, to the extent of a few lines, it may
be made to pass upwards upon the back of the humerus, by the falling
of the forearm to the ulnar side ; in which case the character of the
accident would probably be recognized by the projection of the olec-
nmon process, while the head of the radius might be felt moving in
its socket ; by the partial flexion and complete pronation of the forearm,
and by the general immobility of the joint. In a case reported by Dr.
1 Parker, New York Jouru. Med., March, 1852, p. 1S9.
626 DISLOCATIONS OF THE RADIUS AND CLNA.
Waterman, caused by a fall on the haii<^, tho anu was at a right tin^h,
and pronatcd.'
Its reduction ought to be accomplished easily, one would think, by
the fiamo measures which have bt^cn found successful in reducing i
dislocation of both bones backwards; but in Waterman's case mk
metliod failed, and the reduction was promptly effected by bending
the forearm forcibly liack.
Pirrie says that in a case occurring iu the practice of Mr. Gossel,
which the coronoid proceeds rested on the internal condyle, and tlie p
on bending the arm was insupportable, owing, it was Bup[tO0ed to tl4
pressure of the coronoid process against the ulnar nerve, "redortiuA
was accompliE^hed by extension and counter-extension applied br tw
persons pulling in opposite directions, and by the pressure of the oW
ranon process downwards and outwards, wliile the forearm vaa
denly flexed."*
CHAPTER IX.
The radiu.- and ulna may be dislocated at the olbow-joint baek-
warda ; laterally, that is, cither inwards or outwards ; and ionvanU
i 1. Sislocations of the Hadini aad Ulna Baokwurda.
Causes. — In sixty cases ob8er\'ed and recorded by me, tJie avoaf*
age is about twenty years ; the youngest Iwing four years old, anJ t"
oldest fifty-three. Twenty-three of this number occurred bi ehiWiW
under fourteen years of age.
Generally the dislocation has been produee<l by a fall uponihr mIxi
of the hand, as when in running a person Iiils fallen forwards with i)x
forearm extended in front of the body, or he tuny have fiUlim fraiii)
DISLOCATION OP BADIU8 AND CLNA BACKWARDS. 627
Wght; once I have known it producwl by a blow received upon the
MCE and lower part of the humerus; and in several instances the
■tiente have declared that they had fallen upon the elbow; it is pro-
uced, occasionally, by twisting the forearm violently, as when the
mb has been caught and wrenched about by machinery, by a. blow
pon the front and up[K>r part of the forearm, and by forced flexion.
Pathology. — The radius and ulna are not only carried backwards
ehind the articulating surface of the humerus, but they are also,
irougb the action of the triceps, almost
Iways drawn more or less upwards, so that
ften the coronoid process of the ulna rests
1 the olecranon fossa. In some cases it has
een known to mount even higher, while in
thers it is arrested short of this point. The
idins still retaining its relative position to
he ulna, lies upon the back of the humerus,
T rather upon the posterior mai^in of its
ittculating surface.
The anterior and two lateral ligaments
K generally more or less completely torn
iBQDder; but the posterior ligament and the
lonnlar do not usually suffer disruption.
The biceps muscle is drawn over the lower
krticnlating surface of the humerus, but is in
1 condition of only moderate tension, while
fe brachialis amicus is forcibly stretched,
weven torn.
The median ner\-e is also pressed upon in front by the humerus, and
the ulnar is ot^casionally painfully stretched over the projecting ex-
tremity of the ulna from behind.
St/mptoiati. — Sir Astley Coo|)er does not mention particularly the
x«ition of the arm as to flexion or extension, except to say that " the
leiioD of the joint is in a great degree lost;" nor, in his original work,
Hiblished in London in 1823, is there any illustration accompanying
he text to indicate in what position he had usually seen the limb ; but
a the later editions, edited by Mr. Bransby Cooper, is found a drawing
'hich represenrs the forearm at a right angle with the arm. It is very
ertain that Sir Astley never sanctioned this error by anything which
e had written or communicated to others. It is very certain, I say,
ecause the fact that it seldom, if ever, occupies this position, could
ot have escape<l the notice of one whose experience was so large, and
'hose habits of observation were generally so accurate. The truth is
Imt it is almost constantly found only slightly flexed, or forming an
M^e in front of about 120°.
This fact is especially noticed in my records twenty-six times, and
fit had ever been found in any other position, it would certainly have
Men stated. Once, where the dislocalion was accompanied with a
iracture of the outer condyle of the humerus, the arm was at first
ttraivht, a position in which it is said to be found occasionally with
children ; and in the case of a patient admitted to Bellevue Hospital,
628 DISLOCATIONS OF TBE RADIUS AND ULNA.
on the 14th of December, 1864, the dislocation having existed thitly-
one days, but unaccompanied with a fracture, I found tlie arm Hlrul^ht,
aud there existed also & preternatural lateral mobility of the elbow-
joint ; but never, in any case of a recent dislocation, and IhiL once ia
an old dislocation, have I found it flexed to a right anj^Ie ; yet 1 mil
not deny that such unusual phenomena are possible in recent disloca-
tions; indeed, it is certain that they have occasionally been preeentfd,
but they must be regnrdeil aa only exceptional, and as by no ni»n
diagnostic of this accident.
Sir Astley Cooper and Miller declare that in this dislocation tba
forearm is usually supinated; Pirrie says "the hand is between proia-
tion and supination, but more inclined to the latter." Desault thinki
it is sometimes in supination and sometimes in pronation ; Denut^ con-
cludes that it will occupy that position, whatever it may I>e, in whti^
the force of the blow has thrown it; while by most sui^ical writers na
allusion is made to the pasition of the forearm in reference to jirunalioi
or supination. For myself, I can only say that 1 have found the for**
arm and hand almost constantly in a position of moderate! but positiit
pronation, and I am compelleii to regard it, therefore, aa one of tin
usual signs of a backward dislocation of these bont:;^
The limb can be neither flexed nor extended without force, and rock
motion is almost always accompanied with pain. It Is, however, pi»
sibic in most cases to give to the arm a slight lateral inoUoo, eudi it
does not belong to it in its natural condition.
In front, ana deep in the fold of the elbow, is felt the lower end rf
the humerus, forming a hard, broad, and somewhat irregular projcttiu^
over which the iut^uments and muscles are swollen, and toidall
pressure. Behind, the head of the radius may be felt, when not rooek
tumefaction exists, rotating or moving under the finger when iiso 6v^
arm is supinated and pronateil ; while the olecranon prtxivsa piWfS
strongly backwards and upwards. If now we flex the itrm slightlTi
this projection of the olecranon process will be sensibly incnawwi; Ix*
if an attempt is made to straighten the arm, it will be dimuibdiH), tk
reverse of what we have seen tohap|>en incasesuf fracture of the lomf
end of the humerus (at tlic base of the condyles). This dreuinsisiiM
becomes, therefore, an important diagnostic mark between tbe§e l*<
accidents.
The relation of the olecranon process, also, to tlic condyles is chas^'
and the upper end of this process, instead of being a little belirwubti
internal condyle, as it would be naturally when the arm is fllij^Mf
flexcti, is found generally carried upwards towanl the shoulder, frw
half an inch to one inch or more above the condyle.
Measuring from the internal condyle to ihe styloid proiiw of it"
ulna, the forearm is shortened ; the same result will he ol>uini«i iht
by measuring from the acromion process to either of tlie ntjliMit [^
cesses; while from the acromion process to the condyle,tlic IctigtkfA
be the same in both arms.
The signs which have now been enumerated will be snfBatiitH
enable us to make the diagnosis promptly in the great ntaHjri^^l
ee, but if considerable swelling has already taken place, inrifaf
)CATION OF RADIUS AND ULNA BACKWARDS. 629
ay be rendered exceedingly difficult, if not inapossible ; and in
see we should confine the patient at once to his bed, and proceed
156 the tumefaction by cold water lotions as rapidly as possible,
ing the limb carefully from day to day in order that we may
e earliest opportunity to ascertain its actual condition and apply
per remedy.
Jation to the difficulty of diagnosis in certain examples of this
b, and under certain circumstances, Mr. Skey, in his Operative
', has made some very judicious remarks.
ere injuries of the elbow-joint, whether in the form of fracture,
ion, or a compound of the two, are frequently followed, at a
iterval, by swelling of a formidable kind, in which it is impos-
it by the aid of a perfect intimacy with the anatomical structure
3int, to detect the relations of one part with another ; but even
his difficulty, the two points in question are readily distinguish-
Tn such forms of swelling, the arm, including the length of six
X)th above and below the joint, may be involved in the extrava-
and this swelling may distend the arm to a circumference of
pd beyond its natural size. In such circumstances, in which it
issible to determine with any certainty whether any, or what
re broken, or whether or not dislocated, the difficulty of the case
at once be stated to the friends of the patient."
nosis. — If the luxation is recent, reduction is in general easily
; but if considerable time has elapsed, the reduction is often ac-
hed with difficulty. As to the probability of its reluxation, I
ready spoken when considering the subject of fractures of the
J process. Unless this process is broken, it is not likely to occur
wrhere some violence has again been applied. It has happened
lowever, to find these bones unreiluced in several instances. In
* these examples surgeons recognized the accident and supposed
ey had accomplished reduction, while in others the dislocation
rtaken for a fracture.
1, W. F., twelve years old, residing in Erie County, N. Y.,
ught to me six weeks after the accident had occurred. The sur-
[lo was first called declared it to be a dislocation, and told the
he had reduced it; but the dislocation was now complete, and
I immovably fixed in its abnormal position.
le 10th of May, 1850, J. P., of Canada West, aet. 25, was thrown
load of hay, striking upon his left hand, and producing a dislo-
lack wards of both bones at the elbow-joint. A Canadian sur-
ho saw the patient within three hours, recognized the disloca-
id by pulling the arm straight forwards he supposed he had
it ; the patient also thought he felt the bones slip into place,
rapt was made subsequently to flex the arm, and it was imme-
dresscd with a straight splint laid along the palmar surface,
sixth day it was found to be unreduced, and the surgeon again
ed to reduce it as before, and thought he had succeeded. The
plint was reapplied. At about the end of six weeks three sur-
residing in Canada also, placed the patient under the complete
9e of chloroform, and attempted the reduction. They first made
630 DISLOCATIONS OF THE RADIUS AND ULNA.
extension for Imlf an hour in a straight line, then 6ve men oeizecl npoo
the arm and foicarni, ben<Hng it with great forve to a riglit aoglc. It
was now believed that the ulna was redu<*d, but not tJie radius. Four
days after, the attempt was renewed. Three months after tlie accident
the young man called upon me, and I found the arm nearly straijthl^
with almost complete anchylosis at the elbow-joint. Both thv nuliui
and ulna were displaced backwards, but not upwanls. The srm ffU
of the same length with the other, and the relation of the eondylis
the olecranon was bo manliest, that the absence of the usual displace-
ment upwards was easilv determined. I was unwilling to niakcanf
further attempts at reduction, not believing that I Rhould succeed afltf
so much time had elapsed, and after so many incifrctual attumpts liwl
been made by clever surgeons.
In the following examples the dislocation was supjxeed to have bets
a fracture of the lower end of the humerus.
A man, residing in Pittsfield, Mass, dislomted his left arm by fell-
ing from a horse. The surgeon who was called regardeil it as a fiao-
tureat the l>aseof the t^oudyles, and treated it accordingly. Ten weelu
ai'ter, the error was discovered and an attempt was made to reiluci
it, but without GucoGss. A sec^ond iittempt was also made, with till
same result.
The patient was brought to me eight months after the acci<lcnt, wili
the hones still unreduced. The forearm hung at a very obtuse an^
with the arm, and there was very slight motion at the eilww-joinl. I
di.scouraged any further attempts at reduction.
Mr. W., of Alleghany Co., N. Y., a-t. 43, fell from a Imd of lay,
striking upon his left arm, Feb, 16, 1853. Four hours after, hewM
seen by a young but very intelligent surgeon, who thought ihehunwrui
was broken just above the condyles. After eight weeks, the fact (lot
it was a dislocation having become apparent, three surgeons, well knowa
to me as men of large experience, attempted its reduction, aided tff
pulleys and chloroform. Ihe patient was al.so bled, and naueeatcd wita
antimony. The efforts were jirotracted through many hours, and ftfr
Siuently varied. A second attempt made by these same gentlomeu, ■
ew days after, was equally nnauccesaful.
On the ninth week Mr. W. came to me, and I placed him st <«•
in the Buffalo Hospital of the Sisters of Charity, where, assisted ly »f
friend Prof, Moore, of Rochester, I renewed tte attein})t at rcdufJi*
The patient was placed under the influence of chloroform, and dunig.
B great portion of the lime occupied the pulleys werv in um- I^'
elbow was pulled upon, twisted, flexed, and extended, unUl tbo*
seemed to be neither adhesions, nor ligaments, nor capsule, to pre**''
the reduction. We could move the joint in every direi-tion, even btt^
ally, as well as forwards and backwards. Still tlie Ixhhm would d4
return to their sockets. Section of the tric«>^>s scemeii to bu ibe wif
remaining expe^licnt, but the injury already done to th« joint m* ^
great that we did not deem it prudent to protneoute tlie allempt u9
further. We had occupie<] two hours in the various procedures. W
lent inflammation supervened, but he was able to return home in ^»^
two weeks. Two yeara aller, I learned that the arm still inaiiBn
DISLOCATION OF BADIUB AND DLNA BACKWARDS. 631
nreduced, and nearly anchylosed ; the whole limb was also much atro-
hied and very weak.
John Sharkie, mt. 53, fell on the 4th of Aug. 1854. A botanic
octor, who saw him on the same day, and n regular physician, who
iw him on the third day, thought he had broken his arm. About
iz weeks aAer this he came under the charge of an almshouse doctor,
'lio "rebroke" it, supposiug it to l>e a fracture; and two months later
e " broke " it ^ain ; but as the arm was not improved by these opera-
ions, he finally urged the poor fellow to submit to amputation ; and it
fB8 in reference to this last proposition that Sharkie consulted me. I
Hud the radius and ulna dislocated backwards and upwards one inch ;
he arm perfectly straight and the elbow anchyloscd; no pronation or
opination. I did not think it prudent to make any attempt to reduce
t, but assured him that if let alone it would ultimately be quite useful
n many ways, and that he should never think of having it cut off.
Id at least eight additional cases, according to my records, the acci-
lait has been overlooked by reputable surgeons ; the injury having
been supposed to be either a fracture or a mere contusion. Two of
these had been examined by house surgeons at Bellevue. In one other
cue my house sui^eon supposed he had reduced the dislocation, when
he had not.
Id three or four instances, also, the accident has been overlooked by
the patient himself, or by some empiric, no surgeon having been call^
to tee the case until after the lapse of
Nveral days or weeks. fio. ve.
In general, when the reduction has
wen effected promply, the patients
We recovered the complete use of
tte elbow-joint within a few weeks ;
bvt many exceptions have from time
to time come under my notice.
A lad eight years old was brought
to me, whose arm had been dislo-
»led six months before, and the re-
iQctioD of which had been accorn-
>liBhed easily and promptly by Sir
Utley Cooper's method. At this
itae the arm was bent to a right
Dgte, and quit« stiff at the elbow-
liot. Four years later I learned
ut the stiffness still continued in a
reat measure, with only slight im-
rovement.
TVeatinetU, — Sir Astley Cooper
iQS describes his own method of
educing this dislocation : " The pa-
ient is made to sit upon a chair,
od the surgeon, placing his knee
w the inner side of the elbow-joint,
n the bend of the arm, takes hold of the patient's wrist, and bends the
ID tbo bend of (he
632
DISLOCATIONS OF THE :
AND ULNA.
arm. At the eame time be presses on the radiiis and ulna with
knee, bo ns to separate them from the us humeri, and thu!) thetx
noid process is thrown from the posterior fosea of the humerus; ui|
whilst this pressure is supported by the knee, the arm is to be forcib/f
but slowly bent, and the reduction is siion effected."
The same practice has been recommended by Ericlisen, fiil
Samuel Cooper, and others. The plan recommended by Dorsey ii
nearly identical with that just described, only that, instead of the kom,
he advises that the surgeon " interlock his fingers in front of the artn,
just above the elbow, and draw it backwards.
On the other hand, Lieton and Miller recommend, a^ a better mod*
of procedure, that the patient shall be seated upon a chair, anil tint
the arm and forearm shall be pulled directly backwards, so as to relax
as completely as possible the triceps muscle, while couuter-ext^nsiou ii
made against the scapula.
Skey says : " Extension of the forearm should be made from the
hand or wrist in a straight direction downwards, as if for the (lurpoM
of simply elongating the arm."
Pirrie prefers that an assistant shall grasp the forearm ne:ir its mid-
dle, instead of the wrist, and pull the aim straight forwards, M'hilett
the same moment the surgeon seizes upon the olecranon ]>r<">ce?B wrlh
the Ungers of one hand, and, placing the palm of the oUier against tbt
front and upper part of the forearm, pulls forcibly backwards, so a.^ U
draw out the coronoid process from the olecranon fos»a. Watcnnaa
recommends forced extension; that is, bending the forearm fbroiUj
back, as preliminary lo flexion, with the view of lifting the coronMa
process from the olecranon fossa.'
For myself, having generally practiced the method reci>mmend«l iff
Sir Astley, and having usually succeeded in the first attempt an'l *''
the employment of only moderate force, I confess that my pn^lili
tions are in its fiivor ; yet I am not entirely certain but rhat an tt]ii
experience witli cither of the other modes recommended might W'
changed these convictions. The truth is, I think, that in rpcrnl «w*
very little forte is generally requisite to accomplish the rc<liicli"n, mb
that it is not very material which of these several inoilcs wt^ tahf*}
but in case of a failure by one mode, we ought immediari-ly and *i^
out hesitation to resort to another, as the following case of failiut hf
flexion will illustrate;
A lad, eet. 11, fell in a gymnasium from a height of six frat,*ln^
ing probably upon his hand. I saw him within tweuty miaote>,iM
found the arm in the usual position. I attempted immi^ialely ton-
duce it by Sir Astley "s methoil, bnt afler a fair yet unsuccessful triit
I extended the forearm upon the arm until it was nearly atni|^t, ""^ '
then, with only moderate force, drew it promptly into place.
If we still continue to encounter difficulties, the patient oofthl <t
once to be placed under the influence of an anaistbetic, and, if ««•
aary, the pulleys should be employed.
DISLOCATION OP RADIUS AND ULNA BACKWARDS. 633
When the reduction is accomplished, which is indicated generally
7 the sudden slipping of the bones and by the restoration of the
itnral form to the elbow-joint, the surgeon, in order to confirm his
JDion, must flex the forearm upon the arm to a right angle. If the
nes are in place, and there is not much swelling, this can generally
done without causing much, if any, pain ; but if it C4innot be done,
is fact furnishes presumptive evidence that the reduction is not
ected. In one instance, however, of recent luxation, this rule has
t held good. A girl, aet. 10, fell from a tree upon her hand. I was
attendance within half an hour, and found the usual signs charac-
rizing this accident. Reduction was accomplished readily by pulling
the hand moderately, with the forearm flexed, while my left hand
«8ed back the lower part of the humerus. After the reduction it
as found impossible to flex the arm to a right angle without causing
vere pain, and it became necessary, after placing it in a sling, to
low the hand to drop very low beside the body. A good deal of in-
immation followed ; but in a few wrecks the arm was well, only that
•ra period of two years or more the elbow remained very tender.
On the other hand, an omission to apply this rule has often led the
iTgeon to believe the reduction accomplished when it was not. This
ime thing has happened to myself, and as it is the only instance in
hich I have omitted to adopt this test, and the only one also in which
have left a bone unreduced which I believed to have been reduced,
will be proper to state the case and its results more fully.
A lad, aet. 11, fell from a fence on the 22d of Deceml)er, 1858, and
islocated both bones backwards. I saw him within two hours from
ie occurrence of the accident. The elbow was already considerably
Pollen and quite tender, but the signs of dislocation were very mani-
»t. Seizing the wrist with one hand, and placing my knee against
Je front and lower part of the humerus, I pulled steadily for some
©e, and with much more force than is usually necessary, until at
ngth two distinct and successive snaps were felt, such as one often
els when the two bones resume their sockets. Relinquishing my
top, it was observed by myself and the parents that the deformity
id disappeared. The reduction seemed to be complete, and so I
inounccd. I then requested the lad to permit me to bend the elbow,
d place it in a sling, but this he peremptorily refused to do, and ran
ray from me, nor w^ould any arguments or entreaties persuade him
allow me again to touch it. I reassured the parents and child, bow-
er, that all was right, and left the house. During several successive
ys I saw the little patient, but although the arm remained swollen
d very tender, I did not sus|)ect the cause until the ninth day ; and
I the tenth day, having placed him under the influence of chloroform,
c reduction was easily and satisfactorily accomplished. The recovery
IS been slow. At the end of six weeks I found the motions of the
bow-joint not completely restored, and the forefinger was partially
iralyzed ; but from this condition it has gradually recovered, and
vo months later the functions of the arm and hand were completely
stored.
The mistake in this instance was the more mortifying because I had
41
636 DISLOCATIONS OF TIIE RADIUS A« D DLSA.
dislocation, tore off the mediati nerve and brachial arlerv. Amjiuta-
tion was made, and the life of tlie patient saved.'
Dixi Crosby, of New Hampshire, has treated two cai^es of anvwnl
dislocation of the forearm backwards, by t>ending the cIIkiw (orribl*
HO as to break the olecranon process, after which the redaction »«
easily accomplished by extension. R. 0. Mussey, of Cincinnati, lias
succeeded once in the same manner.' I have rei»rt«d three similar
examples.
The dislocation being reduced, it may be a matter of pnidciKt,
Boraetiraes, to apply a right-angletl splint, first carefully padded, to ihe
palmar surface of the arm and forearm ; remembering, however, that
considerable swelling will smm occur, and that it ought not therefore
to be bandaged to the limb very tightly. At least once a day it should
be remuve<l, and the arm examined ; and in very few cases can it bg
necessary or judicious to continue its application beyond one wrdc
At the same time, if there is any es|>ecial tendency in the radium to
become displaced backwards, owing to a rupture of its annular lig*-
ment, this must be prevented, if possible, by a compress and bandage
Some sumeons regard these precautions as necessary in all cnscs, rait
I have seldom employed any spliut or bandage whatever, nor have I
ever had reason to regret this omission.
Finally, we are to place the arm in a sting, and adopt such meafiiinfl
as are calculated at first to reduce the inflammation ; and at a vitt
early day we ought to begin to move the elbow-joint, in order to prt^
vent anchylosis.
i 2, Dislocations of the Radius and mna Outward* (ta the Kadiil
Side),
The large majority of outward dislocations of the forearm arr in-
complete; indeed, only niue examples of n complete dislocation h^rt
been collected by Deuucf, including two seen by himself.* MalctifETW
has since added two more ; MoUere, of Lyons, haa reported one,* ami
Varick one,* making in all thirteen cases. Dr. Varick's case in re-
ported as follows:
"Geoi^ Knight, at, 9 years, was thrown violently from n iraSM
while in rapid motion, striking on his head and back, with Iii*lc4
arm liehind him in a state of flexion. He was bronjrht to my uffi"
on the 31st of August, 1867, within fen minutes after the rweiptof
tlie injury, and, consequently, in the moat favorable condition for ii>»-
nipulation, no swelling of the soil parts having yetooenrn-d. Tliefcr^
arm was in a state of semiflexion, sn|»ported liy the hand of the«|^
site side, the ulna lying to the outer side of the i>xlerunl cnndyle, *i|*
slight posterior projection of the olecranon. The olecranon, luuu*'
process, and greater sigmoid cavity could be distinctly defintJi*"*
1 Dobntyn, Des Luxuliona dii Coiido. ThAee Innug., Ltnivnin, IMS, p- 71.
■ Uriwby. Mu»Bi>y, Trans, Amer Med. Anno , vol. iii, p. 2&T.
■ Dptiiica, Kamoirc >ur Im LuxHUiin» dm Coudra, Psri*, ISM.
• M..liero, Monthly Alt*tr»cl Mod. Bci,, vol, i, 1874, i.. 2fl9. _^
^ Thuodore B.V>rioh.U,D.,JorM>yCUy,H.J.; Mod Rec,, Nov. t.MT.p-lK-
DISLOCATION OF RADIUS AND ULNA BACKWARDS. 635
the elbow was bent about ten or fifteen degrees, the olecranon process
separated at the line of epiphyseal union. In a few moments the
reduction was completed, and the arm brought to an acute angle, but
the olecranon had separated full half an inch. We were quite certain
that the ulna was perfectly reduced, but the head of the radius did not
seem to occupy its original position fully. Only moderate inflamma-
tion ensued. Passive motion was soon commenced, and considerable
motion of the joint was finally obtained.
In April, 1869, a gentleman, ajt. 30, consulted me on account of a
dislocation which had then existed ten weeks, and which had not been
recognized by his surgeon. In attempting to reduce the dislocation
I fractured the olecranon, and brought the ulna into position ; but I
could not reduce the radius. Almost complete anchylosis of the elbow
remains.
In 1870, a man was brought to me whose elbow had been dislocated
eight weeks. Under ether, I succeeded in reducing the dislocation,
but fractured the olecranon process in doing so. He has recovered
very good use of the joint.
October 22, 1869, before the class of medical students at Bellevue,
I reduced a dislocation in the case of a woman set. 37, which had ex-
isted since the 10th of the preceding March, a little more than seven
months. I have seen her often since; she has a somewhat limited but
very useful motion of the joint.
A few years since I assisted Dr. Sayre in reducing an old backward
dislocation of these bones in the case of a boy. Other means having
failed, while Dr. Sayre forcibly flexed the arm, I cut the triceps, afl^r
which the reduction was easily effected. Some months later the arm
»
was nearly anchylosed at the elbo\v-joint, and it did not promise very
well, so far as the usefulness of the member was concerned.
Dr. W. F. Westmoreland, of Atlanta, Ga., has reported a case in
which he succeeded readily in reducing a dislocation of the elbow
backwards of five months' standing in a woman aged 22 years. The
reduction was followed by great pain, a good deal of swelling, tempo-
rary impairment of circulation in the radial artery, complete paralysis
of the little finger, and partial paralysis of the middle and ring fingers.
On the fourteenth day, at which period the history of the case closes,
all these symptoms were rapidly disappearing.*
Nevertheless, the fact is in the main as stated by Boyer ; and if so
many cases can be found in wdiich surgeons have succeeded at a late
period, they are not probably in the proportion of one to five as com-
pared with the failures : but the failures have not received the same
publicity. Nor, indeed, have all the severe accidents, such as violent
inflammation, suppuration, gangrene, and even death, been faithfully
declared. Denuc^ says he has been able to trace out five or six ex-
amples in which, although the arm was reduced, grave accidents re-
8ulte<I, and Velpeau's patient actually died in consequence.
Michaux, at the H6pital de Jjouvain, in 1841, in reducing an elbow
* Westmoreland, Atlanta Med. and Surg. Journ., May, 1866.
1
636 DISLOCATIONS OF THE RADIUS AJf D TLSA.
dislocation, tore off the inedian nerve and brachial artery. Am|"itii-
tion was made, and the life of the patient saved.'
Dixi Crosby, of New Hampshire, has treated two cases of anri«ii»
dislocation of the forearm Irat'kwards, by l>en<linf^ the elbow forciUy
60 as to break the olecranon process, after which the reduetion **i
easily accomplished by extension. R. D. Mussey, of Cincinnati, lias
flucceeded once in the same manner,* I have rejMirted three similar
examples.
The dislocation being reduced, it may be a matter of prod^nct^
sometimes, to apply a right-angle<t splint, first carefully padded, to ihe
palmar surface of the arm and forearm ; remembering, however, thit
considerable swelling will soon occur, and that it ought not theitiuit
to be bandaged to the limb very tightly. At least once a day it shoaU
be removed, and the arm examined ; and in very few cases can it ht
necessary or judicious to continue its application beyond one week.
j^t the same time, if there is any csjiecial tendency in the mdius la
become displaced backwards, owing to a rupture of it* iinnnlur liir*-
ment, this must be prevented, if possible, by a compress and bniidj^
Some sui^reonB regard these precautions as necessary in all cas«, l«it
I have seldom employed any splint or bandage whatever, nor have I
ever had reason to regret this omission.
Finally, we are to place the arm in a sHnp, and adopt such meosurM
as are calculated at (irst to redu<« the innamination ; and at a vny
early day we ought to l>egin to move the cllmw-joint, in order lo fwv-
vent anchylosis.
I 2. Dislocations of the Radins and Ulna Outwards (to the Radial
Side).
The large majority of outward dislocations of the fiircarm arv in-
complete; indeed, only nine examples of a complete di^locsiion han
been collected by Denacf, including two seen by himself.' Malpiipif
lias since added two more ; Moliere, of Lyons, has reported one,' and
Varick one,* making in all thirtt«n cases. Dr. VarJck's case is rf-
ported as follows :
"George Knight, ffit. 9 years, was thrown violently from a wap"
while in rapid motion, striking on his h<tad and back, with )ii»Mi
arm iK'hind him in a slate of Hexion. He wiis brought In m_v oSrt
on the 31st of August, 1867, within ten minutes after thi- nwiirto^
the injury, and, consequently, in the mo!*t fiivorable condition for ma-
nipulation, no swelling of the soft parts having yet occurred. Tb* f^*-
arm was in a state of semiflexion, Bnp]Ktrted by the hand of thf oj^
site side, the ulna lying to the outer side of the external condyle, ^f^
slight (wsterior pnyection of the olecranon. The olecranon, mnaw^
process, and greater sigmoid cavity could l»e distinctly defiDti),W
■ D"briiyn, Dca LuxbHodb du Cim.ln, Thft« Inimc., L...i««lii, lW«,|i.7t.
* Criieb}', Muficy. Trans. Amvr M(^d. Auw , vul, iii, |>. 8^7.
* Di>nuc4, Memoire «ur lei Lunaliitn** dc* CaiidM. Pari*, lliM.
* M..liore, Monlhly Abstracl Med. Sci,, vol, i, 1874, |>. 269 ^
* TboodareB. Varick, H.D.,Jor<eyCity,».J.; Hod Rm., Nov. I, lltTtlt'll'-
DIBLOCATION OP EAD1U8 AND DLNA OUTWARDS. 637
6 head of the radius, in its normal attachment, could be felt rotating
bcutaDeously on pronating and Riipinating the forearm. Free motion
the forearm in every direction was present, giving the impression of
ing attached to the arm solely by the soft parts. The projection of
! internal condyle was out of all proportion to what is seen in cases
incomplete hixntion. The trochlea, coronoid depression, and the
cranon depression were distinctly recognized. Complete dislocation
the ulna outwards was di^noscd, which diagnosis was corroborated
my friend, Dr. B, A. Watson, who was present and assisted in the
action.
'The patient was placed fully under the influence of ether, and
derate extension, combined with lateral pressure, effected the reduc-
Q without difficulty. The subsequent treatment consisted of rest
I cold irrigation for a few days, followed by
eive motion of the parts, which resulted in per- *"'"■ *"■
t recovery. The amount of inflammation which
lowed the injury was exceedingly sli(;ht, due
:iaestionabty to the prompt reduction of tiie lux-
jn."
Incomplete dislocations must, therefore, in this
e be r^^arded as typical ; but even these are by
means frequent.
Causes. — A careful examination of a lai^ nunj-
■ of recorded examples, and of those which have
DC under ray own eye, renders it certain that a
jority of these accidents result from a blow re-
ved directly upon the inner side of the forearm
upon the outer side of the humerus, or from the
ion of two forces pres.'iing in an opposite direc-
[i. Of course those forces must act upon the
les somewhere in the neighborhood of the elbow-
it. Occasionally it has been produced by a fall
)n the hand ; sometimes by a violent twist of
arm, as when the hand is caught in machinery ;
1 in other eases it has Itccn found consecutive
>n a dislocation backwards, being produced in
attempts made to accomplish reduction of this
£r form of dislocation.
Patholoffy. — In most of the examples of simple incomplete outward
atioQ of the forearm, the great sigmoid cavity of the ulna still
braces the lower end of the humerus, but in.stead of reposing upon
trochlea, it i^ carried outwards half an inch or more, so as to rest
central crest upon the depression which separates the condyle from
trochlea. If the annular ligament remains unbroken, the radius
displaced in the same direction and to the same extent, its head
ting against and directly below the epicondyle.
Daasionally, however, where the violence has l)een greater, the cen-
1 crest of the great sigmoid cavity rests fairly upon the condyle,
upon the articulating surface of the humerus where the head of
1 radiiifl was formerly applied, and the dislocation approaches more
It rr¥<|ueDt form or
iplet« out**rd illi-
anoriberamrm.
i OP THE RADIUS AKD ULNA.
1
nearly to the character of a complete luxation. At the same time, owing
perhaps to the resistance affbnled by the skin, or some of the liga-
ments, the head of the radius may be thrown either forwards or bact-
wanls, 90 as to be out of line with tlie ulna. Such a displacement
generally implies a ruplure of the annular ligament.
We have now only to suppose the action of a more considerable
force in the same direction to render the dislocation complple; in which
case the upjier end of the radius is sometimes thrown completely for-
wards, and its head may even be found resting in front of the ulia,
occasioning an extreme pronation of the forearm and hand.
The anconeus and brachialis anticiis are the only muscles in eitlier
of these dislocations whose fibres are generally much disturbed; lh«
biceps and triceps being only made to traverse the articulation a little
more obliquely.
Deuuc*^, Malgaigne, A, Cooper, and others have preferred tospak
of the dislocation liackwards and outwards as a distinct form or sjtnioi
of dislocation. I j)refer to regard it as only a variety of the ontwtrd
luxation, since it may, and no doubt often does, occur coiisei'utivelf
upon a simple incomplete outward dislocation ; and if the disloRtticm
outward is complete, the bones of the forearm can swirccly fail to l»
drawn more or less upwards. Sometimes also it has been consenjlirt
upon a simple backward dislocation, or upon unsuccessful attempts tt
reduction whore the form of dislocation was originally Irackwards; yi*,
I as it does not so naturally follow upon a complete backward dislocaliffli
ae upon a complete outward luxation, I find sufhcicnt reason foretndv-
ing its mechanism in this place.
The beak of the olecranon process not only, but a lai^ portion of
the boily of this process, now lies above and behind the condyle; the
brachialis anticus becomes more stretched, if not actually torn ; tml d«
biceps is laid against the articulating surface of the humcrun ; bill d*
triceps becomes again relaxed, as in simple dislocation backwanUand
upwards.
In all these dislocations the capsular ligaments are more nr !«!«■
tensively torn, but the principal arteries and nerves d" not gamiilj
aaScT greatly, if at all.
Symptoiita. — The forearm is usually flexed to about the same ■ngW
at which we have found it in dislocations backwanls; once I Imvl
found it nearly or quite straight; ixtasioiially it is flexed to a rigH
angle. In all the ca'^es seen by me the forearm has been pronattil, m
the elbow-joint has been very immovable. The most strikiR|;dtac>
noatic sign, however, consists in the unnatural form of the rlhow-
joint, which is so remarkable as not to be easily misundcn^lood. Tb*
internal condyle of the humeruB {epitr<x?hlea) projects strongly to th*
inner side, leaving a deep depression below; while upon llie otba
side, the head of the radius, with its cup-Hkc extremity, can befr
Einctly felt, and made to rotate outside of its socket. iThe )J«n«w«
proce^, driven from its fossa, projects more or Ifss piistcriorlr, u*
even the fossa itectf may sometimes be plainly felt.'
A girl, twelve years old, had fallen u]iori the inside of her elh*t
producing a dislocation outwards of the forearm. I saw hfTwiih*
DISLOCATION OF RADIUS AND ULNA OUTWARDS. 639
half an Tiour. The forearm was bent upon the arm about fifteen de-
frees, and immovably fixed. The head of the radius could be dis-
indlj felt external to and a little in front of the outer condyle, while
he olecranon process of the ulna, which* rested upon the back and
rater surface of the humerus, was less distinctly felt than in the oppo-
site arm. The inner condyle projected sharply to the inside, and the
olecranon fossa was plainly felt with the fingers. The child was suf-
ering very little pain.
Seizing the wrist with my right hand and the lower end of the
iQmerus with the left, and making moderate extension in these oppo-
ite directions, the bones easily, and after only a moment's eflTort, re-
umed their places. Her recovery was rapid and complete.
James O'Neil, aet. 16, was admittetl to Bellevue Hospital in Dec.
865, with a dislocation caused by the kick of a horse, tne blow hav-
Dg been received on the ulnar side of the forearm near the elbow-
oint When he came under my notice the dislocation had existed
hree weeks. I found the head of the radius reposing upon the radial
nd posterior side of the humerus. The ulna was displaced one inch
othe radial side. The forearm was not at all, or but very slightly,
lexed upon the arm. The natural deflection of the forearm to the
Jdial side was a little exaggerated : forearm pronated : elbow-joint
Imitting of a little nu)tion ; but motion causeil great pain.
This patient was not in my service, and I have not learned the
«alt of the attempt at reduction.
If the dislocation is complete, the position of the arm is usually the
me, but the pronation of the hand is greater, and the projection of
e inner condyle more striking.
If now the bones, by a continuance of the original force, or by the
tlon of the triceps, are drawn upwards also, the arm becomes a little
ore flexed, and the olecranon process more prominent, while the
n^h of the whole limb is sensibly diminished.
Prognosis. — In recent cases of incomplete outward luxation, and
bere no complications exist, the reduction is generally easily effk'ted ;
id M. Thierry claims to have reduced an outward and backward
xation after eight months. A patient of whom Debruyn has spoken
IS not so fortunate. On the 16th of April, 1841, a lad, set. 18, fell
K)n the palm of his hand and dislocated both bones outwards and
ckwards; on the following morning a surgeon attempted to reduce
e dislocation, and the attempt was repeated on the next day by
other surgeon ; but on the day following this last attempt, gangrene
sued in consequence of the great violence employed by the surgeons,
d, although the limb was amputated, the patient died. The autopsy
owed that lK)th the brachial artery and the median nerve were torn
under, and that the tendons of the biceps and the brachialis anticus
jre slipped behind the outer condyle, probably having been thrown
to this position during the violent twistings to which the arm had
«n subjected.^
* Denned, op. cit., p. 108.
640
DISLOCATIONS OF THE RADIUS
I have Been three examples of dislocations upwards and rtatmnls
which the medical attendants had faileti to reduce. The (iKt vaa in
the case of a lad, William Kinkaid, fourteen years old, who hnil falloi
from a wagon and struck upon the palm of his left hand. The sur-
geon who was immediately railed made exlciisinn, and supposed ibatib*
reduction was accomp1ishe<l. The lad was hrought to roe a few moutb
atUr the accident. The arm was slightly flexed, and neither prow
nor supine. There existed only a slight motion at the elbow-joiiit. I
did Dot think it worth while to make any attempt at reduction. ScKtriJ
years after this, in the month of February, 1859, 1 had an opportiiuiw
of examining the arm again. He had now recovcml considerable
motion in the joint, but he could not tie his cravat. Pronation and
supination were perfect.
In the second example, a lady, set. 33, had fallen upon the inside ef
her elbow, and reduction not having been aceompl isheil, I found hcfi
nine weeks after the accident, with 8carccly any motion ul the elboi
joint, and complaining of a numbnes!? in the forearm and hand.
The third instance of unreduced dislocation I will relate more
length.
Francis Banlield, aged twenty -two years, a resident of AlI«^hiBf
County, rf.Y., on the .31stof Septemler, 1857, fell fromtiie sweep of »
threshing-machine to the ground, a distance of about five feet, strikinf
upon the palm of his hand, his arm being extended in front of faim.
On rising, he found his arm forcibly flexed and abducted. He strait:!)!-
ened it without difficulty, and it nsHumed the position U now nxapie*.
A physician was called and saw the patient an hour and a lialf afWr
the accident, who pronounced it a case of dislocation of the radius Knd
ulna, and made eiiorts at reduction, which he (nntinue^l from 8J a-K.
until 2 P.M., a period of Ave and a half hours, to no purpose, when \m
abandoned the attempt. During the attempt at reduction, the cxieo-
sion was made at times with the arm flexed, and at others ext«iidei
At 9 P.M. another physician was called, who maile cDbrts at rvdurti"*
until 3 A.M., upwards of six hours, at which tiTiie he also alMiulomd
the attempt. On the third day another physician, the jmtietU boBf
under the influence of ether, made efforts at reduction for tWBi^
minutes, when he pronounced it in place, and appliitl a baiiili^
From the patient's account, the arm was swollen to such ati extent ■
to render this point difficult to determine. On the fifth day the
physician was called, and believing tliat he discovered a grating,
Dounce<l it a fracture of the external condvle.
Four months after the accident, when tne patient applied to me. tin
limb presented the following appearances: "The forearm estcmW
ujmn the arm; looking at the limb along its radial margin, w ooliei
a gentle outward inclination of the forearm from the elbow dowi
by manipulation this may he greatly increaswl; the power of j
tion and supination is not affected ; the inner condyle project? w
to the ulnar side; the head of the radius, completely n^moved ftwni*
socket, projects to an equal extent on the mdial side. The Uf
the olecranon process is an inch higher than the top of the inncrct
DISLOCATION OF RADIUS AND UI.NA INWARDS. 641
dyle, so that the radius and ulna are carried upwards as well as out-
wards."
I believe that the external condyle was not broken, as in that case
the arm would be permanently deflected outwards to a much greater
extent. For, although tliis arm may be deflected outwards by the sur-
geon to an angle of 135°, still the degree of mobility which exists
would be adverse to the supposition of its being a fracture of the exter-
Dal condyle. The condyles also can be plainly felt in their natural
sitaations, which would not be the case if a fracture of the external
condyle existed. The patient was advised not to submit to any further
attempts at reduction.
The following will serve as an illustration of a recent accident of
this character :
John Collins, of Buffalo, set. 8, fell while wrestling, his companion
fidling upon his arm. I found the forearm slightly flexed, pronated,
and both radius and ulna thrown over to the radial side and carried
upwards. Pressing firmly upon the radius from the outside, the bones
assumed suddenly the position of a backward and upward dislocation,
from which position they were readily reduced to their original sockets
by simple extension.
TrecUment — In relation to the treatment of these accidents we have
little to add to what has already been said of the treatment of disloca-
tions backwards. 'The reduction, if effected at all, has generally been
aoeomplished by moderate extension, or by extension combined with
lateral pressure. If the head of the radius is in front of the humerus,
or of the ulna, the hand should be first supined, and then the extension
should be applied. In some cases the reduction has been effected by
placing the knee in the bend of the elbow and flexing the forearm,
while the surgeon was making extension from the hand.
{ 3. Dislocation of the Radius and Ulna Inwards (to the Ulnar Side).
This form of dislocation is much more rare than the dislocation out-
wards, a fact which may perhaps find a sufficient explanation in the
peealiar form of the trochlea, the inner half of which rises much higher
than the outer, forming thus an elevated inclined plane, over which
the articulating surface of the ulna must rise before the dislocation can
oocnr.
Like the opposite dislocation, the typical form of the accident is that
in which the displacement is incomplete; indeed, no example of a com-
plete inward dislocation has, we think, been yet recorded.
Causes, — A fall upon the hand or forearm, a blow upon the radial
ride of the forearm near its upper end, or upon the ulnar side of the
arm near its lower end, a violent wrenching of the limb, are among the
causes which may occasion this dislocation.
Pathology. — The ridge which divides antcro-posteriorly the greater
rigmoid cavity of the ulna, having been driven over the elevated
inner margin of the trochlea, falls down upon the epitrochlea, so as, in
Bome sense, to embrace it instead of the trochlea; while the head of the
642
tINS OF THE RADIUS AND OLSA.
MmI (roqiic
radius passes inwards also, and is made to occtipy the trochlea, from
which tne ulna has estaped. Generally the head of the radius is fiiand
in the same line with the ulna (Fi)?. 280), htf
it may euffl?r a luxuttoti and be found a liull
in advance of the ulna, or possibly a little ia
the rear.
I choose also to regard the dislrxntinn in-
wards and upwards as only a variety of tbt
disloeation inwards; in which form of lhefii>
cident the coronoid process of the ulna is thrust
upwards above the cpieondyle, and the held
of the radins occupies the olecranon fowa, or
rests ujion the back of the humerus gomewhtn
in this vicinity.
In addition to Uie injury suffcrol bv tlie
ligaments and muscles, the ulnar nerve in biith
varieties of inward dislocation is peciilinrly
liable to contusion, in conaequeni-e of its heing
crushed hetweeu the olecrunuo process aud tlw
epi trochlea.
Symptotns. — If tlie dislocation is only ii
warns, the olecranon pnx-ess can be fell pro-
jecting upon the inner sidfe, and eomplrtflr
concealing the epicondyle; while the heail*
Miion 'of^'ibB ^^^ radius, having abandoned its socket, imf
(ijtearni. be felt indistinctly in the bend of the *""
The external condyle (epicondyle) b* remi
bly prominent. The forearm is generally more or less flexed, and d«
hand forcibly pronatod. The natural outward deflexion of the fon^sinnii
also lost, or it may be even inclined slightly inwards. This phcnoni"K*"
is explained by the position of the epicondyle, upon which the jirmlff
sigmoid cavity now rests, allowing the ulna to overlap a little uivm tl*
humerus; rendering the forearm actually somewhat shorter alcmgi*
ulnar mai^in, although the head of the radius may still occupjtk
summit of the trochiea-
If the bones are displaced upwards as well as inwards, a cunsido^
shortening is declared, and the head of the radius may now he ii^
behind the trochlea, or over the olecranon fossa. In ibn-e i\f thefc^
examples seen by Malgaigne, all of them ancient, the fifrcarm ww "O
a state of supination. Otner surgeons have met with ca.'tt's iu whi^
the forearm was supine, but they must be considered as cxoeptiw*'"
the rule.
The following example of this disloc-alion, unrc<lucod after the lip*
of fourteen years, is reported to mo by Pr. T. H. Squier, of Elmin.
N, Y. : Thomas Cook, now in his nineteenth year, was fotir Tear-n*
ten months old when he fell from a pile of Itoards about a^ ai^ ^*
roan's shoulder. Acording to his statement, given at the tiuif. I""*
right arm caught between the boards, and, in Hilling, he tiimtitl bkihi'
ersault. The mother, to whom the child iinmiHliutcly ran. gra^
his arm which be said was broken, and foun<i thai it would ntllu*'
DISLOCATION OF RADIUS AND ULNA INWARDS. 643
torn in various ways. When the surgeon arrived, three hours after-
wards, the arm was very much swollen and the accident was supposed
to be a fracture. At present flexion and extension are perfect. The
forearm has an inward deflection of a hand's breadth more than the
other. The power of pronation is complete, but the forearm and hand
cannot be supinated entirely. Tlie external condyle is very prominent,
bat the internal is almost hid by the olecranon, which projects inwards
Dearly as far as the point of the epicondyle. The finger can be laid in
the olecranon fossa behind, and all the back part of the trochlea can be
distinctly traced. By flexing the forearm slowly, as it approaches a
right angle, the tendon of the triceps may be felt, lodged, as it were,
on the back part of the point of the epicondyle; and by continuing the
flexion, the tendon suddenly slips over this point and places itself on
the anterior aspect of the arm. When the forearm is fully flexed, the
tendon is advanced full three-quarters of an inch in front of the epicon-
dyle. The arm is very serviceable, but invariably pains him after a
hard day's work.
Prof/nosis. — Malgaigne was unable to reduce the dislocation in a
recent case of incomplete internal dislocation, which came under his
own notice. Triquet succeeded in a child seven years old, on the
fifteenth day, after many trials ; but the movements of the elbow-joint
were never restored. Dubruyn succeeded on the fifth day, but not
without difficulty; the case reported by Squier was mistaken for a frac-
ture, and no attempt at reduction was made ; and in the only remain-
^ example which has been put upon record, the precise character of
he accident having been determined by Velpeau, reduction was easily
locomplished, and on the eighth day the patient was dismissed.^
Of the four examples of inwards and backwaixls luxation seen by
falgaigne, not one was ever reduced; but as the history of them all is
ot complete, it is by no means to be inferred that reduction could not
ave been easily accomplished, at least in some of them, at the first.
for, with such imperfect details before us, can we understand fully
'hat complications may have existed, such as would perhaps render
lese exceptional, rather than illustrative examples.
One of these patients had a completely anchylosed elbow at the end
f two years, but pronation and supination were preserved. In the case
f another, however, even flexion and extension were as perfect as in
ie normal condition.
Treatment — The indications of treatment are the same as in disloca-
ons outwards, with only such slight modifications as the judgment of
irery surgeon must naturally suggest. I prefer to employ by way of
lustration the example diagnosticated by Velpeau.
On the 10th of May, 1848, Alexandrine Guyot, set. 22, entered the
[ospital of La Charit6 with an incomplete inward dislocation of the
^rearra, which had just occurred. The hand and forearm were in a
tate of forced pronation, half-flexed and the whole limb from the elbow
own wards was deflected inwards. There were present also all the
* Denuco, op. cit., pp. 154-16G.
644
DISLOCATIONS OF THE RADIUS .
other usual signs of this tlislofatiou, and Vt'Ipcau Iiad no iloiiU 3i lo
ite true clinraoter.
In (inier to aonmplish reduction, one assistant mrnlc countcr-wtrii-
siou upon tlic arm, while a second made direct extension upon ihc
forearm. At first the tractions were made in the dirertion of tlie Kt*-
arm (flesed and prone), but gradually the arm was »traigUlen^]and
aupinated. Tben the surgeon, seizing with one hand the su[M;rior ex-
tremity of the forearm, and with the other the inferiiir extremitv of
the arm, acted forcibly upon the two portions in opposite dirootioit^
and imraediatelv the rttlnctiou mos effected with a noise.'
I 4. Dislocation of the Radius and TTlna Porwards.
Sir Astley Cooper, Vidal (de Cassis), and others have denied tint
this dislocation wn-s possible without a fracture of the olocranou pnt-
ceas ; but Monin, Prior, Velpean, Canton,* and Denuc^ have each re-
ported one example, so that its existence may now be ciuisiderwi it
•DfdlnlwitloDDribrc
established. Nevertheless, it is only as a result of veiy vinl«il**l
extraordinary accidents, by which the forearm ia forcibly fl«<<li*l
greatly extended, or twisted, or in some other unusunl and iodii* I
way the olecranon is placed in front of the hninenig. f
The tbllowing is a summary of the (iicts in VeliieutiV case. Al<*'l
andrine Carelli, let. 23, was knocked down by a. onrringp, on ibtf"!
' JX'nutrf, gp. cU., p. 166.
' Oub. Quart. Journ. of M«d. 8rL. *at-^*M
DISLOCATIONS OF THE WRIST. 645
trf July, 1848, the wheel passing over the right arm. The arm was
Rand in a right-angled pasition, and it could neither be flexed nor
extended ; the forearm was strongly supinated ; the projecting angle
Dsuaily made by the olecranon process was replaced by the irregular
extremity of the humerus ; the forearm was shortened upon the arm ;
the head of the radius resting in the coronoid fossa, and the olecranon
[»rooess being also carried upwards and a little outwards. Reduction
iras easily accomplished, and the patient left on the nineteenth day,
irith only a slight remaining stiffness in the joint.*
A case is reported to have come under the observation of Mr. J. W.
Langmore, house surgeon at the University College Hospital, London.
It was occasioned by a fall upon the elbow. The reduction of the
alna was easily accomplished by placing the knee in the bend of the
elbow and flexing the arm. The radius was then reduced by pressure
and extension.^
Chapel has reported a case of dislocation forwards and outwards,
which he readily reduced soon after it occurred, while Colson, Leva,
tnd Guyot have each reported one example of .vMfe-luxation forwards,
in which the extremity of the olecranon process has been found resting
opon the extremity of the humeral trochlea.^
Treatment — If the dislocation is complete, and the forearm is short-
ened and flexed upon the arm, the reduction should be fii'st attempted
by violent flexion, or by flexion combined with extension from the
^st, and counter-extension from the lower portion of the humerus.
" the dislocation is incomplete, and the forearm is extended upon the
ipm, the reduction may be readily accomplished by extension alone, or
>y moderate flexion.
CHAPTER X.
DISLOCATIONS OF THE WRIST (RADIOCARPAL).
Regarded as an accident of not unusual occurrence by Hippocrates,
L L. Petit, Duverney, Boyer, and by most if not all of the older
^ters, its frequency began to be questioned by Pouteau, and finally
ts existence was almost absolutely denied by Dupuytren, who remarks :
'I have for a long time publicly taught that fractures of the carpal
od of the radius are extremelv common ; that I had always found
hese supposed dislocations of the wrist turn out to be fractures; and
hat, in spite of all which has been said upon the subject, I have never
net with, or heard of, one single well-authenticatecl and convincing
latse of the dislocation in question." Dupuytren subsequently dec^lared
hat he would not positively deny the possibility of the accident, yet
* Denuc6, op cit., p. 110.
* New York Med. Record, March 1, 1867, from the London Lancet.
* Denuce, p. 120.
DISLOCATIONS OF THK WRIST.
tliat "it must at least be aJmittwl tbiit the aL-culimt is an entremelj
rare one." Wishing to ex{jlii'm tliia infrequeiicy, he says: "Ineisoi-
ining tlie etructure of the »*tl \KiTtf, one cannot fail to [>erc«ivi> tlut ii il
not Ihe ligaments which prevent the diB placement of the articular itur-
faee forwards, but that this effect is especially due to the inultiluileof
flexor tendons, deprived as they are at this point of all the ilcsky Mrn,
arid i-educed to the simple fibrous liseiie wbich composes them. Thw
tendons are bound together Iwneath the anterior annular ligaraeuiof
t)ie wrist, and thus oiler so efficient a resistance that severe falls an
insufficient to tear them through; the hand is fonvd into a stale nf
extreme extension, and the tendons arc firmly applied on the antcrint
part of the radio-tarpal articulation. If the extension is still furtbct
augmentitl, the wriHt-joint is yet more closely clasped by these pirl^
and their power of ■■esistance is incalculable; I am (fmvinwd iWt
force eciiiivalent to one thousand [lounds weight would be inadoii
to overcome it ; and the known power of the tendo Achillis is »a&-
cient to prove that this computation is not exaggerated.
"The risk of dislocation backwai-ds liy a iafl on the dorsal surfae*
of the hand is equally precluded by tlie tendons of the extensor m
cles. Their arrangement and relations at the back of the joint
similar; it is true, they are not quite so strong ; but we muitt adnA
that their power of resistance is very considerable, wiien we labi
consideration how they are inclosed in shealhs as ihcy cro^s bentalk
the posterior annular ligament of the wrist. I huvc not alludnl to t
ulna, for it has rpally little or nothing to do with tliese muvcments,
it does not articulate (directly) with the hand.
"To sum up, then, the extreme rarity of dislocation forward*
backwards is owing to the obstacles opposed by the tlexor or extcmi*
tendons."
The opiniou of such a writer as Dupuytren, whose experience i
very great, and who descrilie<I only what lie had seen, is alwam
titled to profound respect; yet it has been the pnictitT of iieirlf
who have made any reference to his opinions in this mutter lo sp
of them lightly, and not a few have tiilsely represented him as MTiiig
that such a dislocation was "impossible." The fact is, tlint suf^rt
do still constantly mistake fractures of the lower end of the mil"
for dislocations, as my own personal observation nui aittnl; am! iwt*
withslamling examples have l>een reported by Kcn6, Maijorlio, Vwhiv,
Cruveilhicr,VoiIlemier, Boinot, Malgaignc,St«Utelten, liraiishyOwpfft
Kei^usson, \V, Parker, and others, yet the whole number of ae« 6f
which the distinction is claimed is, to this day, m> ineonsiderdik^
only to establish the value and accuracy of DupuylrenV opinioo tk
the " accident is an extremely rare one. ' Ihit it is, gx-rhapi*, nii*t r
markuble, that while very few of these supposed example* ha'.i" (w
verified by an uutojtsy, in every instance in which ihe uutou'y hat t«»
made, the dislocation has been found to bi> otuipliiitliil with u fruiui^
geneinlly of the lower extremity of the radius or of the My Und BpojA;'
sis of the ulna.
The existence of a complication, however, does not n'ndw tl» i/^
dont any the lees a dislocation, although it may reniler tho ditfoM*
P18LOCATIONS OF THE WRIST. 647
more difficult, and modify somewhat the indications of treatment. A
Jmowledge of the fact, also, that such complications have always been
observed in the autopsy, may leave us in doubt as to what is the nat-
ural history of a simple, uncomplicated dislocation, if, indeed, it does
not warrant a suspicion that such a case never occurs. We shall,
nevertheless, after a careful analysis of the cases as they have been
reported, and by a consideration of the anatomy of this articulation,
be able to determine with some degree of accuracy, perhaps, what are,
or what ought to be, the usual causes, signs, treatment, etc., of these
accidents.
Partial luxations have also been frequently described by surgeons.
I have never met with an example, but the following case, related to
me by the patient himself, I believe to have been a case in point.
Lewis C, of Buffalo, a?t. 18, by a fall upon his hand, broke the left
forearm below the middle, and at the same time, as he affirms, partially
dislocated the carpal bones backwards. Dr. Spaulding, of Williams-
ville, N. Y., took charge of the limb, and pronounced it a fracture,
with partial dislocation, and for more than a year after the accident
the bones had a tendency to become displaced in the same direction.
Whenever he attempted to lift even the weight of half a pound, with
his hand supinated and his forearm extended horizontally, the lower
end of the radius would spring suddenly forwards, and all power in
the arm would be lost. When this happened, as it did quite often, he
always reduced the bones himself, by simply pushing upon them in the
direction of the articulation.
Fourteen years after the accident, I examined the arm and found it
in all respects perfect, except that the forearm was shortened about
one-third of an inch, which shortening was due, no doubt, to the over-
lapping of the broken bones.
(I am unable to verify the accuracy of the statements made in the
following paragraph ; but as there seems to be no reason why they
should not 1^ accepted, it will be proper to give them a place in this
treatise.
"According to Francis L. Parker, M.D., Professor of Anatomy in
the Medical College of South Carolina (Trans. S, C Med, Ansae.), there
•ire thirty-three cases of so-called dislocations of the wrist-joint on
record (omitting the cases of W. Parker and Ren6), including his own,
viz., case of dislocation of the wrist-joint backwards. Of these, twenty-
three are said to have been luxated backwards and ten forwards, and
of this entire number only seven, five backwards and two forwards,
are free from all objection. Of the twenty-six cases of doubtful or
unsatisfactory dislocations, sixteen were complicated with fracture of
one of the bones or processes connected with the joint; three were com-
pound, three were incomplete, two were arthritic or pathological speci-
mens, and two were objected to from other causes. Of the thirty-three
80-called dislocations, the sex is recordc^d here in fourteen instances; of
these eleven were males and three were females. Of the seven cases
cla.<«sed as genuine ones, one post-mortem was made (case of M. Malle),
which confirmed the diagnosis ; in six remaining cases the patients
regained the ase of the limb in a very short time, without a tendency
6iS DISLOCATIONS OF THE WRIST.
to displacement or deformily. Of these seven cases accepted as genmi
two backward disincationii were produced, the force of the fall beti
received, in one instance, on the dorsum of the hand (Hamilton's);
the other upon the palmar surface (Parker's); in M. Mai le's case,
forward di^placeraent, the presumption is that the patient fell itn i1l_
palm of his hand, but this is not definitely stated ; and in the four re>
tnaining cases this point is not specified. He lays down the lo]lowin(
practimi conclusions, which may be derived therefrom : 1st, The wri*-
joint may be dislocated backwards or forwards without fracture or ■
nipture of the integuments; both are extremely rare; the backwaid
displacement Is the most frequent. 2d. Cases of so-called di»)ocatim
of the wrist may be associated with fracture of the radius and uliu,or
with either of these bones sejwrately, with both styloid procewtf,
either of iheni, or with fracture of the articulating surface of the mtliiwi
no instance has been recorded of a dislocation of this joint <Y>inpli<4l^
with fracture of the oarpiil bones. 3d. Dislocation of the wrist baeli-
wards or forwards may be complicated with rupture of tht* integumeiiti
anteriorly or posteriorly, or laterally, with or without fnicturv of the
styloid processes.'")
i 1. Dislocations of the Carpal Bones Backwards,
QiHws. — The same casualty, namely, a fall «|ion the palm of the
hand, which, as we have elsewhere noticed, produi'cs rre<|uently a fr*^
ture of the lower end of the radius, oocasioually a ditilocation of tk
radius and ulna backwards, at the elbow-joint, may also, it is liflirvtd,
occasion sometimes a dislocation of the carpal bones backwant. la
several of the cases reported, lliis cause has l>ccn assigned ; but in tli'
only example of simple dislocation which ha-* ever come uiidrJ
notice, and which I have every reason to believe was a simple d if l»-
ration unaccom[)anie<l with a fracture, the cnrnal lx>ni« were tli«*B
back by a fall upon the buck of the hand. The following i^ a bna
account of the case :
The Rev. Stephen Porter, of Geneva, N. Y., let. 75, while walkinj
with his son alter dark, and holdiii)^ in his ri^iht hand a Sjit<^hpl,6lr)il<»
and feil. In the cSbrt bi save himself, and still rtftainiuf; ItUp^
upon the satchel, his right hand struck the sidewalk Hexul, awl
such a way as that the whole furce of the fall was received upon tl*
back of the hand and wrist, thus tlirowing the hand into a Hste>
extreme flexion. In less than twenty minutes he was at my In**
Nil swelling had yet occurred, and the moment 1 hxiked at iluwi*
I said to him, " You have broken your arm ;" so much did it rwnill*
a fi^cture of the lower end of the radius. A further examinnticai I")
nie to a different conclusion. The palmar surfot* of the wri*t p""
sentcd an abrupt rising near the railio-earpal articulation, lh<- runnsn
of which was on the same plane and continuous with the hoi«« "f f*"
forearm, and a corresponding elevation exisieit upon the dorxal *^^
terminating in the carpal bones and hand ; tlie hand wa» •ligMf
• F. L. Parker, Had. Hec., Nov. 1, IBTl.
DISLOCATIONS OF THE CARPAI, BONES BACKWARDS. 649
JDctjued backwards, but the fingers were moderately flexed upon the
palm. To this extent the accident bore the features of a fracture of
the radius ; but the hand did not fall to the radial side ; the projec-
tiona upon the palmar and dorsal surfaces were more abrupt than I
had ever seen in a case of fracture, and which, if it were a fracture,
would imply that the broken extremities had l>een driven off from
nch other completely; the most salient angles of these projections
were abrupt, but not sharp or ragged ; the styloid apophyses could be
distinctly felt, and I was not only able to determine that they were
not broken, but, by observing their relations to the palmar and dorsal
eminences, it was easy to see that these latter correiiponded to the
utuation of the articulation.
in addition to these evidences that I had to deal with a dislocation,
ttti not a fracture, we had the testimony furnished by the rednrtion,
which was not made, however, until by every iKjSsible means the <liag-
noaiswas definitely settled. Seizing the hand of the gentleman with
my own hand, palm to palm, and making moderate but steady cxten-
Bion in a straight line, the boues suddenly resumed their places with
the u^tia! sensation or sound accompanying reductions. There was no
psting, or chafing, or crushing, nor was the reduction acconiplished
rndually, but suddenly. To teat still further the accuracy of the
oiagnoeis, I now pressed forcibly upon the wrist from before back, but
wiiliouf producing any degree of displacement, nor could any crepitus
(till be detected. No splint was applied, and on the following murn-
ii^ Mr. Porter preached from one of the pulpits in the city, only re-
l«ning his arm in a sling.
Sixteen months after the accident, September 15, 1858, this gentle-
■Dia again called upon me, and I found the arm perfect in all respects.
(From Ferguuon.)
sxcept that it was not quite as strong as before ; the lower extremity
)f the ulna was preternatural ly movable, and occasionally he felt a
ndden slipping in the radio-carjial articulation.
Pathological Anatomy. — In the examples of compound or compli-
ated dislocations, which have been exposed by dissections, the po»-
erior and lateral ligaments have been found extensively torn, as also
650
DISLOCATIONS OF THE WHIST.
frequeutly the anterior ligament, with or without separation of ihi
radial or ulnar apophyses ; the extensor muscles torn up from tbe lower
[)art of the forearm and displaced ; the first row of the carpal ImjiW
ying underneath the tendons, and upon the bones of the forearm,
sometimes haviug been carried directly upwards, sometimes upwanb
and a little iuward^, and at otiier times upwards and outwanis; the
arteries and nerves have occasionally escaped serious injury, but more
often they have been displaced, bruised, or torn aannder.
Such are, briefly, the pathological circumstances which mav be sup-
posed to exist, also, in a lesser or greater degree, iji nearly afl cases of
simple dislocations.
In compound dislocations, however, the muscles, or rather the Iwi*
dons, are twisted, torn, and thrust aside, producing ver\- extcDsii-e
lesions among the deeper structures of the forearm and hand btfiift
the integuments can \k made to yield..
On the 2d of May, 1852, Silas Usher, set. 54, had his right »m
caught between the bumpers of two cars, bruising the hand and Hl-lo-
eating the carpal bones backwards, the radius and ulna being tiiniwa
forwards and pushed completely through the skin into tbe jialmof ilje
hand. Most of the flexor tendons had been merely thrust aside, but
one or two were torn asunder ; the median nerve was torn off, bui tht
radial and ulnar nerves were apparently uninjured, and there was m
fracture. The patient being a temperate man, in perfect healtli. and
the bnnes having been easily replaced by moderate extension, it >nt
determined to make an effort to save the arm. The limb was tlici*fcw
laid on a carefully padded splint, and cool water lotions dilit^nilj
applied. Phl^monous erysipelas began to develop itself on thetbira
day ; and on the ninth, gangrene havJug atlaeked the limb, I sid|mi-
tated a little above the middle of tJie humerus. On the foiirti*ntl'
day hiemorrhage occurred suddenly from the stump, and when 1 r«cW
him he was pulseless and dying.
The result demonstrated the error of the attempt to save tlie limb
without resection of the lower ends of the bones of the forwimi.
Siftiiptoma. — The usual signs have already been sufficienily stiwd
in the example which we have given. The most important diagiywW
marks are found in the abruistnes
Fib. 3S3. of the angles formed by the i«»-
jecting bones; the relation of ibe*'
prominences to the styloid ajxipk^
ses; in the total abeencu of [Tefi-
tus; and In the reilucUon, whidiii
accomplished cosily, suddenly, «J
with a chantcteristic scusatioo. U'
Dliloculiou of the c»rpal bdnea bapk-»n!>. " fraCturC eompli«ltl« ttw l>«iJ«li
crepitus may also W pmtenL ll
should be remembered, moreover, that when the styloid procna of tbi
radius is broken, if the hand is moved baekwards and (iirwanls tlui
proeesH will move al.^o, which might lead to the supposition tbal ^
radiiiH was broken higher up, and that it was not a dislocation at li^-
Protpuisie. — In compound dislocations tlie pri^noeis is excofdioglj
DISLOCATIONS OF THE CARPAL BONES FORWARDB. 65t
Tive, unless the sui^eon determines to resort to amputation, or, what
igeDerally much preferable, to resection. In dislocations complicated
nh fracture of tlie posterior edge of the articulating surface of the
»dius ("Barton's fracture"'), some difficulty may be experienced in
Auning the bones in place ; but when this fracture docs not exist, the
Dsterior margin of the articulation, considerably elevated above its
aterior margin, constitutes a sufficient protection against a reluxation
1 that direction. In all cases, also complicated with fracture, even of
D apophysis, intense inflammation and swelling are likely to follow,
od the danger of a permanent anchylosis is greatly increased.
Treatment. — Extension in a straight line has generally been found
ufficient to accomplish the reduction; to which may he added a slight
ocking or lateral motion, if necessary. ,
The reduction may be effected also by pressing the hand backwards,
'hile the surgeon pushes the carpus downwards from behind and
bove, in the direction of the articulation.
Unless a tendency to displacement exists, no splints or bandies of
ly kind ought to be applied, but it should be treated by rest and cool
Iter lotions until all danger from inflammation has passed.
i 3. Dislocations of the Carpal Bones Forwards.
The causes, mechanism, symptoms, pathology, treatment, etc., of this
Hdent resemble in so many points those of the preceding dislocation,
th only the differences neces-
ily due to a change in the
■ection of the bones, that I
d it not worth while to do
)re than to relate one single
ample, contained in Bransby
'oper's edition of Sir Astley s
irk on Fractures and Dittloca-
na. The case did not come
der the observation of Mr.
N)per himself, but was related
him by Mr. Haydou, a sur-
on residing in London. It
especially interesting as fur-
ihing an example of a disloea-
D of both wrists at the same
)ment, and from similar causes, but in opposite directions.
A lad, aged about thirteen years, was thrown violently from a horse
the 11th of June, 1840, striking upon the palms of both hands and
on hia forehead. The left carpus was found to be dislocated back-
Lids, the radius lying in front and upon the scaphoides and trapezium,
le right carpus was dislocated forwards, the radius and ulna project-
; postenorfy, and the bones of the carpus forming an " irregular
lott^ tumor terminating abruptly " anteriorly.
> Philudelphie Medical Bxaminer, 1888.
652 DISLOCATIONS OP THE LOWEK END OF CLXA.
A very careful examination was made to determine what parts tanw
in contact with the resisting forco, but atthmigh the palms of botk
hands were extensively bruised, there was not the slightest braise on
the back of either hand. >'or
*■''''■ ^'*''- were the gentlemen present able
to find any evidence wfaalevw
that the dislocation was acct
panied with a fracture. "M<
over," says Mr. Ilavdou, "
were strengthened in our opin-
ion that this was a case of ifi
location, unattended with My
fra<!tnre, because the dislocations aiJiieared so perfect ; the two luinon
in each member so distinct; the reduction so complete: the strength of
the parts after reduction bo great ; and lastly, by the very trifling pail
felt after reduction, for within an hour after, the pnllent could roUtt
the hand, and supinate it when pronated — this could not, we belit
have been done had tliere existed a fracture."
m uf ibi- varpal bi
CHAPTER XI.
DISLOCATIONS OF THE LOWER END OF TUB ULN.\ (ISFEKrOE
KADIO-ULNAK).
In connection with fractures of the lower end of the radiiK tliil
accident is not very uncommon. I have myself met with it onH*
these circumstances several times; but without a fracture it istpitt
rare. Dujiuytren met witli but two cases in his long and estiaisn
practice. Sir Astley Cooper dttes not re(«rd a single instance, aw
many surgeons affirm that they have never seen the dislocsuon i*
question.
i 1. Diilocations of the Lower End of the Ulna Backwardi.
To the eleven or twelve examples eollecled and referred lo br Sbl-
gaignc, I am only able to add two cants of ancient luxation «ra I7
myself,
Ca)we«. — Puges mentions the case of n little girl in whom liwaw
dent occurred in both arms, but at diOerent periods, by beinf; Itfttd 1*
the hands. One of the patients seen by Desault, a child five y««* M
had the ulna dislocated backwards by extension at^inipouivd *<''
forced pronation, and in another example, cited by him, fortwl pW»
tion alone, as in wringing wet clothes, was founa to have bnoMiB-
cient. In Herteaux's case the patient had fiillen upon brrwrisL
Pathological Anatomy. — liuptiire of the synoviaj incmbmae !«*■
form ligament), and also of the ligament which binds the ultialotK
DISLOCATIONS OF LOWER END OF ULNA BACKWARDS. 653
Boneifbrra bone : the little head or lower extremity of the ulna aban-
Joning its socket in the radius, and being thrown backwards, or in
some cases battk wards and outwards, so as to cross obliquely the lower
*nd of the radius ; or it mav incline inwards as well as backwards.
House Surgeon Owen, of Bellevue Hospital, called my attention,
ipril 4, 1869, to an example of this dislocation in ward 28. The
patient, Mary Fay, vet 27, having puerperal mania, was confined some
time in February, in a strait-jacket, and the accident happened during
this confinement, about six weeks before she came under my notice.
I found the right ulna displaced backwards so that itsartiular surfaces
were completely separated ; but it did not override the radius, and
with moderate pressure it was returned to place. The dislocation and
reduction, which had been frequently made by the house staff since the
iccident, caused no pain, but was accompanied with a slight grating
iensation.
Dr. Moore, of Rochester, has found this dislocation existing in con-
lection with a Colles fracture. In the chapter on fractures of the
adius I have made especial reference to the views of this distinguished
argeon upon this subject.
Several examples are mentioned also in which the end of the bone
as been thrust completely through the integuments.
Prognosis. — In recent cases the reduction has generally been acconi-
lished without difficulty, and in only three or four instances has the
one become spontaneously displaced.
Loder re<luced the ulna after eight weeks, and Rognetta after sixty
ays. In one of the examples to which I have already referred as
aving l)een seen by myself, the dislocation had existed twenty years,
be accident having occurred in Ireland when the person was fifteen
ears old. When I examined the arm, July 21, 1850, the right ulna
•rejected backwards and a little outwards, about half an inch. He
aid he had been lame with it for several years, but the motions of the
rrist-joint were now completely restored, and both pronation and su-
pination were perfect.
Symptoms. — The hand is usually fixed in a position midway between
upination and pronation. Boyer, however, found the hand in a state
f extreme pronation. The extremity of the ulna is felt and seen dis-
inctly upon the back of the wrist, prominent and movable ; and the
tyloid process is no longer in a line with the metacarpal bone of the
ittle finger; the fingers, hand, and forearm are slightly flexed.
Treatment. — The reduction may be accomplished by holding firmly
pen the radius and at the same moment pushing the ulna forcibly
oward its socket ; or by simply supinating the hand strongly. Some
ases demand also extension and counter-extension.
Grenerally the bone has been found to remain in its place without
SBistance, yet in three or four of the examples upon record the con-
tant tendency to displacement when the pressure was removed has
endered it neceesary to employ splints and compresses.
The dialocatiou forwards is said by Malgaigne to be more rare thia
the di^loc'utiou backwards. In addition to the nine cases collected bjr
him, I have been able to add one reported by Parker, of Liverpool;
leaving, therefore, a diHerenoe of only three or four in &vor of tU
lusation backwards ; and not euSicient, I think, to warrant any posi-
tive conclusions as to the relative frequency of the two accidente.
While the diElocatioD backwards is usually caused by violent pro-
nation of tbe hand, this dislocation is moMt often occasioned by vioW
supination. The hand is therefore generally found to be supiiiatol
forcibly, and the projection formed by the end of the liune is seeu upm
the front of the wrist instead of the back.
By pushing the ulna toward its socket while an attempt is made to
dex the hand, or by extension, supination, etc., it is made to rcsiinie lis
position readily. In the case reporte*! by Parker, however, the reduo-
tion was effected only while tlie hand was pronatBl,
Parker's case, already referred to, is thus related:
" John Dalton, aged forty, applied to tbe hospital Aug. 9lh, 1841,
under tbe following circumstances :
" States that he is a carter, and falling down, the shaA of the art
fell upon his hand and forearm, in such a way as to supinate thm
forcibly. He complains of pain in the left wrist. The fumraii
supinated, and cannot be pronated, the attempt causing much suflrrii^
The wrist-joint can be flexed or extended without much pain. Ub
looking at the back of the wrist, the appearance is characteristic; tin
natural prominence of the nlua is wanting; an evident depratwo
exists, as if the lower end of the ulna bad l)een dissected out ; it can bl
traced, however, on a plane anterior to the radius, it^ button-lihe IkW
being distinctly felt under the flexor tendons. Several im-fltvlual anA
very painful attempts were made to accomplish the reduction, by piuli-
ing tlie head of the ulna into its natural situation. This waaatliS
effected by seizing the hand to make extension (connter-extenuni
being made at the elbow), then forcibly pronating the band, at tit
same time pressing backwards the dislocated head of tlie boue villi
the fingers of tlie left hand. After persevering for a short time,tlR
bone was felt to assume its natural position, tlic wrist aoqaind iv
usual appearance, and the ordinary movements of the joint could hi
readily performed. There was no tendency to retlislocation, »ikJ li»
man was dismissed with directions to keep the bone quiet, wkI b
foment it. He attended as an out-patient for two or throe dn>'S, afi*
which, complaining of nothing but a little weakness in the psrt,i
bandage was applied, and ordered to be worn for n short IJine.'"
J
DISLOCATIONS OF THE CARPAL BONES (AMONG THEMSBLVES),
BuuKD t(^ether on all sides by strong ligaments, and enjoying only
a very limited degree of motion among themselves, the carpal boDes
seldom bei-ome displac-ed except in gunshot wounds, or in connec-
tion with extensive lacerations and fractures of the neighboring jiarts.
Simple ilislocatiotis, or rather subluxations of these bones, do, however,
occasionally take place, but, so far as we have been able to ast^rtain,
only in one direction, namely, backwards.
The bones of the oirpus, which are said occasionally to have suflered
:<tniple liackward subluxation, are the semilunar, cuneiform, and pisiform
of ihe first row, and the magnum of the second row.
Kicherand, the editor of Boyer's Lectui-es, says that he once met
with a subluxation of the oa magnnm backwards, of which he hoB given
us the following account : " Mrs, B., in a labor jialn, seized violently
the edge of her mattress, and squeer^l it forcibly, turning her wrist
for\vards ; she instantly heard a slight crack, and felt some pain, to
«hich her other sufferings did not allow her to attend. Fifteen days
afterwards, happily delivered, and recovered by the care of Professor
Baudelocquc, she showed her left hand to this celebrated accoucheur,,
aod expressaed lier disquietude about the tumor which appeared on it,
especially when much bent. I was called to visit the lady. I found
tliaC this hard cirt^um scribed tumor, which disappeared almost totally
by extending the hand, was formed by the head of the os maguum,
luxated backwards; I replaced it entirely by extending the hand, and
making gentle pressure on it. As the affection did not impede the
motion of the part, as the tumor disappeared on extending the hand,
and ns it would have been but little apparent in any state of the hand
had Mrs, E. been more in fltsh, I advised her not to be uneasy about
it, and to apply no remedy to it.'"
Rtchernnd adds also that Boyer and Cho(>art had each met with the
aamc dislocation.
Bransby Cooper saw the os magnum displaced backwards in a stout,,
muscnlar young man, by a fall upon the back of the hand when in ex-
treme flexion. The hand remained slightly bent, and the projection of
the oe magnum was very distinct. Beduction was attempted by extend.-
ing the whole hand, at the same time making pressure upon the dis-
placed bone ; this not succeeding, extension was made from the middle
and forefingers only, while pressure was kept up on the os magnum,
when suddenly the bone resumed its natural position. On flexing the
656
DISLOCATIONS OP THE CA
hand, however, the dislocation was immediately reproduced; and it
became ne(«asary to apply a compress and splint. For several da;i
after, he was in tlie habit of pushing it out by flexing the hand, io «d«
that the young men at Guy'e Hospital might see ita reduction ; whidi
was always easily accomplished by simple pushing upon it.
Sir Astley says that both the os magnum and cuneiform are sorat-
times thrown a little backwards, from simple relaxation of the liga-
ments, producing a great degree of weakness, so ai; to render the hand
useless unless the wrist be Bupi>orted; and he njcntions the case
young lady in whom the os maguum was thus displaced, aud who mi
obliged to give up her music in consequence ; for when she wishnl to
use her hand, she was compelled to wear two short spUnls^, maileltft
to the back and forepart of the hand and forearm. Another \aAj,
whose hand was weak from a similar cause, wore, for the purpMeof
giving it strength, a strong steel chain bracelet, clasped very liglitjf
around the wrist'
Gras has dest^ribed a dislocation of the pisiform bone,* and Fergia-
son says he has known an example in which this bone was detnrluJ
from its lower connections by the action of the flexor carpi ulnari&i*
Little benelit, he thinks, can be e.'Ei>ected from any attempts to kvef'i
in place when it is dislocated, nor is its displacement of mui:h iikiis^
quence. Erichsen thinks he has seen a dislocation of the us lunaif
produced by a fall upon tlie hand when forcibly flexeil. By exteo^ioa
and pressure it was easily replaced, but when the baud was flexed iIm
dislocation was immediately reproduced.'
Notwithstanding that Sir Astley, Miller, and otiiers have taught ibat
the cuneiform bone is liable to displacement, and that South has affirmol
the same of the unciform, I have found no account of au ex<uii)il« <£
simple dislocation of single carpal bonee except in the cases of tiw i>
magnum, pisiformis, and lunare, as above mentioned.
Maisonneuve has reported an example of simple dislocation, wilJioiil
wound of the integuments, at the middle carjial articulation. A nuu
had fallen forty feet, and was carried <lying to the HAtel Uieu, Tk
eymptoms were almost precisely those of a dislocution of both fi***/
the carpal bones backwards. The reduction was not iici'ora|iiisM
during life, but after death a simple effort of traction was suffiiic'iil*'
replace the bones. The dissection showed that the bones of the jewnJ
row were almost completely separated from those of llic firwt, Dp*
which they were overlapped backwards. A small frajjiui-ut nflwlfc
the scaphoids and cuneiform remained attached to the second row, l*>l
with this exception, the separation was complete.'^
' Sir A. Cooper, op. oit,, p. 135.
* Note to Cheliui, l>j Huulh, op.
* Pi'r|[u«suii, op, fit., p. 190.
* EriotisMi, Science and Arc or Surg , Amer. ed.,
* UnitoDDeuTe, M»lg«igi '" ' ■•■- ■
It., from Uiia. de la Son. de Cblnif|.i i ^
DISLOCATION OF THE METACARPAL BONES. 657
CHAPTER XIII.
LOCATION OF THE METACARPAL BONES (AT THE CARPO-
METACARPAL ARTICULATIONS).
s metacarpal bone of the thumb may be dislocated either back-
or forwards. The backward is the most frequent; and it may
>duced by a fall upon the back of the distal extremity of the
I, which throws it into a state of extreme flexion : it has also
ccasioned by a force acting in an opposite direction, as when a
•f powder is exploded in the palm of the hand, or a blow is re-
upon tlie extremity and palmar aspect of the last phalanx.
! dislocation may l)e partial or complete. In the few examples
tial dislocation which have been recorded, the position of the
has been either moderately flexed or straight, and the signs of
cident have been occasionally so obscure as to have led to an
in the diagnosis, and the luxation has remained unreduced.
the <lislocation is recognized, reduction is in most cjises easily
plished by pressure, combined with extension ; after which it is
mes necessary to apply a splint to maintain the apposition. If
luction is not accomplished, the joint is permanently maimed,
iplete backward luxations are more frequent than incomplete, and
educed by the same class of causes; generally by a fall upon the
r surface of the thumb.
I symptoms are sufBciently clear, although the position of the
> is not always the same. It has been found perfectly straight,
It any inclination either way, or flexed more or less, with the
irpal bone also inclined inwards toward the palm. The motions
joint are interrupted, and the proximal extremity of the meta-
bone riding upon the back of the trai)ezium, projects sensibly
3 direction, and the trapezium is also felt unusually prominent
the thenar eminence. The overlapping varies from a line or
three-quarters of an inch. In the patient mentioned by Bour-
:he head of the metacarpal bone almost reached the styloid pro-
'the radius.
5 reduction is to be eflected by extension alone, or by extension
iioderate pressure.
:wo of the examples reported, although the reduction was accom-
i very easily, the disloc^ation was reproduced when the extension
, and it became necessary to apply splints. Malgaigne did not
e, in the case seen by him, any such tendency to displacement,
the case of Bourguet's patient the reduction was never accom-
3, although the attempt was made on the second day by a sur-
and repeated after about two months by Bourguet himself,
gusson, who has met with several of these dislocations, says that
658
DISLOCATION OF THE METACARPAL BOXES.
he has seen even a splint and roller fail of keeplne the hones in place
and lie recommends, for the purpose of security, tliaf the splint slioali
extend some distance upon the forearm.
Sir Astley Cooper aavs that, in tlie cases of this accident which lu
has seen, the metacarpal hone of the thumb has been thrown inwsr<I%
between the trapezium and the root of the metacarpal bone supportii^
the fore&ngcr; forming a protuberance toward the palm of the hand;
the thumb ha!« been bent backwards, and adduction was impossible.
This distinguished sui^on cites no examples, nor are we able
find upon record an instance of complete inward dislocation of ihii
bone, such as Sir Astley has described,
Vidal (de Cassis} believes that he Itna met with a partial forn-aid
dislocation, which he reduced readily, bnt the patient having removed
the retentive means, the dtsloi<aLiou was reproduced and the lioue vrtt
not again replaced.'
Malgaigne has collected only three examples of a dislocation of eilhtf
of the other metacarpal bones. One, observed by Boiirguct, was a dis-
location forwards of the metacarpal bone of the index finger, havii^
been caused by a great force applied to the hack of the phalanx ticit
the carpus. Reduction was eflectcd by extension and pressure, llw
bone resuming its place insensibly and not suddenly. With the atd*
of splints it was retained in position, and the cure was perfixl. The
second, seen by Ronx, was a backward luxation at the (nirito-nietacaiv
pal articulation of the second, or great finger, producwl by on ei(Jo-
sion in a mine. By pressure made directly upcjn the pnijevtiug bnne
he was unable to reduce it, but by uniting pressure with exlenuoi
from the finger, he succeeded readily. After the reduction «iis ei^doli
it was noticed that when the hand was straightened the bone \x
reluxated, bnt that it was easily kept in place when the band ml
flexed. The third example (occurring in the same joint), mentiomJ
by Malgaigne, occasioned by a fall upon the clenchetl hand, waH pr»l>-
ably incomplete, and Malgaigne is not quite certain that it wa$ iwil •
fracture.
The following very instructive case of for\vard Inxatinn ofthesMaml
metacarpal bone at its proximal end, has been reported to me by Dt
J. Marsh, Asst. Surgeon U. 8. A.
On the 1st of April, I8fl8, Corporal Charles C, »et. 25, wiHStrwi
accidentally on the back of his right hand by a hammer weighing »m«
pounds. The hand was at the time firmly clenched, and (werwl wit^
a buckskin glove. The blow was re<«ived obliciuely. Dr. MonhM*
him half an hour after the accident. A marked depression wwrnKlil?
discovercil on the back of the hand, corresjMnding to the prmiotfi
end of the bone, and from this [mint a gradual elevation of the boot
could be traced to its natural level at the distal cud. On the |«lmuf
the hand the displacement was equally manifest. In thi.<4 position i<
was fixed, and seemed immovable. It was (iisily and quickly wliifwl'
however, by making extension from the fingere, while at tli« """
moment pressure was made by the thumb in the palm of the i^i^
> Vidal (de CmsU), Trniti de Patholugie Etterne, etc., Sd P«ri«ed.,t. il.^W^
DISLOCATION OF THE METACARPAL BONES. 659
[t returned to its place with the usual sensation accompanying a reduc-
ion of a dislocation, and the deformity at once disappeared ; a ball of
ow was now placed in the palm of the hand, and secured there by a
oiler. On the 13th of April he returned to duty, but his hand did
ot acquire its full strength for some time longer.
The following example of dislocation of all the metacarpal bones,
ccept that of the thumb, is probably without a parallel. Corporal
arrigan, at the battle of Fredericksburg, Dec. 13th, 1862, while
)lding his gun at " ready," was hit by a ball on the back and ulnar
le of his left hand, the ball traversing the back of the hand between
e last row of carpal bones and the skin, and emerging on the radial
le, sending the carpal bones forwards and dislocating the metacarpal
nes backwards. Great swelling ensued, and the nature of the acci-
nt was not known for some months. When I examined the hand^
e years later, the displacement was very conspicuous ; no fragments
bone had ever escaped. The motions of all the fingers, except the
lex and little fingers, were unimpaired.
In April, 1849, Stephen Peterson, aet. 24, was admitted into the
iffalo Hospital of the Sisters of Charity, with a partial dislocation
:;kwards of the proximal ends of the metacaq)al bones of the index
i great fingers of the right hand ; produced, as he affirms, by strik-
r a man with his clencned fist, about one year previous. He says
It he called upon a surgeon immediately, but he was unable to keep
5 bones in place. The projection was very manifest at the time of
r examination, and the hand had never recovered the power of grasp-
r bodies firmly.
During the same year I found in the hospital a precisely similar
se, in the person of Francis McCoit, ret. 32, a sailor, which had oc-
rred four years before, in consequence of a blow given with his fist.
16 same bones were partially displaced backwards, and remained
ireduccd. This man had also consulted a surgeon soon after the in-
nr was received.
In both of the above examples I instituted a careful examination to
itermine whether it was not the bones of the carpus which were thus
splaced ; but the result was conclusive as to the nature of the acci-
int, and I have obtained casts of both, in order to illustrate partial
islocations of the metacarpal bones.
In 1866 I met with a similar case, only that the metacarpal bone of
ie index finger was alone dislocated, at Bellevue Hospital, in a woman
8 years of age, caused by falling upon her hand with the fingers
ioeed. Reduction was easily effected.
OP THDMB AND FISGERS.
During qiiife half an hour I mnAe continued and varied attempts to
reiluoe the iioue by exteueion, by forced dorsal flexion, and by ppessitig
the upper end of the first phidiinx in the direction of the joint nliile
preEiiure was made against itK lower end ao aa to bring it into dorsal
flexion, and finally by mlling to my aid the "puzzle" and chlurvtiirm,
but nil to no purpose.
One week later I repeated these efforts, and with no better KueMak
The parents peremptorily refused to allow me to cut the lateral liga-
ments or flexor tendons, so the bone remains unreilnced.
In the following case the relative position of the bones was the iftRii
as ill the preceding case, but tJie reduction was not difRcull.
Beruard Lawler, »t, 10, was admitted to Bellevue Hospital in Jan-
uary, 1864, with a fracture of the femur and other eevere injiirioi
The dislocation of the thumb was not noticed until the ninth thj.
The reduction was then easily accomplished, in presence of thecliGa
of medical students, by forced backward flexion.
Surgical writers have recorded, from time to time, a great maaj
cases in which it has been found difficult or impossible torfttd (fr
duction ; and it is asserted upon the authority of Bromfield, qnoled by
Hey, that the extending force has been increased to sucli an ninouol «
to tear off the last phalanx without having succeeded in reducing tlie
first ; but while surgeons have united in their testimony as lo the ex-
ceeding obstinacy of a large proportion of these dislocations, liiej- tn
far from being agreed as to the source of the difficulty.
Sir Astley Cooper finds a sufficient explanation in the eix short dqiI
powerful muscles which are inserted into the first and lust phalaoi,
and especially in the flexors.' Hey believes the rmistance to be in U«
lateral ligaments between which the lower en<l of the metacarpal htmt
escapes and becomes imprisoned. Ballingall, Malgaigue, Ericli!«,
and Vidal (de Cawis) tliink the tnea-
■arpal bone is locked between dwtwo
's of the flexor brevis, or rather be
twccn the opposing sets of niuficlee whiii
centre in the sesamoid bones, as a InittB
is ^tened into a button-bole. I'ailloai,
Lnwrie, Michel, Leva, Bifchy, anil Bi*«
affirm that the ant«rior lit;iinii-nl b«i><(
torn from one of its attJU'limcatfe, W"
between the joint surfaces mid intcrp**
an eflfectual obstacle to re<liiclinn. V*
puytreii ascribes the diffimlly to tlw *^
tered relations of ttie Uileral li|[UtKiri!V
Liu.flnim.. which are naturally parallel toihfl«rt
of the metacarpal bone, but which u*
now placed at a right angle ; to the s]^iasni of ihe miu^clofi, and t" ^
shortness of the member, in consequence of which the force of i ^
■ Lnwrie, of Glatgow, aaje that Sir Antloy in « convoniatiun w((h blu itKitf^
ih»t ihe "leaNinciid Ikiiim" Wiethe lourcn of Iho diAculty. S«w Ani«- J<**-
Med. Sc'i , vol. xxW, p. 200, with observaciups and vijwrttnVDU b; Lawrl*.
662 OF FIRST PRALANGES OF THUMB AKO FINGF.BS,
During quite half an hour I made coiittniie<l and varied attempult
reduce the lione by exteuaion, by forced dorsal flexion, and by pressii
the upper end of the first phalanx in the direction of the joint whil
pressure was made against its lower end so as to bring it into dorarf
flexion, and finally by culling to my aid the "puzzle" and chlorofors^.
but all to no purpose.
One week later I re|>eated these efforts, and witli no bett*r snoo
The parents peremptorily refused to allow me to eut ihe lateral liga-
ments or flexor tendons, so the bone remains unredu<«d.
In the following case the relative position of the bones was the saw
aa in the preceding case, but tlie reduction was not difBcuIt,
lleruard Lawler, let, 10, was admitted to Eellevue Hospital in JiOi^
uary, 1864, with a fracture of the femur and other »ievcre injnricL^
The dislocation of the thumb was not noticed until the nintli dgy^
The reduction was then easily aeeomplished, in presence of thecliM;
of merllcal students, by forced backward flexion.
8urgieal writers have recorded, from time to time, a great man
oases in which it has been found difficult or impossible^ to atfecX n
duction; and it is asi^rterl upou the authority of Bromfield, quoted h]
Hey, that the extending forc« has been increased to such an amounts
to tear otT the last phalanx without having succeeded in reducing tbl
fii-st ; but while surgeons have united in their testimony as to the o^
ceeding obstinacy of a large proportion of these dislocations, they ttt
far from being agreed as to the source ol' the difficulty.
Sir Astley Cooper finds a sufficient explanation in the six short tdt
powerful mnscles which are inserted into the first and last phalinir'
s the reaisiance
St pha
lobo i:
and (Specially in the flexors,' Hey belie
lateral ligaments between which the lower end of the metacarpal h
escapes and becomes imprisoned. Ballingidl, Malgaigiie, Ericl
and Vida! (de Caflsis) think the t
Fill. MT. carpal bone is loclced between tbf (••
~ heads of the flexor brcvis, or rather bl
tween the opposing sets of mnsclo w'
centre in the sesamoid bones, ks a bn
is fiistened into a button-holv. Pailli*
Lawric, Michel, Leva, Blechy, and B
aflirtn that the anb^rior ligimii'til ba
torn from one of its attai'hmenl&,fc
between the joint surfaces ami iatety
an eflectua! ol)stacle to reduction.
puytren ascril>eH the difficulty tothMl
tercd relations of the lateral li^^
cio.ehiu.b. ^|j;^|j are naturally paraUel t_ _.
of the metacarpal bone, but wUtlll
now placed at a right angle ; to the spasm of the muscles, sal MJJI
shortness of the member, in consequeuoc of which the force of eJ
' Luwrie, ot GiMgow, Mf* tliat Sir A«lle^ in b converution with bin 4)
thkt the "lesanioid bonc^a " were the H)urvM uf Ihc difficulty. SinAaMr. i<*<
Med. Bti., vol. iiii, p, 280, with observalioi . - - .
FIB8T PHALANX OF THE THUMB BACKWARDS. 661
a "puzzle," and making extension in a straight line, while an assistant
made counter-extension from the hand and wrist. The use of the
ioint was soon completely restored.
Examples, however, are constantly occurring, which are only re-
laced after long-continued and painful efforts, or which, indeed, cora-
•letely exhaust the patience and baffle the skill of the most experienced
Qrgeons.
Mary J. S., ait. 23, fell upon her right hand with her fingers and
mini) extended, in September, 1853, and dislocated this bone back-
ards. A young surgeon attempted to reduce the dislocation half an
)ur after the accident, by the same manoeuvre adopted by myself
ccessfully in the case of the servant-girl ; only that he made exten-
>n upon the last phalanx at the same moment. The surgeon believes
at the bone was reduced, but one week later he found it displaced,
id, as he believes, reduced it again. The same thing occurred a third
ne.
Six months afler this, the girl consulted me to ascertain what could
t done for her relief. The thumb occupied the usual position, and
Imitted of no motion except at the carpo- metacarpal articulation.
It is quite probable that the dislocation was never reduced, an error
bich, if it did occur, might easily be excused, when we remember
at from the first the thumb was greatly swollen.
In May, 1848, having been called to see G. H., who had attempted
icide by cutting his throat, my attention was arrested by the appear-
ice of his left thumb, and which I found to be occasioned by an
tcient dislocation of the first phalanx backwards. The accident had
curred, he afterwards told me, twelve years before, in consequence of
fall while wrestling. A very respectable country surgeon was called,
id made three several attempts to reduce it, but failed.
The several bones of the thumb occupied their usual positions, that
to say, the positions which they usually occupy in this dislocation,
5t notwithstanding the almost complete anchylosis of the phalangeal
iiculations, and the awkward encroachment of the distal end of the
etacarpal bone upon the palm, the hand was quite useful.
In September, 1864, 1 found in my service at the Charity Hospital
Hackwell's Island), New York, an unreduced dislocation of this kind
a girl. The surgeons had tried to reduce it, but had failed.
On the 25th of July, 1857, Catharine Ernst was brought to me, by
!r parents, having a dislocation of the first phalanx of the right hand,
hich had already existed some days, and upon which several unsuc-
ssful attempts at reduction had been made. The dislocation was
ickwards, but the phalanges, instead of standing at an acute or right
igle with each other and with the metacarpal bone, as is usually the
se, were in a straight line with each other and parallel with the
etacarpal bone. Whether this phenomenon existed from the first, or
as due to the efforts already made at reduction, I could not determine,
It the same thing has been noticed occasionally by other surgeons.
he first phalanx, moreover, instead of being placed directly behind
le metacarpal bone, occupied a position upon its back a little to the
idial side of the centre.
662 OF FIRST PUALANflES OP THDMB AND FINGERS.
During quite half an hour I made continued and varied attemple to
reiiu« the l>oue by extension, by forced dorsal flexion, and by pn«siD|
the upper end of the first phalanx in the direction of the joint uliilt
pressure was made against its tower end t^o as to bring it into donl
flexion, and finally by calling to my aid tlie "pu!u:le" and chlorofum,
but all to no purpose.
One week later I repeated these efforts, nnd with no better Mccat
The parents peremptorily refused to allow me to cut the lateral lig*-
ments or flexor tendons, so the bone remains unreduced.
In the following case the relative position of the bones was the sanH
as in the preceding case, but the reduction was not difficult.
Bernawl Lawler, ivt. 10, was admitted to IJellevue Hm^pital in Jwh
nary, 1864, with a fracture of the femur and other severe iDJaritk
The dislocation of the thumb was not noticed until the ninth day.:
The reduction was then easily accomplished, in presence of (liedi
of medical students, by forced backward flexion.
Surgical writers have recorded, from time to time, a greol many
cases in which it has been found difBcuU or impossible to cffi*l it-
duction ; and it is assertetl upon Uie authority of Bromfiold, qiioled hf
Hey, that the extending force has been increased to such an anxiuntM
to tear off the last phalanx without having succeeded in n-dncing; ibl
first ; but while surgeons have united in their testimony as to the (3-
ceeding obstinacy of a large proportiim of these dislocations, they M
far from being agree<l as to the source of the difficult.
Sir Astley Cooper finds a suEBctent explanation in the six shnrt loi
powerful muscles which are inserted into the first and lost tihalanlr
and especially in the flexors.' Hey believes the resistance to iw in the
lateral ligaments between which the lower end of the metacarpal
escapes and becomes imprisoned. Ballingalt, Malgaigne, En<:J»ait
and Vidal (de Qu«is) think the mtur-
Flo. »7. carpal bone is locked between Hk tw
heads of the flexor brevis, or rather b^
twecn the op[>osing sets of mnecW vrhick
centre in the sesamoid bones, as a I
is fastened Into a button-hole. WilloUi
Lawrie, Michel, Leva, Blei:hy, and Kc
affirm that the anterior ligiiment beiiff
torn from one of its uttachment^ &fl
between the joint surface* and Jnlrrpi
an eflectnal oltslaele to rednclion. P**
puytren ascribes the diflicnlty tti tbr il*
« ten>d relations of the lateral lifani) "
cio'Bhiwh. which are naturally parallel lo tlwi
of the metacarpal bone, but whidi
now placetl at a right angle ; to the npnam of the mu.»cl(«, and M
shortness of the member, in consequence of which the force of Mtm
' Ltwrie, of Olnigow, i«;a tliBt Sir Axtloy in t. convcmallon with him 4k>
th«t iho " »e«timoid bones " w*ro the source* of the difBculty. So* A»cr. J**
JUed. Bel, vul. xxii, p. 230, with oUervntiuns nnd nxperlmsnu by LBwria.
FIRST PHALANX OF THE THUMB BACKWARDS. 663
has to be applied very near to the seat of the dislocation. Lisfranc
found in an ancient luxation the tendon of the long flexor so displaced
inwards and entangled behind the extremity of the bone as to prevent
reduction. Deville discovered in an autopsy a similar displacement
of this tendon outwards. Wadsworth has made the same observation.^
The modes of reduction practiced and recommended by these differ-
ent surgeons are as diversified and irreconcilable as their views of the
mechanism and pathological anatomy of the accident.
Sir Astley Cooper recommends that extension shall be made by
bending the thumb toward the palm of the hand, to relax the flexor
muscles as much as possible, and then, by fastening a clove hitch upon
the first phalanx, previously covered with a piece of sofl leiither, the
extension is to be continued, only inclining the thumb a little inwards
toward the palm of the hand. If these means fail after having been
continued a considerable length of time, he advises that a weight shall
)e suspended to the thumb, passing over a pulley. Finally, in the
vent of the failure of this method also, Sir Astley thought that no fur-
ber attempts should be made, and especially that no operation for the
ivision of these parts is justifiable.
Lizars and Pirrie adopt the views of Sir Astley with little or no
ualification.
Fio. 288.
Sir ABUey Cooper's method of reducing dialocations of the thumb, with pulleys.
Charles Bell proposed flexing the joint, employing also at the same-
ime pressure ; and in obstinate cases he advised subcutaneous section
f the lateral ligaments with a small knife, a method which has since
«en practiced successfully by Liston, Reinhardt, Gibson, of Philadel-
hia, Parker, of New York, and others. Syme and Lizars justify the
ractice in certain cases. In one case which has come under my notice,
fter failing to effect reduction by the usual methods, I succeeded
romptly after cutting one lateral ligament; and in the second case I
nly succeeded after cutting both lateral ligaments.
EoeeVf from his experiments upon the cadaver, concludes that the
idocated phalanx must first be bent forcibly backwards, or into the
OBition termed by some writers dorsal flexion, so as to throw the head
Tthe phalanx forwartls upon the articulating surface of the metacarpal
one. Parker, of New York, in his notes to the American edition of
amnel Cooper^s work, recommends the same procedure.
Vidal (de Cassis) recommends also that the extension should be made
rat backwards, so as to increase the displacement of the first phalanx
» Wadsworth, Amer. Med. Times, Feb. 18, 1864, p. 77.
664 OF FIRST PHALANGES OP THOMD AND FISQEKS.
in this direetioii, and to throw forwards its articular surface in the
r«?tion of the articular surface of the metacarpal bone.
This method, namely, dorsal flexion, as the first and most eeeeni
part of the manceuvre, seems to have met with more general ammi
than any other, and the following observations, made by the late Reub^
D, Miissey, of Cincinnati, illustrate the general practice among Amoo
can surgeons at thia day.
" I tilt the dislocated phalanx up until it stands upon its artimlathif
end, place both forefingers so as to bold it in that position, and at tit
same time press against the distal extremity of the metacarpal bun
make firm pressure with the thumbs against the base of the diskitHtfl
phalanx, and slide it into its pla(«, which can generally be accompli^btA
with ease.
" More than twenty-five years ago, the chairman of this commilie^
from attention to the mechanism of the metacarpo-pbalangea! joint
the thumb, i-onvinced himself that the principal imi)eiliment to tb«[^
duction of the first phalanx from backward displacement is tlie»h
flexor of the thumb, between the two portions of which (lying ci
together where they are fastened to the sesamoid bones) tlio ht-ad nf I
metat^arpal bone has been thrust, the contracted part or ncrk of (tat
bone lying firmly grasped by them. Fifteen yeare ago, n caiw oti!
ciirred of this dislocation which he could not reduce in the ordiDU^
way. A subcutaneous division of one of the beads of this mutide m^
made with an iris knife, and the reduction was accomplished wtlh tl*
greatest ease.
" Last year another case occurred, in which we failed of rcdurtioD bf
Dr. Crosby's method, which we believe to be the best, and the sobn-
taneous division nf both heads of the muscle was ma<Ie, and ibe ml*^
tion instantly effected. The punctures were covere<I with collorlioo,
and the thumb supported by a splint. As the patient was iutempmlft
entire abstinence from liquor and the adoption of a light diet wcrrai-
joined. Neither pain nor inflammation followed, aud a month »lin-
wards the joint had free motion. After the Intem|»rate and imijoltf
habits were resumed, the joint in a few weeks was found am-liylxi'A
In these teases, the knife, in the subcutaneous operation, wan isrHn
down to the metacarpal bone, so far behind its head as to pnTlwJdl*
possibility of mistaking the lateral ligaments for the muHfS. W
ligaments are very short, and inserted close to the articular si '^
and arc probably, one or both, ruptured in this dislocntion."'
Dr. J. P. Batchelder, of New York, in a paper read tx-fnre tlif 5"
York Medical Association in 1856, says: "The wirgeon shitalil ■*
the metacurjial portion of the dislocated thundi l>Gtwei'n the ihumlf*
finger of one hand, and flex or force it as far as may U^ into tbtfj
of the hand, for the purpose of relaxing the muscles connMlJ •■
the proximal end of the phalanx, particularlv the flexor brevi* [k'S*
He should then apply the end of the thumb of his haud afui^^
disjdaced extremity of the ihslocatcd phalanx, for the puiw**f •!*
ing it downwards, and at the same time gnisp the displaced thonib*"
> Muwy, Tmng. Amor. Med. Amoc., toI. iii, tSSO. p. SAT.
FIRST PHALANX OF THE THUMB BACKWARDS. 665
is other hand, and move it forcibly backwards and forwards, as in
tPODgly forced flexion and extension, the pressure against the upper
xtremity of the first phalanx being kept up. In this way the dislo-
ited bone may be made to descend, so as to be almost or quite on a
DC with the articulating surface of the metacarpal bone, when the
iamb may be forcibly flexed, and, if it be not reduced, as forcibly ex-
inded, and brought backwards to a right angle with the metacarpal
one; when, if the downward pressure, with the thumb placed as before,
irected for that purpose, haa been continued (which thumb, by main- '
lining its position, acts as a fulcrum, as well as by its pressure), the
Mie will slip into its place, and the reduction be eflected in less time
lan has been spent in describing the process."*
Six successive cases of treatment by this method are mentioned in
le Amencan Journal of Medical Sciences for April, 1858 ; one by
lickard, one by Morgan, two by Cutter, and two by Crosby. I have
Iso once succeeded by the same method.
By those who have regarded extension as an important element in
le reduction, various instruments have been devised for the purpose
obtaining a secure hold upon the dislocated member. Sir Astley
)oper, as we have already seen, recommended the sailor's clove
fccfl f Lawrie advises that the thumb shall be thrust into the open
ndle of a large door key f Charri^re and Luer, of Paris, have each
(rented forceps, so constructed with fenestra and straps, as that when
B blades are closed the member is held very firmly in its grasp,
chard J. Levis, of Philadelphia, recommends " a thin strip of hard
)od, about ten inches in length, and one inch, or rather more, in
Fig. 289.
LeTi8*8 instrument for reduction of dislocations of fingers or the thumb.
dth. One end of the piece is perforated with six or eight holes.
le opposite end is partly cut away, forming a projecting pin, and
iving a shoulder on each side of it. Towards this end of the strip,
lort of handle shape is given to it, so as to insure a secure grasp to
3 operator. Two pieces of strong tape or other material, about one
rd in length, are prepared. One of these is passed through the
les at the end of the strip, leaving a loop on one side. The other
jc is passed through another pair of holes, according as it may be a
amb or a finger to which it is to be applied, or varied to suit the
* Batchelder, New York Journ. Med., May, 1866, p. 840.
* Op. cit., p. 661 ; also Bost. Med. and Surg. Journ., Oct. 1, 1857.
* Liiwrie, Am. Journ. Med. Sci., vol. xxii, p. 229.
48
666 OF FIRST PHALANGES OP THUMB ANP FISOEBS,
length of the linger, leaving a tiimilar loop. If a dislocated thumb a
to be acted on, the second tape should be passed through the
nearest the first. The ends of each separate tape are then tied togetbff.
"To apply this apparatus, the fiu^rer is pBS.«cd through the lou|&
The loop Dfiare^t the first joint is thou tightened by drawing on the
ta|>e, which is then brought along the strip to the o))posit« «nd, am»
one of the shoulders, and secured by winding it firmly nrouiid the
projecting pin. The other tape is tightened in a like manner, iTti^irf
the other shoulder, and winding around the pin in an opposite dim-
tion, when, for security, the ends of the tapes are finallv tied tiigi-lber."'
This apparatus enables the operator to apply both extension inJ
Besion or leverage in any direction. The proximal end of thephf
lanx may be lifted, or even rotated so as to allow one eide of tlie tnoi
to approach the socket before the other.
Malgaigne describes an apparatus invented by Kirchoff, which il
very similar to, yet not quite bo complete as this of Ixtvis.
la the April number of the Buffalo Medical Journal, for 1S4". I
have described an instrument, or rather a toy, in my possession, whidi
I suggested might be useful for the purjK>se of making extension up*
dislocated fingers ; and which, as will be seen by a refereooe to oik of
the cH^os already reporled in tins chapter, I have since applie<l succe^
fully. It is made by the Indians, and may always be obtained dnrii;
the watering season, at the Indian toy-shops at Niagara Falls. Tta
Indians call it a "puzzle," and know no other use for it than to ftsW
/^''Wi'ttiitiuV
it upon the thumb or finger of some victim, and then puUll
until he begs to be released.
The "puzzle" Is an elongated cone of alwut sixteen (
inches in length, made of ash splittings, and braided ; tbc o,
the cone being about three-fourths of an inch in diameter, wi '
PIR8T PHALANX OF THE THUMB FORWARDS. 667
ite end terminating in a braided cord. When applied to the
, it is slipped on lightly, forming a cap to the extremity, and to
he length of the finger, but on traction being made from the
ite end, it fastens itself to the limb with a most uncorti promising
If constructed of appropriate size and of suitable materials it
les the more securely fastened in proportion as the extension is
sed ; yet, applying itself equally to all the surfaces, it inflicts
ist possible pain and injury u|K)n the limb. When we wish to
e it, we have only to cease pulling, and it drops off spontane-
Holmes says that the same instrument is made by the Indians
line, and that several years ago Dr. Davis, of Portland, brought
• Boston, and showed it to the Society for Medical Improvement,
)ting that it might be used in the same manner which I have
mended.^
tally, in some compound dislocations it would be better not to
pt the reduction of the dislocation until resection has been prac-
Samuel Coo})er relates a case in which the reduction was fol-
by inflammation and death within a week after the accident,
Torris, of Philadelphia, mentions an instance which came under
iservation, where violent inflammation and tetanus followed the
tion.* Roux, Evans, Wardrop, Grooch, Sir Astley Cooper, and
other surgeons, have practiced resection successfully in these
tnts, and have added their testimony in favor of this mode of
lure.
i 2. Dislocations of the First Phalanx of the Thnmb Forwards.
> to the present moment, I have met with but two examples of
lislocation, while, as has been already stated, the backward dis-
on has been seen by me nine times.
»race Kneeland, of Rochester, N. Y., eet. 24, dislocated the first
nx of the right thumb forwards, by striking a man with his
led fist ; the force of the blow being received upon the back of
econd joint of the thumb. The dislocation had existed three
ivhen he called upon me, and in the meanwhile several attempts
teen made to reduce the bone by simple extension. The first
nx was in front of the metacarpal bone, and in the same plane ;
le last phalanx was slightly inclined backwards. The hand was
ly swollen and quite painful.
zing the dislocated thumb in the palm of my right hand, with
Qgers resting upon the back of the patient's hand, I forced the
halanges into flexion by firm and steady pressure continued for
seconds, when suddenly the bones resumed their places, and all
nity disappeared,
ense inflammation resulted, followed, after a few days, by suppu-
1 Trans. Am. Med. Assoc, vol. i, p. 267.
' Norris, Amer. Journ. Med. Sci., vol. xxxi, p. 16.
6G8 OP FIRST PiXALANOES OK THUMB AXD Fi:
ration uader tbe palmar fascia; and in the eud the thumb was ulmoit
completely aDchjlosed.'
Ou the 24th of April, 1855, J. M. Booth, of Buffalo, iet. 10, tailed
at my office, having a dislocation forwards of the first plialaox, war
sioned, about half an hour before, by being thrown from a hoiK-. Tlw
last two plialanges were neitlier flexed nor extended, but straight, and
parallel witli the nietacaqial bone.
By the same niuiioeuvre adopted in the preceding case, but will
only very moderate force, the dislocation ivtis promptly reduced.
The usual causes of this accident are falls or blow^ upon the thomb
while it is flexed; and the symptoms which characterize it are, in
general, such as we have seen in the two examples whiuh have just
been given. The metacarpal bone projects posteriorly, and the 6nt
phalanx producer a corresponding projection toward tlie palm; (be
two phalanges are extended ujwu each other, and parallel with ib«
metacarpal bones. N^laton saw a case in which the firat pliatsnx ni
flexed ubont 45° ; and in several examples it has been observed to be
slightly rotated inwards.
In the few examples of this accident which have been reportid, tbe
reduction was easily accomplished; or, at least we may say thit the
difficulties in the way of reduction were not so great as they an usotllf
found to be in dislocations backwards. Malgaignc has been tlrle »
collect but four undoubted examples, all of which were itduoed;
Lenoir was able to efl'ect the reduction by moderate measures, after tbe
bone had been dislocated thirty-eight days. Ward suc-ceedeil by idupll
extension.'
Lombard, after the trial of other plana, finally .succee<led by rev«»-
ing the phalanx. Employing, as we have before termwl it, " dorsil
flexion," with extension and lateral motion; but in all, or nenrlTiQ
the other examples, the reduction hiui^ been eflixited by fl(Ofiii|[ [hi
thumb forcibly towai-d the palm; the revei-se of the method wliiti
we have seen preferred, especially by Ameri<»u surgeons, in diiilun-
tions backwards. My own exi>crience also authorizes nie to rewm-
meud this plan.
i 3. Dislocations of tbe First Phalanx of the Fingers.
The index and little fingers, owing to their ex])osed situalioo^
most liable to these dislocations. I have met with three exampl»<'f
traumatic dislocations of these joints, one of winch was a forwanl ibJ
two were backward luxations, and all had occurred in the index fingtr.
James Neabitt, of Buffalo, ipt. 11, dislocaUxI the index finger of ih«
right hand, backwai-ds, by a fall down a flight of stairs. On thv *"*
day, Feb. 11, 1851, he called upon me, and I found the flngtr msiti*
flexed nor extended, but straight and immovable. The prtjcLtir*'
occasioned by the ends of the two bones were very markc<l, and saA
BB to render an error in the diagnosis impoesible. Uvductioa m
sccompliehed witli great ea»e, by reversing tlie finger and
PHALANQES OF THE THUMB AND FINGERS. 669
rate extension, while at the same time the proximal extremity of
rat phalanx wa« pushed toward the distal end of the metacarpal
Id short, the process w&n the same as that which wc have
imended in dislocations of the thumb backwards.
Buknrd dUlOHllon ot lint philui. BedocUon b; cilauiDD.
the second case, presented in a woman 35 years of age, at Charity
tal, April 16, 1868, the dislocation was caused by her husband
S pulled the finger violently backwards. The metacarpal bone
rust through the skin on the palm of the hand. Four weeks
ow elapsed, and the wound had healed. A few days before, the
surgeon had placed her under the influence of ether and had
pted r^uction, but had failed, and she refused to allow me to
the attempt.
the example of dislocation forwards, occasioned by a blow from
I ball, received upon the end of the finger, the first phalanx waa
toeition of extreme extension, and the second moderately flexed,
ition was eBect«d with great ease by extension in a straight line,
f the surgeon were to experience difficulty in the reduction, it
no doubt be advisable to resort to the method of extreme flexion,
one instance, I have seen nearly all the fingers of the left hand,
he thumb of the right, dislocated backward by the contraction
cicatrix after a severe burn.
CHAPTER XV.
LOCATIONS OF THE SECOND AND THIRD PHALANGES OP
THE THUMB AND FINOEBS (PHALANGEAL).
rwiTHSTANDiso slight difEorences in the form of the articulations
ai the thumb ami fingers, and in the size and situation of the
which compose the phalanges of the fingers, we are disposed,
.ly to the practice of some other writers upon this subject, to con-
ill the dislocations to which these several joints are liable, under
ction. Nor, indeed, after the attention which we have given to
slocations at the metacarpo-phalangeal articulations, do we find
to add in relation to these accidents ; since in almost every point
BALANGES OP THE THUMB AND FIKOERS.
of view in which tliey may be considered, tliey Imve so niudi in
common.
The Ia8t plialanx of the thumb is, of all t)ie phalanges, moft liable
to dislocation, and this generally takes place backwards. Verr fre-
quently, also, it is act'ompHuicd with sucli a laceration a-« to render it
compound, Tlie dislocated phalanx is usually reversed in the Imck-
ward dislociition, and straight, or nearly so, iii the forward dislocation,
In most cases reduction may be accomplished Ciisily by forced doral
flexion in the case of the backward luxation, and by forced palmir
flexi'in in the cose of the forward dialocation,
In the winter of 1848, a young man was brought into ray clinic,
who had met with a forward sn!)luxatioD of this phalanx about one
month bt'lbre. He had fallen upon the cud of his thumb, and of the
accident was followed by a good deal of inflammation and swelling,
be did not notice the displacement until some time aflonrurds. The
proximal end of the last phalanx projected two or three lines toward
the palm ; the finger was straight, and thi.i joint anchylosed. I liid
not think the chance of restoring and maintaining the bone in pmitimi
sufficient to warrant any interference, and he was dismissetl witli ito
assurance that after a few months It would occasion him no great tD-
convenieoee.
On the 2d of March, 1851, Thomas Burton, aged abon( twenty-two
years, by a fall dislocated the second phalanx of the middle finger tf
the right hand, backwards. The force of the concussion was received
^ upon the extremity of the finger. Niue hours afler the twridenC I
found the bones unreduced; the finger nearly straight, or with only
slight flexion of the second phalanx n|)on the first ; the thin] phtlaol
forcibly straightened upon the second ; all the joints rigid ; finger TOJ
painful and somewhat swollen.
By moderate extension alone, applied for a few seconds, the reduc-
tion was accomplished.
James Cooper, set, 2-3, came to me on Sunday morning, the Hth''
Dec. 1851, to obtain counsel in relation to his finger which had be«
dislocated the day before, but which he had himself reduc«l by«iinpl»
extension made in a straight line. Mis own acconnt of it was, tiM ki
fell upon a slippery sidewalk, striking up«)ii the cad of his ring fiaC
in such a way that it seemed to double under him. On cxamiMli^'
he found the second bone dislocated inwards, or to the ulnar side, eit^
pletely, the end of the first phalanx torming a broad prnjwlion ui>«
the opposite side; the last two phalanges fell over towoni the uiodk
PHALANGES OF THE THUMB AND FINGERS. 671
■
finger, but they were neither flexed nor extended. Seizing upon the
end of the finger with his right hand and pulling forcibly, he promptly
redaced the dislocation himself.
The bones were now completely in place, but the joints were swollen,
tender, and quite stiff.
In Sept. 1851, by the politeness of Dr. Briggs, the attending surgeon,
I was permitted to see, in the hospital of the New York State Prison,
It Auburn, a forward dislocation of the second phalanx of the little
Fio. 294.
Dislocation of the second phalanx fonrards.
inger of the left hand, unreduced. This man was at the date of my
lamination forty-one years old, and the dislocation had existed eigh-
een years ; having been occasioned by a fall. A surgeon in Greene
)o., N. Y., had attempted to reduce it soon after the dislocation oc-
nrred, but had failed. The joint was nearly anchylosed, yet the finger
rag quite as useful for all ordinary purposes as before.
Dislocation of the last phalanx is frequently occasioned in the game
»f base ball, by the ball being received upon the extremity of the finger.
A young man who was studying medicine, and a private pupil ol
nine, in attempting to catch a very hard ball, received it upon the ex-
»emity of the middle finger of the left hand, dislocating the last pha-
anx forwards. Twenty minutes after the accident, I found the distal
xtremity of the second phalanx projecting backwards through the skin,
!ie tendon of the extensor muscle being torn completely off from its
oint of attachment to the last phalanx. The last phaknx was in a
^ition of slight dorsal flexion, or extreme extension.
Seizing upon the extremity of the finger, I attempted to reduce the
slocation by direct traction, aided by pressure upon the exposed end
^ the second phalanx, but I was unable to succeed until I brought the
8t phalanx into a position of palmar flexion.
A slight disposition to reluxation was manifested, and a gutta-percha
Jint was therefore applied; and, to prevent inflammation, the young
an was directed to keep it moistened with cool water lotions. Only
moderate amount of inflammation followed, and in a few weeks the
ire was complete.
Such accidents, attended with laceration of the integuments, freauently
miand amputation, or at least resection of the projecting bone, but we
link Mr. Miller is scarcely right when he sjiys that compound dislo-
itions of the fingers almost always are of such severity as to demand
DQputation. I have myself met with three other cases which were re-
noed, and did well.
672 DieLOCATIONS OF THE THIGH.
In one case of simple dislocation of the last phalanx of the tbnmlt
backwards I have been obliged to resort to section of the lateral lig*
mcnts before accf>mpli8hing the reduction. Tliis was in the person rf
a woman admitted to Bellevne Hospital in February, 1SR4. The afr
cident had happened seven days before, by falling and striking ui
the end of the thumb. The position of the last phalanx was extended,
that is, in a line with the axis of the first phalanx. She eaid, howevo;
that it was at first " bent straight baok," but that a man took bold of
it and pulled it out. Having placed her under the influence of cibff,
I attempted reduction by forced backwai-d flexion, but &iled. I tbco
cut the lateral ligaments by subcutaneous incision, and the reductluo
was accomplished with great ease.
CHAPTER XVI.
DISLOCATIONS OF THE THIGH (COXO-FKHORALl.
The femur is especially liable to dislocation in four tUrrctioM)
namely, upwards and backwards upon the dorsum ilii, upwnrdHsiKl
backwards into the ischiatic notch, downwartb and forwards iiilollN
foramen thyroideum, uid upwards and forwards upon the pubes-
Dislocations are occasionally met with which cannot be amngt4
properly under either of these divisions ; indeed, it is scarcely nivtxut
to say that the head of the bone may be thrown in almost rvery dilu-
tion from its socket, upwanls, downwanis, inwanla, and outn-ards, *
in either of the diagonals between these lines; and that while in a n*
majority of cases it will assume one of the positions first namtvl, it m^
in a few exceptioual examples fiitl short of, or much exoecd, the litnili
assigned in this division. Thus, we shall have occasion hemftw W
mention examples of dislocation directly upwards, in which tlw hoA
of the bone will be found resting upon the fossa between the «,,
margin of the acetahnlnm and the anterior inferior spinous pnoemJ
the ilium, or still higher, between the anterior superior and the ant
inferior spinous processes, or a little to the one side or to iho other''
these points, Examples will be shown of dislocalioas direcJy d*Kn>
wards, in which the head of the femur will rest uiton the notch bctww
the lower margin of the acetabulum and the tulwr isehii, or still li>*A
and actually below the tubemeity, or downwards and Imckward* bcl«»
the spine of the ischium, into the lower or h^^or sucro-sciatic Mm
The head may be thrust across the foramen thyroideum, aixl be oo^
arrested in the perineum u|)on the ramus, or even beyond the nunw ">
the ischinin and pubes ; it may lodge upon the anterior aiu'lkce iif tb
body of the pulws, as well as u|>on its superior edge; and finally, i<
may rest against the jrasterior margin of tlie aeetabnlum inttnw «
rising umn the dorsum, or it may only mount upon iw tMrpOt "
either of the directions named.
^LOCATIONS OF THE THIGH. 673
I In regard to frequency, the four principal dislorationa occur in the
9er in which we have mentioned them ; thus, of 104 dislocatinns of
e hip whioh I have taken the pains to collate, excluding the anoma-
lous or pxtmordiuary dislocations, and which my intelligent pupil, Mr.
Frank Hodge, has carefully analyzed, 55 were upon the dorsum ilii,
28 into the great ischiatic notch, 13 upon the foramen tliyroideiim,and
8 ujmn the pubes. Chelius and Samuel Cooper have, however, re-
verned the order of the last two varieties, arranging dislocations nimn
the pul)es,'in the order of frequeney, before dislocations into the fora-
men thyroideum.
Coxo-femoral dislocations may occur at any period of life; a case of
thyroid dislocation is reported in the Lancet for May 16, 1868, which
occurred in a child six months old. One example is mentioned in the
GaseUe MMicak, of a recent dislocation upon the dorsum ilii, in a child
eighteen months old.' Dr. N. Fanning, of Catskill, N. Y., informs
me, in a letter dated June 25th, 1867, that he has reduced a dislocation
njwn the dorsum ilii, on the tenth day, in a little girl eighteen months
old. Mr. Kirby has reported, in the Duhlin Medical Press for October
26, 1842, a ai.se of recent dislocation in the same direction, in a child
of three years,* and Dr. Buchanan has seen another, at tlie same age,
in a little girl ; the dislocation being into the ischiatic notch.' Mr.
Image communicated to the Suffolk branch of the Provincial Medical
and Surgical Association the case of a Iwy, three and a half years old,
with a dislocation upon the dorsum ilii. It had existed twelve days
when he was admitted to the Suffolk Hospital in May, 1847. Mr.
Image, in reporting this case to the Society, remarked that he had been
induced to lay it before thera "in consequence of a charge having Iteen
urged against a neighlmriug surgeon, of pretending to reduce a dislo-
cation of Ihc femur on the dorsum ilii, in a child only four years old,
that child being a pauper, and chargeable to the parish. It was agreed
and proved by authorities that no snch case was recorded, and therefore
bad not occurre<l, and that seven years old was the earliest period at
which this accident had taken place."*
J. M. Litten, of Austin, Texas, reports a case of dislocation upon
the dorsum ilil in a girl four years old, which he reduced by manipu-
lation.' In the January number for 1847 of the American JoumaJ of
ifetlicaf Sciencrs is reported a foru'ard dislocation in a boy aged five
years, and a dislocation into the ischiatic notch in a girl of the same
age.
I>r. J. C.Warren, of Boston, met with an incomplete dislocation
toward the foramen thyroideum in a child six yearn old, which, having
been displaced eight or ten weeks, he was unable to reduce.* Sir
Astley Coo|ier mentions a cose in a girl seven years old.^ I have my-
self met with two dislocations upon the dorsum ilii, which occurred at
" New York Joorn Mod., Nov. 1850, p. 419.
» Amer. J.nirn. Mpd. Sd., vol. xxxi, p- ;!07, Jsn. IMS.
a McHl.-Chir. Rev., Doc. Id'iB, p. 261.
Svw York Juurn Med., Sept. 1B4H, p. 2SI. * Ibid., Mspfh, 18G2, p. 259.
^tHlon Med. and Surg Journ., vol. xxiv, p. Ii20.
.. Cuoper, on Diiloc., Anier. ed., p. 88, Cise 27.
1
ten yeare, and one into the foramen thyroideura.' Norris reporic
case at eleven years,' and Gikton at twelve.* (Ju the other hand, E
P. J. Kline, of' Portsmouth, Ohio, has reportwl to me a case of dtsl^,
cation of the femur iu a woman a^d sevenlv-three, and which thirteen
years later he found unreduced ; and Gautliier has seen a dislocation
of the hip in a woman eighty-six years of age.' The largr majuritr,
however, occur between the tifteerith and forty-fifth years of life. Vmta
an aualysisof eighty -four cases, we have obtained the following reaulb:
Dislocations of the hip are much more frequent in men tlian in
women ; owing, probably, to tlie greater exposure of the former l" llie
accidents from which these dislocations usually result, and jKisaiblj',
also, in some measure, to certain peculiarities in tlie form and .stnulun
of the neck of the femur in the male. Of one hundre<l and fifteen
cases collected by mp, one hundred and four were in males and cleveo
in females. I)r. J. K. Rodgers, of New York, mentioned, howtvcr,
at a meeting of the New York Kappa Lambda Society, that he hai
seen and reduced four dislocations of the temur upon the dorsum ilii
in females, and that a fifth ca«e had recently come to his kuowlwigp m
the New York City Hospital,'
Gibson mentions an example of dislocation of both thighs nt ti«
same moment.'
i 1. Sislooationi TJpwardi and Backwardi on the Donun Ilii
.S^B.— *■ Ui-wnrdi^ en ilii' dorMim jlii;" Sir A. Conpor, Millrr. Pirrir. " I'l.im*
■nd ouiwiiril;" R'lyer, Dii|iiivlri<n. ■' Upwnrds »ad hiii'kwiircl<< tipin ibc b*it<<
tbehii^bono;" ChcliuB. -'lilic;" Gcrdy, Vidsl (deCiu«iii), HHl^-ilgni.
Coiwcfl. — Generally they are occasioned by some violence whici
forces the thigh into a state of extreme adduction, or of adiludioa
unite<l with rotation inwards; and eapeciallv when at tlie same in*'
ment the head of the femur is driven upwards and baekwanU. Thi%
a dislocation upon the dorsum may result from a fall from a liri|lili|
when ihp force of the concussion is received upon the outside of thC
knee: the thigh being thus (K)nverted into a lever of the first kiw^
whose long arm is outside of the margin of the acetabulum ; or the
dislocation may be oeeasione<l by a fall upon the foot or kni-c, wbih
the limb in adducted, by which the head of the femur will lical tlw
same moment driven upwards and outwanls from its socket. TT*
accident is equally liable to result from the fall of a heavy wbW4
such as a mass of earth, upon tlic back of the pclvb when ibe bo^ H^
much bent forwards.
' BuHhIu M>>d. J«ui
My Re
' Ai
iii,p.e. Tram. New York State M«d.aW|fl
SibtoD'i 8urf.,TDLIl^a
Aiiier. Ji.i>rn. UoA. Sui , Foh. ISSO, p. 206.
Oxtithicr, HilBMienF, np. I'it., p. 806.
J. K. Rodicera, Now York Jotirn. Mrd , July, lfiS9, vol. i, flnt Hr.,p.ll
Olbaon's Surg., vol. 1, p. 1186, «lilb *d.
CPWARD8 AND BACKWARDS ON THE DORSUM ILII. 676
The following case presents an extraordinary example of this form
if dislocation produced by a force acting upon the thigli as a lever of
be lirst kind :
B., of Ebchestcr, N. Y., (et. 10, fell, in Feb. 1841, from the top of
he high bank just below the Genesee Falls, at Rochester, a distance of
bout one hundred feet. Before he reached the bottom of the preci-
lice, he struck upon an oblique plane'of ice, from which he slid gradu-
lly down upon the surface of the river, which was then completely
rozen over. He did not lose his consciousness in the descent, nor
Aer his arrest upon the river, but began immediately to call for assists
JHK. He remembers very well that when he struck the glacier, the
OQCuesion was received upon the right side of the right knee, and a
nark of contusion at this point confirmed his statement. Dr. Ellwood,
if Rochest«r, assisted by myself, reduced the dislocation within one
lour after its occurrence. We employed pulleys, but the reduction
vas accomplished easily in about two minutes, and without the appli-
stion of much force; the bone resuming its place with an audible
inap. His recovery was rapid and complete.'
Paifiological Anatomy. — The capsule is lacerated more or less ex-
auively, but especially in its posterior half; the round ligament is
iiptnred ; some of the small external rotator muscles are generally
rtrtiehed or torn completely asunder, the gluteus maximus, medius,
u»d roinimus arc pushed upwards and
Tulded upon each other, the head of the Fio.jm.
Femur resting upon or within the fibres
of the deeper muscles ; the triceps ad-
ductor is put upon the stretch.
Surgeons have not been agreed as to
Uk cause of the great diFBculty which
■Bs usually been experienced in the re-
liction of this and of all other forms of
^o-femoral dislocations. While some
Vve ascribed it alone to the resistance of
■■e muscles, others have with equal con-
dence ascribed the opposition to an en-
mglement of the head and neck of the
>ne in the rent capsule, or in the liga-
ent; and still others believe that tiie
ipediment ought to be looked tor some-
mea in the muscles and sometimes in the
.penle, or in both at the same moment.
Sir Astley Cooper thought that the
tpsular ligament was generally too much
im to offer any impediment to re<luction, DiaiMMimi upon the donum im.
id he refers to some dissections in con-
rmation of this opinion. Natlian Smith affirmed that the chief ob-
tacle to reduction by extension was to be found in the resistance
fiered by the glutei! muscles, which, although at first relaxed, would
' Truu. New York BtHlo Med. Soc., 1856, p. 76. My report on Diilocatior
676 DISLOCATIONS OP THE THIGH,
1
Boon become tenae under the stimulus of the extension, and whiph, ,;
order that the bone mi^htreaumoilspoeitifin, must aftually beetrelch*^
eonsidembly beyond tlieir norniftl length.' \V. W, Reid declares tiigf '
the sole, reeistauoe is itt first in the abductors and rotators, but tJW
finally the jwons maprniis, iliacu? internus, and tricej»s atlductor become
tense where the pulleys are employed.* Chnssaignnft recognizes no
other impediment to rednetion fKan the contractions of the muscles.'
Dr. Fenner, of New Orleans, gives the particulars of a dissection of
the hip of a man admitted into the Charity Hospital, who died fmn
injuriea reoeivcd by the burstinir of ii st«iniboat boiler. His roi«litii«
being eonsidered hopeless, no attempt was made to reduce the di*l«»-
tion. The limb was shortened one ineh and a half, and the toes iiimed
inwards. Extensive ecchymosis existed. On raising the pliiIiMi
maximus and mediiis, the naked head of the femur was found lyin{
on the dorsum ilii with the li^mentnm teres hanging to it, but far-
tially torn off. Portions of the obtnrator cslemus pyriformis, and
gemelli, were ruptured and lacerated. The eapeule was torn through
one-half of its extent.
Dr. Fenner now proceeded to cut away the muscles, and when ill
the external muscles about the joint had been removed the thigh omid
not be brought down ; the ilinciis internus and psoas magnus \nn
then severed, which permitted it to descend a little, but the hea<l owitf
not be replaced ; the trice|)S adductor was then divided without efi«i
The ilio-iemoral ligament was found tensely fitretcheii. All the ini*
clee between the pelvis and the thigh were then severed, and Miilil
was impf^sible to reduce the dislocation ; the head of the femur «nil4^
not l>e forced back through the reut in the capsule from which it hi*
escaped ; and it wae not until the opening was enlargwl from onr-hJf
to ihroe-quarterB of an inch, that the reduction was acoomplishtd.
I)r. Fenner infers that the capsule possi?sse» sufficient elA^tintytO
allow the small head of the femur to pass out through a luomu^
opening, which might at once contract, so as tn oflfer considenUe rwiS-
ance to its return, and that oeeasionally this is the true expluuiliM'f
the difficulty in reduction.* Dr. Gunn, of Ann Arbor, Michigan, «ft«f
re|>eated experiments made upon the dead l>ody, concludes thai ll*
musclee offer no impediment whatever to the reduction, and thallbl
"untom portion of the capsular ligament, by binding do«-n thrhesi
of the dislocated bone, prevents its ready return over the edgrnftta
acetabulum to its place in the stx-ket."* Dr. Moiirc, of K«ch«l*t
who has often repented the same experiments npon the iinlarw, ^
dares, also, that in attempting to reduce the femur by extension «!>'■*
he has constantly observed that the untorn portion of iho cap*l*
offered the main resistance, and that reduction could not be
plished until this was more completely broken up.*
1 Siirirital Memoirf, by N. R. Smilh, 1S3I,
' BhIThIo Mod Joi.rn., IHf.). Tr»iii. N. Y. Stall' Mr^. Soc., IM2.
• London M(«]. TiatPi hikI OHzett^, Dm. ISAS, p. Oil.
' New York Journ. Med,, Sent. 1M8, p. 868: from New Ort«»o. Med. »irf **
>iir.. Jii1v,1!U(t.
■ Ibid., Nov. 1868, p. 42S et tea,
* Ibid., Jin. 186G.
UPWARDS AND BACKWAKD8 ON THE DORSUM IHI.
677
Susch, of Bonn, has arrived at similar conclusions;' as also Profea-
oreRoeer, Weber, and Gell6. Professor Von Pitlia declares emphat- ■
ally, that upon a knowledge of the ilio-feinoral ligament is based the
Drrecl understanding of the various forms of hi{>-joiut dislucatious.'
But probably the most complete and conclusive defence of the views
itertained by the gentlemeu just referred to has been furnished by
h. Henry J. Eigelow, the Pro-
ssor of Surgery in Harvard ^"■' '"''■
Fniversity. In some resjiects,
iso, his opinions are wholly
riginal. The following is a
riefsuramary of these opinions.
The ilio-fcmoral ligament,
illed by Dr. Bigelow the Y
gament (Bertin's ligament),
iie internal obturator muscle,
0(1 that iwrtion of the ai|>.sule
f the joint which is immediately
ubjao^nt, are alone required to
iplain, and are chiefly rcspon-
ible for, the phenomena of the
Mir regular dislocations. The
egular dislocations are those
D which complete disruption
tftheilio-fcmonil ligament ha?
rat taken place.
The irregular dislocations are
liose in which the ilio-femoral
igimeut has sutfered complete
lisruption.
In reducing either of the reg-
ilir dislocations the limb must
K flexed, in onler to relax the
liiKfemoral ligament; but if
tber portions of the ca{>sule
re not sufficiently torn to admit the return of the head within ita
wket, it must be torn by circumduction of the limb. After flexion,
nd perhaps circumduction, the reduction may be completed by rota-
i>n, or by ext«>nsion of the thigh at right angles with the anterior
irface of the body.
The dorsal dislocation owes its inversion to the external fasciculus
' the ilio-femoral ligament.
In the ischiatic dislocation, "dorsal below the tendon " (Bigelow),
le head is arrested, in extension, by the tendon of the obturator and
>e subjacent capsule.
The flexion and eversion of the limb in the thyroid dislocation are
oe to the ilio-femoral ligament.
■ Te«r-Bo»k of Med. and Sarg. fi^r \mi. Hv<]<tnham Soc. PiiblicHtiona ; from
LRhiT. of Clinical Surzerv, vul. iv, purl i, llcrlin. IH<>3.
* Ton Pltba'a and BiUrotb'e Surgery, vol. iv, lSfl5.
lo-fi'iiiori] llgimnil. (Biffolow.)
678
SLOCATIOSe DF THE THU
In the pubic dislocation the ascent of the limb is fiually arresUtl \\j
■ the ilio-femoral ligament.
The coaclusiou at which we ought to arrive seems to be thai, in
Bome cases, the capsule being completely or almost completelv toni
away, the muscles offer the only resistance ; and that aecorduig to the
exact poi^itiou of the Itmh or degree of displacement, one orsnoflnf
set of muscular fibres will oppose the reduction ; and iu other •
the muscles being paralysed iiy the shock, or hv anawlhetics, tta
[wrtially torn capsule, into which ihe head of the bone is recxivnla
ill a button-hole, or the Y ligament, prevents its free return into tW
socket.
Sifmptome, — Sir Aslley Cooper aflirmetl that tlic limb vss i
times ii}und shortened in this dishtcation to th» extent of three b(^
Liston, B. Cooper, Gibson, and othent, ro^ieat the affirmation. ChrliH
places the extreme of shortening at two and a iialf inches ; MiNtf,^
two inches ; while Malgaigne declares that he Ims never seen tlw link
shortened more than half an inch, and that iu some tv!>es it it bA
shortened at all, and the very npjKfsite npinions enltrrtiiitiet) hy mM-
sui^fons he attributes to eri'ors in the measurement. I ntu ivtait,
however, that Malgaigne has fallen into some error, and that, while
the avera^re shortening is about one inch or one inch ami a half, it
does occasionally reach three indies.
The thigh is rotated inwards, adductnl, and slightly flvstd <^
the uplvis. The great toe of the dislocated limb, wlieo the ptu*'
staiKis erect (and in this position the examinatinu ought, if puufe
CPWAEDS AND BACKWARDS ON THE DORSUM ILII. 679
I be made), rests upon the instep of the foot of the sound liml), and
le IcDee touches the oppposite thigh near the upper mat^in of the pa-
ila. It must not be supposed, however, that the position of the limb
io all cases precisely such as we have described. Indeed the degree
r rotation, addiictioD, flexion, etc., will vary according as the head of
le femur is more or less displaced, the capsule, incUiding the liga-
lents, more or less torn, or as it may be torn in its upper or lower
la^iDs, as the muscles may be ao-
oal^ rent asunder, or only put
ipoQ the stretch, and perhtips also
tcconjing to the amount of injury
md consequent relaxation which
hay may have sustained from the
ihock. The thigh can be easily
leied; adduction is more difficult,
Qnt abduction is almost impossible,
3xoept to s very limited extent: the
bod)' of the patient is a little bent
fwwards, the roundness of the hip
'■i lost in consequence of the relaxa-
ion of the glutei! muscles; the tro-
Jatiter major is depressed, and
'pproocbes the anterior sujierior
pinous process of the ilium ; and
^ the patient is not fat, and swell-
ig has not already taken place, the
^ of the femur may be felt iu its
ew position rotating under the
and when the limb is turned in-
ards or outwards, but especially
Ay it be felt when, by flexing or
(tending the limb, the head is made
> move downwards and upwards,
pon the dorsum ilii.
As we have already said, this ex-
uination ought to be made, if possi-
e, in the erect posture; after which,
will be well to place the patient al-
roately upon his back, u|>Dn his
■und side, and upon his belly, uutil
le diagnosis is rendered corauiete.
The difTerential diagnosis between dislocation upon the.dorsum ilii
id a fracture of the neck of the femur may be briefly stated as follows.
In fracture, we may expect to find crepitus; the limb is in mostcases
lobile; the toes are generally turned out; the limb is shortened m^xier-
lely or not at all ; the patient is sometimes able to walk for a short
istance; fracturesof the neck of the femur generally occur in advanced
ife.
In dislocation, crepitus is not often present, and only when a frao-
arecoexista; the limb is immobile, or nearly so; the toes are turned
DISLOCATIONS OF TH
1
in ; the limb is Hliortencd more ; tlie pftti^it is nnable to bear the treight
of his body upon his toot for one moment. Skey, however, says he iiu
seen a patient with a i-ecent <lislo«ition, who w&lked one-quarter of a
mile, to the hospiCnl. I do not thinlt any other similar case is npoo
record, Disloiations of the femur generally occur in middle life,
I have been frequently told by )>ersons who have culled upon nx
with children suffering under hip-diseaee, that they had been iulbrmed
the hip was out, and they expected me to reduce it. In two or thnc
instances they have blainetl their sni^eons very much, becnn»e thqr
had not detected the nccident at the time of its occurrence. Norris, a
Philadelphia, mentions an extraordinary example of this kind,
having been presented at the Pennsylvania Hospital, and which w^
to serve as u suiBcient warning to pa-vent similar mistakes in fuEum
A lad, twelve years old, was brought to the hospital from a neighlinr-
ing Sitittr, ^v*llo a sliort time previous had been suddenly atlackm with
lameness in his right limb, and which, Uf
I'lo. --M. his friends, was attributed to som» injuiy n-
reived in play. Two physicians, who b«l
i i _= -^^ I I ''^^" "^"^ to see the boy, pronounced his
\ \^~' m / ti) be laboring under dislocation of the bip,
A^ At and hud made two strcmg etlbris with (M
I>ul!cys, to rciiut« it; but, after musing prat
suffering, they gave up all ho)>c» of ever re-
placing the bone, and sent him to I'hilaiM-
phia. The symptoms were plainly ihrat (f
hip-joint disease in its early stage. TbeU-
titude was that assumed by th(i6« laborin|
under this affection; the leg seemed leiflilb*
I / ened, but a careful measnrenienl show«l iW
it was of the same length with the other; the
buttock was flattened, and the motionsoftlK
joint were tolerably free but painful'
If the supposed dislocation oocun in i
child, or ill a person under ten yean of tff«
we nuglit to take especial pains to a«*rt»i'
that it is not a separation of the epiphysis, m
which accident we have mentioned HimeU*
aniples when speaking of fracturw of lbcD«i
of the femur.
Examples have occasionally been repnW'
of "everted dorsal disloontionV' i" "^
idomidiiiiHaiiion. most of tho usual signs of a dorMiI diil*^
(Bigtiow.) (jQ„ jipg present, except that the litnl' *
everted, and sometimes slightly abdia*'-
condition to a rupture of the outer Bbnt"'
iral ligament, and he uRirms that under these ein-nmstw*
tbund inverted, but it is also easily evertvd; the fa*
Bigelow attributes thi
the ilio-fc
the limb
3 may
I, Med. Scl., vol. iiv, p. S
rPWARDS AND BACKWARDS ON THE DORSUM ILII. 681
aj be slightly everted, it may lie flat upon the bed, or it may even
nnt backwards.
The treatment of the everted dorsal dislocation consists in reducing
first to an ordinary dorsal dislocation by flexion and rotation in-
irds, aided by adduction, if necessary.
Prognosis, — Boyer says the limb remains always weaker than the
ber, the round ligament never uniting completely; and that inflam-
ition of the cartilages and synovial glands may ensue, ending in
ries of the joint. Such results have, indeed, been occasionally met
th, nor are examples wanting in which more rapid inflammation,
salting in the formation of acute abscesses, has followed, but these
e only rare accidents. In the large majority of cases the patients
Dover speedily, and in the course of a few weeks, or months at most,
e limb seems to be as sound and as useful as before.
Examples of non-reduction, however, from an error of diagnosis, or,
liat is more pertinent to our present purpose, from a failure to accom-
ish the reduction where the attempt has been made, are numerous.
3rtunately, Mr. Chelius, the author of a most excellent System of
trgery, to which we have already had frequent occasion to refer, has
fficient reputation, the world over, to enable him to bear a portion
these failures, without injury to himself or to the profession which
i 80 eminently adorns. We shall therefore make no a[)ology for re-
>rting the following unsuccessful attempt to reduce a dislocation of
le hip in which Mr. Chelius himself was the Oj)ei:ator.
On the 11th of June, 1851, John Mauren, a German, set. 19, called
my office and related as follows : " When ten years old, I fell from
tree, a height of six feet, and dislocated my left hip. I was then
ving twelve miles from Heidelberg, and I was immediately taken
lere, but I did not see Mr. Chelius until the next morning. He took
le to the University, and, before the medical class, attempted to reduce
,bat he could not. During several weeks following, he tried six
mes, using pulleys, etc., but he could never succeed."
On examination, I found the limb shortened two inches, the head of
ie femur lying upon the dorsum ilii; the knee was turned in, but the
€8 were inclined a little outwards. He was able to walk rapidly, of
►orse with a manifest halt, yet without pain or discomfort.
TreaimerU. — Regarding dislocations of the femur upon the dorsum
ias the type of all the coxo-femoral dislocations, the remarks which
6 shall make under this section may be considered applicable, with
ily certain qualifications, to all the others.
We shall arrange the various methods of reduction which have
en employed by surgeons, under two principal heads, namely, manip-
ition and extension. It is not possible, however, to classify rigidly
I different procedures, so as to bring them under these two simple
visions, without some violence; since neither manipulation nor ex-
ision has usually been employed alone, but almost always some
jree of extension has been recommended in connection with the
inipulation ; if not in the first instance, at least in the event of the
lore of manipulation alone ; while, on the other hand, extension is
dom if ever practiced without manipulation. We intend, then, to
44
UPWARDS AND BACKWARDS ON THE DORSUM ILII. 683
".When I made this examination, he was lying on a table on his
ck. 1 raised the thigh to about a right angle with the trunk, and,
th my right hand at the ham, laid hold of the thigh, and made what
tension I could. From this trial I found I could dislodge the head
the bone. At the same time that I did this, with my left hand at
B head and inside of the thigh, I pressed it toward the acetabulum,
lile my right gave the femur a little circular turn, so as to bring the
tula inwards to its natural situation ; and on the second attempt it
mi in with a snap observable to the gentlemen standing around, but
)re 80 to the poor man, who instantly cried out he was well and free
)m pain. His knees could then be brought together ; the legs were
the same length, and the foot in its natural situation. The knees
ire kept together for some time, with a roller, to confine the motion
the thigh ; and in three weeks he was at his work, without the least
iffness in the joint."
Subsequently Mr. Anderson reduced by a similar method a dislo-
tion upon the dorsum ilii in a child eight years old, and which had
«n out nineteen days.*
Says Pouteau, in a memoir on dislocations of the thigh upwards
id outwards : " We observe then, first, that the thigh ought to be
ixed to a right angle with the body during the extension and coun-
p-extension ; second, that we ought to rotate the thigh from within
itwards, when the extension appears to be sufficient; third, that this
isition puts into relaxation, as much as possible, the triceps and
uteal muscles, which oppose the chief resistance to the extension,
us saving the patient from excessive pain ; fourth, that the flexion
the thigh places the head of the bone in the best position for a
turn to the cotyloid cavity during extension; fifth, that feeble ex-
Dsion suffices for the reduction, because all of the muscles of the
igh are relaxed."'
On the 7th of January, 1811, Dr. Philip Syng Physick, of Phila-
Iphia, reduced an outward dislocation of the hip, after extension had
led, by flexing the thigh to a right angle with the body, and then
Hng to the limb an "outward circular swecp."^
8o early as 1815, and i>erhaps much earlier, Nathan Smith, Professor
Surgery in the New Haven Medical College, taught that the only
Tect mode of reducing a dislocation upon the ilium was to flex the
upon the thigh, the thigh u|)on the pelvis, and then to carry the
lb diagonally to the opposite side, from whence it was to be brought
.wards and downwards;^ and in 1824, Dr. Smith, being under oath,
mied as follows: "I do not think that the mechanical powers, such
the wheel and axle, or the pulleys, are necessary to reduce a dislo-
ed hip, or any other dislocation." He further adds that he once
luced a dislocation upon the dorsum ilii after he had pulled in every
•ection but the right, "by carr}Mng the knee towards the patient's
Anderson, Medical Commontariep, Edinburgh, 1776, vol. ii, pp. 261-4.
Vidal (de Casnis) ; from (Euvres poFtliiinies de PouIpmu, Paris, 1783.
Physick, Dor»f»v'8 Sure , 1813, vi, p. 24*2 Mom. of Nathan Smith, 1831, p. 172.
eUw'i paper in Trans New York State Med. See., 1856, p. 169.
Trana. N. U. State Med. Soc, 1854, p. 55.
884 DISLOCATIONS OP THE THIGH,
face.'" Sul)sef|uently the son of Dr. Smith, Nathan R. Smith, the
present distinguished teacher of surgery in the Medical College tt
Baltimore, gave a more full account of his father's method, illustrating
his views of the pathology of these dislocations, and the mccliani«a
of their reduction, by several drawings. It must be noticed, howrvw,
that Dr. Nathan Smith left no written explanation of his views and
practice, except that which is to be found in the affidavit alreiuij
quoted, and that the account published by his son is from meniur^,
aod it is given as followB: "The patient being prepared for the ouer-
ation by whatever means may be deemed necessary, may be pisewl i&
an attitude couvenieut for the operation, with the body securely fixd,
by placing him in the horizontal |)usture, on a narrow tuble covcrad
with blankets, and on the sound side. To the table his body shoald
be firmly fixed, and this can be conveniently done by folding a
several times, lengthways — then applying the middle of tne hmi
baud thus made to the inner and rpper part of the sound thigli—
carrying its extremities under the table, crossing them beneath it. tuid
tlien carrying them obliquely up and crossing them firmly uvor On
trunk, above the injnreti hip. The ends may then be scoured tH-nratli
the table. To support the trunk the more firmly, a pillow mav b«
placed on each side of it upon the table, and be inchideil in the IkuhJ-
age. Should the operator design to employ any degrt-e of exlMwiaa,
a cotiuter-ex tending band may be placed iu the jierlnenm, and mrriM
up to the extremity of the tabic, be fixed to some more firm budv, uT
held by the hands of assistaufs.
"The o^Krator now standing on the side t^o which the patient's bark
presents, grasps the knee of the dislocated member witli his right bod
(if the left femur be dislocated — oier rerxd, if the right), and tlietnkl*
with the left. The first effort which he makes is to flex Uie leg up"
the thigh, in order to make the leg a lever with which he may o|)cti»
on the thigh-bone. The next movement is a gentle rotation of the
thigh outwards, by inclining the foot toward the ground, and ralaiing
the knee outwards. Next the thigh is lobe «/j^A//y abducted by pnw-
ing the knee directly outwards, Lastly, the surgeon freely flew*ll>*
thigh upon the pelvis by thrusting the kuee upwards toward thi* bit
of the patient, and at the same motiumt (he (ilniudion w to be iwraw^
"Professor N, Smith regarded the free flexion of the thigh upouthe
Elvis as a very important port of the compound movemcnl. Ht
lievwl that it threw the head of tJie Iwne downwards, bohiuH I'm
acetabulum, where the margin of the cup is less prominent, and f<viT
which, therefore, the abductor muscles would drag it with less difficulif
into its place.
"The operator may slightly vary these movcraenlit, a.* he inatw*
them, so as to give some degree of rocking motion to tiie head of <*<
OS femoris, which will thereby be disengaget) with the mwv &iiii'J
from its eoufincd situation among the muscles."'
■ It<'|>ortof IhoTnnlof >n Action fur MHlpTuclice. Lownl p. fuos ui B**^'
HrcIinis Maine. iSH ; nliu Buff, Miil Jonr. vol. xlli,n. SIG.
• MfdicHl Hnd »uriticnl Mwii'-irs, b» Nutlmn SmitU, Into Prof, of Surt^. •"•
in Tiilo Culloj;,-. Edited by Nutli-n R Sinilb, Profdwor of Siirgtfj l« irw' ''
Murj'lnnd. liBltiiiiuru, 1831, pji, 103-182.
AND BACKWARDS ON THE DORSUM
685
Dr. Luke Howe, of Boston, who was a pupil of Nathan Smith's,
gives the following aceotint of the method practiced by hira suocesa-
fully, about the year 1820, and which method, he rays, was recom-
mended by his preceptor : " The patient was permitted to lie on his
back on the bed where I found him, the knee of the luxated limb
turned in and over the other. I raised the knee in the direction it in-
clined to take, which waa toward the breast of the opposite side, till
the descent of the head of the bone gave an inclination of the knee
oat«-ard9, when I made use of the leg, being at right angle with the
thigh, as a lever to rotate the latter and turn the head of it inwards.
It then readily returned to its socket, with an audible snap. During
imltb'a method of rcduc
D Ut m.nlpLilrillt,n. [Froi
this operation, the two assistants who had been placed to make the
lateral extension and counter-ex tens ion, if ultimately required, were
directed to draw moderately at their towels. How much of the Buc<!es8
of the operation is to be imputed to their extension, and the rotation
of the thigh by the leg, I am unable to determine; but aa Dr. Smith
succeeded without the aid of either, and as the head of the femur
seemed to descend by an easy and natural process, I am inclined to
believe that all that is necessary, in auch cases, is to elevate the knee,
when the ilium, the muscles attached to it, and perhaps the ligament,
become the natural fulcrum, over which the thigh, as a lever, actJj to
bring the head down and inwards into the socket.'"
DISLOCATIONS OF THE THiOH.
Kluge, in 1825, combiDeJ moderate extension with manipulatinn,
by flexing both the 1^ and thigh, while at the same moment tlie thi|^
was abducted and the knee rotated inwards.' Wathman, in 1826,
directed that in this dislocation the limb should be seized hy the kim
and nnkle and slowly lifted forwards until it came to a right angli
with the long asis of the body ; when, if the outward " selt-twidtiiur
of tlie thigh occurs, " which cannot be prevented by fcist holdini^
the movement of the head of the bone is declared, and it vrill oulj
remain for the surgeon to let down the thigh gradually upon tlii- liffl
so that the two linibe will come aide hy side, and the reduction will b«
accomplished,'
Rust recommended also, in 1826, a similar ptun, combining mole-
rate extension by the hands, with flexion and abduction of the ihtgh.'
Colombat, whose opinions date from 1830, suggested that the patient
should lay himself forwards upon a bed or table, no higher than hii
hips, with the sound 1^ and foot resting upon the floor, and that tliM
the sui^eoD seizing the foot with one hand, so as to flex the leg, ghouiJ,
with the other hand, exercise a moderate degree of extension, and >t
the same time move the limb to tho right or to the left, backwanis ittd
forwards, in order to disengI^^ the licad of the femur; and, lintliy,
that he should communicate to tlic thigh a sudden movement of ci^
cular rotation, either from within outwards, or from without inwanis
as the surgeon may choose.*
Collin states that, in 1833, he had reduced four dislocations of ll*
hip hy a method very similar to this recommended by Colombnt.'
Dr. William IngaJls, of ('helsea, Mass., reduced a compound disln-
cation of the femur, in which the head of the bone resteil ujwii the
pubes, after an unsuccessful attempt had been made to r«hice it '?
extension. " An assistant, taking the ankle of the dislocated liml) iR
his right liand, and plat^'ing his left in the ham, W-nt the leg at rielit
angles upon the thigh, and the thigh upon the |>clvi3, tlien lifting «r'tl>
a power little more than sufficient to elevate the whole limb, he arritd
it to itB greatest state of abduction, at the same time rotating the fmiir
inivards, while Dr. Ingalls passed his thumb through the wound, and
pressing upon the htwl of the femur, directed it toward the acelabuluiiL
At this moment he directed the limb to he forced toward ita felio*. I?
which the reduction was eflected with the greatest possible eawiw
elegance,"*
Similar methods of reduction, with only such slight variatioisi*
scarcely deserve a sgietnal notice, have been suf^est^xl and praoiifl"
from time to time by Palletta, in 1818 ;' Desprez, io l836,'Vi«l. ■
1841 ;" Fischer, Mahr, and Clark, in 1849.'"
1
■ Cheliiu'i .SurR., by South, Amer. ed., toI. li, p, :141. ■ IMd., p S^
• Ihid , p, 2*1, note by South.
* MHinigDe, op. ait., vol. ii, p. 625.
■ Ibid., p. 823.
■ lagalU, Brnnaby Cooper's ed, uf Sir Aatlej'i Eagllafa ed., I8U, ud Aeht «-
• Wi.
ffABDS AKD BACKWARDS OS THE DORSUM ILII. 687
1851, Dr. W. W. Reid, of Rochester, N. Y., published aa account
! methwl practiced by himself successfully in three cases of dis-
jn upon the dorsum ilii, the first of which dated from the year
His method, as applied to a dislocation upon the dorsum ilii,
(8 in " flexing the leg upon the thigh, carrj-ing the thigh over
und one, upwards over the pelvia as high as the umbilicus, and
ibductiug and rotating it." '
Markoe, of New York, adopts the same procedure, except that
the limb has been sufficiently flexed and abducted, be directs
he limb shall be gradually brought down, and he affirms tliat it
ing this last manoeuvre tlmt he has usually found the bone resume
ice in the socket.'
elow, of Boston, declares, as has already been stated, that in all
gular dislocations, that is to say, in all those dislocations in which
io-femoral ligament is not torn, the thigh raust be first flexed, in
to relax this ligament, and then reduction may be effected by
iion directly forwards, the thigh being at a right angle with the
or by rotation. In some cases, where tliere is probably only a
i-hole slit in the capsule, free circumduction may be required in
that the capsule may be torn more freely.
BclaitUOD or Ih« Illo-remonl llgiDicst bj fleilOD. (BIgelow.)
I method of reducing the dislocation upon the dorsum ilii, is to
he thigh upon the abdomen, abduct and then rotate outwards ;
flex, then adduct and rotate a little inwards, to disengage the
)f the bone from behind the socket, then abduct and pull directly
688 DISLOCATIOSS OP THE THIGH.
npwards. When necessarj-, circumductioo is practiced to laocrele the
capsule more completely.
Reduction by extension dates from a period equally early with re-
duction by tnaoipiilation. Hippocrates retwrn mended, when other atn!
gentler means had failed, to make extenaion and counter-eitenaon;
Uie extending bands being made fast above the knee and above llii
ankle, so as to distribute the points of preeeure ; and tho counter-n-
tending bands being secured around tlie chest under the armpits, nnJ
also, if thought necessary, in the perineum of the aouud etde.
lltppocntn'i mode ot reducing dijlaci>llsii> at (he bip br eilf ntloD.
Among the methods recommended and practiced by HippoonW,
was sitting across the upper round of a ladder with a weight atlarW
to the thigh of the dislocated limb ; or anspendiog the |uUicnt (hmi *
sort of gallows with the head downwards, and if the weight nf 'he
patient's own body proved insufficient, the surgeon niiglii add hit
also; a method which Hippocrates characteriKes as " a good, proper,
and natural mode of reduction, and one which has something of ili»-
play in it, if any one tak^ delight in such ostentatious modes uf pro-
cedure." '
With various modifications as to the position of the Knib, and tt V>
the |x)ints upon which the extending and counter-extending forces tit
to be applied, and with ditfcrcntly constnicted appliances, saipM
have continued to employ extension down to tliis day.
The great majority have regarded flexion of the thigh as «w
tial to success ; some holding the limb only slightly flex(^, and odiffl
insisting that flexion should be increa.se*l to a right angle with in*
body.
The French surgeons, including Boyer and Vidal (de Cassis), prtfrt
generally to apply the extending bands to the feet, in onler tbaith*
muscles of the thigh may not lie stimulatetl to contraction by tka pW"
sure of the bandages. Mr. Skey adopts the same method.
Sir Astley Cooper, Samuel Cooper, B. Coo|>er, Fergnsson, Mill*,
Pirrie, Eric'hsen, and the English surgeons generally, make fiist tk»
' Work* of Hippocntei, 8yd, ed., London, roX. H, p. MI.
UPWARDS AND BACKWARDS ON THE DORSUM ILII. 689
ira above the knee. J. L. Petit and Diiverney, among the French,
w Dorsey, Gibson, witti moat of the American surgeons, recommend
le same, but Gerdy seeks to multiply the points of application, and
rthis purpose secures the extending band to the whole length of the
g, and to a small portion of the thigh above the knee.
The counter-extending bands are now almost universally made to
Krate against the perineum of the dislocated limb, but Koux, follow-
gthe practice of Hippocrates, places it in the perineum of the sound
nb. Gibson recommends the same practice.
Lizars recommends that sometimes the reduction should be attempted
'simply placing the heel in the perineum and making the exten-
)n with the hands, very much as Sir Astley Cooler advises us to
oceed in dislocations of the humerus. Moi^n and Cock, of Guy's
ofipital, have reduced six cases of dislocation of the hip-joint by
icing the foot between the thighs, so that it pressed against the
■per part of the dislocated bone, and thrust it away from the pelvis;
tension and rotation of the limb being made at the same time by
iiatants.' Three of these were examples of dislocation upon the
rsum ilii, two upon the pubes, and one into the foramen thyroideum ;
d most of them had occurred in weak or elderly persons.
Ambrose Par6 was among the first to recommend the use of pulleys
r the reduction of dislocations. Most surgeons since his day have
iployed them for the purpose of making extension more energetic
id steady, and that it might be longer continued. Sir Astley Cooper's
an of procedure is as follows :
The patient having been bled freely, and the muscles still farther
Ailler Cooper') msthoil.)
axed by nauseating doses of antimony and by the hot bath, he is to
placed on his back ujKin a table of convenient height between two
pies; a strong padded leathern girth or )>erineal l>and, constructed
as to receive the thigh, and to press at the same moment against the
"ineum and the outer surface of the pelvis, is then applied and made
t to one of the staples situated behind the patient in the direction of
> Cock ftnd Morgan, Cheliui, op. cit., vol. ii, p. 242, note by South.
690 DISLOCATIONS OF THE THIGH.
the axis of the limb. A wetted linen roller is next to be tight!]'
applied just above the knee, and opon this a leathern strap is to be
buckled, having two short stra[)S with rings at right angles witli tk
(urcnlar part; or, iugt«ad of this, a round towel made in the kout
called the clove-hitch. The knee is to be slightly heut, but not quiie
to a right angle, and brought across the op;iogite thigh a little abnn
the knee. The pulleys being now attached, the extension is to be
commenced.
A very simple and eOicieut mode of making the extenaioo, if one
has not the pullej's, is to employ for this purpose a small rope, liie
ends l>eiug tied together, and the rope being then doubled upon iu«tr
once or twice, so as to make four or eight parallel cords. The oppo-
site ends of this bundle of ropes being made fiist to the limb anil the
1
|iF«lfir
staple, the exteuaion is made by thrusting a stick through its omtn
and twisting it.
I have several times had occasion (o resort to this plan ; and tnAeti
it has been for some time known and practiced among en rgmm in tiiit
country,' having been first, according to Professor Gilbert, introduce
by Fnlinestock, of Pittsburg, Pa.
Jarvis's adjuster, to which I have already made allusion when spetli*
ing of dislocations of the humenis, has been often used with siuxvs in
dislocations of the hip as well as in dislocations of the shoulder.* Is
power is equal to that of the pulleys, while the direction of the htm
can be varied with much greater ease. The most serioua ot^ectioM
to the instrument, as employed for the reduction of dislocRtktDi, M
its complexity and its expenslvcness.
Mr. Fergusson says that the Lancet for July 2flth, 1846, oootMiHl
1 OUtrart, of PhilndelphU,
Tol. XXIV, April, 1845.
' Crundill, Boit. MpJ, und
Kud. Auoc., to). Ui, ISJiO, p, 867.
to Pirrie'B Surg.; alio Amn. Joorn. Ib^S^
e- Journ., Tol. xjxii, p. 77; AUm, TraM. A»*
JutIb'b nAjoMler :
>r>ill«lD(»Usaortliah1|i.
a " windlasa" for mnkiiig extenslun, with a "forceps," hy wliicli the
»W^'>(l''>g power can be instantly disengaged.' Mr. Bluxltam's " dis-
»tioQ touniiquet" is al»o verj- simple, and Mr. Ericbaen affirms that
by it "any amount of extending force that may be required can be
readily set up and maintained."' Sedillot, a French surgeon, ha'^ sng-
eted that when pulleys are used, we should measure the exaet power
fiLOCATIOXS OF THE THIGH.
employed in the reduction, by an ingeniously contrived ap[iarat;«vj
called the dynamometer.' Snch an instrument might occn^oiiallr 6|
useful in {ireveuting the npplioition of excessive force, especially wKcb
the patient is under the influence of an aneesthetic.
Finally, without attempting to determine the precise n^l alive value
of these different procetlures, all of which claim for themselves the t«-
tiraony of experience, we are prepared to admit that no one of them it
without merit, and that each may in certain casts posee^ advantBgH
over the others. Precisely what the cases are to which each indiviiltul
method may be especially applicable, we believe it would be impossihie
to declare unless the cases were actually before us; and even theiiit
would probably be found difficult often to say which was tlie best UDlil
a fair trial of one or more, and a final success, had determined the qu*
tion. The time has not yet arrived in which we may institute a ripd
comparison between the relative merits of the two leading plans of re-
duction, manipulation and extension, for while it is true that rediictioo
by manipulation has been practiced from the earliest davi it is eqmllj
trne tliat extensiou has been generally preferred and practiced by «u^
geons in all agee. Indeed, it was not until l>r, Keid, of RochffiCff,
again called the attention of the profession to this subject, illiulraciDg
hLs views by the results of several successful experimentw and by ta^
nious arguments, that reduction by manipulation could be said to ha"*
been fairly introduced as an established meth<^Kl of practice ; a lai^
majority of all the cases u|)ou record of reduction by manipulation
having been reported since the year 1851, the period of Dr. Reid'g first
communication to the Buffalo Medical Jouniil,
The following summary of a paper prepared by myself, with the ^^ew
of determining, if possible, the relative value of the two metli<Nl*, and
exhibiting an analysis of sixty-four cases in which manipulation nt
employed, will enable the reader to form some estimate of the diffirulty
in which this subject is involved; and if it does not actually decide*
moot-point, it will at least demonstrate that the method by manipuli-
tion is not without its hazards.'
" Of forty-one cases in which the fact is stated, twcuty -eight wt«
reduced on the first attempt, seven on the second, four on the tliini,
and two cm the seventh. In seven examples the head of the femur tat
been thrown from one position to another upon the ix>tvi8, travcllinj
from the dorsum of the ilium to the ischiatic notch, and from thtiM
to the foramen ovale ; or directly from the dorsum to the foruncn. »nil
back again ; or iu other directions, according to the character tif li*
original dislocation ; in some instances these changes being muk tf
oflen as seven times in succession. In the majority of caacs no *^"
consequences seem to have followed upon these changes a( pmit*!*
One of my own cases will especially serve to show with what ii»{MBi7
sometimes these changes may l)e made.
IV. p^ 680.
_he Fomiir by MnnipuUtlon. By *• AM**
BufTxIo MeaicalJuurnltl. Hov. 1867; Feb . Mnrcli, JonP. 1869. WlUi l»bW<**
■trucled bj ray very intelligent pupil, Lucien DBUtainvillo.
UPWARDS AND BACKWARDS ON THE DORSUM ILII. 693
"John Caswell, set. 28, was admitted to the Buffalo Hospital of the
Sisters of Charity on the 13th of January, 1858, with a dislocation of
he left femur upon the dorsum ilii, which had occurred six days be-
ore. His own account of the accident was that he was standing at
he bottom of a well, bent forwards until his body was at a right angle
nth his thighs, when a bucket holding five hundred pounds of earth
ell upon his back and hips. No attempt had been made to reduce
he dislocation. Five times in succession manipulation made by my-
elf feiled, leaving the head of the bone each time upon the dorsum
lii; the sixth attempt, made with the addition of moderate extension
y the hands, threw the head into the foramen thyroideum. By re-
ersing the movements, it was easily replaced upon the dorsum ilii.
he seventh trial was made in the same manner, except that when I
ipposed the head of the bone to be opposite the lower margin of the
•cket I did not permit the limb to turn either outwards or inwards,
it while lifting at the knee with my hands, with sufficient power to
ise his hips from the table, I brought the limb down gradually to a
je parallel with the opposite, and thus finally the reduction was
oomplished. No pain or inflammation followed, and in two weeks
) left the hospital ; but whether he was able to walk or not at that
ne, I am unable to say." ^
Since this paper was written, the following cases have come to my
lowledge. December 9th, 1865, Dr. James R. Wood attempted, at
e Bellevue Hospital, the reduction of a dislocation of the femur upon
e dorsum ilii, of five months' standing, in a man sixty years of age,
the presence of Dr. Sayre, myself, and the class of medical students,
le patient was under the influence of ether. Manipulation alone was
iployed. Probably half an hour had been consumed in the various
brts, when, at a moment when the thigh was being forcibly abducted,
e neck was broken within the capsule, and very close to the head.
was able to feel the head of the bone distinctly, after the fracture,
d to move it freely separated from the neck.
Dr. David Prince, of Illinois, who was present at the time, informed
5 that he had himself fractured the neck of the femur in attempting
e reduction of an ancient dislocation of the hip by manipulation.
In Markoe's paper, published in the New York Joarrial for January,
•55, several cases similar to that of Caswell are reported, in which
8 results have been equally fortunate; but the case mentioned as
Lving been under the care of Dr. Post, had a more serious termina-
m. This patient, John Kelly, set. 21, had a dislocation into the
hiatic notch, and on the same day the reduction was attempted by
anipulation. On the first trial the head of the bone was thrown
to the foramen ovale ; and, after having been moved backwards and
rwards between these two points several times, it was finally carried
rectly from the foramen ovale into the socket by manual extension
plied in the ordinary way, but without pulleys. "In this case,"
fs Markoe, " the cure was very slow, and he left the hospital with
me degree of pain and swelling about the joint. I learned that an
^ Buffalo Medical Journal, vol. xiii, p. 682.
694 DISLOCATIONS OP THE THIGH.
abscess formed in or about the joint, which wa*? opened, and vfhen I
eaw him, a year afttr, there was every appearance of seated morbos
coxariiis."
In Case 14, nf Mnrkoe's paper, the thigh vras broken at the n»k
after manipiitation bad been empluyed, but while extenaion was being
made by the hands, united with "a lifting outwards." Whether the
I fracture was due to the ext«n8ion, or to the manipulation, seems not
be clearly determined. The dislocation had existed seven weela
when this attempt at redaction was made.
Dr. Bigelnw has reported a case of dislocation upon the dorsum, of
siK months' standing, in a man 123 years of age, which he attemptcil to
reduce, and caused a fiiicture of the neck of the femur. His aecouni
of the manner in which the amdent occurred is as follows : *' I flwed
the limb once slowly upward upon the abdomen — a movement nhirti
was attended with a continued tine crepitation about the hip." I'poa
examination, the head of the bone was found to be separated fronj tb*
neck.
Dr. Dawson has reported to the Cincinnati Academy of Medicin* i
case in which this accident occurred in his own hands. Captain Wil-
liamson, a gentleman in middle life and fair health, was rweii'wi rt
Dr. Dawson's clinic with a disKx'ation into the ischiatic notch of nine
weeks' standing. He was placed under the influence of ellicr, and
varions methods of manipulation employed. At Isist "more forwwu
used, the thigh was pressed forcibly across the abdomen," and this mt
followed by rapid circumduction. At the sixth repetition of this mi-
nceuvre, the neck of the bone suddenly gave way.'
A lad, set, 15, fell through a hatchway, dislocating the left frmnr
upon the dorsum ilii. The sui^eon first called did not reeognitt Uw
accident. April 29th, 1873, eight weeks and on-; day after, this iHtirat
was receivetl into St. Francis Hospital, and reduction atteraptwl ^
Drs. Rose and Lellraan, both gentlemen of experience. It ww re-
duced (apparently) with ease, the patient being under the infltiwwerf
ether. Extension, with a six-pound weight, was applii<d to lh« lifflh,
in order to secure quiet, and three days later they found llie boM
out of place, ami they repeated the attempt at reduction by manipul^
tioQ. It was now ascertained that the neck of the femur was bnitiii
but whether this accident hapjiencd in the Itrst or second attemiil d
not quite certain. Two days later I paw the patient, and fonno lit
limb shortened one inch and a half, and nitiitcd outwards when un-
e«pporte<i. The head of the bone cmild be fell on the dorsum.
Dr. Rose informs me that Dr. Krakowizcr told him that be liuil Jii4
met with the same accident.
As.si8ted by my pupil, Mr. Hodge, I have also 8n«'*?«l«l in wllw**
ing sixty-two eases of attempts at reduetion by extension ; a pfii
majority of which, we find, were reduced in ihc first trials; Iml 6™
cases of recent dislocation were not reduced until after several attem^.
had been made.
In five cases the femur was broken. The first oeoumd u* SB:
Thomas's Hospital, London. Ben. W'hittenbiirg, let. 40, was admitted
Nov, 4, 1827, with a dislocation into the ischiatic notch, of twenty-two
weeks' dnration. After bleeding, etc., had been practiced, an attempt
was made to reduce the bone by pulleys, in which the reporter pro-
fesses to believe they were successful, but on the following day it was
plainly enough not in place. Mr. Travers again resorted to extension,
and while exteni^ion was kept up and the a^istants were rotating the
limb outwards, the neck of the temiir gave way.' Malgaigne mentions
a case in which, while he was himself directing the operation, the thigh
was broken through its lower third. He was attempting to reduce the
bone by extension, but it was not until he gitve the signal for rotation
outwjinls ibttt the bone gave way.^ Gileon says that Dr, Physick, at
the Pennsylvania Hospital, while engaged in rcdncing a dislocated
thigh by the piillevB, broke the femur in consequence of exerting too
Ditich force upon it in a lateral direction by an additional pulley; and
tiiat a similar accident is supposed to have happened to Drs. Harris
and Randolph in the same hospital, in the year 1838, while using the
pulleys upon a Iwy twelve yeara of age; for during extension and
counter-extension, at the moment of rotating the limb, and of drawing
it forcibly outwards by a towel, a sudden crack was heard.^
The fifth case is related by Sir Astley Cooper as having occurred
at the Brighton Hospital, under the care of Mr, Givj-nne; the dislo-
cation was upon the dorsum ilii, and was su])posed to have existed
about one month. The neck of the femur was broken in the first
attempt at reduction, and while the surgeon was making extension,
with gentle rotation,'
Sir A.stley says: "There are plenty of cases upon record, of fetal
abscesses from violent attemptjs at the reduction of dislocated hips."
We presume that this remark has reference to attempts at reduction
by extension, since, in his day, this was almost the only mode in use
among surgeons. He adds, moreover, that Mr. Skey has mentioned,
in the Ijancet* a fatal case of phlebitis following protracted extension
of the hip.
Malgidgne has collected no less than eight similar examples, with
several more in which serious consequences and even death followed
promptly upon violent attempts at redurtion by mechanit-al means,'
The head of the btme has lieen rej<eatedly thrown from the dorsum
ilii into the isehiatic notch, and B. Cooper mentions a case in which
the bone was carried from the foramen ovale into the isehiatic notch,
from which latter position it could not afterwards be (■hange<l.'
As lo the relative chances of failure by the two methods, the testi-
mony of the recorde<l cases is equally unsatisfectorj'. Of the feilures
by extension, the experience of almost every surgeon, the journals, and
696
JCATIOKfi OP TH
the treatises furnish a suffideut number of exam[>le9; while among tlit
sixty-lour cases of attempts at reduction bv iimriijmlatiDu cotletli^ 'nj
me, aud excepting the cases in which the bone was broken, only tm
were positive failures. It In somewhat remarkable, liowevcr, ihat ilitM
two cases occurred in the experieuce of the New York City HwjhuI ;
and that they are taken from a total of 6fteen, this being the whole
number which had been treated by this metliod at the dale of these ul)-
servations, id the New York Uot-pitah One had existed one muuth,
and, after repeated trials by manipulation and fretjuent changes of posi-
tion, it was finally reduced by pulleys. The other, a dislocation into
the ischiatic notch, had existed only a few hours, At least seven or
eight trials were made to accomplish the reduction by manipulation,
but without success. The lirst attempt by extension failed also, but io
the second attempt the femur was kept at a right angle with thi^ bcxJ|,
and the bone was soon brought into its socket'
We have in these two examples not only a record of failure by nunip-
ulation, but an equal record of success by extension; while, on tw
other hand, we find in an analysis of the sixty-four cases, sixteen tri-
umphs of manipulation over extension.
>Ve must not omit to mention, in order that the reader may form*
just estimate of the value of these statistics, that the great majority,»-
pecially of the cases treated by manipulation, have occurred in private
practice, and it is unnecessary to suy that such stntistira do not tttmitb
the most reliable basis for conclusions. As a general rule, udsugcm-
ful cases are not published by private practitioners, but suceestful uH4l
are pretty certain to be made known ; while, on the other hand, a e«n(l
of <.^a!ies furnished by any single hospital will geuerallv be found H
have given both nns'iccessful and successful caises. The writer
heard lately of a complete laifure to reiiuee by mani|nilati'in in a r^
luxation of the hip, after repeated elforts on several succ<.^vt> duys.iuiJ
where skilful surgeons were iu utt4.'ndance ; but it is beltvvcd thsiDO
account of the result has been published.
We have already called attention to the fact that, in the New Vok
City Hospital, two of the fifteen cases re[M)rted were fuiluns; a dnwio'
stance of remarkable signifiisinee, esitc^ially when we consider tbeckiO
of the several gentlemen who were the operators in thwe cows; ubIiC
plainly renders a new series of statistics necessary, drawn solely fo
the experience of one or more similar Ihi^ establisliment«, IwKn
shall be prepared to decide positively upon the relative value of i^
two procedures.
Nevertheless, we shall not hesitate to express our present conviewA
upon this subject, reserving to ourselves the right of a clinngo of vpiw*
whenever the proofs shall warrant it.
Manipulation, owing to the greater power which may Ix; liraii^l M
bear upon the neck and head of the bone through the action »f 1^
shaft of the femiu- as a lever, is most liable to throw itie ht-ad of tte
bone into new positions, and consequently most liable to niptaiYtlN
various soft tissues about the joint, to produce inflammation, MipjMin*
UPWARDS AND BACKWARDS ON THE DORSUM ILII. 697
tion,and caries. For the same reason it is most liable, also, to fracture
the neck of the femur. It is not certain in our mind but that, when
the principles which control the reduction are more completely under-
stood, these evils may be lessened; yet we can scarcely persuade our-
Belves that by any future observations the state of the question will
ever be greatly changed. We cannot but think, also, that some con-
clnsions ought to be drawn from the circumstances that, since the time
of Hippocrates to the present day, manipulation has been occasionally
noommended and successful examples reported ; the reduction being
acoomplished in most instances by processes identical, or nearly so,
with those now adopted ; yet generally the writers appear to have been
ienorant of what had been done before, and, indeed, they have gener-
uly avowed their belief that the method suggested by themselves was
Jtogether new and original. Possibly this slowness to establish, and
otal inability to sustain and peri>etuate a reputation, was not the fault
>f the method, and had no relation to its failures. Until within a few
ears, the number of surgical books, and especially of medical journals,
'as comparatively very small, so that valuable truths often died with
leir discoverers, or were known and remembered only by a few; but
is possible, also, that it has a deeper significance, and that it implies
>me defect in the procedure, or serious danger, in consequence of which
has from time to time lapsed into desuetude and finally into complete
blivion.
The rules which the author would give for the employment of ma-
ipulation are very simple.
The patient being laid on his back upon a mattress, the surgeon, as-
iming that it is a dislocation upon the dorsum ilii, should seize the
x>t with one hand and the other he should place under the knee; then,
exing the leg upon the thigh, the knee is to be carefully lifted toward
be face of the patient until it meets with some resistance; it must then
e moved outwards and slightly rotated in the same direction until re-
istance is again encountered, when it must be gradually brought down-
mrds again to the bed. ' We do not know that the whole process could
€ expressed in simpler or more intelligible terms, than to say, that the
imb should follow constantly its own inclination.
All writers have united in the necessity of flexion ; and, indeed,
rith very few exceptions, the advocates of extension have insisted
ipon carrying the dislocated limb more or less across the sound one ;
►r of making the extension at right angles with the body. They
lave also been nearly unanimous in their statements that the thigh
hould then be abducted and finally brought down. Nathan Smith
las added the injunction to rotate the shaft of the femur outwards,
nd to press gently upon the inside of the knee while the thigh is
eing flexed upon the body, so as to compel the head of the bone to
Ug the outer margin of the acetabulum and to prevent its falling
•to the isc*.hiatic notch ; a suggestion which has been erroneously in-
3freted by some ^vriters to mean that he would carry up the limb
acted, a thin^ which is simply impossible until the reduction is
^complished. In adopting this practice, however, we must not forget
te danger which we incur when the limb is completely flexed, and
45
DISLOCATK
I OF THE THIQH.
the braul of the femur is below the edge of t)ie noetabulum, of tbrov
iug it over into the foramen ovale. Dr. Xathiin Smith has also tidtiral
the advantage which sometimes may be gained by giving to the limb
at this moment a slight rocking motion.
These movements of the limb, with perha[)s other slight modifi-
cations, such as titling the knee moderately or forcibly when the hiiM
refuse to mount over the margin of the acetabulum, pressing witb
the hand or foot upon the pelvic boues, and violent cireumduolioii, an
all which have been usually practiced in successful manipulation.
We refieat, however, that as a general rule, in the firet trial, ik
knee must be tarried only in those directions which o£Fer no
and these will be found almost always to be the same; the kneeafllN
dislocated femur hanging over the sound one will be made easilv U
asfiend to about a right angle with the body ; we can then carry it oirt-
wanls a short distance, probably not more than four or five dcgn«i;
at this moment, frequently, the thigh will begin to rotate outwanUrf
itself, and with cont^iderablc force, or, as Wathman says, " a self-twi*
ing of the thigh occurs, which cannot be prevented by fast holdin;;.'
^Vhen this action takes place, the reduction is immeiiiately iu«o-"
plisfacd ; and it ia in fact at this moment, before the limb Ix^ns
descend, that the bone most frequently resumes its socket. If it iott
not, then as soon as the limb begins to fall the reduction occurs, ([Mi-
erally witli a loud snap. It is pretty certain that this manipulation ii
to fail if the knee has de.'wended more than a few inches without tttt
rednction having taken place ; and it will l)e better to repeat the m
ncenvre at once, rather than to bring the limb completely down.
GEenerally aniesthetics ought not to be emploved, since the opCTStioo,
if successful, ia not usually painful, and we neea that the patient sbnunl
preserve his oonsciouanesiS, in order to admonish us when wc are u*iif
improper violence. It is probable, also, that the action uf ivruii'
muscles sometimes alfords material assistance in the reduction. U
however, the patient is very sensitive, or the parts about the jmnt wt
very tender, or manipulation without aniestheti(» has tutlcd, tncn «»•
tainly these agents may be properly and advantageously cmplrircd.
If we propose to attempt reduction by extension, it is no lonj;
necessary to resort to the lancet, antimony, and the hot bath, u pc
liminary measures, since the muscles can l)c at once overcome k^ lb*
much more certain and more powerful agents, chloroform, rther, ««^
The method recommended by Sir Astley Coo|»er, and innwt nft«
practiced by surgeons of the present day, is essentially aa follom:
The patient is platvd upon a bed of suitable height, reclining on b*
back, but partly over u|ion the sound side. Obsi'rving notr w tiM
of the axis of the dislocated thigh, one strong staple is to be rcu**
into the wall upon one side of the room, and another ui>on the vi<|"^
siile, Imth of which shall correspond as nearly as possible with ImM
of the shiifl of the femur. The sljiplc in front of the body wUI tl
higher than the bed, and the staple behind will he, in tbc sum pi*
portion, lower than the bed. The limb being stripjiod, two pieevi
strong factory cloth, eaeJi about four inches wide and t<n> feet loif
ahoiild be laid parallel with and on each side of the limb ; the eran
of each strip being about opposite that portion of the thigh which is
just above the two coudvles. Over the centre of these strips, above
the eondyk's and patella, a strong roller, three niches wide and at least
three yards long, previously wetted in water, is to be turned as tightly
as it can be drawn until the whole roller is exhausted ; the extremity
of the roller being made fast with a needle and thread rather than with
pins. The upper ends of the side strips are then to be brought down,
and tied to the lower ends, forming thus two lateral loops, upon which
one of the hooks of the compound pulleys is to be made fast, while
the other hook la secured to the front staple in the wall. Instead of
these rollers we may employ, if we choose, a leathern thigh-belt. For
the purpose of counter-extension a sheet is folded diagonally, and its
centre being applied to the perineum of the dislocated limb, the ends
are tied firmly into the back staple. To prevent the body from moving
laterally, under the action of the pullej's, one assistant should be seated
upon the Ited, with his back against the side and back of the patient,
and his right arm thrown over the body; it is well also to station
another beside the sound limb, so as to retain it also in its place upon
the bed. Underneath the upjwr part of the dislocated limb a strong
and broad bandage should be placed, of sufficient length to tie over
the nc(^k of the surgeon when he is standing about half bent over the
body of the patient.
Everything being arranged, and all portions of the apparatus having
been suRiciently tested to make sure that nothing will give way during
the o})eration, the aniesthetic is to be administered, and as the ]>atient
tails gmdually under its influence, the action of the pulleys should
commence, and be slowly but, steadily increased; a third assistant
managing the ro|», so as to leave the surgeon unembarrassed, and able
to direct his whole attention to the position of the trochanter major
and of the head of the femur. In oiiler to this, he should place one
hand opon each of these prominences, and wattJi carefully their de-
scent.
The length of time which will be required to bring down the limb
must differ greatly in different pereons, according to the peculiar cir-
cDmst.inces of the case, and the condition, age, etc., of the {tatient; but
it must never Ik forgotton that a slow and steady action is much more
effective than rapid and irregular tractions, and it is in this especially,*
rather than in the relative amount of power, that the pulleys possess
always so great an advantage over the hands.
■ft hen the surgeon finds that the head of the bone has nearly or
quite reached the socket, if it does not take its place spontaneously, he
may place his neck in the noose which passes underneath the thigh,
and Mit upwards and outwards, in order to raise the trochanter major,
and thus enable the head to rotate toward the acetabulum. It is In
this part of the manteuvre, and especially when at the same moment
one of the assistants, after bending the leg upon the thigh so as to
make of it a lever, has rotated the tliigh outwards, that the fracture
of the neck has generally taken place ; and we cannot be too cautious,
therefore, particularly in old persons, not to bear very strongly ujron the
Boose, Dor to permit the assistant to rotate outwards with gi'eat force.
700
DISLOCATIONS OP THE THIGH.
If the bone does not enter the M)cket, we may increase the tieim,
or suddenly rclease the tension, or, in fine, again resort to nianiputa-
tion alone.
When the reduction ia awomplished, the patient should be laid
upon his back, with the knees resting over a pillow, and lied t<^tiiw
lightly with a towel or a strip of cotton cloth. In order also (he mm
certainly to prevent a reluxation, the thi);h of the dialocntoii limb
should be gently rotated outwanis, by which the head will be pr(»«d
forwards against the anterior portion of the capsule.
Such an araident, however, as a recurrence of the dislocatioo, in ttx
case of the femur, is exceedingly rare; and I should have deetnod it
altogether impossible, except as the result of considerable violeooe
again applied, had not at least two examples been reported to us upas
very excellent authority, Malgaigne savs he has himself seen anei-
ample of reluxation upon the dorsum iiii, occasioned by an untimelf
movement;' and Veriieuil has seen, ten days after the reduction of •
dislocation nj>on the isehiatic notch, the dislocation reprodaced bv t
sudden effort of the patient to sit up;' indeed, it Is when the limbil
in a flexed position that the accident seems most likely to occur.
Of course, in these remarks we moan to except those cases in wbidi
the upper margin a( ib(
acetabulum is broken <)(
and the head of the fbiuur
has conse<^uently Iwl id
natural support in tliii
direction.
The possibility of Oui
accident is also oonfirm-
ed by the example* ^
"voluntary" dislocati{)4
which I shall relm* i«
the last section (if tbii
chanter.
The method of pififl-
sion recommended liylV.
Bigelow, namelv, "ii
the thigh at a right anifll
with t he body, has alrrulT
Ix-en referred to: m
there is much rewtf *•
l>elieve that, as a rule, il
Is iin-femblc to extern**
as pract i<HHl by Sir A«li**
Coojwr. Nearly ill fot-
geons, however, haw iw
Trir-odrDiieiiicaUit.'dsiun. [Dittriow.) ognized the nA^Mitt «
flexing tJie ihigb iii'*<^
tain cases. Dr. Bigelow suggests that where greater force a R<)nina
> HalgalKne, op. fit, torn, ii, p. 880.
* itiid., p. e
IfUPWARDS AND BACKWARDS INTO ISCBIATIC NOTCH.
than can be obtained by the usnal methods, a tripod should be era-
ployed, as shown in the accompanying woodiuit.
*rhe following case, report<?d to me by Dr. N. Fanning, of Catskill,
N. Y,, illustrates the occasional necesgity of resorting to extension, aud
is of special interest on account of the extreme youth of the patient. I
have referred to the same case once before.
A little girl, two and a half years old, was caught under a falling
door on the 24th of May, 1867, but her parents sa'ipected no injury
beyond a severe bruise until ten days later, when they consulted Dr.
Fanning. The left femur was then fouud to be disIocatc<I upon the
dorsum ilii. Dr. Fanning attempted first to reduce the dislocation by
manipulation, but he failed. He then directed the father to make ex-
tension by the legs, while the mother made counter-extension by seiz-
ing the child under the arms, and thus he eoon succeeded i ~
tile reduction.
k
I 2. DiBlooatioDB IFpwards and Backwards into the Great Ischiatio
Notch.
.'^fn. — " Upwards nod bnckwiirJs inio ihe iscliiiitic nolnh ;" Sir A. Conner, " Up-
wards and bacbwardd into ihn great aacro-scJHtic notch;" Lizitn. " Back ward d
intu the Mcro-BuiHtiv f»rHiiiPn ;" S, Cooper. " Biii'kwRrd!< into Ibe uobintic notch ;''
Liiton, B. Cocip«r. Milltr, PIrtie, ErlcWn, Skoy, Gibann. " Downward* and out-
wards on the Da iBchiiim ;" Bnyer, Doraej. " Backwards and downward* intu the
i»phiatii; noli'h;" CheliuB, Petit, Duverney. " Up-in tha isnhium;" Bertratidi.
" S«cro.sciatio ;" Gerdy. " lachlBlio ;" Malgaigne. " Dorsal below the tendon ;"
Bigolow.
Boyer considers this dislocation as only secondary upon a dislocation
upon the dorsum ilii ; but it is very certain that it often occurs as a
primary accident. Not unfrequently, also, what was primarily a dis-
lonation into the isohiatic notch, becomes subsequently a dislocation
upon the dorsum ilii.
Giiues. — A fall upon the foot or knee when the limb is very much
in advance of the body; or the fall of a heavy weight upon the back
nnd pelvis when the thigh is nearly or quite at s right angle with the
Ixxiy, Indeed, the causes are very similar to those which produi-e dis-
locations upon the dorsum ilii, except that it is necessary to suppose
the limb in a position more nearly at a right angle with the trunk, at
the moment in which the force is app]ie<l.
PfUholotfical Anatomy. — Mr. Syme, who dissected the body of a man
recently dead whose thigh had been dislocated into the ischiutic notch,
fouud the glutieus maximus nearly torn asunder, the head of the femur
being imbedded in it« substance; the gluteus minimus, the pyriformis,
and the gemellus superior lacerated; the capsular ligament extensively
torn close to the edge of the acetabulum, and the round ligament com-
pletely separated fi-om the femur. The head of the femur was lying in
the great ischiatic notch, upon the gcmelli and the sacro-sclatic nerve,
behind the acetabulum and a little almve it ; being situated between
the upper margin of the notch and the great sacro-sciatic ligaments.'
Figure 308 is a representation of this specimen.
BD8 AND BACKWARDS INTO ISCHIATIC NOTCH. 703
Mth behind and below the tendon, Bigelow calls it "dorsal
; tendon."
pOBltlDO. (lKblatic)"I>erM]belowthalcDdoii." (Blgeloir.)
704
DISLOCATIONS OF THE THIGH.
Symptoms. — The position of the limb is io some cases nearly the same
as in certain dislocations upon the dorsum. It is shortened usuallr
about half an inch, the thigh being flexed upon the Ixxly, adducira,
and rotated inwards; but the flexion is often less than in dislocationa
upon the dorsum, white, on the othrr
hand, it is sometimes much greater.
Generally it is such that, when (he
patient is standing, the end of the
great tt>e of the dislocated lirab
[^ "V, touches the ball of the grml toe of
""■— "- the i^oiind limb.
Bitrplow observes that the extreme
flexion which is sometimes fouiMlto
exi»t, esjieciully when the patient is
in the recumbent position, is gen(r^
ally due to the arrest of the hewi of
the femur by the internal obtuntnr
and the subjat^vnt tintorn CKp»u]&
When the patient rises, the weight of
the limb may force the head iipbe-
, hind the tendon of the obturatfirjoT
groEt iKhlalla' notch. "Beraw (be l<'ndgn," if the limb is brODght doWII vltb
whontiiepwionif.rccuBibaDt, (itLKdour,) force, the tendon and OLpeule mw
give way and the head may sseetw
to any point upon the outer surfnw of the ilium, and in this way u
ischiatic may be converted into an iliac dislocation.
The head of the femur is sometimes distinctly felt in its newpwi-
tion, especially when the limb is mov«l upwards or downwards. The
trochanter major is approximated toward the anterior sujierior spioooi
process of the ilium.
Sir Astley Cooiwr remarks that this dislocation is the raoei iliffirall
to detect, and Mr. Syme mentions a case in which the nature of th«
accident was overlooked by lunLHcIf, and the thigh (vas not rcdiKwi
nutil the thirteenth day;' and subsequently Mr. Symc has callwl »1-
tentiou to what he considers as one of tlie most important diagniistie
marks — indeed, he says it is never absent, nor is it ever m« witii in
any other injury of the hip-joint, " whether dislocation, fractu
bruise;" this is "an arched form of the lumbar part of the ^i-inei
which cannot be straightened so long as the thigh is struighl, or on t
line with the patient's trunk. When the limb is raised or bentap*
wards upon the pelvis, the back rests flat u{kiu the Ix-d ; but fo
as the limb is allowed to descend, the back becomes arched as bdwt
This position, assumed by the back when an attempt is in*"
straighten and dcpresa the limb, b due to the action of the p|«<
mngnus and iliacus inlernus. But, in addition to this valuable *i)»
the inversion of the toes, immobility of the limb, and the sbemKrV
■ Amor. Journ. Med. Sci., vol. iviii, p. 242.
« Atner. Journ. of Med. Soi., Dot. 1848, p. 401, from Lond. and Edinb. Mi"^
Jour., Julj, I84S.
^WARDS AND BACKWARDS INTO I8CHIATIC NOTCH. 705
itus, are generally sufficient in themselves to distinguish it from a
ture of the neck. Dr. Squires, of Elmira, N. Y., in a note ad-
sed to me in March, 1860, suggests, also, that in ancient cases the
action of the head of the femur may be felt by passing the finger
the rectum or vagina. In this way Dr. Say re and myself deter-
ed a dislocation into the ischiatic notch which had existed six
iths, in a boy twelve years old ; and Dr. Wood, with myself, diag-
icated the same dislocation in a woman at Belle vue Hospital, which
existed four weeks, in the same manner.
Prognosis, — I have seen two dislocations of this character which
e not recognized by the surgeons at the time of the receipt of the
ry, nor for some weeks afterwards. One was in a lad twelve years
who was brought to me from an adjacent county in August, 1847.
i accident had happened eight weeks before. His limb was short-
1 one inch ; it was also forcibly adducted and rotated inwards.
Col^rove, a very excellent surgeon, had made a thorough attempt
•educe the dislocation with pulleys a few days before he was brought
ne, and I did not deem it advisable to subject him again to the trial,
twithstauding the dislocation, his limb was quite useful. The second
i in the case of the boy seen by Dr. Sayre and myself, to which I
'ejust referred.
rreatment. — In employing manipulation, we may follow, with only
ight modification, the directions already given in dislocations upon
dorsum ilii. We find the head of the femur lower, consequently
extent of the circuit to be described in the manoeuvre is diminished,
in other respects the processes are identical.
iV^e must not forget, however, that there is especial danger, while
impting to reduce this dislocation by manipulation, that the head of
bone will be thrown across into the foramen thyroideum. I have
aady mentioned one case occurring under the care of Dr. Post in
New York Hospital, in which the head of the femur, originally in
ischiatic notch, passed backwards and forwards between the ischi-
J notch and the foramen ovale many times, and which, although
reduction was finally accomplished, was followed by morbus coxa-
3. Parker mentions a second case in the same paper,* in which his
t attempt to reduce by manipulation carried the head of the bone
} the foramen ovale ; but the second attempt was successful. In
. Hutchinson's case, to which I have already referred, the first
Jmpt at reduction was made without an anaesthetic, and by manipu-
on after the method described by Reid. The first two attempts
ed, and in the third, the limb being more abducted than before, the
d of the bone was thrown into the foramen ovale. By reversing
movements, it was replaced in the ischiatic notch ; and this change
position was made seven or eight times. The patient was now
erized, and the bone was lifted into its socket in the same manner
ich I have described in the case of Caswell. Malgaigne refers to a
ient ot Lenoir's and to another of his own, in whicn the head of
^ Markoe's paper, N. Y. Journ. of Med., Jan. 1865.
706
DISLOCATIONS
3F THE THl
the bone was lodged under tlie mai^in of the afetabulum during tfie
attempts at reduction.'
On the 23d of March, 1855, Charles McCormick, est. 21, a laborer
on the " State Line Railroad," was caught between two cars, with hit
back resting against one car, and his right knee against the other, the
right thigh being raised to a right angle with his bodj. As the ran
caiue together he felt a " cracking " at his hip-joint, and found bim-
self immediately unable to walk or stand.
Two hours after the accident, assisted by my son Theodore, mi
Austin Flint, Jr., I examined the limb carefully, and made arruig«-
ments for the reduction with the pnlloys, in tsse the attempt by urn-
nipuIatioQ should fail.
The patient lying upou his back, I seized the right leg and thigh
with my hands, the leg being moderately flexed upon the thigh, uid
carried the knee slowly up toward the belly, until it had approached
within twelve or fifteen inches, when, noticing a slight reaistanoe la
farther progress in this dii-ectjon, I carrietl the knee a«;ro!is the body
outwai'ds, until I again encouutcred a slight resinUinee, and immedi'
ately I l>egau to allow the limb to descend. At this moment a smWia
slip or snap occurred near the joint, and I supposed reduction vasnt-
complished; but on bringing the limb down completely, I founil it
was still in the ischiatlc notch. 1 think the head had slipped ofrfMin
the lower lip of the acetabulum, after having been graduiilly lifl«d
upon it.
Without delay I commenced to repeat the manipulation, and in 1"*-
cisely the same manner. Again, at the same point, when the limb W
just beginning to descend, a much more distinct sensation of slippins
was felt, and on dropping the limb it was found to be in place and in
form, with all its mobility completely restored.
No anaisthetic was employed, and no jierson supported the body or
interfered in any way to assist in the reduction. No outcry was tnwle
by the patient, yet he informed me that the manipulation hart bin
considerably. The amount of force employe*] by myself was just »u(5-
cient to lift the limb, and the time occupied in the whole prooedan
was only a few seconds.
After the reduction he remained upon his back, in bed, eleven (l>}*i
in pursuance of my instructions. At the end of this time he began W
walk about, but was unable to resume work until at^er eight nvcks tf
more. It is probable that he could have walkeil immediately aJUr H*
reduction, without much If any inconveuienw, so trivial was tlie in-
flammation which result4<d from the ai^rident. He never iwmplainiJ
of pain, bnt only of a slight sorcniss l)uck of die trochiuitvr m^,
near the head of the bone. This soreness continued mivenl vem,
and was especially present when he bent forwanls. After tlw hi[M of
four months, when I last saw him, be occasionally felt a [Min at dis
(toint in stooping, bnt the motions of the joint were free ; he wallad
rapidly and without halt. .
UPWARDS AND BACKWARDS INTO I8CHIATIC NOTCH. 707
If the reduction is attempted by extension, we ought to remember
that the head of the bone lies more behind than above the socket, and
that it is not requisite to carry it downwards so much as forwards ;
Fio. 313.
Redaction of dislocfttion upwards and backwards into the great Ischiatic notch, by extension.
(Sir Astley Cooper's method.)
J^^ especially that it must mount over the most elevated margin of
^^ socket, in order to resume its position. The extension ought,
'^^refore, to be made at a right angle with the body, as the following
^se will illustrate :
John Hebden, set. 40, was sitting with his legs hanging over the
^^k, when his left knee was struck by a ferry-boat, dislocating the
^^d of the femur into the ischiatic notch. I found him at Bellcvue
hospital on the following morning, about twenty hours after the acci-
^^Ut, September 29, 1866. In the rc^cumbent posture the limb was
^^tty strongly adducted and slightly rotated inwards. It was short-
'*^ed three-quarters of an inch. In the erect posture both adduction
'^d inward rotation were very slight.
Having etherized him, I made three separate attempts at reduction
^y manipulation, but failed. I then made extension in the following
^^^anner: The patient resting upon his back, I stood astride his body,
^^d clasping my hands under the knee, I pulled directly upwards,
^hile an assistant held down the pelvis. I dia not feel the bone resume
708
DISLOCATIONS OF THE THIGH.
its place, nor was I aware that reduction was accoroplisbcd, but wlieii
I let the limb down the bone was found to be in its socket.
Two or three minutes later, and beturc the patient had rccovend
from the effects of the ether, I raised the knee, to indicate to somt
young men, who had just come in, how the dislocation hud been re-
duced, when it slipped out a^ain, with a sudden jerk and a gralinj
sensation. This sensation I had felt once or twice before while nil-
nipulating. It was scarcely as rou^h as the crepitus of a fracture, und
it probably indicated that the cartilaginous mai^in of the acclabulun
had been broken off.
The limb was now brought down to the bed, and it was found tn be
in the same position as before reduction was attempted. Slandinc
again over the patient, and placiug my hands under the knee, I pullM
upwards, and the head resumed its place; this time with a sudden jprt
and with the same rough sensation. The limb was then placed in tlw
extended i>osition and secured by a long splint, which was not rcmeved
until the eleventh day.
The facility with which the reluxation took place in the preceding,
case will sufficdently explain what happened in the following css«oa.
the tenth day after reduction, and on account of whicli I was subse-
quently consulted.
William Milne, xt. 19, of Orleans County, N. Y., was thrown froa.
a wagon May 13, 1858, dislocating his left femur into the ischiatic
not«h. Dr. Watson, of Clarendon, Orleans County, was oonsultal
within three hours. Drs. Wood and Tafft were also present. Dr.
Watson laid the patient on his back, and without anasthetics rednoel
the dislocation by manipulation. The bone was felt distinctly as it
slipped into its place, and the limb immediately resumed its tiatoiU^
position and length, as all the surgeons present affirm. He was sow
out of the house on crutches, and on the eleventh day went iu bathing
When he came out of the water he complained of his hip, and o
following day it was seen to be shortcneci, Subaefiuently it wa
amined by several surgeons, all of whom pronounced it dislocated
An attempt was then made to reduce the dislocation by Jarvis's ad-
juster, but without anaathesia, as the patient refused to be rendenl
insensible. The attempt did not succeed, and the father brought u
action against Dr. Watson in the Supreme Court of Orleans Coauij,
Judge Davis presiding, for September, 1858. The prost-c-ulor fiiiled W
ap|>ear, and Dr. Watson, the defendant, took judgment by default.
Lente relates a case in which, extension being employed, ibe coA
was suddenly cut while the limb was abducted and rtituUii outwanl^
when the h«id of the femur led the ischiatiu notch, an<] ruec iipno tb(
dorsum ilii, assuming a position directly aliove the atwtabuluiii, i '
below the anterior superior spinous process; and from which foiat
it was subsequently, with great difficulty, returned to the aocktit.'
' Lenlo, New York Joi
I. Med , Novombor, 1860, p- tU-
INTO THE FORAMEN THYROIDEUM. 709
i 3. Dislocations Downwards and Forwards into the Foramen
Tbyroidenm.
/n. — "Downwards into the foramen ovale;*' Sir A. Cooper. "Downwards
the obturator foramen ;" Lizmfs. " Downwards and forwards into the foramen
iratorium ;'' B. Cooper. " Inwards and downward? into the oval holp;" Chelius.
^wnwards and forwards into the foramen ovale;*' Pirrie. " Downwards and
ards;" Boyer. ** Subpubic;" Gerdy. '» Ischio-pubic ;** Malgaigne.
lauses. — In order to produce this dislocation the limb must be, at
moment of the receipt of the injury, in a position of alxluction.
haps most often it is occasioned by the fall of a heavy weight upon
back of the pelvis when the bocly is bent and the thighs spread
nder.
Pathological Anatomy, — The capsule gives way upon the inner side
ecially ; the round ligament is torn from its attachment, and the
id of the femur, pressing forwards and downwards, finds a lodg-
nt upon the obturator externus muscle, over the foramen thyroi-
im.
Symptoms, — ^The thigh is lengthened from one to two inches, ab-
ated and flexed, the body being also bent forwards or flexed uj)on
thigh. The dislocated limb is advanced before the other, and the
8 generally point directly forwards, but they may incline either out-
rds or inwards. The hip is flattened or depressed ; the long adduc-
3 are felt tense upon the inside of the limb ; the trochanter major
less prominent than uj)on the opposite side ; and the head of the
le may sometimes be felt in it« new position. The lengthening of
limb alone is sufficient to distinguish this accident from a fracture
the neck.
The flexion and abduction are due in some measure to the tension of
psoas magnus and iliacus internus, and perhaps to a similar con-
on of other rotators and flexors ; but, according to Big(*low, the
•femoral ligament offers the chief resistance, and constitutes the
jf impediment to the restoration of the bone.
Vreatment, — It is pretty certain that in the following example there
\ a spontaneous reduction, or rather, I ought to say, an accidental
uction of a dislocated femur from the thyroid foramen. Perhaps
ras only an example of a i)artial luxation ; of which species of for-
•d luxation I shall hereafter relate another case as having come
ler my own notice.
■acob Lower, cet. 10, fell from a tree, a height of about twelve feet,
the ground. It is not known how he struck. He became imme-
tcly quite faint, and when he had partly recovered, he attempted to
up, but could not. He said his leg was broken, and cried out lustily
snever it was moved. The father arrived in about an hour, and
nd him still lying on his back where he had fallen, with his right leg
ried away from the other, and turned outwards. He lifted him up to
ce him in a small hand-wagon, which was long enough for his body,
; only one foot and a half in width. Finding that his right leg was
mucn abducted as to prevent his being laid in so narrow a space, he
710
DISLOCATIONS OF TBE TUIQU.
seized upon it, and with some force pressed the knee iawardij acro«
the opposite leg, when euddenly it resumed its position with a lond
snap like a "camion." 1 uae the language of the fiitler. On thr
following day I examined the limb earefmlj-, and found ita motion
free. He was, however, vomitiug the (
(Xiut«nts of his stomach, and parsing I
lilood from the bladder quite frw-Iy. N
The vomiting soon ceased, but the
hiemorphage from the bladder con-
tinued ihree or four days. On the Di«ioe»>ion
ninth day he walketl out, and on the
twelfth he wua seen climbing upon the
top of u house. I saw him again afWr the l!i]tsc of a year, and t
that he van still complaining of an oct^sioual noreness tn liic r
the hi|KJoiiit. ^^
If we attompt to reduce by manii>ulalion, il will be propw to WW
the Bame rule which we have stafeif an applirablo to dislocations It ''
wards, namely, to carry the limb, in the firrtt ini^tance, only in li
directious in which it is found to move easily, lasu-ad, titenhn,^
holding the leg in a position of adduction while the thigh ih flexed oiri
the al^omen, it wilt be necessary to carry it up abduirtn]; ondvM
the further pn^ress of the knee toward the belly is amsled, the
INTO THE FORAMES THYBOIDEUM. 711
' be moved JDwards, and tioally brought down adducted. When
knee is about opposite the j)ubes, or a little lower, in its descent,
einur should be gently rotated inwards, for the pur])06e of direct-
lie head toward the acetabulum. The reduction may also be some-
s facilitated by lifting the head of tliu bone with the aid of a band
iA under the uptier portion of the thigh and over the shoulder of
ssistant; by giving to the shaft of the fenmr a slight rocking mo-
when it is about to enter the socket; and also by pressing with th#
i against the head of the bone, or by lifting at tlio knee moderately,
a one of the examples recorded by Markoe (Case 8), the reduction
accomplished in the second attempt, by rotating the thigh inwards
aa the thigh had deaceuded below a right angle with the body,
he manner which we have above dir«;ted ; but in a second example
*e 9), a similar manoeuvre curried the head across into the ischiatic
^, while the reduction was finally accomplished by rotating the
h outwards, and at the same moment adducting the limb strongly
direction which carried the knee behind the other one. Markoe
lades that the latter mode is preferable, because it will throw the
of the bone a little upwards as well as outwards ; in which direc-
it will iind a more gently inclined plane toward the socket. He
its, however, that both methods may accomplish the same result.
I am quite certain that the mctli<xl by rotation of the shaft of the
ir inwuds is in general most likely to succeed. la this way also,
712
DISI-OCATIONB OF THE THIGH.
I think, both W. H. Van Buren, of Kew York,' and R. L. Bnidie,
of the U. 8. Army, were Bueocssful;' it is the method preferred hf
Bigelow, who also recognizes the propriety of making outward rotation
when inward rotation iails. " Flex the limb towards a perpend iciilir,
and aliduct it a little to disengage the head nf the bone ; then nXaie
the thigh strongly inward, addncting, and carrying the knee lo ibe
floor." It is especiaity worthy of notice that Anderson, so long ago
fes 1772, in the case already qiioEed when we were considering the hifr
tory of reduction by manipulation, practiced sutves^fully almost pre-
cisely the same method. In one example mentioned by hlarkoe i'
7), it is pretty evident that the head of the femur was thrown into th(
ischiatic notch, by having flexed the thigh too much, so that "thf
knee touched the thorax.' Indeed, it is questionable whether it will
be best ever to bring the thigh mnch, if at all, above a. right angle with
the body, since any further flexion can only throw the head below the
flcttabuhim, when in fact it is already too low,
July 21, 1858, Nathaniel Smith, a painter by trade, set. 33, fell frnn
the Hecoud-etory window of the city post-office, Buffalo, npoa a 6t<io»
favement, striking, as he believes, upon the inside of his right kntt.
saw him within an hour, and found the right tibia partially disloRiti:^
outwards, the corresponding patella dlsloaitctl completely oulwunls,
and the right femur In the foraiuen thyroideuoi. His thigh was fi>ni-
biy iilxlucled, slightly rotated outwards, and lengthened, by nicusuw-
ment made from the pelvis to the ankle, one inch and a half. Tbl
distance from the anterior superior .spinous process to the fold of <ht
groin was ten inches, but upon the sound side it was only eichtWl
half. The head of the femur could be distinctly felt in lriinl,ji»'
under iho pubes.
Having administered chloroform, I firpt reduced the tibia and dx
patella, then seizing the thigh and leg, I flexed the thigh ii[>«n the
body, carrying the limb upwanis abducted until it was nearly or quit*
at a right angle with the body, then inclining the knee slighllv in-
wards, I brought it down again, and when the thigh had nearly res('b*4
the bed, it fell into its socket with a dull flapping sensation. In cvriy
step of the procedure I followed the inclination of the limb. 11*
recovery was rapid and complete.
Sir Astley Coo[)er says that this dislocation is in general rrdu«»
very easily by the aid of pulleys; at least if the accident is re'"*
He advises that the patient shall be placed upon his back, with hii
tliighs separated as far as possible. The pulleys are to be tiiaile TmI
to a band drawn through the perineum of the dislocnt*^! limb, in ■
direction Upwanis and outwards; while a counter-band is to lie pi(««i.
aroun<l the pelvis through the band attached to the pulleys, and wnirJ
to a staple, or delivered to assistants placed nnon the sound Mide ofdM
body. When everything is arrangetl, the pulleys thould be acted opat
until the head of the femur is felt moving from the foramen oviie; '
INTO THE FORAMEN THYROIDEUM.
713
is moment the surgeon must pass his hand behind the sound limb,
d seizing upon the ankle of the dislocated limb, adduct it forcibly,
us converting the limb into a lever of the first order.
If tlie dislocation has existed some time, he recommends that this
txjedure shall be varied by placing the patient upon his sound side
stead of his back, and attaching the pulleys perpendicularly over
Fio. 317.
Sir Astlcy Cooper*8 mode of reducing a recent luxation into the foramen thyroideum.
BC body. Sir Astley especially cautions us not to flex the thigh during
1*686 manoeuvres, lest we force the head of the bone backwards into
iJe ischiatic notch, from whence he affirms that it cannot afterwards
G returned to its socket; but the experience of surgeons has since
Wn that this latter statement is incorrect, and that it may, in some
^, be afterwards reduced, although it has fallen into the ischiatic
otch. Mr. Liston says that this accident happened to himself while
^mpting to reduce a dislocation of only a few hours' standing, in a
t>nng and powerful man, but he had no difficulty in returning it to
8 first position.*
firainard, of Chicago, reduced a dislocation of that form of which we
■enow speaking, after both the compound pulleys and Jarvis's adjuster
id failed, by placing between the thighs a piece of wood wrapped
>out with several layers of a wadded quilt, and making use of this as
fulcrum upon which the thigh operated as a lever. The legs were
mply pressed together, care being taken to keep the knees straight.^
* Practical Surg., Amer. ed., p. 98.
' firainard, Northwestern Med. and Surg. Journ., 1852,
46
714
DISLOCATIONS OP THE TH
The majority of eurgeons of the pi-eseut day place the limb in ll||
flexed position before attempting to make traction. This may be d(
with the patient lying u\v3n his uack, aD<i by the hands, alone, or w
pulleys, or the patient may be placed in a sitting posture, aud the i
tension made at right angles with the body. In all of tliesc atti^iopt
to redu<« by traction, measures must be taken to secure immobility
the pelvis.
May 23, 1868, a man, 40 years of age, was admitted to Belleim
having a di.'^loeation of the lefl femnr into the foramen tliyroidenfl]
whieh ha<l been caused six haan
before by the fall of a hcait
weight upon his back whin
3too)iing. The limb was slietitlf
alxluctcd, and moderately fleied
upon the i>elvis, while he bw
lying upon the bed ; the nc^itioa
being that represented in Fik
315. There was s very markd
depression in the situation uf lie
trochanter m^or, and a fulnea
U[K)n the inside of the liiolv
ciiiised by the tension iif ibt
long adductors.
The jtatient being undfriht
iutluenee of other, the lums^
surgeon, Dr. E. D. Hmlsoii,
first attempted, utwler my in*
struction, to reduoc the disloor
tion by maniputatiou, ieim,
Efltctof a™ioiiuponihBiiio-t™o«nig«n.-oi In *"'' rotation, with addorti'«;
the iiiyruid ditioQitiuu. (Fnioi Bigi^Low.) but failing in this, a fuldcil jiittl
was placcil in the (lenneuni ow
responding to the dislocated limb, and comniittcil to afsistanls, «lw
were directed to pull upwards and outwards, the patient lying ufod
his right side, with his leA thigh flexed to a right angle witii bis tiiilfi
Dr. Hudson then pa^^^cd a baud under the uifixr jutrt of th? thi^ham
over his shoulders, lifting itnd preying tlie kni-e furcibly tnwanlt tf
the same time. In a few seconds the reduction was ai-compli^lial.
After the reduction is accomplished, the patient .should Ix- laid ii|)M
his back in bed, but instead of rotating the limb outwards, ax we wf*
advised after a disloL-ation upon the dorsum ilii ur into the ischittiB
notch, it should be geutly rotated inwards, and the knees Uuie Umnd
together.
i 4. Llalooationi Upwards and Forwardi apon the Pnbtt.
Syn.— " Upwiirds Hnd forn-unU on the horUuiilnl lr»aeh of iho ib«f*-b«<;"
Chpliui. '■ Forwnrtis iii-,n ih.- [.ubos ;'■ Pirrio. " On tli.- h.^ly of ih« |imI«.1*I»*
theBpliicnnii Imim-eKe purl of tlie buno;" Skey. •■ Surpubic;" Otrij. "11'**
piibici" Malgnigno.
OiMflee. — This accident is generally occasioned by a fell npon '*•
foot when the leg is thrown backwards behind the ocntre of gmviiy
OFWABD8 AND FORWARDS tPON THE PDBE8. 715
uin a &}] from the back end of a wagon, the foot being iostiDctively
thrown backwards in order to save the head; or it may happen to a
penoD who, while walking, snddenlj puts one foot into a hole, in con-
sequence of which tlie pelvis advances, but the leg and upjier part of
the body incline forcibly backwards. Occasionally it has resulted from
ibll upon the back of the pelvis, or from a severe blow received upon
the Bame part. A patient was admitted, under the care of Dr. Ure,
lotoSt. Mary's Hospital, London, with a dislocation upon the pubes
*«»sioned by swimming. His account of it was, that when in the
ictof "striking out" he felt a catch in the right groin which he
thought was cramp, and that he was able to walK after the accident,
bat with a good deal of difficulty. The e.\aniination proved that he
W a dislocation upon the piil)cs, which Dr. Uro eiL-^iiy reduced,'
P<Uho(offical Anatomy. — Sir Astley Cooper dis.sci'tc<l the hip of a
pereon whose thigh had been dislocated upon the pubes for some time,
ihe true nature of the accident not having been at first recognized.
The acetabulum was partly filled by bone, and jmrtly occupied by the
trochanter major, both of which were much altered in their form. The
spMilar ligament was extensively torn, and the ligamentum teres
Woken off completely. The head and neck of the femur had torn up
Poupart's ligament, so as to penetrate between it and the pubes, and
•y underneath the iliacus internus and psoas muscles; the anterior
fural nerve was lying upon these muscles, over the neck of the femur,
^he head and neck were flattened and otherwise much changed in
»m. Upon the pubes a socket was formed for the neck of the thigh-
One, the head being above the level of the pubes. The femoral artery
* UedicRl Newi and Libr«r;, vol. xvi, p. ] j tiovt Lond. Laocet, Not. T, 1867.
716
DISLOCATIONS
and vein were to the inner side. This specimen b still preserved it
St. Thomas's Hospital.
The ht'ad of the lemur may be found lying far for«'ard upon tl»
Eubes, aa in Physick's case mentioned l)elow: or It may lie brtlw
aek, along the iUo-pubic mat^n, and rest below and in front of tb
anterior sujierior spinous process of the ilium. When the head nsti
directly below this process, the dislocation is cousidered anomslooi
or irregular, and this form will be considered hereafter as the "jub-
spinous" dislocation.
In the aocompanying drawing the relation of the ilio-feraoral
ment to the head and neck of the femur is shown, when the heid.
aftccn<ls moderately ujun thi
*^' ^- pubes. The extreme di*p!»iw
uient shown in the pm>ctltiif
ilhit^tration from Sir Aal^
Coo)>er is only ]>ossible wb«iff
that portion of the capsuln bf
ncAth the obturator inl«niudi|
torn, and perhajts the 'iblomUt
itself. Atvordiug to Btgtloit
the ilio'femoral ligiinifiil an
the psoas mj^;ntis and ilUm
iut«rnus are then the only n
maining caiis^ of eversion.
Sifriiptonut. — The thigh i
shorttined, abducted, flcxa.
slightly, rarely extended, aaj
romted outwards. The tr*^
chanter major is lont, or nnrif
so, while the head of the huN
may be generally felt lik« ■
round ball, lying upon at il
front of the Gody of ihf |miW
to the outside of the (riuunl
artery and vein. I^rn-y al
H patient in whom lb*- fern*
was placed nearlr at n rijrfl
angle with the Uwly ; and I'hrt
DLincMiop upon iiif pu!>M M«w the Bi.iB.inr In- ick oncc met wilh a di»lomti«i
rLrturepinpof ll.elilutn, (Frani Billow) npOH the pul)eS " d inVllj l«tt*
the ai«(flbiilnm," in wliii^ t"^'
limb was not at all shortened, but, on the contrary, a very little l«igl
ened." Other surgeons have r>ccasionaHy seen similar examnlw.
The differential diagnosis lietween a fracture of the iieckof llieB™
and this dislocation may be thus brie6y etated. In the frecton' ih*
is crepitus, mobility, slight evorsion easily overcome, madentfl w *
shortening, no abduction, the trochanter major rotstm on a short nii^
and the head of the bone cannot bo felt. In this difllocntion tha« ■ M
UPWARDS AND FORWARDS UPON TBE PURE
||b, the limb ie immobile, the eversion is extreme au<l not ea«ilv
ftnie, there is generally more sIiorteoiD^, the thigh is abdtietcd,
pehanter major rotates upon a longer mdiiis, and the head of the
(BD generally be distinctly felt in its unnatural position.
I^oms. — Sir Astley Cooper remarks that although this accident
y of detection, he has known three instances in which it was
K^ed, and he cannot but regard such errors as evidence of g
Bsnesg on the part of the surgeon who is employed,
a reduction has generally been accomplished. In retvnt cases, with
nt difficulty i and when not reduced, the patients have occasiou-
iBcovered with very useful
vUmerii. — From the several
«d examples of dislocation
the pub(« reduced by ma-
Ition, it would be difficult
y practical conclusions,
! methods have differed
dely from each other. I
mention only three, which
le found in our own jour-
' One of these has already
mentioned tn conneetion
iJie history of this process,
ease of compound disloca-
teduced by Dr. Ingalls, of
n, Mass., and the two re-
pg examples were both re-
I by E. J. Fountain, of
fa^rt, Iowa. Dr. In^^alls
oed by carrying the limb
fe greatest state of alxlue-
md rotating the thigh in-
V} the replacement of the
bmng aided also by pressing
,'i(8 Jiead with his fingers
I into the wound ; while
nnntain succeeded equally
p of his cases, by an almost
fe mode of procedure,
jr, by adductlng the limb
ly, rotating the thigh out-
^and then flexing the thigh
die body. The first of
tonntain's eases occurred in
1854. The patient, an
718
; OP THE THIGH
and vein were to the inner side. This specimen is still prescrvei) i|^
St. Thomas's Hospital.
The ht'ud of the femur may be found lying far forward ii|><iii ttfl
pubes, as iu Pliysiek's case mentioned l)eIow ; or it may lie farth*
baek, along the ilio-pnbic margin, and rest below and in front of '
anterior superior spinous process of the ilium. When the heat) n
directly below this process, the dislocation is considered anoniatai
or irregular, and this form wilt be considered hereafter as the "
spinous " dislocation.
In the accompanying drawing the relation of the ilio-femoral ligl
ment to the head and neck of the lemur is shown, when the hai
ascends moderately uptm tl
*■»■■"»■ pubes. The extreme displaa
ment shown io the pmwdi^
illustration fWim Sir Astll
Cooper is only poestble wha
that portion of the (9i|isule b
neath the obturator inlemas i
torn, and perha[>s the ohiura
itself. According to BigeltH
the ilio-femoral ligament m
the psoas magnus and iliw
internns are thou the nnly i
mnining causes of eversioti.
S^njjtonwi. — The thif^h
shortened, abducted, fles
slightly, rarely extended, oi
rotated outwards. The tr
chanter major is lost, or luu
so, while the head of the ba
may be geuemlly felt like I
round ball, lying upon or I
front of the botly of tho \nM
to ihe outside of the frniiin
artery and vein, lanry <■
a patient in whom the (raU
was placet! iicarlr at u rifl
angle with the bo(iy; and I'h*
DlilocnHon upon ibe pub» below Ihs «nttti«r In- 'f^ Once met wilh % dt^lnnltt
fertor splnr of H.» Ilium. (Kram BIkcIo^.j upon tllC pul>es "dirwtly l»ftl
the acetabulum," in which "^^
limb was not at all shortened, but, on the pontnirj-, a vi*ry little leoffk
ened.' Other surgeons have occasionally seen similar examplts.
The dilferential diagtiosis between a fractnti- of the nivk nf ll» frto
and this dislocation may be thus briefly slat<'"i. In tin- fracluft t)«
is crepitus, mobility, slight eversion easily overcome, moderate i< '
shortening, no abduction, the trochanter major rotates on a sbori radii
and the head of the bone cannot be felt. In this dislocatioa thei* i* i
» Dorwy» Surgerj, vul. i, p. W8, 1818.
JPWARD8 AND F0BWAED8 UPON THE PUBES. 717
I, the limb is immobile, the eversiou is extreme and not easily
le, there ie geoeraliy more shortening, the thigh is abdticted,
Jtanter major rotates upon a longer radius, and the bead of the
Q generally be distinctly felt in its unnatural position.
noais. — Sir Astley Cooper remarks that although this accident
of detection, be has known three instances in which it was
ked, and he cannot but regard such errors aa evidence of great
ness on the part of the surgeon who is employed,
"eduction has generally been accomplished, in recent cases, with
t difficulty ; and when not reduced, the patients have occasion-
uvered with very useful
ment. — From the several
I examples of dislocation
le pub^ reduced by ma-
on, it would be difficult
any practical conclusions,
le methods have differed
;ly from each other. I
ention only three, which
found in our own jour-
Jne of these has already
lentioued in connection
e history of this process,
se of compound disloca-
luced by Dr. Ingalls, of
, Mass., and the two re-
; examples were both re-
by E. J. Fountain, of
ort, Iowa. Dr. Ingalls
id by carrying the limb
greatest state of abduc-
a rotating the thigh in-
the replacement of the
ing aidM also by pressing
8 Jiead with his fingers
into the wound ; while
mtain succeeded equally
of his cases, by an almost
! mode of procedure,
by adducting the limb
, rotating the thigh out-
md then flexing the thigh
tie body. The first of
intain's cases occurred in
1864. The patient, an
lale, had &l]en from the
story of a house to the
frectaring his lower Jaw, and dislocating his left hip. The
a a trifle ^ortened, and tlie foot strongly everted. The promi-
tHilocUlon upwuda anil formnla upon
ri8
. OF THE THIi
Tience of the trochanter was lessened, aud the head of the bone onuli
be felt upon the pubes, A.^isted by Dr. Arnold, he niluced the link
in the following manner: The patient was laid on the floor, and \ihati,
completely under the infiuenee of chloroform. The dislocated link
was then " seized by the foot and knee and rotated outwards, the lag
fiexed and carried over the opposite knee and thigh, the heel kept weB
up, and the knee pressed down. This motion was coiiliiiued by carm
ing the thigh over the somid one as high as the upiwr part of m
middle third, the foot being kept firmly elevated. Then the limb vai
carried directly upwards by elevating the knee, while the foot wn* hell'
firm and steady, at the same time making gentle oscillations hy llH'
knee, when the head of the bone suddenly drojiped into its sorketi*^
The time oraupied was not more than thirty seconds, and the font
employed was very slight.
The second case occurred on the Slstof October, 1855, in the per>ai
of John McCarthy, an Irish laborer; the dislocation having beea
occasionetl by &Iling with a horse, while riding. The reduction n*
effected in about twenty seconils by the same process, and without th»
aid of chloroform.
It ia probable that no one metho<! will sueceed equally well in all
cases ; but if the head of the bone, as in the case dissected by Sir
Astley Cooper, has not only actually surmounted the pubes, but pusW
itself fairly into the pelvis, theu the limb ought to be abducl«d in tilt
manner practiced by Ingalls, and forcibly rotated outwards, in nrdw
that the head may be thus lifted over the pubes; and subs«queiiltyl
should be flexed upon the body, odducted and brought down. Bui Mi
this nianceuvre we ought to be careful not to continue the rotation not-
wards after the head of the femur ha.'^ risen above the pubes, )«t Ot
head and neck should grasp, as it were, the psoas magnns and ili»o^
internus muscles, underneath which they have been thrusL On tbt
contrary, it will be necessarj- at this point to rotate the (high agai«
gently inwards, which, by compelling the head to hug the front of tl«
pubes, will enable it, while the flexion is being made, to slide ilowK
wards under theae muscles fo^-ard the socket. If, however, the ln«l
of the bone has never risen upon the summit of the pnbeH, and i; n
actually engaged under the muscles which pass over it at this [vnii^
then tile rotation outwards will not be necessary in any part of dt
procedure.
Baron Larrey has reported a case of dislocation "before the b
zontal portion of the pubes," which he re«!u('c*l " by suddenly rai*
with his shoulder the lower extremity of the femur, while witb b
hands he depressed the head of the bone."' This is the Mtme oh* I
which we have already spoken as being attended with the UDW
phenomenon of the thigh placed at a right angle with tlie h<idy.
If reduction is attempted by extension, the ]ialient ought to he !•■
on his back upon a table, with the dislocated limb falling off »li^i^
186Q, n. fi!
■ Larroj, Loud. Hed.-Chir. BeT.,I)ec. 1820, p. WO; vol. i,'ant kHm, Tran 8
leUn ds la Fbc. do M«d., No. I.
ANOMALOUS DISLOCATIONS. 719
•ora ite side. The extending band, made fast above the knee, should
ien be secured to a staple in the line of the axis of the dislocated
iigh, and of course below the table ; while the counter-extending
and, crossing under the perineum, should he made fast in the same
ne, above the level of the table, and beyond the head of the patient.
When extension is commenced, and the head of the femur has begun
) move, the reduction may sometimes be facilitated by lifting the
Fio. 822.
Kedactlon of dislocation upon the pubes, by extension.
Bpper part of the thigh with a jack-towel or a band passed under the
thigh and over the neck of the surgeon, as we have recommended in
both of the backward dislocations. It may be found advantageous
•feo to flex and rotate the limb aft«r extension has brought the head
near the socket.
i 6. Anomalous Dislocations, or Dislocations whiob do not properly
belong to either of the Four Principal Divisions
before Described.^
1. Dislocations directly Upwards.
Syn, — '*Soo8-cotyluidiennes;" Malgaigne. *' Sixth dislocation;'' Mutter.
Malgaigne alBrms that the head, in this dislocation, is situated ex-
fftial to the anterior inferior spinous process, and about one inch below
* MnlgHigne, Traite des Frac. ct des Lux., torn, ii, p. S60et scq. Samuel Cooper,
Iwt Lines, vol. ii, p. 391. Pirrie's Surg., Amer. ed., 1852, p. 276. Skey's Sur^.,
mer. ed., 1851, p. 110 et seq. Gibson's Surg., sixth American ed., vol. i, p. 886.
uy*8 Hospital Reports, vol. i, 1836, pp. 79 and 97 ; vol. iii, 1838, p. 168. London
iDcet, Lond. ed., vol. i, 1848, p. 184 ; vol. ii, 1840, p. 281 ; vol. i, 1845, p. 412 ;
A, if, p. 159. London Med. Gaz , vol. xix, pp. 657 and 659; vol. x, p. 19; vol.
cxHi, p. 404. Med.-Chir. Trans., vol. xx, p. 112. Lente's paner on •♦ Anomalous
Ulocationa of the Hip-joint," in New Yorlc Journ. Med. for Nov. 1850, p. 814 et
q. Philadelphia Med. Examiner, No. 51. Amer. Journ. Med Sci., vol. xvl, p.
L New York Med. and Phys. Journ , 1826, vol. v, p. 697. New York Journ.
[«d., Jan. 1860, Dr. Shrady's case. Dislocation of the Hip, by Jacob J. Bigelow,
L.D., 1869, p 105.
«
720
DISLOCATIONS OP THE THIGH.
the anterior superior spinous process ("subapiiioa'i"). But this poEitioi
is not uniform. It may bo found in front of the inferior process, «
ftbove ("supraspinous") as well as hehimt, or externHl to it.
The symptoms which characterize this &eci<1ent are shortening of tlw
limb, slight atxliietion and extension, with extreme eversion or rotation
outwards. The everaion of the toes, together with the slight amoDnt
of shortening which has in general been observed, has led sever&l timai
to the supposition that it was a fracture of the neck of the femur ; hot
the rigidity, and the position of the trochanter and head will usoallj
render the diagnosis clear.
The following is probably an ex&m]>le of the subspinous dislocatioa:
Bennett Morris, let. dl, was thrown backwards, in wrestling, in 1851.
He felt a snap in the hip-joint, and found his thigh placed in a poH-
tion of moderate abduction, so that he rould not get his knee) togethtf.
He wfis able to walk, but not without limping. This condition con-
tinued three years, during which time ho was constantly lame, and
suffered much pain when walking.
At the end of this period, when in the act of jumping from hit
wagon, his horses having be(<ome frightened, he felt a snnp, nml il
once the complete functions of the joint were restored. He could walk
without pain or halt, and he could bring his knees tt^tlier. Three
months later, while a.scending a flight of steps, carrying a liwivjr
weight, his foot sllppetl, and the luxation was reproduced, and in this
condition it remained up to the period at which he consulted me, <M
1869, I found the thigh apparently elongated, but upon nicnsnmneid
it was found shortened half an inch. It was moderately aUlurtol inl
rotated outwards. All the motions of the joint were restrid«<l.
.Although I felt very confident that the reduction eoiihl be agtii
accomplished, the patient left without permitting me to make tin
attempt.
Otlier surgeons have met with examples of the upwani dislocaUrti
(Bubspinous) in which the patients have been able to walk quite wdl
immediately after the acciaent. Bigclow supposes that in theae csms
the up]>er portion of tlie capsule has been completely torn from th«
margin of the acetabulum, and that the head has been )>erroit((dta
ascend until it was arrested by the under surface of the ilio-fcmi<nJ
ligament at the point where it rises tVom the antorior inferior spintw
process of the ilium.
Cummins reports a case which occurred in the practice of GiWuv
of New Lanark, where the head of the bone was believed to be sitiuia
just below the anterior superior spinous process, and inwards tutcnri
the pubes ("supraspinous"). The limb wa.e shortenwl fully iKiW
inches ; the toes everted ; adduction and abduction werv excirdinfl^
painful and difBcnlt, but flexion was more easily perfiirmnL Tt«
Dead of the bone could be felt in its new position, esp<x;inlly vrlva tlM
thigh was moved. At first it was supposed to be a fnii-turv, Imi thii
error having been corrected, the surgeons proooe<lert to attvropt rrdaf'
tion on the eleventh day. Extension was made by pulleys, and vbA
the hea<l of the bone had descended to the margin of lira oivily, Mt
Gibson lifted the upper end of the femur by means of a luwel, ai Ut
ANOMALOUS DISLOCATIONS.
721
' tnoineat pressing the knee toward the oppoeite thigh, and forcibly
iDg the limb inwards ; hy which meaos ttie reduction waa occom-
ed.'
>nte has seen the head of the femur in the same position as in the
reported hy Cummins, not as a primitive dislocation, but coose-
t upon an attempt to reduce a dislocation into the ischiatic notch,
shortening was about two inches; the limb veir much rotated
ards ; the rotundity of the affected hip greater tiiaa that of the
V, and the trochanter major one inch fitrther removed from the
!rior superior spinous process. The bead of tlie bone could be felt
inctly in its new position.
lie reduction was effected finally with pulleys, by the aid of chlo-
rm, and by rotation of the limb in various directions.'
722 DISLOCATIONS OP THE THIGH.
Moi^n also reports a case in which the head of the femnr wM
above the acetabulum, and a little to the outride of the ilio-pectined
eniiuenco' ("siibsi>inoiis"). f
In a majority of eases these dislocations have been reduced by m*-,
nipulatioii alone, or by manipulation aided by pressure. The lii _
should be seised iu the usual manner, at the knee and auble, carried)
up towanl the face, abducted, then rotated inwards, gently addiicte^l'
and finally brought down agitiu to the bed. At the moment when ihf
rotation and adduction commence, the head of the bone should bd)
presseil toward the socket bv the hands, and, if necessary, lifted a li
over the margin of the acetabulum, by moderate extension at a right
angle with the body.
Bigelow, who regards as iri-egiilar only those which are accompani
with a complete rupture of the ilio-fcnioral ligament, but whose claast>
fication in that regai-d I am not fully prepared to adopt, has neverihe*
lesa given us the most
ligible and most firobablc ei^
planation of the mcchaoism df
these irr^ular upwards disl»>
cations, and of several othw
forms of irregular dis)oi'StioiH.<
According to this writer, lis'
"anterior obliqui' disloratioa,*
in which the limb is foaai
greatly adducted, and al tli*
same time strongly evertrtl, il
a regular dorsal disl'HStitn,
the head being ailvanw)! npcM
the dorsum t
a poi
fik
anterior mareiii of the iliaca.
If now the limb be brouirf*
down, the neck of the (vmai
will be made to bear agtini
the outer fibres of the ili*-
femoml ligament, and aa that
gradually give way the hail
__^ _^_ _ will Ijecfime more and mott
hooked over tlie tvmainiif
fibres of the ligament, aud above the inferior spinous prouees ("nipi*
spinous ") ; or, continued efTorU being made to Btraighten the limb, tU
ligament will give wav entirely, and the femur will assume the po*-
tion indicated by the Jotted lines.
Bigelow ret« mm ends a plan of treatment essentially the sameutJU
hitherto recommended by myself. " The anterior obHqtie dialunUMI
may be reduced by inward circumduction of the extended HmbacnM
the symphysis, with a little eversion, if necessarv, to disengage the htti
of the bone. Inward potattoo then convert* this into the oomnnn liw
ation upon the dorsum." In the anpragpinowt dinlocation, heiwM^
< PIrria'f Surgery, p. 270. See alio Fhil. Hed. Exmni., Nu. 61, Uilttcr'* (■»«■
ANOMALOUS DISLOCATIONS. 723
lends also inward circumduction, with as much eversion as may be
ecessary to disengage the head from the pelvis, by which the disloca-
on is at once converted into dorsal.
. DisloccUions Downwanh and Bachoards upon the Poaterm' Part of
the Body of the Ischium, between its Tuberosity and its Spine,
James C, eet. 35, was admitted to the Pennsylvania Hospital, on the
3d of January, 1835, under the care of Dr. Hewson. The patient,
muscular man, had been crushed under a falling roof, and, as he
lought, with his right thigh separated from his body. When received
ito the hospital, one hour after the accident, the right thigh was flexed
pon the pelvis, and rested upon the left ; the right leg was also flexed
pon the thigh ; the knee was below its fellow, the toes turned inwards,
od the whole limb shortened at least one inch. The head of the bone
>ald be felt distinctly resting upon that portion of the ischium which
€8 between the acetabulum, the tuberosity of the ischium, and the
pine.
On the following day, the muscles of the patient having been sufB-
iently relaxed by suitable means, the pulleys were applied; but, after
second attempt, some of the bands having given way suddenly, the
ulleys were removed, when it was found that the reduction had been
coomplished, although neither the patient nor his attendants had
oticed the return of the bone to its socket. For several days there
as entire loss of sensibility and motion in the leg, owing probably to
le pressure which had been made upon the sciatic nerve ; but those
^mptoms gradually disappeared, and at the time when the case was
ported, about two months after the accident, he was walking with
titches.
Dr. Kirk bride, who has reported this unusual case of dislocation,
>ubts whether the extension was necessary to the reduction, as the
2ad of the bone was brought very near the margin of the acetabulum
f lifting the thigh with a towel, and it probably afterwards entered
le socket so soon as the extension was relaxed.*
Malgaigne has referred to several similar examples.
. Dislocations Downwards and Backwards into the lesser or lower IscJii-
atic Notch.
Syn. — ** Behind tuber ischii ;" Gibson, S. Cooper. ** Fifth dislocation;" Gibson.
September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a
3irited horse, when the animal, being restive, suddenly reared and fell
ack on his rider, in such a manner as that the weight of the horse
as received on the inside of the left thigh ; Mr. Lowell having fallen
Q his back, a little inclined to the left side. The surgeon, who was
nmediately called, recognized it as a dislocation, and thought he had
icoeeded in reducing it; but a day or two later it was seen by a second
' Kirkbride, Amer. Journ. of Med. Sci., vol. xvi, p. 18.
724
DI8LOCATIOSS OF THE THtGtI.
surgeon, wlio declared that it was still out of place, and repented tbN
attempt at reductioii, but without euocess, as the result proved.
In December of the same year Mr. Lowell called upon John
Warren, of Boston, who was now able to determine, eflsily, as _
affirms, the precise character of the accident. The limli was elongstM
contracted, and the head could be felt in its unnatural pot-itinn. B
advice of Dr. Warren, he was taken to the Masaachnsctta Gent-n
Hospital, and a persevering attempt was there made to rcduoe tbt
bone, but with no better success than hiid attended the eRbrtA pro*
viously made.'
Mr. Keate lias reported a case produced in a very similar way bf
a horse having fallen backwards with the rider into a deep and narrov
ditch; but the position of the limb was somewhat extraordinary, coo*
sidering that it was a dislocation backwards, the whole limb beiii(
very much abducted and the toes being turned outwards, as if tbt
head of the bone was in front of the tuber ischii, rather than l>ehii>d it
The thigh and leg were much flexed, and the whole liuib wasHhi>rt<
ened from three to three and a half inches. The head of the femin
could Im distinctly felt " inferior to the ischiatic notch, and oo a \tv4
with the tuberosity of the ischium." In the first attempt at rediiotioB
the head of the Irane was thrown into the foramen ovale, fmm whidi
it was, however, after one or two more attempts by extension, and by
tiiling with a jack-towel, restoi-ed to the socket. Mr. Keate believe
that tlie dislocation was originally into the foramen ovale, but that »
the struggles made by the patient to extricate himself, it was thron
backwards into the position in which he found it.'
Mr. Wormald lias reported a primitive acoident of tlie same kin^
oc«isioned by jumping fn»m a third-story window. The patient (iitn
soon after, and at the auto])sy the head of the femur was found unJff
the ont«r e<)ge of the glutteus maximus, projecting through thet^iit
capsule opposite the upper part of the tuber ischii. The shaft of thi
iemur lay across the pubes, and the HmL) was considerably shcultM^
and turned inwards.^
4. Divlocationa Dirrelly Doiimwardg.
S'pt. — " SoiiB-cotjloidiennes ;" MatgBign<>.
The following is one of several similar examples now upon
A man, set. 50, was admitted into the Loudon Hospital undtf thi
oare of Mr. Luke. A dislocation of the lefl femur was ensily (liaxtw^
ticated, but the symptoms were peculiar, inasmuch as the linuM
lengthened one inch, without either inversion or eversion; yet tfce
head of the bone couhl be easily felt, and was thought to be ia tli'
ischiatic notch. By manipular movements reduction was easily eflixtti
> New York Med. *iid Phys. Journ., vol.
Imhc Parker, eto,, by Jahn C, Wnrren, IBM,
* Amw. Joura. Ucd. Sd., vol, xvi, p. 22<t, 1835: Trum Lond, M«d. Gm-, T«L ■■
1«.
■ WomiftM, London Hed. G«a,, 1886,
ANOMALOUS DISLOCATIONS. 725
bout an hour after the accident. The man subsequently died from
he effects of broken ribs. At the autopsy, Mr. Forbes, the house-
argeon, before dissecting the parts, again dislocated the bone. This
ras done with ease, and it was clear that the original form of disloca-
ion had been reproduced, as the bone could not be made to assume
ny other position. The head of the bone proved to be displaced
either into the ischiatic notch nor the thyroid hole, but midway be-
ween the two, immediately beneath the lower border of the acetab-
1am. The gemellus inferior and the quadratus femoris had been torn,
he ligaraentum teres had been wholly detached, and there was a lacer-
tion in the lower part of the capsular ligament.*
Dr. Blackman, of Cincinnati, informs me that, in January, 1859, he
educed a sub(X)tyloid, incomplete dislocation, in a man set. 70, by
nanipulation. Dr. Judkins lifting the thigh upwards and outwards by
Deans of a towel, while Dr. Blackman first flexed and then abducted
he limb.
5. Dislocations Forwards into the Perineum.
Syn. — " Porin^ales ;" Malgui^ne. "Luxation sur la branche ascendunte de
iscbion ;" D'Amblard. •* Inwards on the ramus of tbe os pubis ;" Skey.
D'Amblard published an example of this accident in 1821, occa-
oned by a violent muscular exertion made by tbe patient in an effort
I spring into his carriage, the symptoms attending which did not
iffer materially from those which were found to be present in the
iree following examples, except that in the first case the toes were
irned slightly inwards, while in each of the other cases they were
imed outwards.*
Mr. E., ffit. 35, a calker by occupation. The injury was received
hile at work under the bottom of a canal-boat, July 20th, 1831, the
oat being raised upon props three and a half feet long. The patient
^as standing very much bent forwards, with his feet far apart, be-
jveen which lay a piece of round timl>er one foot in diameter, when
le props gave way, letting the whole weight of the boat upon him-
jlf and his companions. One of the workmen was killeil outright.
>n extricating Mr. E. from his situation, the left leg and thigh were
>und extended at a right angle with the body, the toes turned slightly
1 wards, the natural form of the nates was lost, and the head of the
emur could be felt distinctly moving, when the limb was rotated, in
he perineum, behind the scrotum, and near the bulb of the urethra.
For the purpose of reduction, the patient was laid on his back uj)on
, table, and the pelvis made fast by a muslin band. Extension, accom-
panied with moderate rotation, was then made in a direction outwards
md downwards, bringing the head of the bone over the ascending ramus
>f the ischium, beyond which it was lying, into the foramen thyroi-
leura ; and from this position the bone was replaced in the acetabulum,
* Luke, Med. News and Library, vol. xvi, p. 34, March, 1868; from Med. Times
ind Oa£., Jan. 2, 1858.
' Malgaigne, op. cit., torn, ii, p 876.
726
SLOCATIONS OF THE THIGH.
by carrying the clisliKatefl limb forcibly across the op))o»ite one. The
[intient soon recovered the use of the joint.'
J. B., an Irishman, set. 40, on enteriug the St. Louis Hospital, gavo)
the following account of his accident, which had occurred six hoiin|
previously. He was engaged in excavating earth, and having unden
mined a bank, it unexpectedly fell upon his back while he was staaC
ing in a ijent [Kwition, with his thighs stretched widely apart. Tl
weight crushed him to the earth, breaking both bones of hia right left
the radias of the same fiide, and dislocating the leA, hip into the pefM
Ileum. The thigh presented a peculiar appearance, being placed quil»
at fi right angle with the body, but somewhat inclined forwards. Thi
part at the hip naturally occupied by the trochanter major presented,
a depression deep enough to receive the clenched fist ; while the beid'
of the t>one oould be both seen and felt projecting benenfh the skin at
the raphe In the perineum. Rotation of the limb, which was ditScult
and excessively painful, rendered the ^Hisition of the hcail still mon
manifest. The patient had also retention of urine, oot^nt.'^ionod urola-
bly by the pressure of the femur upon the urethra. Having unsse^
the fractures, Dr. Pope placed the patient under the full influence rf
chloroform, and then proceeded to reduce the dislocated thigh ; fi
which purpose "two loops were applied, interlocking each other mi
the groin, and using the leg as a lever, extension, by nieaun of tbt
pulleys, was made transversely to the axis of the body. A sietif-'
fcroe was kept up fur a short time, and the thigh-bone glided mio ita
socket with a snap that was heard by every attendant and patient is
the large ward,"'
A man, set. 22, viaa admitted to the Toronto Hospital, under the a
of Dr. E. W. Hotlder, January 15, 1S56, having l»eeu injumi by ild
fall of a bank of earth an hour before. The head of the right amnt
WHS found under the arch of tlie pubes, tlie neck resting upon iht
ascending ramus. The thigh formed nearly a right angle with llv
bo<ly ; it was also strongly abducted, and the toes were slightly evcrtt4>,
On the following day, the patient being placed under the influence ■
chloroform, extension and counter-extension were employwJ in li*
direction of the axis of the femur, that is, nearly at right unglbi « '^
the body, white, at the same moment, the upper jmrtion of the kn
was lilted by a round towel. By this manicuvre the hi^ itf tlie b .
was carried into the foranieu thyroideum. The force was now appliii
in a direction "more upwards and outwards; the ankle held Iwtfci
assistant was drawn under the other and at the same time mWrd.'
In a few minutes the complete reduction was acoomplislied. H« «
covery has been steady, anu three weeks later he was discharged, bdi^
able bo walk very well with the aid of a cano,'
> W. pHrkor, Ne» York Hcd. Gm.. 1841 ; N, Y. Jourit. Mad., Hwvb, IW
p. IHS.
' Popp.St.L"uiBMi-J.iii.dS,Lrg. J..ijrn,,July,I8S0; N. T. Jouttt. Med, «««*
I8fi2. p 10K.
» Ui^ldw, Br-ili=h Aruer. Journ., Mnrcli. 18H1,
ANCIENT DISLOCATIONS OF THE FEMUR. 727
i 6. Ancient Dislocations of the Femnr.
Says Sir Astley Cooper : " I ara of opinion that three months after
he accident for the shoulder, and eight weeks for the hip, may be
ixed as the period at which it would be imprudent to attempt to make
he reduction, except in persons of extremely relaxed fibre or of ad-
anced age. At the same time, I am fully aware that dislocations
ave been reduced at a more distant period than that which I have
lentioned ; but in many instances the reduction has been attended
nth the evil results which I have Just been deprecating." A remark
rhich later surgeons do not seem always to have correctly understood,
r which, if they have understood, they have not correctly represented ;
ince it has many times been affirmed of this distinguished surgeon,
hat he regarded reduction of the hip as impossible after eight weeks,
ind they have proceeded to cite examples which would prove that he
fas in error. But long before Sir Astley's day, Gockelius mentioned
\ case of reduction of the femur after six months, and Guillaume de
kilicet declared that he had reduced a similar dislocation after one
fear,* and Sir Astley says that he is "fully aware" of the existence of
mch facts ; yet with a knowledge of what has so frequently followed
Aese attempts, he would not recommend the trial after eight weeks,
ixcept under the circumstances by him stated; and notwithstanding
ke number of these reported successes has been considerably increased
a our day, we suspect that Sir Astley's rule will continue to govern
Jtperienced and discreet surgeons. Certain examples which have re-
intly been published of succeasful reduction after six months by ma-
ipulation, would encourage a hope that the period might be greatly
ctended, were it not that manipulation also has already failed many
nies in the case of ancient luxations, and that the attempt has some-
mes been followed with disastrous results, even in recent cases.
The following are examples of reduction by manipulation after the
ipse of six months:
On the 21st of March, 1856, a man presented himself at the Com-
lercial Hospital, Cincinnati, with a dislocation of the femur upon the
orsum ilii, of six months' standing. The limb was shortened two
iches. Dr. Blackman, under whose care he was admitted, adminis-
»red chloroform, and by manipulating after the method described by
)r. Reid, the reduction was accomplished.^
In a letter addressed to me by Dr. Blackman, and dated April 21 st,
859, he informs me that this patient presented himself again before
he class about six months since, and the restoration of the functions
>f the limb was found to be complete.
The second example occurred in the practice of Martial Dupierris,
>f Havana, Cuba. A Chinese hoy, named Ali-sin, age<l about sixteen
rears, arrived at Havana on the 4th of June, 1856, suffering under a
ievere illness, which confined him for a month or more to his bed,
} Malgaigne, op. cit., tpm. ii, p. 185; from OHlliciniuni Medico-practicum, Ulm,
1700, p. 2S8.
* Blackman, Ohio Med. and Surg. Journ., vol. viii, p. 522.
728
DISLOCATIONS OF THE THIGH.
and the existence of the dislocation was not discovered until he i
EiifScieutly recovered to rise upon his feet. It was tlien ascertains
that be had a dislocation of the left femur upon die don-um ilii. Um
iuquiry, Dr. Dupierris l<>arned that the accident had occurred befM
leaving Cliina, a period of more than sljc months. The boy was si
feeble, the limb somewhat emaciated, and instead of bi'ing rigid frgi
muscular contraction, all the muscles "were in a flaccid eondilioi
except the great gluteal, which was painful to the touch." Deemii
the use of antesthencs improper, on account of the boy's feeble ooo*"
tion, these agents were not employed. Dr. Dupierris daicrib» ti
method of reduction as tbllows : " The body being held by two aseil
ants by means of two bauds, one of which passed beneath tJie pa
neum, and the other under the axillie, traction was made up>m tl
limb by two strong and intelligent assistants. The movement of d
head of the Ume, resulting from this nianffiuvre, was verj- lijuitA
even when the force was much increased ; and the excruciating pa
wiiich the patient referred to the iliac region, compelled us for ihe a
meut tj> deaJBt.
" The following day, the }>atient having ol)taine<l a tolerable nigh^
rest by means of a narcotic |>olion, I concluded to attempt tlie rciliie
tion by flexion, believing that I could tlius Iwtter prevent any acddol
which the necessary force might produce; the operator, in adopu'i|
this method, having it in his power to follow tlic head of the Iwu- W
pressure upon it with the hand, aiding its muvement in the prop)
direction, or correcting any deviatiou that may occur. The emaciili
condition of the boy was eminently favorable for such a procedure.
"The patient being placed upon his back, and the trunlc of the btx
made steady by assistants, with the left hand I grasped the upper ft
of the leg, placed the right hand ujwn the hc^ uf the boue in tl
iliac fossa, and then proceeded to ilex the leg upon the thigh, and tl
thigh u^ion the pelvis. By this movement the great gluteal mat ^^
was relaxtid, and the head of the lione advanced, while with the ligt
hand I directed the latter toward the cotyloid tavity. Aaeoontf
judged the head to be immediately above the centre of the Mcktfi
extended the leg, the thigh remaining flexed at a right aDttla; a
tlien using the limb as a lever, I rotated it from within outwank,'
at the same time ex lend e<l it by making a movement of circiinidiKtil
in a similar direction. When, by these procedures, the liniliwn* broody
near to its opjKisite fellow, a snap audible to the as(iislauli>, and «i
deejier character than is ordinarily observed in the reduction of rM
dislocations, indicated the return of the head of the bone to itMMia
position ; a fact which was further substantiated by the e&talilisboM
of the origiual length and form of the member and the aubsidtw**
the pain.
"The ader-treatment consisted in placing a pud Iwtween tJiekwa
and another between the internal malleoli, un<l L-onlining the Un)
together by two bands, one above the knets, and the other arouodtt
lower iwirt of the legs. But in spite of these precautions to prrm
red is placement, the next morning I found that the dtslouUioa hi
been reproduced. It was again reduced, but for three ^noomiw^
ANCIENT DISLOCATIONS OF THE FEMUB.
729
was a redisplacement. After this, however, the head of the bone
its place; passive motion was daily employed, and all suffering
d. After twenty days of rest, and a liberal use of the lactate of
the patient was allowed to get up ; and, being provided with a
of crutches, upon which he exercised himself daily, improved
rapidly. The muscles gradually recovered their bulk and vigor,
at the end of forty-eight days he was enabled to walk without
hes, although with some fear of falling. About the middle of
lat he was put to work in a cigar manufactory, and has continued
ever since.
le third is a case reported by Dr. A. W. Smyth, of New Orleans,
dislocation was upon the dorsum ilii, of nearly nine months'
line ; and it was reduced by manipulation, in the first attempt,
reduction was accompanied with " a good deal of snapping and
". Brown, of Boston, has published an interesting case of reduction
ancient dislocation of the hip in a child 8 years old. He believes
lislocation to have been caused by rheumatic arthritis. In the
connection he has furnished a table of the cases of reduction of
nt dislocations of the hip, which he has found upon record.^ I
)lish the table, with a single correction, and one aadition.
Authority.
Galliciniiim Med.-practicum, p 2S8.
. Ibid.
Op., chap. 19.
. Ibid.
. Ibid.
Hamilton, Prac. and Dis., p. 679.
Repertoire G^n^rale.
Dislocations and Fractures, p. 85.
. Ibid., p 81.
. Ibid., p. 45.
M6m. de I'Acad. Roy. de Chir. do Paris,
torn. V, p. 629.
Mal^aignc, torn, ii, p. 281.
Op., p. 71.
Trans. Am. Med. Assoc., vol. iii, p. 366.
. Ibid., p. 867.
. Lancet, 1862, vol. i, p. 666.
. Dis. and Fract. of Hip, p. 211.
Ibid., p. 55.
Ibid., p. 54.
Ohio Med.andSurg. Jour., vol. viii,p. 622.
New Orleans Jour. Med., Jan. 1, 1869.
Northwestern Med. and Surg. Journal,
June, 1870.
Lyon Jour. Medicale, No. 4 ; also Month.
Ab. Med. Sci., vol. i, p. 269, 1874.
the comparison of the relative value and hazards of the diflFerent
8 of reduction, I have cited several examples of fracture of the
«n.
Time.
lius, . .
• •
180 days. .
t, . .
. 865 "
^tren.
81 **
rtren, .
. 78 "
fireUf .
99 '*
rris, . .
180 "
let, .
72 **
r. .
26 "
p. . . .
6 years. .
85 days. .
2 years. .
• 1 • • .
1 « m m
• •
umo de S
alicet
, 865 days. .
ard, . .
> • • • • •
r, . .
. 68 *'
• •
. 120 »*
imsj
. 160 »«
•w,
. 90 »'
w.
. 240 **
►w,
• •
28 "
nan, . .
• ■
180 "
1, . . .
• ■
270 "
1, . . .
. 105 »*
%\\, . .
• 1
90 "
1 6« • • *
1 •
. 60 "
K>ntaneous dislocation on dorsum ilii. Reduction after several months,
is Brown, M.D., Surgeon to the Children's Hospital, etc., etc., Boston.
47
By
PARTIAL DISLOCATIONS OF THE FEMUR, 731
>Iished without enlarging the external opening. While the incision
<ras being made the limb was kept rotated outwards, and abducted as
unch as was possible, and it was felt to yield distinctly, so that both
otation outwards and abduction were more complete afterwards than
»efore. I then divided also the tensor vagi me femoris ; and now the
ttempts at reduction were repeated, both by manipulation and exton-
ion, but without success.
The result of this attempt to reduce the dislocation by division of
he ilio-femoral ligament, although unsuccessful, encourages a hope
hat it may sometimes succeed ; and I shall not hesitate to repeat the
txperiment, if a favorable opportunity is presented.
i 7. Partial Dislocations of the Femur.
Malgaigne declares that certain experiments made upon the cadaver
ed him, at one time, to the conclusion that all primitive luxations of
ihe femur were incomplete, and that the old complete luxations found
in autopsies had become so consecutively. Later observations have
taaght him to correct this error, yet he still finds "incomplete back-
ward luxations quite common, and incomplete dislocations in all the
other directions much more common."
I have more than once found occasion to call in question the accu-
racy of Malgaigne's views in relation to partial dislocations, the rela-
tive frequency of which he seems constantly disposer! to greatly exag-
^rate. We cannot see the propriety of calling those eases partial
lislocations, in which the head of the bone has fairly left the cotyloid
iavity, and mounted upon its margin, even if it remains in this position
nthout tearing the capsule ; since the articular surfaces are now as
ompletely separated as if the capsule had given way, and the head of
he bone had escaped through the laceration. It is in fact a complete
iixation. But I doubt very much whether the head of the bone ever
esta upon the margin of the acetabulum without tearing the capsule,
nless it has previously undergone certain pathological changes, suc^h
s I have already described ; at Icjist I cannot hesitate to reject all
hose examples in which the head of the femur is supposed to rest upon
he upper or outer margin of the acetabulum ; and if I permit myself
0 speak of incomplete dislocations at all in this connection, I shall
eserve the term for those rare cases in which the head of the femur
becomes engage<l in the cotyloid notch, after breaking down the fibrous
»nd which, in the natural state, is continuous with the rim of the
acetabulum.
Of this form of dislocation, I think I have met with two examples;
me of which was in the person of the boy Lf>wer, already mentioned,
whose thigh was reducc<l accidentally by his father; and the other
KXJurred in a boy fifteen yearsof age, residing at that time in Rutland,
V^ermont. He was brought to me on the 28th of May, 1842, by Dr.
Flayncs, of Rutland, at which time the dislocation had existed five
^ears. His account of himself was that in walking upon a slippery
ioor, his left leg slid outwards and backwards in such a manner as
hat when he fell it was fairly doubleil under his back. On the tenth
732
DISLOCATIONS OF THE TUIQB
day following the accident he began to walk with some help, and I
has eontinrtcd to walk ever since, but with a manifest halt. Thn
months after the injury was rewivod, it was first seen by i
surgeons, who pronounced it n di&loc:ation, and attempted reducdt
without mechanical aid, but were unsuecessfiil.
When the young man was brought to roe, the limb was neitJH
leugthene<l nor shortened, but the thigh was forcibly alxlui-ted i
rotated outwards. It could not be flexed nor greatly eslendod.
head of the femur could be distinctly felt, as it lay anterior to (
socket, but not snfticiently far forwards to rest upon the foramen u
J. C. Warren, of Boston, has reported a similar example in a c
six years old, who was brought, April 21, 1841, to tlie Mnssacliu
General Haspital. Dr. Hale, who saw the lad at the end of two wwiq
thought it a dislocation, but it had been treated by another surges
its a case of hip-disease. The dislocation had now existed ei^t a
ten weeks. The limb was a little lengthened, abducted, tum^ os
wards, and advanced in iront of the body, with very slight motioni
either flexion or extension, and almost no tenderness about the joii '
Dr. Warren, also, was able to feel indistinctly the head of the bo
" immediately external to, and in contact with, the insertion of (I
triceps and gracilis muscles."
An attempt was made by manual exten.sion and manipulation B
accomplish the reduction, but without success.'
It is probable that both the above cases, which I have described M
length, were examples of partial dislocation ; yet I cannot ««»« '
from others a doubt which I actually entertain whether they wen; m
after all, only examples of hip-joint disease, arrested after haviij
wrought certain slight pathological changes in the joint and the tiM
adjacent. If, however, they were not examples of incomplete disliw
tiuns of the hip-joint, then I (juestion whether any such cases tuH
ever occurred.
1 B. Coxo>FemoraI Sialocations, complicated vith Fracture ef
the Femur.
Such complicntioiis are exceedingly rare, but it will not do to Jt
their possibility ; although in some of the cases re[>ot-t«d, the tcfltiiM
is so incomplete as to leave a doubt whetlier the surgeons have i
erred in their diagnosis.
James Douglas has reported a case of dislocation ujion the fiA
complicated with a fmcturc of the neck of the femur, the adiala
dition of which was verified by an autopsy ; the patient hani^ i<
twelve years after the injury was received, Yhe head uf the fn
still remained above the pubes, and was in no way connected nlh^
neck or shaft. The upper end of the femur projected in llw p*
lying o[>on the iuside of the femoral artery and vein. Many tifc
curious juthological changes had also occurred.'
' Wnrren. Bo»t. Med, and Surg. Journ., vol. iiiv, p. 220.
> Amer. J.iiirn. Med. Sci., vol. iiiiii, p. 465, rrom Luod. and Baia, Jlimti I**
«r U«d. Scl.,Doc. 16U.
COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 733
The well-authenticated examples of reduction of the dislocation,
rhere the feraur was broken also, are still more rare ; and several of
be recorded examples which my researches have discovered, need
dditional confirmation.
John Bloxham, of Newport, in the Isle of Wight, claims to have
sduced a dislocation of the femur on the pubes, which was accom-
anied with a fracture of the thigh a little above its middle. The
)llowing is the account of this interesting case which we find in the
fOndon Medico- Chirurgical Review^ copied from the Medical Gazette of
LQgust 24th, 1833. We regret that we are unable to see the account
3 published in the GazeltCy which might supply some circumstances
nportant to a full appreciation of the case :
On the seventh or eighth day after the accident, " the patient was
lid on his back upon the bed, and kept in that position by meai^ of
sheet passed across the pelvis and fastened to the bedstead ; another
beet was also passed over the left groin, and secured in a similar
lanner. The dislocated and fractured limb was then inclosed in
plints, one of which extended up the back of the thigh as far as the
aberosity of the ischium. Pulleys, which were secured to a staple in
ie ceiling, placed at the distance of a foot to the right of a point ver-
cal to the patient's navel, were then attached to a bandage fastened
mnd the splints as high up as possible.
" The foot was raised with the knee extended, so as to bring the
tnb nearly to a right angle with the line of the tackle, when, by
"awing gradually on the cord, in the course of about ten or fifteen
inutes the head of the bone was rendere<l movable, and was brought
•nsiderably more forward. I then began to press on the head of the
)ne, so as to push it downwards, whilst the pulleys held it partially
sengaged from the pelvis. In a few minutes the head of the bone
iseed over the ridge of the os pubis, and I then directed the foot to
» raised a little higher, which, by putting the gluteii muscles more
pon the stretch, was calculated to render them more efficient in draw-
ig the bone into its proper place. By this manoeuvre, the head of
le bone was drawn backwards, and on the foot being more elevated
id the cord slackened, it continued to recede from my fingers till the
ochanter major made its appearance in the natural situation, and the
sduction was found to be perfectly complete.
" Lest the head of the bone should slip backwards on the dorsum
ii, I directed an assistant to api>ly firm pressure during the latter part
f the process, above and behind the acetabulum.
"The apparatus was then removed, the thigh bound up in short
plints, and the patient laid upon a double-inclined plane. No symp-
)m8 of inflammation appeared afterwards al)out the joint. Passive
lotion was employed at the end of a week, and occasionally repeated
uring the whole reparatory process.'' *
Without intending to question the accuracy of the statements in this
ise, which, in the main, seem to bear the marks of credibility, we
mst express our surprise that so little difficulty was experienced in
1 Lond. Med.-Chir. Rev., vol. xix, p. 420, Oct. 1838.
734
DISLOCATIONS OF THE THIGH
tliP reduction if the femur was actually broken, no more, indeed, tliM
is usually experieneed when the Iwiie ia not broken; and that !~
Bluxham was able to employ sately )>a^ive motion at the end ofl
week.
Charles Thornhill relates, in the London Medical GaxfOe for Jnlyj
18:16, a (use of fracture of the femur through its upper tJiirt), ini
man, tet. 40, with dislocation into the ischialic notch ; which di^Iooa
tiou, he assures us, was reduced at the end of six weeks. But iti
much uiore probable that, instead of rwlueing a dislocation, he re-fiid
tured the bone. During more than one honr and a half, aided faf
pulleys, traetitms and manipulations were made in almost every d'
tion.
The upper part of the thigh was lifted with all the strength of o
man by means of a jack-towel ; it was violently rotated, adducted, anj
abducted. Both the perineal and the knee band gave way, from tl
excess of the force employed ; and, finally, the head of the femol
resumed its place with an audible crcm/i. After which the " limb «i
of nearly equal length with the other;" but there remained un "in
men.ie deposit" around the acetabulum.'
Malgaigne says that M. £t6ve fouud a poor fellow witli a dislod
tiou of his left thigh backwards, a fracture near its middle, a [>enelral
injr wound of the knee, and a fracture of the fibula in the same Uji
Without delay be proceeded to reduce the dislocation by dir«cltng two
assistants to support the body, three to supjwrt the leg, and two mov
to make extension from a towel tied not very tightly amnnd the tiiif^
above the fracture. The leg was then extended upon the thigh, u
the thigh flexed upf>n the pelvis until it was at a right angle with lb
l>ody ; and after a gradual extension bad been made in this dirediof
M. Et*ve pushed with alt his strength the head of the Imue intoitl
socket. Of which case Malgaigne justly remarks, that the ''extensioa''
practiced by the surgeon was only imaginary.' If ihe reductio
accomplished at alt, it was by manipulation and pre^nre.
Finally, Markoe relates, in the paper to which we have alnvib
several times made allusion, the case of a boy «t. 8, who was admittM
into the New York City Hospital, on the 29th of June. 1853, withi
compound fracture of the right thigh, a simple fracture of the I«A, iM
a dLshKMition of the heaci of the right femur upwards and backwA
upon the dorsum ilii.
When placet! upon the bed, the right limb lay oblitindy aeraMtl
alxlnmen of the boy, with the foot resting against the uxilbt of tl
left side. " The house-surgeon, to whose aire the case fell on ■dmi*'
sion, took the injured limb in his hands and very carefully carntdft
over the abdomen to the right side, and then adducted it and bn<ii)!U
it down toward the straight position," during which proocdair tl
head of the bone is supposed to have resumed its place in the aockrt
Such is the account fnrni.^hed of the symptoms and i
' Amer, Jniim. Med. Sci., vn\, xxv, p. ai8.
• HNlf»i1);ne, r>p cit-, l«in. ii, p. 206 ; from Guollo H&l., 1U8, p. IB.
' Mew York Journ. Med., Jan. 1865, p. SO.
4
VOLUNTARY DISLOCATIONS OP THE FEMUR. 735
this extraordinary case; too meagre, certainly, to entitle it to much con-
science, or to permit us to draw from it any practical inferences. We
ire not even informed what was the name of the young man who alone
aw and treated the case, nor what was his responsibility as a surgeon.
I have been unable to find any other examples of fracture of the
'emur complicated with dislocation ; and, rejecting at least Mr. Thorn-
lilFs case as altogether incre<lible, the proper conclusion would be,
Jiat reduction is sometimes possible in recent cases, if the surgeon will
i^sort promptly, before swelling and muscular contractions have taken
place, to manipulation combined with pressure upon the head of the
bone. Indeed, it is probable that pressure alone is the means upon
v^hich the success will finally depend. Richet says that he has several
times dislocated the femur in the cadaver ; and then, having sawn off
the head so as to represent a fracture, he has always l>een alne to push
the head of the bone easily into its socket.^ By seizing the moment
then when the patient is laboring under the shock, or by placing him
completely under the influence of an anesthetic, no resistance will be
offered by the muscles any more than in the cadaver, and the reduction
may, perhaps, be easily effected.
I have no confidence that anything can be accomplished by exten-
sion ; nor do T think it will be best to wait until the femur has united,
unce such delay will probably render the reduction impossible.
2 9. Voluntary Dislocations of the Femur.
Examples in which persons, having suffered no disease of the hip-
oint, have been able voluntarily to dislocate the femur, have, from
;ime to time, been recorded, but I am not aware that any dissections
lave ever been made in these cases. I shall, therefore, not attempt
my explanation of the facts, but simply record them as matters of
jurious interest, and for the purpose of inducing others to make of
:hem a subject of investigation.
Sir Astley Cooper mentions the case of a man who could throw out
the head of the thigh-bone at pleasure, and reduce it with equal
Pacility. A similar case is alluded to by Samuel Cooper, in his ¥ir9i
Lines. Gibson mentions a case reported by Dr. Lewis, of North Caro-
lina.* Dr. Bigelow has seen two cases, both of which were dorsal.
Dr. Moore, of Rochester, has furnished an account of the case of John
Parker, whose leg was first partially dislocated at Drury's Bluff, May
13, 1864, and which was at the time reduced by his companions. The
accompanying illustrations (Figs. 326, 327, p. 736) were obtained from
photographs, and indicate the position of his limb when a voluntary
sabluxation upon the dorsum existed.
The following case was reported to me in 1865, by John M. Forrest,
M.D.,.of Portland, Maine, to whom the man presented himself as a
"substitute," while Dr. Forrest was in the service of the U. S. Army.
The application was rejected.
"William G. Gliddon, set. 37, farmer, says that he has been able to
> New York Journ. Med., March, 1864, p. 293; from Bullet. deTh6r.
* Gil>8on'8 Surgery, vol. i, p. 867, 6th ed.
738
DiaLOCATIONS OP THE PATELLA.
Boine persons there seems to exist a preternatural laxity of the Uga*
meiitum pat^Ilte or of the tendon of the quadriceps exteusor, whick
exposes the subject to this accident from very trifling causes. Fei^i*
son saye he has known it to be occasioned by a child's stepping upM
the knee of a person lying in bed; and Skeysays he has seen twucasM
wbicii occurred spontaneously during sleep. B. Coo)>er has seen t
- young lady m-Iio frequently dislocated her patella outwards by mere^
striking her toe against the carpet, or in dancing. Boyer, Sir Astllfl
Coo|ier, and others mention similar examples.
Pathological Anatomy. — Most frequently the dislocation is only \iU-
tial, the inner half of the patella resting upon the articular sHrfo<w of
the outer condyle; and in consequence of the pei^uliar obliquity of tb«n
surfaces, together with the action of the vast! and rectus fi-'niori-t, tia
outer margin of the patella becomes tilted forwards.
If the disloeatiun is more complete, this margin begins to &11 ov«r-
bnckwards, as in the accon])>anying drawing; and in more extre
cases the patella lies flat upon the outer side of the condyle, with
inner margin directed forwards.
When the dislocation is partial, it is probable that ndther the a
sule nor the ligamentum patellte usually suffers much laceralioo; I
in complete dislocations the capsule at least nii
have given way more or less. Norris, of I'hilatlel-
phia, reports a case of partial luxation in whieti lbs
complications were more serious. John Scanlin,i
32, WHS admitted to the Pennsylvania Hospital,
the 27th of August, 1839, in consequence of injur
received a short time previous by having liccomr i
tangled in machinery. In addition to several fr
tures in otiier limbs, he was found to have a wibliiar
tion of his left patella outwards, its outer cdjije bat
much raised, and resting on the side of the «xteni
condyle of the femnr, while its inner edgv was J
pressed, and firmly fixed in the hollow bctweeati
condyles. The internal lateral ligament of th« kn
was niptured, allowing the head of the tibia to I
moved c<msidcrably outwards. A depression exiate
also, between the tubercle r>f the tibia tind the lort
en<l of the patella, at the middle and inner side
""wTiouiwiiX "" '''® knee, evidently pro<hiced by a rupture of thelig
mentum patellse in nearly its whole extent Tbi
was almost no swelling, and the limb was moderately flexed. By fc
pressure the patella could be restored Xo position, but as aonp u I
hand was removed it returneil to its original position. At ti
two months "a good degree of motion existed at the knee
nflamed or
[mil
iful."
Symptoms. — The limb is slightly bent, but immovable;
of the knee is considerable increased; the inner condyle
naturally, and the patella is distinctly felt upon the outer s
> Morris, Aaiar. Juurn. Ued. Sci., vol. ixt, Feb. 184U, p. Sit.
the
■itai
itedly. Planting hie right foot 6rmly upon the floor n little in ad-
ice of the left, with hie toes turned out, he throws his weight upon
the right leg by carrying his pelvis well over to the right, and tnen
contracts ptiwerfully the gluteal muscles. Instantly the head leaves
the socket, and seems to mount upoD the dorsum ; the trochanter major
becomes rotated inwards, causing a slight inward rotation of the leg
and foot. He can do the same when lying on his hack, but not with -
the same ease. Rpduction is accomplished without change of position,
but by what precise nmnoeuvre I have not determined. The reduction
is more quiet, and less sudden, apparently, than the dislocation. Both
mana?uvres are accompanied with some pain. He is not lame, nor
does the dislocation take place without his volition. I have seen one
case, also, which, although pathological in character, was nevertheless
caused by an early injury, and as such may properly be noticed in this
connection.
Dr. O. Gillett, wt. 65 (1867), of Westernville, Oneida Co., N. Y., was
injured in his left hip-joint when 16 years old, by lifting a heavy
weight. He felt at the moment something give way in the joini, and
he has been lame ever since; at fii'st he wan quite lame, but after a
time the soreness about the joint diminished, and up to within about
three years the lamene.^ was chiefly due to a lack of development in
the limb. Since then the joint has again become tender, and during
the last nine months he has been able to throw the head of the bone
[t of the socket, backwards and upwards. Indeed, the bone is dislo-
ted whenever he sits down, and resnmes its place again when he
inds up. It is qnite apparent tliat the u]>per and outer margin of
the acetabulum is irartly absorbed ; and probably, also, the head and
neck of the femur are in some measure deformed and absorbed. The
dislocation is apparently incomplete ; and while it exists the thigh is
lucted and slightly rotated outwards. This abduction and outward
ition does not properly belong to a dislocation upon the dorsum of
ilittm; but as the condition of the joint and of the adjacent muscles
ab&ormal, it will not require to be expf
CHAPTER XVII.
DISLOCATIONS OF THE PATELLA.
I 1. Dislocations of the Patella Ontwardi.
^ Cinw«. — In the majority of cases it has been occasioned by muscular
Ition ; and especially is this liable to occur in persons who are knock-
beed, or whose external condyles have not the usual prominence an-
^orly. It may be caused by suddenly twisting the thigh inwards
Aile tJie weight of the body rests upon the foot, and the leg is thus
kept tunied outwards; or by falling with the knee turned inwards
and the foot outwards. Occasionally it is the result of a blow received
upoB th» iaeide, or upon the front and inner mai^in of the patella. la
738
DISLOCATIONS OF TQE PATELLA
Bome persoos there seems to exist a preternntunil lasity of tlie l<g*^
mentum patella or of the tendon of the quadrloops exleneor, whicfc'
exposes the subject to this accident from very trifling causes. Fet^;uft>'
sou sayB be has knowo it to be occasioned by a child's stepping upoi.
the knee of a person lying in bed; and Skey says he has seen two case
which occnrred spontaneously during sleep. B. Coo|>er has aeen a
- young lady who frequently dislocated her patella outwards by mere^.
striking her toe against the carpet, or in (liincing. Boyer, Sir Astl^
Cooper, and others mention similar examples.
Paihological Anaiomy. — Most frequently the dislocation is only par-
tial, the inner half of the patella resting upon the articular tsurfaoe </
the onter condyle; and in consequence of the peculiar obliquity of tlictt
surfaces, together with the action of the vasti and rectus li-ntoru, 1^
outer mai^in of the |mtella becomes tilted forwards. i
If the dislocation is more complete, this margin begins to &1I mm*
backwards, ob in the accompanying drawing; and in more extrenu
coses the patella lies flat upon the outer side of the condyle, with iH.
inner margin directed forwards.
When tlie dislocation is partial, it is probable that neither the op*
sule nor the ligamentum patcllte usually sutlers much laoeration ; IhiI
in complete dislocations the capsule at least raoit
Fio. 3M. \mv^ given way more or less. Norris, of Philaiid*
phia, reports a case of partial luxation in wbit^ tlit
complications were more serious. John S(anlin,a
32, was admitted to the Pennsylvania Hn^ital, a
the 27th of August, 1839, in consettuenoe of injuriM
received a short time previous by having become ni-
tangled in machinery. In addition to severul frac-
tures in other limbe, he was found lo have a snli
tion of his left patella outwards, its outer edge being
much raised, ami resting on tlic side of tlie extem
condyle of the femur, while its inner edge was ^
pressed, and firmly fixed in the hollow belwieFa tlM|
condyles. The internal lateral liganu-nt of the koM
was riiptnral, allowing the head of the tibia to bl
moved considerably outwards. A depression esiMf^
also, between the tul>ercle of the tibia and tlic Wei
end of the patella, at the middle and inner oidcd
""'wiu'uutirBrdr "" the knee, evidently prwluccd bya rupture of the 1^
mentum patellie in nearly its whole extent. TwH
was almost no swelling, and the limb was moderately flexed. By itm
Eressnre the patella could be restored to jiosition, Imt h» Mcm is iIm
and was removed it returned to its original position. Al tI»««J*f
two months "a good degree of motion existed at the ku<«-j(^t, «"'''
was in no way iuflamed or painful.'"
Symptoms. — The limb is slightly bent, but immovable; the bw
of the knee is oonsidemblo increased; the inner condyle prtjecti*
naturally, and the patella is distinctly ftlt upon the onter side. If tM
> Norrli, Amer. Journ. Med. 8cL, vol. zit, Feb. 1M(I, p. XTe.
DISLOCATIONS OF THE PATELLA OUTWARDS. 739
dislocation is partial, the outer margin of the patella forms an irregular
sharp ridge in front of the external condyle. If it is complete, the
inner margni presents itself in front of the external condyle, and the
outer margin looks backwards. Usually the patient suffers great pain
as long as the dislocation remains unreduced.
Watson, of New York, saw a case of complete dislocation of the
patella outwards in a fat young lady with lax fibre, and occasioned by
dancing. He says the knee was slightly but firmly flexed. It was
reduced by a very slight pressure with the fingers, and although some
inflammation with effusion into the joint ensued, the use of the limb
was completely restored in a week or ten days.^
Prognosis. — Reduction is in general easily accomplished, but a re-
luxation is very prone to occur. In the few examples reported of a
permanent luxation, the patients have eventually recovered the use of
the limb in a great measure. Boyer saw four cases of this kind, in
three of which it existed in the left leg, and had remained from infancy.
The patellse were easily replaced, but unless confined they soon became
displaced again ; not one of them found it necessary to apply for surgi-
cal aid, as " they suffered no great inconvenience from the luxation^
and it exempted them from military service."
After retluction, very little or no inflammation usually follows. Mr.
Key has, however, narrated a case in Guy^s Hospital Reports^ of death
from suppuration in the knee-joint, following upon the reduction of an
inward subluxation. The dislocation was produced by a fall while
carrying a pail, and was reduced by very gentle pressure; but the
patient, a girl aet. 20, although apparently in good health, was believed
to be somewhat strumous.^
Treatment. — In order to relax completely the quadriceps extensor, by
whose action chiefly the patella is held in its unnatural position, the
body should be bent forwards, while at the same moment the leg is
extended upon the thigh and the thigh flexed upon the body. The
surgeon will accomplish these indications in the most simple manner
by placing the patient in a chair and then lifting the foot upon his own
shoulder, as he kneels or sits before him. Sometimes the patella will
resume its position at once when this manojuvre is adopted; but if it
does not, slight lateral pressure, made with the fingers, will generally
be found sufficient to accomplish the reduction.
A man, aet. 27, was sitting on a box, and in jumping off tripped
himself with his right leg, causing a partial dislocation of the patella
of the left leg outwards. Half an hour after the receipt of the injury
I found him sitting with the knee bent, and in great pain. The patella
lay upon the outer half of the articular surface, with its outer margin a
little tilted upwards. Lifting the leg and thigh to a right angle with the
body, and making very slight pressure upon the outer margin of the pa-
tella, it immediately resumed its place. Very little inflammation ensued.
In some instances, where other means have failed, the reduction
has been effected by violent flexion and extension of the knee, aided
by lateral pressure.
* Watson, New York Journ. Med., vol. i, p. 806. ' Op. cit., vol. i, p. 260.
740
6LOCATION8 OF THE PATELLA.
I have already mentioned, when speaking of dislocations into t
foramen thypoideum, the case of N. Smith, in whose person I found a
the same moment a diaWtntion of the thigh, a subkixation ontwBnll^
of the tibia, and a complete outwai-d hixation of the porresiwndinj"
patella. This was occasioned by a fall from a height upon the inside «
the knee. I reduced the tibia first, and then easily replaced the palcllt
by lifting the leg and pushing with my fingers against its outer margi>(
In many cases the patients themselves have reduced the dislocatioK
immediately, and the sni^eon is only consulted in relation to the aflo^
treatment. Liston says that this is so constantly the fact, or else mA'
dislocations are really so rare, that it has never happened to hio
have an opportunity of reducing any form of dislocation of the patelli,
A young gentleman, let. 25, residing in Somerset, N. Y., callod upoo
me in consequence of having discovered a doating cartilage in his ku(
joint. His account of the matter was that on the Ist of Febnnii_
1858, he was kicked hy a cow upon the outside of the right leg, ubmit
BIX inches below the knee, and that he immediately found the |)H[e)li
dislocated outwards. After several efforts, he finally su"ceedt-d ii
ducing it himself. His knee soon became greatly swollen, so that for
five weeks he was unable to walk, and he has l>een more or les* hm
to this time. Six months after the accident he <liscoverts:l a flcatinj;
cartilage on the inside of the patella, about one inch in diameter, whtd)
occasionally slips between the joint surfaces, and suddenly trips him up.
I 2. DislocatioDs of the Patella Inwards.
Caugfu. — Ivesn frequent than disloentioris outwards, they are ow*-
sioned generally by direct blows received upon the out«r margin of the
patella.
The symptoms, pathological anatomy, and treatment, will be ihi
same as in dislocations outwards, except so (nr «
Fill, M (j^ggg j„„g[. necessarily vary from the opposite pia-*
tion of the pat«lla.
i 3. Dislocations of the Patella upon iti Axia
.<;.vn— "Semi.rulutiiiiii" Miller. '-Luxulion Tertioli;'
MHigsigno.
These accidents, of which I have found reroidtd
about twenty examples, and one additional coiH-lut
been seen hy myself, seem to be the result ofihi
same causes which produce lateral luxations; ""''
indeetl, they may be regarded as only exw^
forms of incomplete lateral dislocutionsx In I
latter accidents, as wc have already noticed, the t*^
ternal or the internal margin of the |mtcll«, aooonl^
ing as the subluxation is to the outer or inner siJ%
is thrown more or 1(«8 obliquely fiirwank; a pcwti*
into which it is carried [wirtly by the noctiliar fcf*
°',"IiuuiTa.''.rit!" of tl'P articulating surfaces, and partly bv the trti*
of the vasti and rectus femoris muscles. If now tin*
0 contract suddenly and violently, and the return of ll*
DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 741
patella to its normal position were prevented by the lodgment of one
of its margins in the intercondyloidean fossa, the other or free margin
would be compelled to rise until it became perpendicular to the limb,
or it might perhaps even become completely reversed in its socket.
The signs of the accident are such as to render an error in the diagnosis
almost impossible. The limb is generally found forcibly extended, oc-
casionally it is in a position of mo<lerate flexion, but the projection of
the sharp border of the patella directly forwards under the skin is itself
sufficient to determine the true nature of the injury.
Reduction may be effected by the same manoeuvres which we have
recommended in lateral luxations; but if these measures do not suc-
ceed, we may direct the patient to make a violent effort himself to flex
and extend the limb, or the surgeon may force the limb into flexion
and extension alternately, or he may rotate the tibia upon the femur,
and then flex. Finally, he ought to make use of lateral pressure also,
upon both margins of the upright patella, but in opposite directions.
In all cases it would be advi^^able to put the patient under the influ-
ence of an anaesthetic before attempting reduction. In a case reported
by Dr. H. Hunt, of Beloit, the reduction occurred spontaneously as
soon as the patient was chloroformed, although it had resisted all the
efforts previously made.^
Watson, of New York, has related the following example of rota-
tion of the patella upon its inner margin (" Luxation Verticale Ex-
terne,^^ Malg.) :
Henry Burton, aged about thirty-tive years, of rather slender frame,
while riding on horseback in a crowd, received a blow upon his knee
from a horse ridden by another person. When seen by Dr. Watson,
soon after the accident, the leg was perfectly straight, but could be
flexed to about an angle of 140° without causing pain. " The patella
appeared to be slightly drawn up, and it was twisted upon its axis,
presenting its outer edge, in a prominent hard line, in front of the
knee; its inner edge was resting either in the groove between the
condyles of the femur, upon which its posterior face should naturally
play, or in the small depression on the anterior face of the femur,
immediately above this groove. The anterior surface of the patella
was turned inwards, its posterior surface outwards, and it rested nearly
at right angles with its natural position. Its upper and lower attach-
ments were both preserved, and could be distinctly felt ; and a sort of
band appeared to pass from its under, or, as it now lay, its outer face,
inwards to the deeper portion of the knee-joint. This band, as I con-
ceived, was caused either by the tension of the capsular ligament, or
by the rupture of its edge, as it passes from the outer side of the
patella. The position of the bone was so well marked that no one at
all acquainted with the anatomy of the part could mistake the nature
of the accident.
" With the leg extended, and the anterior muscles of the thigh
forced downwards as much as possible, pressure was made upon the
patella, with the expectation of forcing down its prominent edge. The
» H. Hunt, M.D., the Medical Record, April 1st, 1873.
742
OCATIOSS OF THE PATELLA.
effort Avns followed only by an increase of pain, the bone remnini
permanently fixed. Another attempt was made to ejtnt it« poster
edge inwaiiis, and to bring its anterior edge outwards, without pra
ing it npninst the eondyles of the femur, by fonring the head of a ke
against the posterior, now tlie onter, fatw of the patella (using thi*
a fulcrum), and pressing tlie prominent edge of the bone toward t
outer condyle. This mancenvre gave him no pain, but was as fruitla
in its result as the other. At length the knee was forcibly bent a
immediately straightened i^in; and then, by canting the ]iatolla ■
before, and poshing it slightly downwards and inwards, it sprung w'"'
a sudden snap into its proper jMisition.'"
Dr. Joseph P. Gazwim, of Pitlebnrg, Pa,, has met with a simil«
case. On the 10th of September, 1842, -James Porter was tlirowti wbd
wrestling, and immediately found himself unable to rise. Dr. Gm
eaw him al>nut an hour atW the accident, and found the patella of tk
right leg dislocated on its axis, and resting on its inner edge in tf
groove between the eondyles of the femur. Dr. G. proceeded to a
tempt reduction, but failed, ntler having made repeated triaN by lift
ing the limb toward the body and by prcseurc in oppoi^ite dirertinai
In consultation with Dr. Addison, it was now determined to diWdl
the ligamentum pjitelhe, which was done by intnKbicinfr lK?neath il
skin a narrow-bladed knife, and cutting elose to the tulx-rcle^lt
tibia. Again the attempts at reduction were renewed, but witliiM
success. The patella euuld be moved on its edge more fttrly t
before the cutting, but resisted every eflbrt to replace it. The psiitt
was now bled in the ereet posture and until the approach of oym
but to no purpose. On the following morning it was determinntl
adopt, with some modification, the mode practiced so suecmAfuIly h
Dr. Wat-ion. " The thigh was strongly flexe<I," says Dr. (.tazmm, "fl
the pelvis, and the heel elevated. Then the I^ was flexed slead"
and loi-cibly on the thigh, and suddenly straightened. Al the raoim
of straightening the leg, I pressed very strongly against the lower (il|
of the pati-lla from without, with the lieatl of a door-key well wrag^
while Dr. Ad<lison pressed with both thumbs against the uppt^r m
of the l)one toward the external condyle. On the fourth trial tl
manceuvre succeeded, the lx)ne springing into its place with a sbs^
Recovery was uninterrupted, and two or three months aller, the patia
had the com|)lete use of his limb.'
The following case is reported by Dr. S. F, Morris, New York:
"Mr. B., aged 27, of slender bniid, while playing nt liall, in a
deavnring to strike the ball hod to jump up iitid turn [mrtially raai
when, on resuming his former position, he fell, hiM leg n-ftisiRg to bM
He apjireeiated the nature of his ininry, and, with the niil nt tlwHi
in the store, endeavored to 'push it back.' Failing in tbU,Mtr|p>
aid was sought, but, dt^pite three attempts at rediieli>Ki, th« pan
remained displaced. He was then taken to bis home.
"I saw him about two hours after the accident. He compUtOidl
■ WHtuiti, New Torh Juurn. Hi-d., Uct. ISSO. p. S09.
■ aazMm, Aln«r. Journ. MtA. Suj,, vol. »xi, April, IHS, p. Ml.
DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 743
Bevere pain when any manipulation was made. The leg was i)erfeetly
straight. The patella was firmly wedged (its outer edge) in the inter-
Dondyloid fossa; its anterior surface looking outwards and slightly
iown wards, its posterior face looking inwards and upwards. The
prominence of the edge of the patella, thus twisting on its longitudi-
nal axis, left no doubt as to the diagnosis.
" Xo attempt was made at reduction by me until the patient was
etherized, when, assisted by Dr. C. M. Bell, of this city, it was easily
performed in the following manner: The leg was raised from the bed,
the thigh flexetl on the pelvis. Dr. Bell then placed his thumb, as a
fulcrum, beneath the under (posterior) surface of the patella, and pressed
on the up{)er (anterior) surface; at the same time I slightly flexed,
then suddenly extended and rotated the leg inwards. The patella im-
mediately resumed its natural position."*
Dr. Sternberg, Assistant Surgeon U. S. A., has also published a case
in the Medical and Sur(/ical Reporter, reduced readily when the patient
was under the influences of chloroform. I am unable to find the date
of the record, but I think it was in 1869.
The following case is reported by G. P. Davis, M.D., of Hartford,
Conn.:
" A few weeks ago I was summoned to a nurse-girl, who was re-
ported to have ' put her knee out of joint.' On entering the room, I
found the patient lying on her face, both legs extended, and the left
foot pointing towards its fellow.
"On turning the patient upon her back, the left patella was plainly
seen in a condition of ' vertical' displacement, t. f., turned ujxm its
inner e<Ige, so that its upper surface looked toward the opposite knee.
It was rigidly fixeil, and the limb was entirely helpless.
" I learned that while sitting upon the floor, playing with the baby
under her charge, she suddenly reached forward, at the same time
twisting her body partly around, in order to seize the child, who was
a little out of her reach, and w'ho, she feare<l, was about to fall. She
immeiliatelv became conscious that an accident had befallen her knee.
" The patient was etherized as she lay upon the floor. The whole
limb was then elevated by an assistant, so as to relax the muscles in
front of the thigh, and, by forcibly crowding down these muscles
toward the knee with one hand, manipulating the patella at the same
time with the other, reduction was effected with the utmost ease."*
April 1, 1875, through the courtesy of Dr. A. R. Robinson and of
Prof. S. B. Ward, of this city, I was i)crmitte<l to see a case of "semi-
rotation" of the pntella. The accident had happened the day before,
in the person of Susan Newman, aet. 31, a muscular Scotch woman,
while wrestling. Dr. Robinson being (»lled, attempted reduction by
Cressure and by other means, but without success. Al)out seventeen
ours after the accident I found her in bed with the left leg extended
upon the thigh, and tJie patella standing upon its inner margin, which
» Morris, Now York Mod. Record, May 16, 1869.
• DhvIs, Med. Record, Dec. 1, 1874.
744
DISLOCATIONS OF THE PATELLA,
rested in the iDtercondyloid notch. The patella wa:; not vertical, b
leuned over toward the outside of the knee,
White placiug her under the influence of chloroform, she beot i
leg to a right angle, but the jmtella continued to occupv ite sbnorii
powitton. When completely under its influence, Dr. Ward extend
and flexed the 1^ with no result. He then tilted the pstella dot
until il lay flat upon the outer condyle (this wa:« the |>ositiua it ti
also when, being partially chloroforme<l, she flexed the lej^) ; and a
a second attempt, with moderate pressure against the outer idst^o
the patella, it suddenly resumed its position. None of the tendiiM
or muscular attachmeut8 were ruptured.
Dr. J. M. Boyd, of Thorntown, Indiana, report* a case of ver
dislocation; the patella resting upon its internal margin, in a ni^^J
yeai-s old, and whieh was eaiisoi by muscular "spasms." Aue
were immediately made by a surgeon to reduce it, but without sue
Subsequently Dr. Boyd tried also and fiiile<I ; but at the end of a
weeks the muscular spasms returned, and before Dr. Boyd could r<
the house the bone had resumed its position sp<mtnneously.' Ml
gaigne has reported, also, a («5e In the GaztUe MMicale, for 183$, i
which reduction was accomplished spontaneously during an atte
made by the patient to walk. The same writer refers (o a caac rcdnc
under the influence of chlonjfoim. Mr. Flower [H<JmfJ» i
records a similar case.
In a case of the same kind, published originally in Rrui^a Magasit
and which is copied at length by Mr. B. Cooper iu his edition of 8
Astley's great work, the reduction was found impossible, nntwtth#MJ
lug the surgeon finally had the temerity to sever completely the tjeuA
of the quadriceps extensor, and the liganientum patellH^, Ext«ni'
suppuration followed, under which the poor fellow fiiuilly sunk i
died.
<! i. Dislocations of the Patella Upwards,
Oecasinunlly the Itgjinientura jNitellie has been found so mocli cl
gatfld and relaxed, as to permit the patella to glide upwards upcm
fnmt of the femur. Heister and Ravaton have ench seen an exun|
in which a displacement from this cause esistwi to the extent of thi
inches. It is much more common, however, to meet with this di«lu
tion as a result of a rupture of the ligamuntum jKttcllfe, as thi; follii
uig example will illustrate.
On the 18th of Dec., 1850, Dennis MuUanis, let. 50, vnte mimit
to the sui^ical wards of the Buffalo Hospital of ihe Si!iti»ra of Chiri
While at work on this same day, he had Blip|>ed and tiillvn, wrilfc ■
knee forcibly flexed under his body, 1 fi>und the ligament of I
patella torn asunder, and the patella drawn up two or Uirw iwi
upon the front of the thigh. VVe applierl at once (he dreMia|E> ta
by me for a broken patella, and were able to bring the btiue diM
completely to it« plai^«. Three weeks from the time of the nnipt
the injury the dressings were removed, and the patella was fouud In
■ Boj-d, Wmteru Juurn. Mod., May, ISfiB, p. :^TS, uad Junn, IMS, p. ML
DISLOCATIONS OF THE HEAD OF THE TIBIA. 746
nearly but not quite in its original place. From this time we com-
menced to move the joint : in about ten days more he left the hospital,
and I lost sight of him, so that I am unable to speak more definitely
of the result.
In February, 1869, Dr. George H. Smith consulted me in relation
to a gentleman who had ruptured the ligament of the patella in both
legs, a little more than a year before, by catching his heel in descend-
ing ifrom a carriage ; the ligaments giving way in the powerful muscular
effort which he made to prevent himself from falling.
Treated upon a single inclined i)lane in the same manner that I
have recommended for a fractured patella, at the end of five weeks the
patellsB w^ere in place and the ligaments reunited. After walking
about one month upon crutches he caught the heel of his right foot
again and again ruptured the ligament of the patella in the same leg.
A similar plan of treatment failed to accomplish anything, and when
be consulted me the patella was displaced three inches upwards. He
could raise the leg slowly to a position of extension while sitting, and
was able to walk four or five miles a day.
Gibson has recorded a similar case, in which both patellae were dis-
located upwards by a rupture of the ligaments, occasioned by the
exercise of leaping. He recovered the use of his limbs almost com-
pletely.*
(For examples of rupture of the quadriceps femoris, which some
writers have incorrectly named Dislocations of the Patella Down-
wards, see Vefpeau's Surf/cry, 1st Amer. e<l., vol. i, p. 422; New York
Med. Thnea^ April 6, 1861, p. 226, and two cjises reported by myself
in the same volume of the Med, Times,)
CHAPTER XVIII.
DISLOCATIONS OF THE HEAD OF THE TIBIA (FEMORO-TIBIAL).
.Vyn — ** Tibia upon the femur;" •'dislocations of the leg."
Ix consequence of the great size and irregularity of the articular
surfaces between the tibia and femur, together with the remarkable
number and strength of the ligaments which bind the two bones
together, dislocations at this joint are exceedingly rare. They are
known to take place however, in four principal directions, namely^
backwards, forwards, inwards, and outwards. A dislocation may also
occur in either of the diagonals l>etween these points, that is, antero-
lateral ly or postero-laterally. They may be either couiplete or incom-
plete. Velpeau has found upon record thirteen examj)les of c*omplete
dislocations forwards and eight backwards, but not one of a complete
lateral luxation. Velj)eau thought, also, that the antero-posterior
> Gibson, Surgery, vol. i, p. JW(>, 6th ed.
48
746
ONB OP THE HEAD OF THE
luxations were always completr, but Mjilgaigne has shown that fi
opinion is erroneous.
Simple flexion and exteiiHioi), however extreme, are gencmlly inwuf
ficient lo produce either of these dislocations. They may be producfH
by a violent blow upon the lower end of the fetnur or upon the upp^r
end of the tibia, or by twisting the tibia upon the femur, as when tbt
foot 19 made fast in a hole, and the body swings around u[»on the kni
i 1. Biilocationa of the Head of the Tibia Backwards.
Symptoms. — The head of the tibia is felt in the poplitml spaee;
if the dislocation is complete, the pressure upon the popliteal t
becomes excessively painful.
A marked depression exists in front, immediately below tiw pal^li,
and especially upon the sides of the ligameutum patellie; thecnndylesof
the femur project strongly in frtmt; the 1^ nay
be not at all or only slightly shortened, «r llw
shortening may amount to one ineh or morr,
and usually it is in a position of extt^me exten-
sion, or thrown forwards from the line of tlw
axis of the femur; but its position has U*d
found tt) vary greatly in difttTciil c^s<^ lltf
limb being sometimes very much flexea.), and in
others veiy slightly flexed, or perfectly :<lmielit-
Patliologicai Anatomy. — The (MMtfiriitf tip-
ment of the joint is torn; the inust-li!!! of ti»(
ham are put upon the stretch ; the |u>plilr«l
nerves and vessels ciimpreseed ; and the mw) oi
the tibia either rests partly ujion the jtiwtefiiif
liaif of the lower arttcnlating surface iif tb*
femur, or it ]ub«es up and rest£ only nt!;«inai it*
posterior articulating surface, whii-h in tii"
direction extends an inch or more ugtwards. If >
uMi tnoiwiRi.. the dislocation is complete, the crmial Wy.-
ments are also torn, and all the iMirt> uS
joint suffer extensive injury from stretching, laceration, or '■^m ,
Pvor/mmg. — Malgaigne has seen three examples of incon>|'[>
ward luxations which were not reduced, and neither of ili' [■ -
was very greatly maimed in consequence. One walked with i r( i ■
after three or four days, and with a cane after alKmt t'lv "■ ■•
Another did not leave his hcd under one month, an<l it \\a< imn<
one year Itefore he could lay aside his crutches; hut b4)th of thetu ><*•
Anally able to walk at least twelve leafpues per day. MalKiu^if I
forms us, however, that in a similar case seen by I<h.ssii», ibi'Utiirt t
was conlined to his l>ed two years, although he finally n.t'o^'vivJ ■ lil^J
erable use of his limb.
If the reduction is promptly effected, the limb kept rx^rfi-rtlr ■l"''''!
sufficient length of time, and in other respects pntporlv nuuia^n, m^
much inflammation neetl gencrully be anticipated, ana tlic Wmh a'
«ufliT in the end verv little if any maiming.
Treatmcnl, — It will be proper, at first, to attempt tha redixtMit}
DISLOCATIONS OF HEAD OF TIBIA BACKWARDS. 747
simple manipulation, as this is often found to succeed when the dislo-
cation is recent and incomplete, and especially when the system is
greatly depressed by the shock of the injury. If the dislocation is
complete, however, we can hardly anticipate success without the appli-
cation of some extending force.
In the employment of manipulation we ought to be governed at first
by the same rule which we have found so generally applicable in dis-
locations of the femur, namely, to carry the limb in those directions in
which it will move easily, or without much force. If this fails, we
may at once resort to forced flexion alternating with extension, rotating
or rocking the limb also occasionally from one side to the other, while
at the same moment strong pressure is made upon the projecting bones
at the knee-joint in opposite directions or in the direction of the articu-
lation.
Finally, it may be necessary to resort to extension, made by means
of a lacq, or by the hands of strong assistants, above the ankle, always
at first in the direction of the axis of the tibia; the counter-extending
band l)eing applied to the perineum if the leg is straight, but to the
lower and back part of the thigh if the leg is flexed.
A very convenient mode of making extension, where we wish to
apply more than usual force, is to lay the whole limb over a firm
double-inclined plane, or fracture splint, securing the thigh to the
thigh-piece with a roller, and making the extension with the screw
attached to the foot-board. This method, however, while it enables
us to use great force in the extension, prevents the surgeon from em-
Eloying, at the same time, those flexions, extensions, and other manipu-
itions, upon which success so often de|)ends.
Dr. James Carmichael has reported a case in which reduction was
effected easily by flexion, when traction had failed.*
Mr. Rose has related, in the Provincial Medical Journal of June 11,
1842, a characteristic example of this accident, except that the patella
had also suffered a lateral displacement, presenting the usual favorable
termination.
A woman was standing upon a low ladder, when a carriage driven
furiously came in contact with it, and precipitated her to the ground.
Mr. Rose, who saw her almost immediately, found the tibia completely
dislocated at the knee, the head being driven behind the condyles of
the femur into the ham, with the patella thrown to the outside of the
external condyle, and the leg in a state of fixed extension. Immedi-
ately, and without difficulty, the bones were restored by applying one
hand to the patella, the other to the back of the up|)er portion of the
tibia, and simultaneously pulling and pushing thase bones toward their
natural positions. The patient was then removed to a bed, and by the
diligent use of antiphlogistic remedies inflammation was kept in check,
and the case reached a favorable termination without one untoward
symptom. After the lapse of only a few weeks, she had completely
recovered the use of the knee-joint.'
• Nrw York Mod. GMZotie, Aug. 2*2, 1868; from the Lancet.
* Rose, Amer. Journ. Med. Sci., vol. xxxi, p. 216.
748
DISLOCATIONS OF THE HEAD OF THE TIBIA.
Dr. Walshani communicated a case to Sir Astley Coojier, in whii
the (lislwation was ii"t only complete, but the tendnn of th« iiitadt
ceps extensor was ruptured. The le^ was bent forwards. The redu
tion was accomplished very easily by ertenflion made with (lie Ira
by four men, in the line of the axis of the limb. In about one tuotM
this man began to walk with t'rutohe«, but he was not perfectly !■
ered until after five months; at which time the crutches were fina^
laid a^ide.'
1 3. Siilocationi of the Head of the Tibia Forward!.
The signi4 of tbi^ arai<leut are tbc revcrec of those whith Iieloiig;t
dii«W>ations Imckwards. The patella, tibia, and fibula are promine
in front, while the condyles cif the femur may be felt behinu, prffieli
strongly upon the muscles, nerves, and bloodvessels which ownpyll
popliteal space. In ca^ie the dislocation is complete, a shortening tnf
exist to the extent of one or even tlir«"^
iucJies. I>r. O'Beirne. of Dnl.lin, b
tioiied a ease to Mr. H. C'i>o[>er, iu wliie
tlie shortening was three inches uud a hat
and Mr. Mayo has seen one example ii
which the dislocated limb was "fully f<
in<!hes" shorter than the other.*
In consequence of llie |>rc>v«ure iifm.
the popliteal artery, the pulsations ia tl
branches below are frequently inlcrruptd
and in one instance this prea^ure was si
ficient to produce finally a dry Miucnne.
Br. Gorde relates a case in the BtdUHi
dc 2'heiapeuttque, occurring iu a won*
nesirly sixty yoare old. This wooian «
returning home at night with a boiv^
buivlen, and in a state of iutoxStatkj^
when she stepped into a ditcli as deep H
up to the miildle of her thighs. The baij
was thrown forwards by the fall, while tfa
feet stuck at the bottom of the ditch ; the whole force of the tntpuh
being sustained by the thighs. The lower end of the femur wad fouui
driven downwards and biiekwards, and lodged under the miifclw d
the ealf of tite k^; the limb being shortened three inclu^. Itedadiq
wiLS promptly enected, and witliout inflicting any pain of whidi iT
patient cimiplained. In six weeks the patient was curtNl.'
Mr, ToogiHx! lias rejiorted also, iu the i'lorineial J/«iii>a/ JourvSi
June 18tb, 1842, au example of complete dislocation in tliis dtiwtii^
in which the appearance was so dreadful, ttiat Mr. Toogond al U*
despaired of being able to reduce it; but by directing tw«» u
make counter-extension while he made extent'
i\
Ini-oinplete d[
I, the reductioa i
> Wnlshftm, Sir A- Couwr i.n Dliloo , nic, 2d L»n(l. «4., a. V
' a C.K.pi.r'i .!d of Sir Aitle- " "'' - — — ~
■ Gordo, Araer. Journ. Hcd. :
DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 749
immediately effected. At the end of one month the patient was able
to leave his bed ; and sixteen years after, Dr. Toogood saw him walk-
ing *^ with very little lameness."* Parker, of Liverpool, has reported
another example in the London and Edinburgh 3fonthly Journal for
December, 1842, which was occasioned by the fall of a heavy spar
upon a man's back, and the consequent violent bending of the knee
under his body. In this case the limb was slightly flexed, and the
patella was loose and floating. The reduction was effected without
much difficulty by extension- and counter-extension made by two men,
while the operator, placing his knee in the ham of the patient, attempted
to bring the leg to a right angle with the thigh.*
B. Cooper, Malgaigne, Little,' and others, have recorded examples
of this accident.
March 9th, 1865, Hiram We^cott, of Sandy Cove, Nova Scotia, aet.
45, was caught by his sled, drawn by horses, in such a way that a
beam pressed against the front and lower end of the femur while the
heel was caught and arrested by a stnmp. The foot was thrown for-
wards and the upper end of the tibia completely dislocated in the same
direction. It was at once reduced by a person who was present, but
on attempting to use the leg in walking it was reluxated immediately.
Mr. J. H. Harris, medical student, found the limb soon after completely
luxated, with the leg thrown forwards in the position of dorsal flexion
about 40°. The tendons of the hamstring muscles were not ruptured,
but had slid forwards past the condyles of the femur. There was no
external wound. Reduction was easily accomplished by simple exten-
sion. Pasteboard splints were then applied. On the third day the
knee was considerably swollen, and some ecchymosis existed about the
popliteal region. On the fifth day these symptoms had much increased.
Mr. Harris then applied extension to the foot, with the aid of adhesive
plaster, pulley and weights, and by elevating the foot of the bed. The
amount of extension employed was 0 lbs. This gave immediate relief
to the pain, and was continued until the inflammation subsided. His
recovery was steady, ^ud in four months he walkeil with crutches or a
cane.
In 1864 a similar dislocation was presented at the Brooklyn City
Hospital, in which reduction having been practiced, the patient died.
The case is reported very fully by Dr. Le Roy M. Yale.*
Dr. White, of Buffalo, politely invited me to see with him a lad, tet.
10, whose tibia had been partially dislocated forwards eight weeks
before, by a boy's having hit the top of his knee with his head, while
they were at play. His father, who is himself a physician, residing
near town, reduced the limb very easily, by extension ma<le with his
own hands, and by pressing upon the projecting bones. Violent in-
flammation ensued, but at the time when I saw him, the knee was free
from soreness or swelling, and the motions of the joint were nearly
restored.
Dr. Charles S. Downes, of Mclndoe's Falls, Vt., has sent me the fol-
* Toogood, Amer. Journ. Med. Sci., vol. xxxi, p. 466. ' E. Parker, ibid.
» Little, New York Med Times, Aug. 17, ISfil.
* Yale, New York Journ. Med., vol. ii, p. 124, Nov. 1866.
750
DISLOCATIONS OF TliR
TUK TIBIA.
lowing account of a case which occurred in his own ]>ractii*. Orti
1861, Mrs. H,, a rubu^t young married woman, aged abuiit 20 y
was driving a young horse and holding her infant in her nnns, >
the horse ran and she was thrown ont. One of her legs being can
in the wheel, she was carried over three or fonr times in its revolulf
before she became disengaged, holding meanwhile u|)on her infant
such firmness that it suffered no harm.
A few hours later Dr. Downes intd Dr. Burton found a oomi
dislix-ation of the tibia and fibula forward", and the lower end oi
femur could be felt under the muselesof thecalf of the 1^. The li
was shortened four inches and a half. Tlie patella lay loosely in ft
of the femur, with it*; lower mai^in tilted forwaixls.
The patient was laid upon a bed, and a perineal band made fast fii
one of the posts, while a lara was placed uj«>n the foot and attacheil t'>
a rope folded upon itself an(i forming a pulley or " SjHiuish windla.*-,"
such as is described at page 690. In this way the reduction v»
s|>eedilyand easily accomplished. Hot fiimentations were suliwqtiwilb
applied for several days, the limb being kept perfectly at rest. In
about three months she was able to do her ouni housework, and in a
short time after all tnices of her accident had disapjiearfd. ~
The following account of a case was sent to me bv my young fri<
Dr. Alonzo Pettit, of Eiizabethport, N. J.:
"Joseph McGuire, laborer, ret. 26, was stealing a ride upon a freif,
train upon the Central Railroad of New Jersey, on the evening r{
June 19th, 1874. He was sitting upon the platform of the tar, wilii
his feet upon the platform of the next car, his legs extended. TV
train slacking np at a station, before he had time to bend his kn«*,
the cars came together and pushed the head of the left tibia ap^Knl*
upon the femur.
*' I saw him about half an hour aHer the accident, and found a cnm-
pletedislocationof the head of the tibia, with the patella forwant^ u|v«
the femur. The leg was slightly flexed, and sl)i>rtenc<l two and a b-ili
inches. I succeeded in reducing it easily without assistance, or ibeu*
of anffisthetics, by grasping the leg with the left hand, the right t»iw
in the popliteal space, making moderate extension ami flexion, u"
pressing upon the condyles of the femur. There was consiiienUr
swelling and inflammation, but they yielileil under the um.- of refiigtntf
lotions. The 1^ was kept extended for three weeks, dtiritw wfcit*
time he suifei-ed no pain whatever. At the end of two «-i>eks I bqffi
the use of passive motion, cautiously, and af\cr three weeks I %t\tnni
hira to begin to walk, wearing a firm elastic knee-cap. July 22>1,«^
I last saw him, he walked with a very slight halt, and could bond Ik
knee about 25°, and was still improving.
1 in a
I 3. Dislocatlom of the Head of the Tibia Ontwrnrdi.
Occasionally, owing to a violent wreneh of the knee-joint, tb» b
ligaments upon one side or the other are ruptured, and funsr^oe
the joint surfaces separate somewhat from each other ; or < *
limb is moved, the h^dof the tibia may slide a little forward* u
DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. 751
wards, or to eitlier side. Tliese are not ])roperIy examples of sublux-
ation ; nor should we consider as belonging to this class the accideut
origioally described by Mr. Hey as an " internal derangement of the
knee-joint," but which also by some writers has been termed a "sub-
luxation of the knee." Of tliis latter accident I will take occasion
hereafter to speak a little more {Nirticularly.
Ill subluxation, properly so called, if the direction of the dislocation
is outwards, the outer condyle of the femur rests ujwui the inner artic-
ulating surface of the tibia, and if the direction of the dislocation is
inwards, the inner condyle of the femur rests upon the outer articulat-
ing surface of the tibia.
The signs which characterize this accident are such as cannot easily
be mistaken. The limb is not shortened, nor is there anything espe-
cially diagnostic in its position, since it has been found to be some-
times flexed, and at other times straight; but the strong lateral pro-
jections made by the inner condyle of tite femur on the one hand, and
by the heads of the tibia and fibula on the other, cannot fail to inform
us as to the true nature of the accident.
Thf treatment will not differ essentially from that which lias already
been recommended in dislocation of the tibia backwards or forwards.
If any other expedients can prove useful, they must
be left to the judgment of the sut^^eon whenever Fm. 333.
the exigencies of the case shall demand tliem.
I have already mentioned the case of N. Smith,
who, in consequence of s. fall from a window, had
a dislocation of the right femur, tibia, and [>atella.
The tibia was subluxuted outwards, and the leg
was partially flexed upon the thigh, with the toes
everted. By moderate extension, made with my
own hands, united with alternate flexion and ex-
tension, the bone was easily and promptly restored
to its place. Having reduced the femur also, the
limb was laid over a gently inclined plane made of
pillows ; and cloths moisten<^l with oool water were
kept constantly applie<l to the knee for many days.
Very little swelling followed the accident, and his
recovery was rapid and coin|)lete.
A man was rec-eived into the North London Hos-
pital, with a jtartial dislocation uf the tibia outwanis, subiuxnion nf uh h«ii
and although the knee was much swollen, the na- ofihr;iii.i«ouiir.r(i..
ture of the injury was easily doterniined. The
knee was immovable, and the toes turned outwards. Mr. Hallum, the
house surgeon, reduced it by extension and counter-extension made by
his own hands.'
Mr. Pitt reconls a similar case in a young lady, produced by a fall
dawn a flight of stairs. It was retluced easily by extension and coun-
ter-extension. Inflammation followed, but it was Anally controlled,
and she regained the use of her limbs.'
752
DISLOCATIONS OF THR HEAD OF THE TIBIA.
In one case of subluxation, mentioned by Sir Astlev Cooper, and
& set-ond recordeii by Bransby Cooper, the recovery ot tJie ttitiotions
the joint did not seem to have been so rapid; the Joint renminin^
unstable and tender for a loiig time afterwards.'
i 4. SitlacationB of the Head of the Tibia Inwardi.
There is nothing; pebuliar in either the signs, condition, or treatment
of this accident, a» distinguisheil from a. dislocation outivanlfl, to de-'
mand of us a special consideration.
Sir Astley Cooper has luentioned two cases of subluxation inwsnli^
and Mr. B. Cooper has added to these a third. Sir Astley remarks
that in the first accident, the only one indeed which he had himsetfi
ever seen, he was struck with three circurastances : 6rBt, the gral
deformity of the knee from the projection of the tibia ; second, tii«
ea-se with which the bone was reduced by direct extension ; and third,.
by the little inflammation which followed. The second case of which
Sir Astley speaks was cnninmnicated to him by a Mr. Richards. Id i
this case the fibula was also broken, and the reduction was ae(x>n)-
plishe<I only after extension had been ma<ie by
Fio. 3S3. several persons for half an hour. The limb becanW
excessively swollen, and remained so for nuDjr
weeks. Eighteen months after the accident tM
knee continued somewhat stiff, and there wa« >
unnatural lateral motion in the Joint, from the in
jury which the ligaments had suslnined. The m-
lieiit referred to by Bransby Coo|)er had met witk
the accident by a fitll upon the foot, with hi$ \ef
bent under him ; and a fellow- work man had i^'
duced the bone by extension and pressure. Mr.
Cooper thinks that not only the internal Utrnt'
ligament was torn, but also some fibres of the v
tus exfcruus and the crucial ligaments. Violrat:
inflammation ensued, which did not permit hini 10'
leave the hospital nntil af\er ubont two woeka.*'
Fergusaon has seen two examples of nnrcdund'
subluxation inwards, in bolh of which the jitttiiiiB-
Subiuiuiion or the hoi-i had regained useful limits.*
oMhe ubiBinwmdt. Malgaigue mentions that Boyer, CoittalUl, i
Key had each seen one similar example; aad b
also enumerates two additional cases of complete luxation altMdi^
with a protriL-^ion of the bone through an external wound ; in botli i
which the reduction was easily effected and the patients reeo\-erDd.'
I 5. Dialooations of the Head of the Tibia Backward* «iid Ontwu^t.
In June, 1H53, Henry J., of DauM-ille, N. Y., wt. 24, was thro*
' B Cooper's ed. of Sir Aitley, op. olt., pp- 1 11-18.
■ Fcricixtnn, op. cil , p. 264.
< Mdlgiigne, up. dt., torn, ii, p. 964.
f an enraged bull, ami his left leg being caught under the knee by
le horns, was twisted violently. I)r. Prior, of Dansville, and Batton,
of Bums, were called, and found the left knee completely disliwated ;
the tibia Iwing displaced backwards beyond the condyles of the femur,
and also a little outwards. The toot and leg were inclined outwards.
With the assistance of four men, extension and counter-extension were'
made in the line of the axis of the limb, and the reduction was easily
accom]ilished. Pasteboard splints, bandages, etc., were applied to
maintain the bones in j)lace; but the swelling oame on rapidly, and in
the evening these dressings were removed. The limb was now laid
over n double-inclined plane carefully padded, in order to press the
tipper end of the tibia forwards, as it manifc:^tcd a constant inclination
to iMteonie displaced backwards. This apparatus was employed six
weeks, with the exception of two or throe days, during which the
limb was laid upon pillows, but as the pillows did not sufficiently
support the back of the tibia, the double-inclined plane was resumed.
After the removal of the plane, during seven weeks longer, an angular
splint Wjvs kept closely applied to the back of the limb.
Seven months after the accident, on the 2.3d of January, 1854, Dr.
Robinacn, of Horn el Is vi lie, brought the gentleman to me. I found the
bones displaced backwards about three-quarters of an inch, and half
an inch outwards, or to the fibular side. This was the position of the
bones when he was sitting with his leg bent at a right angle with the
thigh, but when he stood erpct and bore some weight upon the foot,
the outward displac-ement ceased, and the backward displacement only
rcmainetl. It was very easy, however, in whatever |)osition the leg
might be, to push the bones forwards by the hands until nearly all
deformity had disappeared. He could flex the leg to a right angle
with the thigh, and straighten it completely, but he could not lift the
f<x)t and leg from the floor while sitting with his limb extended in
front of him. He was unable to Ijear sufficient weight upon his foot
to use it at all in progression, on account of the inability to fix and
steady the limb, but not on account of any pain or soreness which it
occasioned.
It was very plain that the sui^eons were not in feult for this unfor-
tunate i-nndition ; indeed, they seem to have exercised throughout great
ingenuity and skill in its management.
I directed the young man to Mr. John C. Seitlert, of Buffalo, a very
ingenious instrumcnt^niaker, who has since succee<fed, I learn, in
adapting to his knee a mechanical contrivance which enables him to
walk quite well.
Thomas Wells, of Columbia, South Carolina, has described a similar
accident, the tibia being dislocated outwards and backwards, which
terminated fatally on the fourth day in consequence mainly of ex|)0-
sure, intemperance, and neglect to a]iply for surgical aid. The bones
were never reduced, and the autopsy disclosed also a fracture of the
internal condyle of the femur.'
-. Juurn. Mad. Sci,, iq\. i, p. 25, May, 1832.
1CATJ0N3 OF THE HEAD OF THE TIBIA.
i 6. Internal Derangement of the Eoee-Joint
Svn. — "Slipping of the lemiluniir fibr<vciirtilBgmi'' Hey. '■ PHrlial Hislnnllol
or ihe thigb-tH'iie from the srmilutinr CHrtiliiges;" Sir A>l]i>y Co<-p«r. ■■Hublun-
tion of Ihc BuiiiilunMr cHrUlnctni" MHlKfligoe- "Sah1uiiitii>ii »r ihn hn*«>;'' Krivb-
Ben. To Iheip wit think it proper to adrl, as giving riie lu the anmu cla^i »f sj'nip-
toms, " FloHting cartilagus in the kne«-joint."
We have alreti% expressed oar opinion that this accident is in
proper sense a subluxation of the knee ; and we should oot, thercTur^
think it wortli while to make any farther alhision to it, were it uot
necessary in order to enable the student of surgery to distinguish I*-
tween the phenomena which belong to it uud those whiuti lieioDg
strictly to subluxation of this joint.
Sffiapto7ii«. — The patient is suddenly thrown to the ground whiU
walking, as if by an instantaneous loss of power iu the alTected limb,
this loss of control over the limb being accompanied mually witk
iiharp pain, referred to the region of the knee-joint ; or he Irips bis tm
against something iu his path, and the tr>es becoming everted, lUf leg
suddenly gives way under him ; in some e&ses' it lias happened wbea
the [Hitieut was turning in bed, the weight of the bed-clothes liangiog
upon the Iogk so as to occasion a strain and rotation oiitwanis at tu
knee-joint, or it follows upon a subluxation of tlie joint,
example which I shall presently relate.
If the patient is walking when the accident takes place, ami he fiJk
to the ground, he finds himself unable to move the limb, or to Mvi
upon it; but by manipulation, the difficulty is, in most cas(is, as nwly
overcome as it occurred, when immediately the motions of the jiiiat
become free, and he walks off as if nothing had happeinxl.
When the accident has ont^v taken place, it i« aAerwunl.-i ('JcceHlinsI;^
liable to occur from very slight causes, and eventually the knec-joiilt
becomes tender and the cajisule fills with synovia, indicating the extO'
ence of subacute synovitis.
A single example will illustrate the usual history of theae cas«.
A young man, from Colesville, N, Y., wt. 23, consulted me, op I
27th of Oct. 1858, in relation to the condition of his knoe-joinU I
stated that on the 13th of Aug. 1858, while standing with the wht
weight of his body resting uiKin the left leg, a mate struck him on I
inside of the lower end of the left femur. The blow was made «i
the palm of the hand, but with sufficient force to throw liini iltitrn.
was immediately noticed that the tibia was partially disloeulH iu'
at the knee-joint. The whole lower part of the limb wan inrlit
outwards. A person present in the room seized upon tlie fool awl
extension easily brought it back to place; the bone resumiu)); in MH
tion with an audible snap. After this he continued to walk bM
until night. Two days afler, the knee had become ho much inl
that he was obliged to take to his bed, on which he waa conlinMl thi
weeks. Gradually the swelling subsided, and in about five week* ■&
the accident he began to walk on erutehes. On the '2'iii of SepL, I
was walking in the store without crutches, when he snddenlr (eh
eeusatioo of slipping in the joint, and he fell to the floor as if be M
INTERNAL DERANGEMENT OF THE KNEE-JOINT. 755
been tripped up. At the time when he called upon me, this had hap-
pened many times, but had never been attende<l with pain. The joint
was filled with synovia, and tender, yet I could distinctly feel a hard
body just to the inside of the ligamentura patellae, and which moved
freely under the finger.
Pathological Anatomy, — The same class of symptoms, with only
very slight modification, belongs probably to several varieties of " in-
ternal derangement of the knee-joint ;" and first it will be remembered
that the semilunar cartilages upon which the margins of the condyles
of the femur rest, are attached to the tibia by several ligaments; but
when, from relaxation or a violent strain, any one of these ligaments
becomes elongated or gives way, the portion of cartilage which it re-
strains is permitted to become partially displaced, and by interposing
its thick margin between the deeper articulating surfaces the bones are
separated and the muscles lose their control over the joint; second,
these ligaments may not only yield, but a fragment of one of the car-
tilages may become actually broken off from the main portion ; third,
the femur may perhaps escape behind some portion of an interarticular
cartilage, and thus, instead of the cartilage placing itself between the
joint surfaces, the femur itself may have thrust it into this position ;
fourth, a cartilage or some portion of a cartilage may become hyper-
trophied, and thus give rise to the symptoms described ; fifth, in other
cases still, a bony, cartilaginous, fibrinous, or calcareous growth or
concretion forming within the joint, and, if originally attachetl, becom-
ing separated from the capsule, may move about more or less freely,
and give rise to the same class of symptoms which we have described.
This last variety has generally been described under the name of
** floating cartilages;" but since these bodies are not always cartilagi-
nous, and especially since they do not always by any means move so
freely as to be properly designated as "floating," the term is less
appropriate than that originally given by Hey, and which we have
chosen to adopt.
Ireatment. — For the purpose of obtaining immediate relief, it is
general ly sufficient to flex the leg completely and then suddenly extend
it, or to combine this motion with a slight twisting or rocking of the
knee-joint. Sometimes this experiment has to be repeated several
times before it is completely successful, and in a few instances it has
failed altogether. I think I must have met with ten or twelve ex-
amples in the course of my practice, and in no instance has the sudden
flexion and extension of the limb failed to overcome the difficulty.
As to the question of subsequent treatment, especially as to whether
it IS proper to attempt their extirpation when they are found to be
loose, or to make any other surgical interference, I prefer to leave its
consideration to those general treatises upon surgery where it more
properly belongs.
DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 757
8ur&ce of the tibia ; its upper and iuner margin descends toward the ex-
tremity of tlie malleolus inter-
nus, and the outer face of the Fm. sa4.
astragalus presents obliquely
Dpwards and outwards, instead
of directly outwanis as it would
do iu its natural )H>sition. This
cannot occur without a rupture
of the internal tibio-tarsal liga-
ments, or a fracture of the inal-
l«olu^ iutenuis, or both ; indeed,
a fracture of the internal mal-
leolus is a. very common cir-
cumstance in connection with
this form of dislocation. Much
more frequently, however, the riiai^caiiungf ihcioMrendgf ihciihi.inwinis.
fibula itself gives way at a )x>int
vithin from two to five inches of its lower extremity ; or sometimes the
fracture in the fibula occurs through that portion wliieh forms the mal-
leolus exterims. For more iKirticular information as to the causes and
•eJative freH|ueucy of these fractures, I refer the reader to the chapter
>n fniclnres of the fdiula.
Rarely it happens that, instead of this lateral rotation of the astrag-
Uus, there occurs a true lateral displacement of the tibia inwards upon
:he astragalus, and the outer portiou of the lower articulating surface
3f the tibia comes to rest upon the inner portion of the up{>er articu-
lating surtiice of the astragalus ; or it may slide completely off in the
same directiou ; a result w-hich is usually attended with a laceration of
the muscles and integuments, convening the accident into a compound
dislocation. In some cases this extreme displacement occurs without
such lacerations.
In this form of the accident, the true lateral luxation, the fibula
may remain unbroken and undisturbed, the tibia merely having lM^-
come displaced inwards; or tlie fibula may give way also above the
articulation, while the malleolus internus, and the internal lateral
ligaments, are equally liable to rupture as in the other form of the
accident.
Sometimes, in addition to these complications, the lower end of the
tibia is found to be broken obliquely ujtwards and outwards from the
articulating surface, leaving that fragment attached to the fibula which
corres|>onds to the inferior j)eroneo- tibial articulation.
Siftnptome. — The fiwt is more or less violently abducted, the sole of
the fiwt presenting downwards and outwards instead of directly down-
wards; the malleolus internus projects stniiigly at the inner side of
the joint; and at the outer side there is a corrcsjionding depression,
generally most marked a, little above the articulation near the ym'int
of fracture in the fibula. The |)ain is very great, and the f(K>t is im-
movably fixe<l so far as the volition of the jtatient can determine
motion, but the surgeon (van generally move it pretty freely, yet not
without causing a great increase of the pain. When the aislocation
756 DISLOCATIONS OF :
TEB END OF THE TIBIA
CHAPTEE XIX.
DlSLOCATtONS OF TBE LOWEK END OF THE TIBIA tTIBIU-
TARSAL).
Syr..
ifi of ihe anlcle-joitit;'- Clioliu* ond othpts.
The tibia rany be disKwatwl at its lower eiid in four directiou:
namely, inwards, outwards, forwards, and backwards. Most of tho"
dislocations complicate tliemselvee with fractures of the fibula or i
the tibia, or with fractures of both bones.
Dupuytren, Malgaigine, and a few other surgeons have rcfH»rti-«l «
amples also of dislocations forwards and iuwanis.
Boyer, with a majority of the French writers, and pievenil Y.ng\n
and German t^urgeons, s])eak of the^ dislocations as bclungin); tu t)
foot; consequently the outward dislocation of Boyer i^ the iowai
dislocation of Sir Astley Cooper, Malgaignc, myself, aiid ulliers. wl
prefer to regard the tibia as the bone dislocated,
! 1. rialocations of the Lower End of the Tibia Inwards.
jnl luinlioni;" Mnlgiiignc. ■■ DUlucHtioni of lb* tn
Caimfs. — ^This dislocation is occasioned gencTiilly by ■ fell fiwn
height, ujwn the bottom of the foot, tlie foot receivliie at tlw ofl
moment a sufficient inclination outwards to determine ihe main Iba
of the impulse toward the inner side of the ankle. It may be jw
duced also by a blow received directly u}ion the outside «f th» k
just above the ankle, or by a violent twist or wmnch of the fiiol *w
wards.
Pafhohgi^l Anutomy. — I have already, in the ohapler oil fnu-tur
of the filtula, stated my opinion that a large majority of H^a^f tmAm
which have been called inwanl and outward dislocations of the liM
were merely examples of lateral rotation of the asira^lui within ll
half ginglymoid and half orbicular socket formed by llie lowtr rt
tremitiflS of the tibia and fibula; and that true dislocntlnue, either |«
tial or (^nmplete, are at this joint and in these directions vcrr nir <
ciirrences. We shall continue, however, lu aeetmlance with iIm g*«*
practice of writers, to call them all dislocations, whether the utnpll
simply rotates on its axis, or is displaced laterRlly and hnricoiw
from the tibia.
In the most common form of the accident, then, w)»en the foot
violently twisted outwards,the astragalus l>enomefi tiltod ttimn hawiK
and upper mai^in in such a way as that this mai^in ftltdM itrnn
and places itself underneath the middle portion of the lower
DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 759
his shoulders, on the 6th of May, 1854, slipped upon the sidewalk,
and fell, dislocating the left tibia inwards, and fracturing the fibula
four inches from its lower end. I was in attendance soon after the
accident occurred, and found the tibia pn>jecting inwanls, with the
other symptoms usually accom|ianying a simple rotation of the asti^-
alus upon its axis. Seizing the foot with my hands, and flexing the
1^, while an assistant held up the thigh and made counter-extension,
Fk. 336.
I had scarcely begun to pull upon the foot before the nniuction was
effected. Dupuytren's splint was at once applied, and the sulisctpient
inflammation was so trivial as scarcely to des»erve notice. In six weeks
the limb was sound, and free from all anchylosis.
In my report on dislocations, made to the New York State Medical
Society for the year 1855, I have mentioneil twelve similar examples,
in addition to some examples of com|>ound dislocations, all of which
were easily reductnl, but the result** were not alwavs so favoral>le.
If, as rarely happens, the tibia is broken obliquely into the joint,
the complete reel net ion of the dislocated tibia may Ih» found im|Kis-
sible, owing to the obstacle presente<l by the disphu^nl fnigiuent.
The following I am disjiosed to regard jis examples of disKntition
iocompanie<l with fracture of the tibia within the articulation :
Brock way, of Cortland, X. Y., aged about twenty-seven years, (x>n-
snlted me, at my office, a few yc»ars since, in relation to the condition of
his fi^ot. I f<»und the tibia dislo(*iited inwards, and projecting more
than an inch beyond the astragalus ; the sole was tununl outwanls,
compelling him to walk upon the inside of his foot ; the fibula was
bent inwards against the tibia, at a iH)int about four inches al)ove the
ankle, which seemed to have been the seat of fracture of this bone.
He stated to me, that immediately after the receipt of the injury,
which was occasioned by a fall from a height u|K)n the lx>ttom of his
fiwt, he had consulted a surgeon. Dr. A. B. Shipman, of Cortland, and
that although Dr. Shipman made rei>eated and violent efforts to efle<»t
the reduction, he had l)een unable to do so. Indeeil, the bone had
never been removed from the position in which it was at first placed.
760 DISLOCATIONS OP LOWER END OP THE TIBIA.
J. Borland, of Erie Co., N. Y., set. 31, fell under a rolling log, and
dislocated his left tibia inwards, breaking off the internal malleolus,
and fracturing the fibula four inches from its lower end. Dr. Sweet-
land, an old and experienced practitioner, was immediately called,
who, with another surgeon, failed, after repeated eflTorts, to reduce the
dislocation. I saw the patient, in consultation with these gentlemen,
twenty-four hours aftdr the accident. The foot and ankle were some-
what swollen and discolored. The lower end of the tibia projected
so far inwards as to threaten a rupture of the skin ; the foot was
strongly everted. We first flexed the leg upon the thigh, and made
extension with our hands, in the manner I have already direi'ted.
This we continued several minutes; finally moving the limb in various
directions, and adding forcible pressure upon the inside of the pro-
jecting tibia. We then placed the leg over a double-inclined plane,
and, securing it firmly in place, we attached a screw to the foot through
a sandal and gaiter, and while the leg was well flexed upon the thigh,
we renewed the extension and lateral pressure. This was continued,
with the application of more or less power, during half an hour, mean-
while changing the position of the limb o<»casionally by varying the
angle of the splint. Our efforts were prolonged in all more than one
hour, when, as we had made no impression upon the bone, and the
patient had repeatedly implored us to desist, the attempt was given
over. The end of the tibia seemed to rest partly ujwn the astragals
and the extension was plainly all that was demanded, but the obstacle
was beyond doubt within the articulation, or rather between the tibia
and fibula.
Four weeks after the accident, Mr. Borland walked on onitche?,
and during a year he was compelled to use a cane, but since that time,
a period of twelve years, he has walked without any artificial sup|>ort.
For a year or two he felt a yielding in his ankle, as the weight of his
body settled upon his limb ; but this gradually ceased, and for some
years past he has walked without any halt, and seems to step as firmly
as before the accident. The foot still inclines outwards; the tibia
projects inwards one inch, and the broken ends of the fibula can be
felt resting against the tibia, where they are reunited.
Not long since, I had occasion to amputate a limb for a ooniixmnd
dislocation inwards, at the ankle joint, and the possibility of this fnu-
ture was confirmed by the dissection. About one-thinl of the outer
portion of the articular surface was broken off obliquely, and the frajr-
ment was lying so displaced that a re<luction would have been reudea**!
impossible.
l)r. Townsend, of Boston, has reported a case of com{H>un<I dislo-
cation, in which also amputation became necessary; and, with other
injuries, the dissection showed a fragment from the outer margin "f
the tibia, one inch and a half long, and one inch thick at its wi<K>i
part, with a very sharp point, displaced, and lying almost tninsver^'lv
over the astragalus.*
For a more full account of the prognosis and the general manage-
* Townfiend, Muss. IIosp. Krnurts, Bo.-ton Mtxi. and Surg. Journ., vol. iiiiii,
p. 277.
Diai,OCATION8 OP LOWER END OF TIBIA OUTWABD8. 761
meat of these cases subsequent to the reduction, I beg again to refer
the reader to the chapter on fractures of the fibula; and for my views
in relation to the treatment of compound dislocations of the ankle-
joint, I will refer also to the chapter on compound dislocations of the
long bones.
i 2. DislocatioDS of the Lower End of the Tibia Ontwarda.
.Vj"i — " Outward libi(p-lHr*Bl liiiHtion;" Malgaigne. " Dislixulions of tbu Tout
inwnriJ*," nF othtra.
The causes are the same or similar to those which are known gen-
erally to pRKlnce dislocations inwards; only that the force of the con-
cussion or the direction of the rotation must have been reversed.
The external lateral ligaments, ))eroiico-tarsal, are either ruptured,
or the lower portion of the fibula gives way, or lH)th of these circum-
stanc-e» may have happened ; while the internal malleolus may also
yield to the shock and to the weight of the body now resting ui>on it.
The nature of the accident may vary also in respect to the relative
{xjsition of the articular surfaiTS ; the astragalus may simply rotate on
its inner and upi»er margin, or
the tibia, with the fibula, of
Kmrse, may actually slide out-
wards until the lower end of
the tibia more or less completely
abandons the upper surface of
the astragalus.
The modes of reduction, and
the general jirinciples of ti-eat-
ment (subsequently, will not dif-
fer from those which we have
mentioned as suitable for dis-
locations in the opposite direc-
tion. The examples which have
fallen under my observation are
not numerous, but the reduction
lias always Inten easily eitectcd.
Thus, a man, let. 21," fell from
a sca1folding',alighting ui>on his
feet. He says that hi.s teti foot
struck the ground oblit|uely and
upon its outer margin. I timnd
the fibula projecting very strong-
ly outwardo, evidently (iirrying
with it the tibia; the malleolus
interniis was broken off, and the
foot forcibly turned inwards.
Without either flexing the leg
uiKtn the thigh or calling to my
aid any degree of counter-ex- l>i,iorotlQnotUiplow(rendof theUM.oulw.rdi
tension exi-ept what was made
by the weight of the body, 1 gra9pe<l the foot and drew upon it gently,
Imroediat^
762 DrSLOCATIONS OP LOWER END OP THE
while at the same moment I rotated ilic fwit oiitwanls,
the bones resumed their places.
In June of 1846, Henry Wilson, let. 38, consulted me in relation tt
his foot, which he said had been dislocated four weeks before. Hi|
had fallen ujion the outi^ide of his foot and turned it siidilenly inward^
BO that when he looked at it he fonnd [he sole presenting toward tbl
opposite side. Seizing npon it with both hands, he pressef! it fiircibljp
outwanls, and the reiluetion immediately took place with a sn
Very little soreness followed, nor was he confined to his house a sin
day. He had continuetl lo walk nboat with only a slight halt in
gait, nor would he have thonght it necessary to consult me at nil
cepl tliat the tenderness had not yet disappeared. He was not aw
that the fibula had been broken also, until I called his attention to thi
feet. The fracture had taken place two inches above the ankle ; lam
although it was already united, the depression occasioned by iti« bavn^l
fallen in somewhat toward the tibia was very plainly fell and Kva^,
nixed.
i 3. Dislocations of the Lower End of the Tibia Forwards.
iona ;" Mulf-iiignu. " Di»locMtiuiii< of lhi> Aat
ChiMeg. — This dislocation may be prodnoed by a violent extciKitS
of tlie foot upon the leg ; as, for exam])le, when, the foot being io-
gaged under a piece of timber, the body falls backwards to the grtmnij'
or when, the leg remaining fixed, a heavy weight de»vnds ugxin iha
foot, the foot resting upon an inclined plane; by a blow upon ()■
front of the foot; or it may be caused by a fall upon tl»e botiiiin <r
back of the tibia, or possibly even by the toei being brought violcudf
in contact with some firm body. No doubt it may be eaufie<l aUot^
any of that class of accidents which arc known to pmcluc« ftadort
of the fibula with fracture of the malleolus internus, or frueturp of thi
fibula with rupture of the internal lateral Hgitmcnt; for example, lif
a fall ujHin the bottom of the foot, or upon the inside of the $>>k
followed immediately by an outward twist of ihe foot. In tlieeeisai
the luxation of the foot backwaiib, or, as it is generally found tohj
the semi-luxation, may be consecutive upon the accident, Hiid the cw«ll
only of the contraction of the gastrocneniii. It may, thi-rpfiirp, omf
immediately after the fracture has taken place, or not until atUTtti
lajise of several days.
I'atkolwjieal Anolmny. — The displacement may b(> very slight. *
that the end of the tibia is only a tittle advanceil ujmn the mtr
or it may be such that the tibia rests one-half upon the iw
and one-half upon the astragalus, or it may even desert the
entirely. The fibula may at the same time l>e broken at
but it is generally broken two ur three inchcta above ita Ion
ity. The malleolus internus is also somrtim<'!ii broken, but
the internal lateral ligament is torn. Still more rarely a
occurs through the posterior margin of the articular surfaoe fi
tibia.
DISLOCATIOSS OP LOWER END OF TIBIA FORWARDS. 763
Siftttpfoms. — The length of the foot in front of the libia is dimin-
ished, while the projection of the heel is corres|)on<lingIy increased;
the toes are turiiMl (lowuwards and the heel drawn upwards, and 6xed
in this position ; the end of the tibia may generally be distinctly felt
in front of the astntgalus; the extensor tendons of the loc^ are sharply
defined, while the tendo Achillis is curved forwards, and tense.
At the n^iilar meeting of the New York Pathological Society, No-
vember 22, 1865, 1 presented a specimen obtained from the lUssecting-
room of the Bcllevue Hospital College. The history of the case was
unknown.
Before dissection, the foot was observed to be tnrne<l outwards, and
shortened in front of the tibia, while there was a corresponding length-
ening of the heel. The fii)ecimen, after dissection, disclosed a fracture
of the internal malleolus half an inch above its lower end, and a frac-
lure of the fibula a little above its lower end. The tibia was dis])laced
forwards about three-quarters of an inch, so that only the posterior
half of its lower end rested upon the articular surface of the astrag-
aluis, and at the point of contact with the astragalus a new socket was
fornie<) in the tibia, concave upwards, half an inch deep, and present-
ing an api>carance as if the |)09terior lip of the lower end of the tibia
had l)een broken off and had become displaced upwanls. It was sup-
ported by a broad buttress of bone. It is not certain, however, but
that this appearance was occasioned solely by the long-continued pres-
sure of the tibia u|)on the astragalus at this |)oint. The fragments of
the malleolus intenius, and the lower fragment of the fibula, remained
attftcheil to their upjMjr fragments and to the two sides of the astraga-
lus in their normal pusitions, consequently each fragment was inclined
downwards and backwards at an angle of 45°. The lower fragment
of the fibula was driven upwanls, also, but both of the fractures were
firmly united. This s{>ecimen is now in the museum of the Bcllevue
Hospital College,
At the same meeting of the Pathological Society I reported the case
764
D1S1-0CATI0N9 OF LOWER END OF THE TIBIA.
of Mary Conlan, let. 38, admitttxl to Bellevue Hospital, Novemba
13th, 1865, having been thrown tlirec days l>t'fore fiitm a fetrei-l <i
She could give no account of the manner in which she fell. 1 aaw ii
November 16th. The limb was then much swollen, and I ciiagnoafi
cuted a fractnre of the lower end of the fibuhi. (It had been suppcMa
to be a mere sprain up to ttiia time.) The limb was directed to l>e m
with cool water, and to rest upon a pillow. From this time I luokc
at it occasionally, to see whether the swelling had sufficiently subeicfa
to warrant the application of a splint. Novemlier 20th it was exaa
ined again carefully by the house surgeon. Dr. Farrall, but no displiM
ment was noticed. November 23d I found the lower end of the tibil
displaced forward**, and ascertained, also, that the iaternul mallenhM
was broken at its base. The dorsnm of the foot, mea.suring from tk
front of the til»ia to the end of the great toe, wa» ehorteue<l half a
inch. The heel wa.4 lengthened.
There Lun be no doubt but in tins case the dislocation occurred ftih
sequent to the fracture, and tiint it was i^use<l by the contnietioti a
the gastrocnemii. I reduced the dislocation a day or two later, aM
maiotatued it in position by the method which I shall presently «lt
scribe.
Dr. Voas reported to the -Society a similar cas* which had mini
under his notice, and Dr. Buck remarked that he also had met witl)
such examples.'
Dr. Prince, of Illinois, has rcjmrted a case of this charucter, which^
remaining displaced, led to u proscenlion for damages. A ludy, d^
40, met with an accident, August 31, 1863, which rtiiulted in u fnictuti
of the fibula near its lower end, and a jiartial dislocation of tlir lilMt
forwards to the extent of one inch. The toes wore not ]>oinlt^) iIumh*
wards, but the font had its natural angle with the leg. .Vearly tlin»
months after the accident, Dr. Prince, assisted by two other surgrwo^
broke up tiie adhesions, and reduced the bonce to their nalurml f
tions,'
Tiratmad. — The reduction is to be attempted by flexing the \%
upon the thigh, and making extension from the foot, while, at tit
same moment, pressure is ma<)e upon the fnmt of the ttbia and n
the heel. When the bone begins U) slide into pluw, the foot K
be forcibly flexed upon the leg. A slight lateral motion or rotatjuu 11
either direction may assist in restoring the botitv lo place.
In general, the dislocation has been cusily rcdiiee<l, but in a nuj
of the examples reeonle<l great diflficully has hifii exitericncwl in n ^^
taining the reduction ; and in a few rases it iiaa been Ibund imprwuU
to do ISO,
In order lo maintain the reduction, the leg, flexed u|><iti the M^
should be laid on its Imck in a box; and the foot supimrted flrmr^
against a foot-piece placed at a right angle with the Imx. In lb
po!iition,*thc weight of the leg will tend somewhat to overvome tl
' Now York Joiirn. M«!., April, ISflfi, p. •iO.
> Cint'iniiHti Juurn. M«],. April, 1867, p. 20\i. See alio Todd*! CjtlBfwft *
Annt. und Pliys ) Adami on Auklc-Juint, p. ItIO at acq.
DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 765
action of the muscles, which are disposed to displace the foot backwards.
Generally it will be found necessary to make additional pressure directly
upon the front of the leg above the ankle; which, in order that it may
not prove mischievous, must be effected with some soft material, and
mast be applied over a broad surface. Perhaps nothing will better
answer these indications than to pass a cotton band, six or eight inches
in width, through slits or mortises in the sides of the box ; these slits
being of a width equal to the width of the band, and placed at a point
sufficiently below the level of the spine of the tibia, so that when the
band is made fast underneath the box, it shall press the leg firmly
backwards. To prevent the heel from suffering in consequent^ of this
pressure, it also should be supjwrted, or suspended by another band
passing underneath the heel and fastened above to the top of the foot-
board. The plaster-of- Paris dressing, also, answers the purpose ex-
ceedingly well in these cases.
Dupuytren relates the following example of this accident :
Pierre Froment, aet. 33, was carrying a heavy weight upon his back
and had his right foot in advance, when by accident he came suddenly
in contact with a beam placed across his path. Under the fear of
lieing precipitated forwards, he made a sudden effort to throw his body
backwaixls, by which he lost his balance, and fell with the point of the
left foot inclined inwards and forwards, and his whole weight was
thrown first on the outer side, and then on the front of the ankle-joint.
On examination, the leg seemed to be planted ui)on the middle of
the foot ; the toes were directed downwards and the heel drawn up.
On the instep there was a large bony prominent, over which the ex-
tensor tendons of the toes were stretched like tense cords. Behind the
joint was a deep hollow, at the bottom of which the tendo-Achillis
could be felt forming a tense, resisting, semicircular cord, with its con-
cavity directed backwards. The fibula was also broken ; the lower end
of the lower fragment rcmaiiiing atUiched to the foot, while the upper
end of the same fragment was carried forwards by the displacement
of the tibia, so that it lay nearly horizontally, with its broken ex-
tremity directed forwards.
Dupuytren directed one assistant to fix the leg, and a second to
make extension from the foot, while Dupuytren himself, standing on
the outer side of the limb, forced the heel forwards and the tibia back-
wards. The first attempt succeeded partially, and the second completed
the reduction. The limb was then placed in the apparatus employed
by this surgeon for a fracture<l fibula, which we have before described,
and laid on its outer side in a semiflexed pasition. The patient re-
covered rapidly, and in little more than a month he was able to walk.^
But such fortunate results have not usually been observed ; indeed,
Dupuytren encountered much more serious difficulties in two other
cases which came under his own notice, one of which he has himself
recordcil. This was in the person of a woman tet. 48, who was brought
to the H6tel Dieu in 1815, the accident having lust happened from a
slip in going down stairs. The fibula was broken, and also a frag-
* Dupuytren, Injuries and Dis. of Bonee, London od., p. 278.
DISLOCATIONS OF LOWER END OF THE TIB
ment was broken from the tibia. The house surgeon reflaced tlit
bones, and placed the limb in the ordinary apparaliis for broken legh
bnt on the following day Dupuytren found them n-liixated, and ait
the limb on his own splint, but the pressure requii^itc to keep the litn
in place soon induced sloughing, ulceration, and absce^iscs, and aftm
four months' treatment, during which time the tibia had been repeal
edlj displaced, she lefl the hospital, able to use her limb, but wilb i
certain amount of incurable deformity.'
Malgaignc mentions the third example as having; been seen by hii
self in Dupnytren's service in 1832, in which case the attempt ttmiai
tain the rwluction by a tourniquet resulted in gangrene and finally \hi
death of the patient.' Earle lost a patient uHer amputation maili
the eighth day. The tibia could not be kept in place, and the ampih
tatiun became necessary on a«x)uut of the final protrusion of the bcaf
through the iuteguments, which bad sloughed.*
I 4. Dislocations of the Lower End of the Tibia Backwardi.
-UriHl Jilxuliuiis;" MatgHigne. " D[ilocnlioni ul lit
More rare than the dislocations forwards, Mulgaigne has, nevertbe-
les.s, succeeded in collecting five examples.
They appear to liavc been produced, generally, by a cause the «•
verse of that which wc have seen to prmluce in <^rtain cases tlicjir^
ceiling dislocation. Thus, while the dislocation forwards is produced
sometimes when the foot b in violent extension, thie dlMocation h«
occurred, in at least two or three cases, when the foot was foirililf
flexed upon the "
DISLOCATIONS OF UPPER END OF FIBULA FORWARDS. 767
The symptoms are strongly marked and characteristic. The length
of the foot from the tibia to the ends of the toes is increased one inch
or more, the heel being correspondingly shortened, or rather wholly
obliterated ; a portion of the articulating surface of the astragalus may
be distinctly felt in front of the tibia; the posterior surface of the tibia
touches the tendo-Achillis ; the leg is shortened, and the malleoli ap-
proach the sole of the foot.
In most cases one or both of the malleoli have been broken ; and
R. W. Smith, who has reported one of the examples alluded to, be-
lieves that the dislocation is never complete.
Reduction should be attempted by a method similar to that which
has been recommended in all the other dislocations of the ankle; only
with such modifications as the peculiarities of the case must necessarily
suggest.
CHAPTER XX.
DISLOCATIONS OF THE UPPER END OF THE FIBULA.
Syn. — " Luxations of the superior peroneo-tibial articulation ;" Malgaigne.
Surgeons have frequently described a condition of the peroneo-
tibial articulation in which the ligaments have become relaxed, giving
a preternatural mobility to the head of the bone. It is also not unfre-
quently displaced upwards, in consequence of an oblique fracture of
the tibia. I have myself seen several examples of both these accidents;
but simple traumatic dislocations, which can only occur forwards or
backwards, are very rare.
i 1. Dislocations of the Upper End of the Fibula Forwards.
Malgaigne has collected three examples of this luxation, uncompli-
cated with any other accident, and not, apparently, due to any abnor-
mal condition of the ligaments, two of which, at least, seemed to have
been produced by the violent action of the muscles which are attached
to the anterior face of the fibula. The third example, reported by
Thompson in the London Lanceiy^ permits a doubt as to whether the
displacement was occasioned by muscular action, or by a direct blow
upon the part.
The signs which characterize the anterior luxation are the absence
of the head of the fibula in its natural position, and its presence in
front, near the ligamentum patellse; the altered direction of the bi(;ep8
flexor cruris muscle; and, in one case, considerable deformity in the
shai)e and position of the leg has been observe<l.
Thompson and Jobard were unable to accomplish the reduction
while the leg was extended upon the thigh, but succeeded readily after
» Up. cit , 1850, vol. i, p. 886.
768
aisi-ocATinNS op the upper end of J
having flexed the leg. On the other hnnd, Savournin suoreedwl wt
the Ifg extended, but with the foot flexed upon the leg. Mnlgnigi
to whom I am indebted for theae observations, thinks that flexiunl
tlie leg, combined with flexion of the foot, would render the n^iurtia
more easy.
Id whatever position the limb is placed, the etit-frcou must i
ohiefly upon forcible pressure made with the Angers nguiiist the Tm
and upper portion of the displaced bone.
J. E. Hawley, of Ithaca, N. Y., late Professor of Surgery in I
Geneva Medical College, has furnished me with a brief aecouni of fc
case which came under his own observation.
On the 29th of March, 1854, Bamhak, while vaulting upon t
parallel bars in a gymnasium, unintentionally made a complete soraw
sault, and fell with his right foot upon the edge nf a plank. Dr. Hawlq
who was immediately ejille<l, found his right leg »emi-fiexe<I anti in
niovahly fixed. The head of the fibula was plainly felt in front (if !•
natural position, near the ligamentum patellte. The patient wws»
fering the most intense pain. Extension and counter-extension «
made, and while the doctor was pressing with both nf his tliumfai
upon the head of the fibula, it went into its pla(« with an auiliUt
snap. The relief was instantaneous. Complete rest wa.s ohflervetl fit
a few days, while cooling lotions were constantly applied, and ivilhis
a week he was able to attend to his usual duties.
i 2. Diilocationg of the Upper End of the Fibula Backwardi.
Sanson h;is recorded one example, in which the passage iif the wheel'
of a carriage across the upper part of the leg, precisely on a level wid^
the peroneo-tibial articulation, ruptured the ligaments whidi tund Um
fibula to the tibia, and caused a displacement, which, however, tMM
to have been spontaneously overcome. Nevertheless, there rentuixl'
a prcternalural mobility, permitting the fibula to be pushed awljT;
baekwanis or forwards upon the tibia.
I have found only two other cjisiw of backward dislocation, anvt^
which is related by Dubreuil. A man, tct, 62, in order to savr hiai
self from falling, sprang suddenly, with his right leg in a poBitionB
extreme abduction, and at the same moment he expericncwl a wvtf
gain in the region of the peroneo-tibial articulation. The head oftb
hula was found to be thrown hack\t-ard8, and formed tinder the *ti
a marked prominence ; the foot was drawn outwards, and the vIm)
outside of the limb became cold and numb. Dubreuil flrxe<) rheltji
moderately, and pressing ihe head of the fibula from behind (iirwifJ^
the reduction was easily efl^ected. On the following day, ihi- Irnib'
having been straightened, the dislocation was found to be rfpnx!nf«l
It was again replaced, and the knee covered with a leaUier cap, ««ini
rao<leratcly tight. After twelve days of complete rest, the knw**
moved gently, and on the seventeenth day ihe patient walked iriA
the help of a cane. For some time the leg had a tendency to xnA'M
outwards; but in about three months the cure was perfectly estahliKbel
' MaljpiigDD, op. oit.,
I. ii, |>. 1
DISLOCATIONS OP THE ASTRAGALUS. 769
It is probable that in this case the dislocation resulted from the vio-
lent action of the biceps flexor cruris. Such, at least, is the opinion
of both Dubreuil and Malgaigne, and I see no reason to question the
correctness of their theory.
The other example has been reported by Dr. Jos. G. Richardson,
resident physician to the Pennsylvania Hospital. John Dixon, set. 9,
fell five feet and struck upon the outside of the left knee. When ad-
mitteil to the hospital, the leg was partially flexed and the toes a little
everte<l, and he was unable to flex or to extend the limb completely.
The head of the fibula was seen three-quarters of an inch behind its
natural position, and the biceps was felt distinctly attached. There
was no other lesion. The reduction was easily accomplished by press-
ing with the fingers upon the inner and back part of the fibula,
thrusting it outwards and forwards. A compress and bandage were
a])plied, and the limb placed at rest. The reduction continued com-
plete, and after a few days he was permitted to use the limb.*
CHAPTER XXI.
DISLOCATIONS OF THE INFKRIOR PERONEO-TIBIAL
ARTICULATION.
N^:laton relates the only example of a simple luxation of this ar-
ticulation of which we have any information. The patient who was
the subject of this accident presented himself at the hospital under the
care of M. Gerdy on the thirty-ninth day after the accident, which had
been occasioned by the passage of the wheel of a carriage obliquely
across the leg in such a manner as to push the malleolus externus
directly backwards. The lower end of the fibula was in almost direct
contact with the outer margin of the tendo-Achillis; the outer face of
the astragalus, abandonee! by the fibula,* could he distinctly felt in
nearly its whole extent ; the foot preserved its natural position ; and he
could walk pretty well, only that he was i>bliged to stej) with some care.
M. Gerdy believed that the bone was too firmly fixed in its new posi-
tion to be moved, and therefore made no attemj)t at reduction.
CHAPTER XXII.
tarsal luxations.
i 1. Dislocations of the Astragalus.
Malgaigne, who speaks also of luxations "sub-astragaloid," has
thought proper to call the dislocations which we now projwse to (^n-
I ■
1 Richardson, Amer. Jouru. Med. Sci., April, 1868.
, 772
TARSAL LUXATIONS
easily reduced, and recovery has taken plat
vitli a
', with a tolerably usdU
limb : or resection has been practicod witli an equally favnrabl« result};
in still other cases the bone has befit lefl protntdiug, and the jiatieat
Has fioally recovered so far an to be able to walk again, but in mA.
a crippleci condition as to render the achievement a very iluubtfiil
triumph oi' conservative surgeiy.
NoiTis, of Philadelphia, relates the following caw, illustrating iht
imminent danger to which even the life of the ]>aticnt may be expo^
in those examples which are apparently the most simple.
William Summerill, o^t. 30, was admitted to the Pennsylvania Hi
pital on the 26th of September, 1831. An hour previous, while li
sceoding a ladder, he slipped and fell in such a manner as to thro*
the entire weight of his body upon the outer part of his Ifft fi»oU
The foot was turned inwards, and nearly immovable; .i slight de|i
sion existed immediately boJow the lower end of the tibia, and theta
was a hard rounded projection on the outer part of the foot, a little
below and in front of the extremity of the fibula ; the skiu over tii»
projection was not broken or excoriated, but re<ldeued ; there wa§ mi
fracture of either bt>ne of the leg.
The symptoms rendered it plain that the astragalus waa dislocated
forwards and outwards. Dr. Barton, under whose care the psticol
was received, iirocfeded soon after to make attempts at re<IuctinB,
The muscles of the leg were relaxed as much as |M)ssiblc, and cxtWf
sion made from the foot by seizing the heel and front juirt of the liiOt
while an aesistant made counter-extension at the kni>e. The bone vm
also pushed inwards toward the joint bv the surgeon. The% «fi(ifti'
were continued for a considerable time, but had no effect in chan^ng
the jKwition of the lx>iie.
Six hours afterwards, Drs. Harris and Hewson being in rotisultalina,^
the attempt was again made to accnmiilish the reduction, but wilh<ii4
success ; and the surgeons immediately proceeded' to excis*^ the bou&
An incision was made parallel with the tendons, commt-neiiigBstKit
distance alxive the projection, and extending down far cnougli to
pose fairly the astragalus and its torn ligaments. The bone vrm ti
seized with the forceps and easily removed after the division of a I
ligamentous fibres that continued to connect it with the adjoining [«
Very little bleeding occurred, only two small arteries re<iuiring ibl
ligature.
After removal, it was discovered that about one-half of tlie so
which plays in the lower end of the tibia had lioen fractured, and tlrf
it remained firmly attached to the extremity of that l)one. KoattoMl
was rSade to remove this fragment; but, the joint being cwefcw
Bponged out, the sides of the wound were brought togtihrr and daw'
by siutnres, adhesive straps, and a roller; after which the fwjt, ]tha4
in its natural position, was laid in a fracture-liox.
On the fifth day a slough began to form npon the imtsidt? of the to^,
which was followed by suppuration atother ]Kiints,andiiii the thirtMlA
day an opening was made to evacuate the pus near the mallroW in-
ternus. At the end of about eight weeks the fragment of the anlrajE*!*
which had been euRcred to remain was found to be carious, ainl it «•
DISLOCATIONS OP THE ASTRAGALUS.
771
occurs. In the backward dislocation, the position of the foot is not
much changed, but the tibia being slightly carried forwards, the length
of the dorsul iit>pect of the foot is proportionably diminished.
Such are the symptoms which plainly enough indicate the disloca-
tion in the most simple cases ; but in a majority of the examples which
have l>ecn seen, the integuments have l»een more or less extensively
torn, exposing to the eye at once the naked bone, and thus removing
all chance of error in the diagnosis.
Xorris mentions a case, seen by Uammersley, iu which the astr^-
alus was thrown completely out, and was subsequently found in the
SIraiile dlil(
earth where the patient had received his injur}'. Inflammation, gan-
erene, and tetanus supervened, and the patient died on the seventh
day.'
Proffnogia. — It will be readily understo(«l that nothing short of very
great violence could disturb and completely breuk up the connections
of a bone so compactly and firmly seated as is the astragalus, and that,
aside of any unusual complications, under the most favorable circum-
stance^, intense inflammation must naturally be anticipated; and, with
few exceptionn, this has actually taken place. Even when reduction
has been promptly and csisily ellected, inflammation, gangrene, and
death have sometimes speedily ensued. But more often the rednotion
has (>een found to be exceedingly difficult or impossible, and complete
removal of the bone or amputation has been immediately demanded.
In a limited number of cases, on the other hand, the bone has been
> Norris, Amor. Journ. Hed. Sci., 1837, p. 888,
774
ARSAL LUXATION6
useful limbs. Snuli was the fact with Liston'fi, Ltzar's, anil my on
patients, and also with Mr. Phillips's two cases, to all of which I i^hi
agHin refer. It nnist Ik noticed, however, that in each of the cas
mentioned as followed by a successful termination without reduc-tia
the dislocations were simjilc.
Turner, of Manchesler, has reported one oxaniple of coaiponnd loi
ation outwards' and backwards, in which, fiudiiig himself nnable I
etfect reduction, he removed the antragalus, with a tolerai>ly sueceasA
result' Finally, a case was presented in one of the Loudon hosoita:*
in 1839, of a dislocation inwards and backwards, which was reduce
in about ten minutes, by extension accompanied with lateral pressupj
In Sept. 1870, I saw, with Dr. Sayre, in oonsultittion, a disliH
of the astragalus forwunis and outwards, in the person of Mr. Stewiri
of this city, which had just occurred in consenueni* of an injury w
ceived in being thrown from a carriage. The dislocation eeemod to bl
nearly complete, caasing jjreat projection and tension of the skil
Under the influence of chloroform, by extension and pressure, i
easily reduced by Br. Sayre. In live weeks fvuiii this time he wnsabh
to walk, and soon atler the restoration of the functions of the joint «
complete.
Treaiimnt. — Various attempts have been made by surgical write
to determine the line of trratment which should he adopted in the
unfortunate cases, but with very unsatisfactory results, since they ■)
far from having arrived at similar conclusioiL", nor have tliey been ahft
always to settle the question definitely for themaeU-es. The difiiwl^
consists in the multiplicity and lack of uniformity in the compliation
which attend these accidents, rendering it impossible to mtAblish I
classtli(«tion upon which a uniform trentment mny be safely \m
There are certain principles, however, which seem to be sii^cientl]
settled to allow of an authoritative announcement; these maybe brieff_
stated as follows: If the dislocation is simple, reduce the sstnifidR
immediately, provided this is possible. If the luxatiim iscnrnploM
and it cannot be reduce<l, even partially, proceed nl- oxxw to n^fctia
or to amputation. In compound dislomtions, rescrtioii or vntputiiMi
aflbrds the only safe resource. In all eases the inflHinmulion i» liktl
to be intense, in order to prevent whicit complicatJon the siir^^m am
be nnreraitting in his use of the apprapriate i-emedie^.
Out of eighteen cases of complete excision of the asIra^us,tTillecMJ
by Turner, fourteen made good recoveries, and in only oti« iif ibfl
fourteen was there anchylosis.
The several indications and rules of treatment nlwvc enutncnUcd V
shall jiroceed to illustrate a little more fully.
In a recent simple luxation of the astragalus forwards, the leg ebiMl
be flexed to a right angle with the thigh, and, for the purpose of nJ
ing extension, one assistant should take hold of the foot with hi^
bands in the same manner that a servant draws n boot, thai is, «ill
I. Med. and Sur^. Journ., vol ix, BMajr im -l)itb<.
».»ei. Fur Hddilibiial cwM, *iv Med. andeurg. Be|«t*
n Lancet, vot, ii, p. G5B.
DISLOCATIONS OF THE ASTRAGALUS. 773
removed ; the heel also had ulcerated from pressure, and several other
bones of the tarsus were discovered to b^ carious. Fifteen months
later, this poor fellow was still in the hospital, suffering from hec»tic,
with extensive disease in the bones of the tarsus and ankle-joint.
Finally amputation of the leg was practiced by Dr. Barton, a few days
after which he died.^
Norris mentions also two examples of simple dislocation of the as-
tragalus at the Pennsylvania Hospital which came under the observa-
tion of Dr. Barton, in both of which the bone was left unreduced. In
one case inflammation and sloughing soon effected a complete expasu re
of the protruding bone, but after a time the skin cicatrized. At the
end of five months the patient walked and had good use of the joint,
though great deformity of the foot existed, and he continued to be
subject to ulceration of the newly formed skin on its outer part. In
the other case gangrene supervened soon after the accident, and the
patient died.
Norris adds that *^the late Professor Wistar removed the astragalus
in a case of compound dislocation, and the patient was cured with some
motion at the joint."
Dr. Alexander Stevens, of New York, made the same operation in
a case of compound dislocation, and, after several months, he affirms
that the patient ** has recovered with very trifling deformity of the foot,
and with a flexible joint. He walks with very slight lameness."*
I am indebted to Dr. B. H. Hart, of Marietta, Ohio, for an account
of the following case, and for the specimen, which has, also, kindly
been put in my possession.
In June, 1853, Thomas Williams was thrown from his carriage,
alighting upon his left foot and causing a compound dislocation of the
ankle-joint. Dr. Hart was immediately called, and found the bones
of the leg thrust through the integuments on the outside, the malleolus
internus broken, and the astragalus partially dislocated. After enlarg-
ing the opening in the integuments with a pocket-knife, the doctor was
able to reduce the clislocated bones to place. It must l)e mentioned
that this man weighed 225 lbs., and that in his fall he descended a
precipice or bank 30 i\}Qt in height. Soon after the reiluction the
patient had two severe convulsions, which were arrested by bleeding
and opiates, and never returned. Cool lotions were applied to the
limb; and on the sixth day erysipelas superveneil and extended nearly
to the b<Kly. The erysi|>elas continued about nine days. Extensive
suppuration throughout the joint resulted, and some fragments of Inme
came away, an<l on the thirty-third day Dr. Hart removed, without
the aid of the knife, the entire astragalus. In three months the patient
walked upon crutches, and in eleven months he could walk well with-
out a staff, a slight motion having been preservcKl in the ankhr-joint.
The disl(K»ations backwards, of which I have found recordeil only
eight examples, have all, with but one exception, been lef\ unre<luced;
yet in at least five instances tlu^ patients have recovered with pretty
* Norris, Amer. Journ. MeH. Sci., Aug. 1837, p. 378.
'' Stevens, North Amer. Med. mid Suri;. Journ., Jan. 1827, p. 200.
7T6
TARSAL LUXATIONS.
oi' which ought to be preferred whenever the condition of the lint
encourages a reaHoiiahle liope that the (ixtt msiv be saved.
Dr. Grant, of CHnada, has reported a case, however, of success attt^
reduction of a compound dislocutiou of this bone. The man was ^
years old, and in good healtli. Immediately aft*ir the accident tltft
astragalim was found completely dislocated forwards, and lying >rilfc>
its long axis placed transvcreely, so that the anterior extremity itnH
truded through the integuments one inch on tlie onC«r side of the foot/
There was no fi-acture. The first attempt at ntluetion, by ext^usioA
and pressure, failed ; but in the second attempt moderate prewur^
without extension, was successful. Suppuration enr^ned, aud contiaucd
two months. At the eud of eight months he walked without a canej
and at the date of the report the ankle was in all i-esijeets perfect.'-
When essection is practiced, and the bonei.s found to be brokeo. U
it often is, all the fragmeHtJS should Ik- eurefnlly removed, wince itwj
are certain to become noiTosed if left in jiiaee. Xor ought tJie sur^eia
to hesitate to lay open freely the tissues in every direction, in onlef
that he may accomplish this purpose ; even the tendons lying over the
protruding Iwne may be sacrificed unhcsitaticgly, since, after hiving
been so severely bruised, stretched, and luceruted, they are pretty c«^
tain to slough. Indeed, the more freely tlie tissues are divided orer
the bone, the less will be the danger of inflammatiun, and the »afer will
be the life and limb of the patient.
In addition to the examples already cited of compound disloottioa
in which the ostrngalus wa.s removed, the following, re]u>rted by Dr.
W. A- Gillespie, of Etlisville, Va., will also illustrate the oocmionali
value of exsectiou in these severe aceident?.
Mrs. A., aged about 50 years, fell from a horse on tlie 23d of !isr,
183:!, dislocating both ankles. The luxation of the right fo&t w«
accompanied with a luxation of the astragalus outwards, which nni"
jected through a very large wound in the utteguments, and its troi-iile*
was phuvd at au angle of about 45° with its natural position, Eviji
on the following day it was removed by severing its few reniainii^
connections, and the wound was immediately closeil by stiteh«s, «£
hesive plasters, and light dressings. From the moment of the rncvipl
of the injury, and for several days afterwards, she siitterMl cxcruciatiiil
pain in the limb, and on the thin) day tetunug was apprvlivuddl, hat
ite full accession was pi-evenled by the free use of opiati'S. The lirah
was suspended in X. R. Smith's fractui'e-apf>aratu4; and as giin);TnM
with hectic lever soon threatened the life of.the patieni, ffrnutiiiag
Eultioes were diligently applied, aud the {tatient was sustained by wim,
rk, and other tonics. Two mouths after the injury was reocivnl,'
the date at which the report ia given, the wound had entirely bath^
and her complete recovery wits regarded a« certain.' Many c '
similar examples have been reporle^l by foreign sui-gcons.
One word more with regard to the treatment of tlie wiMind oAcr
excision. A oonsiderable experience in uccidetits acd woonds of U '
ASTRAGALO-CALCANEO-SCAPHOID DISLOCATIONS. 777
class, that is, wounds accompanied with great contusion and laceration,
has convinc^ me that the practice of closing the surface with sutures^
adhesive plasters, bandages, etc., is eminently pernicious. The effusions
which must naturally occmr, and which indeed we think ought to occur,
are thus imprisoned beneath the skin, giving rise to swelling, pain,
inflammation, and finally suppuration or sloughing. It is far better,
in our opinion, to leave the wound open, covering it only with cloths
constantly kept moist with c(K)1 water. For this latter purpose some
mode of irrigation is preferable, cOS being more constant and uniform.
To those who have never adopted this treatment of contused wounds,
or of wounds generally, we would recommend an early trial, feeling
confident that they will never have occasion to regret the experiment.
i 2. Astragalo-Calcaneo-Scaphoid Dislocations.
It is perhai)s quite as common for the astragalus to be dislocated
from the sc4iphoid bone and calc»aneum, while it retains its connections
with the tibia, as to be luxated from all these bones at the same time.
This astragalo-calcaneo-scaphoid dUlocation is that which Malgaigne
has termeil *' subastragaloid." Produced by the same causes which
determine true dislocations of the astragalus, it may occuir in the same
directions, and is liable to the same complications; nor will either the
prognosis or treatment differ essentially from that which is recognized
and established in the other accident.
As in dislocations pro|>er of the astragalus, so also in this accident,
opposite results have occ^asional ly followed from similar mmles of treat-
ment. Thus, Dr. Detmold, of New York, stated in 1856 to the New
York Academy of Medicine, that he had recently met with a disloca-
tion of the astragalus, in which the bone retainwl its proper relations
with the tibia, but not with the lM)nes of the tarsus. The. patient had
fallen from a wagon and caught his foot in the wheel. Dr. Detmold
made extension with pulleys, but could not effect the reduction. Sub-
secjuently he was obliged to remove the astragalus on account of the
suppuration which followed and the consequent exposure of the bone.
The wound did not heal kindly, and at length amputati<m of the leg
became ne(*essary.
Dr. Detmold concludes, from this example and others which have
come to his knowlwlge, that if a similar c«se were to present itself to
him again, he would amputate at once.^
The following case, reported by Dr. Thomas Wells, of Columbia,
S. C, is of unusual interest, as' illustrating the danger of leaving the
bone displaced, and als^) the benefit which may, even under the most
unfavorable circumstant^es, result from its final removal.
Dr. S., ffit. .TO, was riding in an 0|)en carriage, some time during the
year 1819, when his horses became frightened and ran, and in leaping
from his vehicle he struck upon his left foot, dislocating the astragalus
from its junction with the scaphoid bone, upwards and slightly out-
wards. Several medical gentlemen made violent efibrts to reduce the
» Detmold, New York Journ. Med., May, 1866, p. 888.
50
780 TARSAL LUXATIONS.
ciirnHl alnne, or iinaccomjmnied with it dislocation of one or more
the other tarsal bones.
i 6. Dislocations of the Oi Scaphoides.
Burnett has seen a luxation of the firaphoiil l>i>ne in which id*
nection.s with the astragahis were iin disturbed, while at the same
it was completely Be|mrated from the cuneiform Imnee. By
presaure exercise<l during several minutes, the os scaphoideH was
to fall into its place. The dislocation wo.s comiHmiid, yet the woa
healed rapidly, and in a short time the recovery wiis almost cotnplel
Several examples are recorded of a true luxation of the os scaphoid
in which the bone had abandoned both the astragalus on the one hai
and the cuneiform bones on the other,
PiMagnel mentions a case in which the scaphoid bone was bnJl
longitudinally, and its internal fragment, constituting the larpwt p
tion, was displaced inwards through a tegumentary wound. HcH
unable to effect reduction, and was cunipolled tn amputate the foot.'
Walker has reported the first example of luxation forwitnls, oa
sioned by jumping upon the ball of the foot. The bone foraied
marked pitijectron upon the top of the foot, and a corresi>ondin([ i"
pression existed below. An attempt was first made to accomplish i
reduction by simple pressure with the thumbs; but this having fail
the surge<m bent the extremity of the foot forcibly downwards, «iid
conliDuing to press u{>on the os scaphoidee, it fell into its Jioiiti
easily and with a di.stinct click. In about three weeks the patienti
able to wiilk with only a slight halt, and no deformity remained."
I 7. Siilooations of the Cuneiform Bones.
The cuneiform hones may be luxated iiartially, and without havii
separated from each other, of which two or three examplt^ are
or, which is more common, the cnueiformo internum may l»e Idm
alone. Says Sir Astley Cooper: " 1 have twice seen this bone dii
eated; once In a gentleman who called upon inc some weeks after
accident, and a scc^ond time in a case which occurred in Guy's Uwpil
very lately. In both instances the same apficarnnccs pn»ent«l thi
selves. There was a grcjit projection of the bone inwards, ami H
degree of elevation, from its being drawn up by the a<rttoM of the til
lis anticus muscle; and it no longer remaine<l in a direct lino with
metatarsal bone of the great toe. In neither case wiis the txini; mine
the subject of the first of these at'cidenls walked with but litlh- hftliin
and I Iwlicve would in time recover the use of tlic tix-l, so n* not<
apjiear lame. The cause of the accident was a titti from
height, by which the ligament was ruptured which oonneelK ttiii» t
witli the OS cmieiforme, and with the os naviculare. The secund c
which was in Guy's Hospital, my apprentice, Mr. Babington, info
> Burnett, Loud. Mol. Umotte, 1837, vol. xll, p. St I.
> PiMoRtK-l. Joiirn. Univ el Hpb., (cm. li, n. SA&.
> Walker. The Medical Rxamlner, IBdl, p 90«.
DISLOCATIONS OF THE OS CUBOIDES. 779
laying hold of the metatarsus and of the tuberosity of the heel-bone,
and drawing the foot gently and directly from the leg, during which
extension Cline put his knee against the outside of the joint, and the
foot being pressed against it, the heel and the navicular bone readily
slipped into their place, and the deformity disappeared." He was dis-
charged from the hospital in five weeks, "having the complete use of
his foot."
In the second ease, the dislocation, produced also by the fall of a
stone upon the foot, was compound, and the patient, Thomas Gilmore,
having been brought into St. Thomas's Hospital, the reduction was
effected by extending the foot and rotating it outwards. Six months
after, when he left the hospital, he was able to walk pretty well with
a stick.
i 4. Middle Tarsal Dislocations.
The scaphoid and cuboid bones may be dislocated from the astrag-
alus and cakianeum, constituting what is termed, by Malgaigne, a
middle tarsal dislocation. It is probable that, to some extent, the same
thing has occurred in many of those cases which are reported as simple
dislocations of the astragalus, or as dislocations at the astragalo-scaph-
oid articulation; but it occurs also occasionally in a degree so perfect
and complete as to leave no doubt as to the true nature of the disjunc-
tion, and to entitle it to a separate consideration.
Mr. Liston mentions the case of a boy, at. 14, w^ho fell from a height
of forty feet, striking, apparently, upon the extremity of the foot. The
scaphoid and cuboid bones were found to be displaced upwards and
forwards, so that the foot was shortened about half an inch, and had a
clubbed appearance. No attempt was made to reduce the bones, and
he left the hospital in three weeks, able to stand on the foot.^ Sir
Astley Cooper has recorded in more detail a similar example. A man,
working at the Sonthwark bridge, London, received upon the top of
his foot a stone of great weight. He was immediately carried to Guy's
Hospital, and his condition is described as follows : " The os oalcis and
the astragalus remained in their natural situations, but the forepart of
the foot was turned inwards upon the hones. When examined by the
students, the appearance was so precisely like that of a club-foot, that
they could not at first believe but that it was a natural defect of that
kind '/* but, upon the a^^surance of the man that previously to the acci-
dent his foot was not distorted, extension was made, and the reduction
was effected. He AViis discharged from the hospital in five weeks,
having the complete use of his foot.^
i 5. Dislocations of the Os Cnboides.
According to Pi6dagnel, quote<l by Chelius, the cul)oid bone may
be dislocated upwards, inwards, and downwards, but Malgiiigne affirms
that he has found no case recorded in which the dislocation has oc-
* Practiciil Surgery; aUo London Lancet, vol. xxxvii, p. 133.
* Sir A. Cooper on Disloc, etc., London ed., 1828, p. 876.
780 TARSAL LUXATIONS.
cnrred alone, or unaccompanied with a dislocation of one or more of
tiie other tarsal bones.
i 6. Dislocations of the Os Scaphoides.
Burnett has seen a luxation of the scaphoid bone in which its con-
nections with the astragahis were undisturbed, while at the same time
it was completely sejmrated from the cuneiform bones. By strong
pressure exercised during several minutes, the os scaphoides was made
to fall into its place. The dislocation was compound, yet the wound
heiiled rapidly, and in a short time the recovery was almost complete.'
Several examples are recorded of a true luxation of the os scaphoide?,
in which the bone had abandoned both the astragalus on the one hand,
and the cuneiform bones on the other.
Pi6iliignel mentions a case in which the scaphoid bone was broken
longitudinally, and its internal fragment, constituting the lai^:est jjor-
tion, was displaced inwards through a tegumentary wound. He was
unable to eflFect reduction, and was compelled to amputate the foot.'
Walker has reported the first example of luxation forwards, occa-
sioned by jumping upon the ball of the foot. The bone formed a
marked projection upon the top of the foot, and a corres|)onding de-
pression existed below. An attempt was first made to accomplish the
reduction by simple pressure with the thumbs; but this having failed,
the surgeon bent the extremity of the foot forcibly downwanls, and by
continuing to press upon the os scaphoides, it fell into its })osition
easily and with a distinct click. In about three weeks the patient was
able to walk with only a slight halt, and no deformity remained.*
i 7. Dislocations of the Cuneiform Bones.
The cuneiform l)ones may be luxated partially, and without having
separated from each other, of which two or three exampli»s are reoonled;
or, which is more common, the cuneiforme internum may l)e luxated
alone. Says Sir Astley Cooper : " I have twice seen tliis bone di>l<>-
cated; once in a gentleman who called u|x>n me some weeks after the
accident, and a second time in a case which occurred in Guy's Ho!?|)ital
very lately. In both instances the same appearances presenteil them-
selves. There was a great projection of the bone inwards, and some
degree of elevation, from its being drawn up by the action of the tibia-
lis anticus muscle; and it no longer remained in a direct line with the
metatarsal bone of the great toe. In neither case was the l)onc nxluwl;
the subject of the first of these accidents walked with but little haltiuir,
and I believe would in time rei»over the use of the foot, so as not to
ap|x»ar lame. The cause of the accident was a fall from a c<>nsidenil»le
height, by which the ligament was ruptured which connects this l)«»ne
with the OS cuneiforme, and with the os naviculare. The s<>ix)nd t^a-^t
which was in Guy's Haspital, my apprentice, Mr. Babington, informs
» Burnett, Lond. Med. Gazette, 1887, vol. xix, p. 221.
* Piwlagnel, Journ. Univ. et Heb., torn, ii, p. 2n8.
s Walker, The Medical Kxaminer, 1851, p 203.
DISLOCATIONS OF THE CUNEIFORM BONES. 781
me, happened by the fall of a horse, and the foot was caught between
the horse and the curbstone."^
In a ease of compound luxation seen by Mr. Key, reduction was
effected, and in two months the cure was so far completed that the
patient walked with only a slight lameness.^ N^laton, in a similar
case of compound luxation, unable to reduce the bone, removed it com-
pletely, and the patient recovered.^
Robert Smith has called attention to a species of dislocation of the
internal cuneiform bone not l>efore very accurately described ; but of
which he has presented two examples. It consists in simultaneous
dislocation of the metatarsus and internal cuneiform ; that is to say, the
first metatarsal bone, together with the internal cuneiform, is dislocated
upwards and backwards upon the tarsus, carrying with it also the four
remaining metatarsal bones. In both of the examples seen and re-
a)rded by him, the dislocations were ancient, and no account could be
obtained of the precise manner in which the accidents had been pro-
duced. The feet were foreshortened to the extent of an inch or more,
in consequence of the overlapping of the bones, yet the heel in each
case preserved its natural relations to the tibia, not being proportion-
ately lengthened as is the case in dislocations of the tibia forwards.
The plantar surface of the foot was turned inwards, and instead of
being concave it was convex, both in its antero-posterior and transverse
diameters. A transverse ridge on the top of the foot also indicated
the line of the projecting bones. Both of these cases were verified by
a careful dissection.^
Dupuytren has rejX)rted in his Treatise on Injuries of the Bones, a
similar case, oc^-urring in a woman, aet. 30, who was brought immedi-
ately to Hotel Dieu. She stated that in descending from the bridge
of St. Michael, with a burden of two hundred pounds, she fell in such
a way that the whole weight of the body wjis received on the right
foot, and that, at the moment she made an effort to check herself in
falling, she ex|)erienccd extremely severe pain in this part, and heard
a very distinct snap ; she was unable to raise herself from the ground.
On the following morning Dupuytren reduced the bones with very
little difficulty by extension, combined with pressure against tlie dislo-
cated ends. The bones went into place with a loud snap, and in two
or three months she left the hospital, with only a little lameness.*
Mr. Smith, without intending to question the possibility of a simple
luxation of the metatarsal bones, of which, indeed, Malgaigne has
collected a number of well-authenticated examples, is inclined to be-
lieve that, when a luxation of the bones of the metatarsus is the con-
sequence of a fall from a height, the individual alighting upon the
anterior part of the fi)Ot, it is, in general, that variety which has now
been described. And this aptness on the part of the cuneiform bone
' Sir AFtlcy Cooper, op. cit., p. 383.
* Koy, Guy's Ho8p. Rep., 183G, vol. i, p. 544.
' Nelnton, Mulgai^ne, op. cit., p. 1076.
* Robert Smith, Trentise on Fnicturcs, etc., Dublin ed., 1864, p. 224 et seq.
' Dupuytren, op. cit., p. 826.
782 DISLOCATIONS OF THE METATARSAL BONES.
to maintain its connection with the first metatarsal bone, he woiilj
ascribe mainly to the faet that both the peroneus longiig and tibialis
aiiticiis have iittachments to each of the bones in question.
CHAPTER XXIII.
DISLOCATIONS OF THE METATAItSAL BONES.
Ldxations of one or more of the metatarsal bones, at the points rf
their articulations with the tiirsus, have been known to occur in almnst
every direction. They may be occasioned by crushing a'-ci<lentft bt
machinery, or more often perba{}3 tliey have been caused by a fUl
backwards or forwards when the anterior extremity of ihu foot «ii
wedged under some solid body and immovably fixed. They may \»
produced also, probably, by simply striking upon the ball of ihf fix*,
in falling from a height. We have noticed, however, that Mr. Smilb
inclines to the opinion that this will, in general, only producv iJie spfr
oies of dislocation which he ha.'J particularly described.
The symptoms which characterize the dblocation of tlie whole mngfl'
of metatarsal bones upwards and backwards will, when the dislocaiimi
is complete, resemble very much those which belong to the dislwatioB
described by Smith. The dorsum of the foot will be ehortenetl aiilero*
posteriorly, the two arches of the foot will be lost upon ibe {>lBDtar
surface, or even actually reversed, a ridge will traverse the Iwck of ilw
£x)t and a corresponding depression will exist underneath.
In some cases, however, the dislocation is not complete, the artica-
J lations being only sprung, and then there can e.\ist no foreehortening
l«rf the foot, and all the other signs will be less striking.
I If only a single bone is luxate*) the diagnosis is generally vetf
I ttsily made out, unless indeed considerable swelling has alreaali
I curred.
Mr, South says that, in 1S35, a case was admitted to St. Thomas'^
[ Hospital, under Mr. Green's care, of dislocation of the last two inrtH
I tarsal bones, occasioned by ihe falling of a heavy chest upim thv iii»i<li
of the foot. Ujion the top of the foot was a large swelling bi'low and
in front of the outer ankle, and behind if a cavity in which twu Hagot
could be easily buried, in consequence of the ba.'ies of ihc niotatam
bones having been thrown upwards and backwanls u|Min ihf! tap*
the cuboid bone. The reduction was accomplished with much aUt
culty by continued extension, and as the bones resumed lhi;ir plait
distinct crackling was heard.'
Liston reduced a dislocation upwards of the first metataml boM
Malgaigne mistook a dislocation oi the fourth bone for a fnuton^ u
DISLOCATIONS OF THE METATARSAL BONES. 783
did not attempt the reduction until the seventh day, when, after five
successive trials, the head entered with a noise into its cavity. In a
dislocation of the second, third, and fourth metatarsal bones, he also
failed to detect the true nature of the accident until the tenth day,
when he proceeded to attempt reduction, but failed. Inflammation,
suppuration, and delirium followed, and the patient died on the forty-
first day. Tufnell failed in a similar case, although his patient finally
recovered with a not very useful limb. Malgaigne failed to reduce
the bones also in a recent case of luxation of the first four bones, al-
though he use<l chloroform and diligently tried various means. The
same writer has seen one example of ancient dislocation, which was
not recognized by the surgeon. Finally, Monteggia reports a case of
dislocation of the last two metatarsal bones, which was not at the time
recognized. On the tenth day swelling commenced, and soon after the
patient died in convulsions.*
These references, drawn chiefly from Malgaigne, sufficiently illus-
trate the diflBculty which surgeons have experienced in the reduction
of these bones, when a portion only is displaced. A difficulty which
is probably due to the fact that it is almost im[K)ssible to make ex-
tension upon a single metatarsal bono; indeed, it is probable that by
pressure only upon the displaced head can we exjKict to accomplish
much in these accidents, and even this cannot be made to act very
effectively, owing to the small amount of surface presented against
which the force can be properly applied.
If, on the other hand, all the bones are dislocated at once, the re-
duction is generally accomplished with ease by simple extension, com-
bined with properly directed pressure. Bouchard and Meyuier suc-
ceeded without difficulty in two casas of backward dislocation ; Smyly
was equally successful on the sixth day, in a case of dislocation down-
wards. Laugier reduced an outward dislocation of all the bones by
pressure and extension easily ; and Kirk succeeded as well, in an ex-
ample of the opposite character, all the bones being carrieil inwards.'
Mr. Sand with has given us an account of a case which occurred in
his own person, from the fall of his horse upon his foot. " I was in-
stantly sensible," says Mr. Sand with, "of the nature of the injury,
and as soon as I was upon my feet, the metatarsus was found to be
drawn upwards, and obliquely outwards upon the tai'sus, by the action
of the flexor muscles. On the removal of the boot, which was cut
away, these were the appearances : The foot considenibly shortened,
the toes turned a little outwards, and a hard swelling, bigger than an
eggy upon the tarsus, with tumefaction of the integuments. The pain,
which was great at first, was kept under by a warm fomentation.
"The reduction was easily effected by my friends Messrs. Williams
and Brereton, and leeches and bread-and-water poultices prevented
inflammation. For several nights the foot was violently shaken by
spasmodic action of the muscles, but the parts preserved their relative
situation ; and, although it wa.s nearly a year before all lameness
ceased, yet at the end of six weeks I was enabled to lay aside my
1 Malgaigne, op. cit., p. 1077 et seq. * Ibid., op. cit., p. 1081.
784 DISLOCATIONS OF THE PHALAXG
crutches. For the ability to uae the foot in f
indebted to a contrivance which rendered the fo*
" Instead of an elastic sole to the shoe jmrt o
wood was procured, around the heel of which
firm, unbending leiither; this reached as hlfth
three small straps with buckles held the lef^ /» .
across the instep secured the foot. The conif<
this simple apparatus is my reason for deecnbin
has since been found useful in various injuries o
In one extraordinary case, however, Dupuytl
ful. Paul Endes, ict. 24, fell, while drunk, int.
and alighted on the soles of his feet. The ace
great swelling, and he did not suspect the nal
present himself at the hospital until three we<
then a-secrtained that he had dislocated the mt
feet. Several fruitless attempts were made to
tiou, but to no purpose, and in about two we^i
CHAPTER XXI
DISLOCATIONS OF THE PHALANGES
DrSLOTATlONS of the toes are less comnKin th
yet a considerable number of cases have been
surgeons. They are ofcasionwl by blows recei
ends of the toes; by the weight of the bo<ly bn
upon their plantar surfaces, as when a horseman
or by a fall, in con.scquence of which the rider
by leaping, etc.
They may be partial or complete ; and in t
overlapping is generally obt*rved. In a grea
dire<'tion of the disphicemcnt is Imckwards, or wi
deviation. Occasionally several bones are displ
but usually only one suffers dL^plaoement. It
to find compound and coaiplicate<l dislocations
fingers.
The position of the toes is not always the san
dislocations. Thus, in the dislocation backwart
reversed upon the foot to nearly a right angle, !
found lying in the same axis as the metatarsal
from which it is luxnte<]. About one year since
dislocation of the first phalanx of the second toe
Brittnn, tet. 60, who had fallen from a fourth-
1 Siindwitli, Amer. Journ. Mpd. Scj., Nov- 1828, p, 21
»o!. i.
■ Dupujtren, op. cit, p 3!tO.
COMPOUND DISLOCATIONS OF THE LONG BONES. 785
upon his feet, and breaking both thighs. I did not discover the dislo-
cation of the toe until sixteen hours after the accident. It was then
lying parallel with the axis of the metatarsal bone, upon which it was
slightly overlapped. The reduction was eflFected easily by pulling upon
the last phalanx with my fingers, while at the same moment I pushed
the head of the bone toward the socket. No swelling followed, nor
has it troubled him at all since his recovery.
With regard to the treatment, surgeons have experienced the same
difBculty in certain cases of dislocation of the great toe as we have
seen exj)erieneed in similar dislocations of the thumb. Occasionally,
indeed, the n^luction has been found to be impossible. The same
doubts have existed also in relation to the causes of this difBculty, and
in reference to the means by which it was to be overcome. We shall
therefore refer the reader to the chapter on Dislocations of the First
Phalanges of the Thumb and Fingers, for a more full c»onsideration of
this matter.
In case the smaller toes are hixated, the reduction is generally
effected with ease, by simple extension, or by extension combined with
pressure; sometimes, also, the bone w^ill be more easily put in place by
reversing the phalanx more completely, as we have advised in certain
cases of dislocation of the fingers.
If the skin is penetrated, it will often be found necessary either to
amputate or to practice resection upon the exposed phalanx.
Sir Astley Cooper relates a case of luxation of "all the smaller
toes,'' from the metatarsus, which had nqt been reduced, and the sub-
ject of which was, in consequence, so much maimed that he was unable
to labor. It had been occasioned by a fall, from a considerable height,
upon the extremities of the toes. A projection existed at the roots of
all the smaller toes, the extremity of each metatarsal bone being placed
under the first phalanx of its corresponding toe. The swelling which
immediately followed the receipt of the injury, had concealed its nature,
and now, several months having elapsed, reduction could not be effected.
The only relief which could be afforded him, therefore, was in wearing
a piece of. hollow cork at the bottom of the inner part of the shoe, to
prevent the pressure of the metatarsal bones upon the nerves and
bloodvessels.^
CHAPTER XXV.
COMPOUND DISLOCATIONS OF THE LONG BONES.
Frequency of Covipound oa compared mith Simple Dislocaiicns, — Com-
pound dislocations, as compared with simple, are of rare occurrence.
Of ninety-four dislocations reported by Norris as having been received
into the Pennsylvania Hospital for the ten years ending in 1840, only
^ Sir Astley Cooper, op. cit., p. 885.
786 COMPOUND DISLOCATIONS OP THE LONG BONES,
two were compound ;' and of one hundred and sixty-six dislocatiw
in ray record of personal observation, only eight were compound.'
Iteialive Firqiimiyy in Ihe IMffri'mt Joints. — In my own ret-ordwl (»«
four were dislocations of the tibia inwards at the ankle-joint, one w
a partial (patholf^ical) Inxation forwards at the same joint, one vraiH
luxation nf the ai^tragahis, one a luxation of the head of tlif humt-n
into the axilla, and one a forward luxation of the radius and i:
the wrist-joiut. I have also met with several examples of compouod
dislocations of the fingers. Both of the uases re[>orted by Morris war
dislocations of the thumb.
■ Sir Astley Cooper, speaking ujwn this jMint, says that the elbow
wrist, ankle, and finger joints are most subject to these a<videntA; and
that he has seen but two in the shoulder-joint, and one in the knean
joint. He had never seen a compound dislocation at tlie hip-joi
he believed that it was " seareely ever" so dislocated. Mr. Bran.*lM
Cooper has, however, reported in detail a very interesting wise of tbil
accident, communicated to him by Dr. Walker, of Charlesti>wn, MnM,
in which reduction was accomplished by martipulation alone, hy Di;
Ingalls on the second day. The patient died at the end of ab<iut ihraf
weeks.' 80 far as I know, this is the only case upon rcoord. Mal^
gaigne says that a compound dislocation at the htp-joint has prohablf ;
never occurred.
Among the cases of ooniponnd dislocation reconled by Sir AMief
and Bransby Cooper, most of which were communieatod to thebe^ev
tiemen by other surgeons, forty-five were dislooHtions of the nnklp, UA
of ihe astr)^ralus, four of the ulna at the wrist-joint, four of the ihumt^
two of the knee, oneof the shoulder, one of the elbow, one of the radial
and ulna at the wrist, one of the scaphoid Imne, and one of tlic tnfW
tarsal bone of the great loe. Other writers have occasionally deeciriM
compound dislocations of the clavicle, but I know of no reconi "fi
compfinnd dislocation of the lower jaw. ,
Proffnomn, as /iFirrminf'l hi/ Ihe Mnde of I^-mtmnf niiopfM bu "">^5
(/ic Ancient and many of tlir Motfern Siirf/rimn, — By most of the n^
writers these accidents, whenever they occnrrc-d in the lnr«vr joiiili
were regarded as nearly beyond the reach of art. Says HipiwcralM
" In cases of complete dislocation at the ankle-joint, ciimplicat<^] x*
an external wound, whether the displacement be inwnnls or oiitnaJ
you are not to reduce the )>arts, but let any other phys>iciAn rtdua
them if he choose. For this you should know for certain, that ll
patient will die if the parts arc allowed to remain redaceil, and ih
he will not survive mope than a few days, for few of them pass tl
seventh day, being cut off by convulsions, and sometimes the lt>f ■«
foot are sciited with gangrene." Hippocrates adds: " Bui if not K
duced, nor any attempt at first made to reduce them, moot of stK^ cm
recover." *
I Norris, Ampr. J.>urn. Med. Sc
• Prir thn in'ist of tlieai. .■»»«. t»
for 1855. nrtklf entUIH '■ Rpporl
Bc»ulu," by F. H. Hiiiniltnn.
' A. UiKipHr. on DislooMliotiB, nit., by B. Coiipi>r, u. fill.
* Worki of Uippoorntw, Sydunhnro cd.. L..nd<>n, vol. ii, p. 0S(.
April, 1811. p. RIS.
'mniwc^tiuni of Ihe Nnw Y»rk Sut" M*i
DialooRtioDK. wtlh wpocikl rcforvoie* tii
COMPOUND DISLOCATIONS OF THE LONG BONES. 787
The same remarks are applied by Hippocrates to compound disloca-
tions of the head of the tibia, of the lower end of the femur, of the
wrist, elbow, and shoulder joints ; death occurring in all cases, as he
believes, more or less speedily whenever the bones are reduced and
retained in place a sufficient length of time, and " were it not that the
Ehysician would be exposed to censure," he would not reduce even the
ones of the fingers, since it must be expected, he thinks, that their
articular extremities will exfoliate even when the reduction is most
successful.
I shall presently show, however, that even Hippocrates advised and
probably practiced resection in certain cases of these accidents.
Both Celsus and Galen adopt almost without qualification the line
of practice laid down by Hippocrates, and affirm equally the danger
and almost certain death consequent upon the reduction of compound
dislocations in large joints.^ Celsus recommends resection in some
cases.
Paul us u^^gineta, however, and afler him Albucasis, Haly Abbas,
and Rhazes, do not regard the rules established by Hippocrates, in re-
lation to the non-reduction of the bones, as so imperative, nor the
results of the opposite practice as so uniformly fatal.
" Hippocrates remarks," says Paulus iEgineta, "in the case of dis-
locations with a wound, the utmost discretion is required. For these,
if reduced, occasion the most imminent danger, and sometimes death,
the surrounding nerves and muscles being inflamed by the extension,
so that strong pains, spasms, and acute fevers are produce<l, more par-
ticularly in the case of the elbows, knees, and joints above, for the
nearer they are to the vital parts the greater is the danger they induce.
Wherefore, Hip})ocrates, by all means, forbids us to apply reduction
and strong bandaging to them, and directs us to use only anti-inflam-
matory and soothing applications to them at the commencement, for
that by this treatment life may sometimes be preserved. But what he
recommends for the fingers alone, we would attempt to do for all the
other joints ; at first and while the parts remain free from inflamma-
tion, we would reduce the dislocated joint by moderate extension, and
if we succeed in our object, we may persist in using the anti-inflamma-
tory treatment only. But if inflammation, spasm, or any of the
aforementioned symptoms come on, we must dislocate it again if it can
be done without violence. If, however, we are apprehensive of this
danger (for perhaps, if inflammation should come on, it will not yield),
it will be better to defer the reduction of the greater joints at the com-
mencement ; and when the inflammation subsides, which happens about
the seventh or ninth day, then, having foretold the danger from reduc-
tion, and explained how, if not reduced, they will be mutilated for life,
we may try to make the attempt without violence, using also the lever
to facilitate the process."^
In the following quotations from three of the most celebrated writers
of the last two centuries, we find but little if any evidence that the
> Paulus ^gineta, Syd. ed., vol. ii, p. 610. » Ibid., p. 609.
788 COMPOUND DISLOCATIONS OF TUE LONG BONE!
opinions of the &ther8 upon this sulyect were not still held in gener
respect: " If the joint be dislocated, so that it is either uncovenxl, d
a little thrust fortii without the skin, the accident is mortal, and t
more danger to be reduced than if it be not reduced. For if it be n
reduced, in fl animation will come upon it, coavulsion, and eomeiim
death. 2. There will be a tilthiness of the part iteelf. .3. An inoun
ble ulcer, and if perhaps it be brought to cicatrine at all, it will e
he dissolved by reason of the noftness of it; but if it be rttluced,
brings extreme danger of convulsion, gangrene, and death.'"
"Si vero in magnis articulis tarn valida fuil facta Inxatio, <it li^
mentis ruptis os articuli multum ait protrusum per int<^mcnta, lut
pars ossis vasis privata moritur, citius autem 8i reponatnr, Tinain si n
reponitur; qnare sola amputatio restat ad couservationem vitte,"'
Heister, who makes no allusion to this subject in the first edition 4
his great work, published at Amsterdam in 173!!, adds the foltoi
remarks in his last edition, translated and published in Lundmi 'm
1768 : "Dislocations attended with a wonnd, especially of the alkouldtt
or thigh-bone, are of very bad consequence, and often endaiij^r tb*
life of the patient; in Celsus's opinion (Book VIII, Chap, XXVV
whether the bones be replaced or not, there is generally great danj^j
and so much the more tlie nearer tlie wound is to the joint. Hippt*
rates lias declared that no bones can be retUiced with security, bwiil*
those of the hands and feet. {Vcctiar. 19, &.) See more on thi* s
ject in that passage of Oclsns just now quoted, though I by nu lue
recommend the following him implicitly.'"
Such were the extreme views as to the latalitv of these aecidFolfc
and of the feebleness of our resources, entertaim-d by the andnit, an
even by the more modem writers almost down to our own day ; «iA
only rare exceptions these limbs were condemned either to grvsl uii
inevitable deformity, or to amputation. Nor, if wc speak only tt
their fatality, have surgeons ceased to n^rd these accidents as aoionf
tiie most grave with which they have to deal.
Palholoffij and Appreciation of Uie Sources of Danger ttM votaparm
enptxiullif with Compound Fracfures. — The danger, according to !?"*
Astley Cooper, consists in the rapid inflammatii)U of the .•tvonvi
membranes, which is speedily followed by suppuration and ulcetatiM^
whereby the ends of the bones become exposed ; and for the n\talr 9
which lesions great general as well as local efforts arc required, anJi
high degree -of constitutional irritation rosnlts. In addition to whifi
ciR-umstancefi, " the violence inflicted on the neighboring parts tU
injury of the musclcfi an<l tendons, and the laceration of bloi)dv»«f^
necessarily lead to wore imiiortant and dangerous conscqucncet ilitf
those which follow simple dislocations."
The sources of danger enumerated by Sir Astley Cooper have U
regarded as sufficient to account for their extraordinary fatality by lk»
■ Ctiirur^i^on'sStureliouge. By JohannesScuUetus.of tJlma.ltiHueTi*. LnaiM
ed., 1674, |>. SI.
' Jahannci de Uortcr. Obimrgilii rppiirgatH, Lufjiiuni Bitavoram, ]H'i, t M
' Oenernl SysMm of Surgery, by Dr. Liiuronc« Uoieter. SCh ed. LondM, I'*"
— ' i,p. IM.
COMPOUND DISLOCATIONS OF THE LONG BONES. 789
majority of those modern surgical writers who have alluded to the
subject; but I must confess that to me they do not appear so. In
compound fractures the mortality is far less; yet one might naturally
suppose, that when the sharp and irregular fragments are pressing into
the flesh, among nerves and blo(jd vessels, the irritation and inflamma-
tion would be equal, if not more than equal, to the irritation and con-
sequent inflammation produced by exposing a joint surface to the air;
indeed, modern experience has sufficiently shown that these surfaces
are much more tolerant of atmospheric exposure, and of the action of
many other irritants, than surgeons formerly supposed. A clean inci-
sion into a large joint, which exposes the synovial membranes to the
air, and which permits the products of inflammation to escape freely,
is attended with much less danger than a small puncture which does
not at all permit the air to enter, nor the increased synovia and the
pus to escape. Very grave results sometimes follow from large wounds
into large joints, but under judicious treatment such results are the ex-
ception and not the rule.* But Sir Astley evidently attributes more of
the bad consequences to the exhausting effects of the efforts at repair,
than to the immediate inflammation resulting from the exposure of the
joint. It is pretty certain, however, that a majority of these patients
die at a period too early to render this cause in any considerable degree
operative.
As to the bruising of the " muscles and tendons, and lawration of
blo(Mlve5sels,'' it cannot be denie<l that it must usually be greater than
in ** simple dislocations;" and I will not say that it is not in a given
number of instances greater than in the same number of instances of
compound fractures. The tissues have often been thrust rudely through
by a large and smooth bone, and the tendons have been stretched vio-
lently or torn completely asunder; while occasionally large arteries,
which are prone to hug the bones about the joints, are lawnited and
left to blee<l. That the importance of these complications, however,
may not be overestimated, we must state that Sir Astiey Coojkt him-
self has remarked how seldom, in compound dislocations of the ankle-
joint, the large arteries are injured ; that a tearing of the ligaments and
of the tendons is almost as likely to occur in simple disl(H*ations as in
compound; and, indeed, that in neither case are the tendons usually
rupture<l, but only thrust aside. Moreover, the skin is ot*ten made to
give w^ay not so much from the pressure of the round head within, as
from the equal pressure of some sharp angular body from without. In
all these respects, there are many examples of compound fractures
which i)ossess not a whit of advantage; in which cases, nevertheless, the
surgeon feels very little doubt as to the ultimate cure.
In short, the causes which, according to Sir Astley Cooper, deter-
mine the extraordinary fatality of these accidents, do not sufficiently
differ from those which operate in compoimd fractures to occasion so
great a diff'erence in results, and the fatality of compound dislocations
* Upon this p(»int, si»e tho very nhUi nrtido, entitled ♦• Amputntions and (Compound
FrHctures," by John O. Stone, in the New York Journal of Medicine, vol. iii, of
2d »erie», p. 316, Nov. 1849.
790 COMPOUND DISLOCATIONS OF THE \Xf3^ B'>SX3L
reniaiiiH unexplained; or if surgical writers have bs
nmted tlie true cause, tliey have failed to give h is ^trips' ici» lal
value. ^
I think the cause of the greater fatality of compcati -c^tMsn^zw
over coni[>ound fractures is to l)e found in tbe simpie &e5 isac s&s
tions are generally reduced, and by splints or other
fully maintainwl in place, while compound fracture
report of cases has proven, are not generally reduced coo^ies^j. 2r3r
can they by any means yet devised, except in
tained in place if reduced. Broken limbs, whether sixnp«e ^ir <\a-
in their cl
pound in their character, will in a great majoritr of cji?«& ii»:<
themselves in spite of the most assiduous and skilful mnemy^ i*.* j<n-
vent it.*
In adults most bones break obliquely, and cannot be ma^ir ic* ?^
port each other, and even in transverse fractures the l»n:»ken c&i? ire
generally nmall compared with the articular ends of the ^aii>e l-'Ot*.
and afford a very uncertain and inadequate sup{)ort for them^e]v«^: d«.<
to speak of the difficulty of once bringing their ^nds into exatt af>pi?i-
tion where the muscles are powerful, or where they lie imlitddeii in a
large mass of flesh so that they cannot be felt. While, on iLr «<lKff
hand, dislocated bones, whether simple or compound, are cafabie, wbtn
restored to place, of supporting themselves; or with only slight a»i?t-
ance, their reduction may be maintained; it is also ordinarily a work
of no great difficulty to rcHhice them.
Herein, then, consists the njost important difference between the;*
two classes of accidents, which are in other respects so similar. In th^
one, the very nature of the injury prevents the complete reduction, and
the conse(|uent violent strain of the muscles, tendons, and other ^aA
tissues; wliile in the other, the nature of the accident leaves it in the
power of the surgeon to reduce the bones, and mo<lern surgery- has in a
great mwusure sanctioned the practice of maintaining tliem in pla^f,
in defiance of the efforts of the muscles, and sometimes, no doubt, at the
imminent hazard of the life of the patient.
Is it not fair to presume that tissues which have been stretcheil and
lacerated, recpiire rest in order that they may recover from the effect «»f
their injuries? And if the soft parts are really more injure<l in di>l«>-
cations than in fractures, does not the indication for rest bect»mo tor
this very reason, more imjK*nitive?
General Inferencei^. — We have c*ome, then, to reganl the shortening
of limbs after fractures, within certain limits and in certain aises, asa
conservative circumstance rather than as a circumstance which the ?ur-
geon should in all cases seek to prevent.
There is abundant evidena* that the ancients had some knowled^t' '»f
the value of rest to the nuiscK»s, tendons, etc., in the pn^vention of in-
flammation after com|H)und dishn^ations, since they constantly urp.* tlw*
givater danger of re<lucing these disWiitions, than of leaving theni un-
rtHluceil ; and they do not lu»sitate to recommend, that in case violent
' " Ropurt on Deformities after Fractures " Traos. Am. Med. A*>«>c., vuU. viii.
ix, and X.
COMPOUND DISLOCATIONS OF THE LONG BONES. 791
inflammation supervenes u})on the reduction, the bone shall immedi-
ately be again dislocated. Galen speaks very explicitly on this subject,
and says that "the danger in reduction consists partly in the additional
violence inflicted on the muscles, and partly in their being then put
into a stretched state, whereby spasms or convulsions are brought on,
and gangrene as the result of the intense inflammation which ensues ;"
and Paulus ^-Egineta remarks : " For these, if reduced, occasion the
most imminent danger, and sometimes death; the surrounding nerves
and muscles being inflamed by the extension," etc.
I have already quoted from Sir Astley Cooper the causes or reasons
which he has assigned for the fatality of compound dislocations; and
the same reasons have generally been assignixl by those who have
written since his day ; but he has elsewhere, when speaking of exsec-
tion, given place to the very idea for which we claim so much promi-
nence, the danger arising from a stretching of the muscles. Mr. Liston,
also, and Mr. Miller, when speaking esj)ecially of dislocations of the
tibia at the ankle-joint, refer to the same source of danger.
Treatvund, — I^t us see now the alternatives which surgery presents
for the treatment of these intractable accidents.
1. Reduction of the bone.
2. Non-reduction.
3. Amputation.
4. Tenotomy.
5. Rese<'tiou and reduction.
The questions for us to consider are, first, by which of these several
metho<ls is the life of the patient rendered most secure? and second,
where, of two or more methods, all are equally safe, by which will he
suffer the least maiming or mutilation?
By Rcdudkm, — We have seen already how the old surgeons regarded
the practice of reducing compound dislocations of the larger joints. It
is not difficult, however, to find in the records of surgery numerous
examples of successful terminations under this practice.
Dr. White, of Hudson, N. Y., ha.s reported a case of this kind in
which the dislocation was at the ankle-joint.^ Pott says he has seen
this practice occasionally su(;ceed,- and Mr. Scott comnmnicated to the
Ixincef, in March, 1837, a case of compound dislocation of the humerus
successfully treated by reduction. Sir Astley Cooixir also records
several cases of compound dislocations at the lower end of the tibia and
fibula, successfully treated by reduction.
A ciireful examination, however, of those cases reported by Sir
Astley as having been reduced without resection, and which resulted
in cures, does not in my opinion, leave much substantial evidence in
favor of the practice; or perhaps we ought rather to say that it leaves
only a qualified evidence of its propriety in certain eases. He has
mentioned about sixteen of these examples, comprising dislocations of
the lower end of the tibia, or of the tibia and fibula, outwards, also
inwards and forwards, all of which, save one quoted from Mr. Liston,
» White, Amer. Journ. Med. Sci., Nov. 1828, p. 109.
» Pott, Chirurg. Works, vol. ii, p. 243.
792 coMPorsD dislocations of the long boseb.
have been reported to him bj other surgeons, and rot one of wbijfl
had he ever seen himself. Many of the caisea are reported very Ioo«iP
evidently in reply to circular letters, and from memory, without ii
cordefl nolea, and by nnknown, and in some twnsc irresponsible rl
^eons. It is not tilM-ays said whether the wounds in the lioft pilf
were made by the protrusion of the Itones, or bv some external vinleaq
yet this is certainly a very material point in determiuin^; whether fl
duction is to be followed by Inflftnimation or not. The results, mhb
times only attained after expasure to great hazards, are, after all, ofh
eufiiciently nn&vorable.
It will be noticed, also, that in Cases 162 and 153, the antra,
was comminuted and removed, either at first or at a later day; aiidji
Cases 154, 156, 156, and 160, the tibia, and also probably the fihfl
were broken, and it does not apjK^r hut that in eonsennenoe of t
complication the limb became shortened, and the mtisolcs vnn ih
put at rest, very much as if the bones had been retra(^-<l ; and in n
of the cases ennmerated under 161, the lower end of the tibta spg
taneously exfoliated. That a commiiiiitinn or that any fmc-ture o
astragalus, or of the tibia and fibula, should l>e rt^nletl in th»c n.
as rendering the accident less grave, can only be eomprehemlvd \^m
full appreciation of the value of relaxation of the muuele^.
The few ciLses which remain after this exclusion do iiulee)! illiw
how nature and skill may triumph over great ditBeulties, but notliiflfil
more.
It is jMissible, also, that some of these examples of room-cry after
re<luction may admit of an explanation entirely consistent with twr
own views of the true source of the danger in Iheiic accidents, if iiulnd
they do not tend actually to cimfirni our doctrines. I have myself hmii
one example of complete recovery utter the rcdndJoii of a compound
dislocation at the ankle-joint, although resection niis not prectired:
*■■■' 'n this ease, all the tissues, or nearly all which suffered any iojiirr,
but ii
were completely torn asunder, and therefore wholly removed i'roni il
danger of which we have spoken. The esnmjiU- to which we alladi' i>
the following: On the 30th of Oct. 18."»8, John Bonniuard, let. ait.w*
caught in the tnw-line of a cnnal-lxiat, causing a comjHiund ilisli]cati'in
of the ri(;ht ankle-joint. I found the foot, iiuniediad-ly atlcr the wvi-
dent, thrown completely back against the lower jiart of the leg, tht
integuments in front of the joint, as well as all of tht^ tcndomp ■iii!
ligaments on this side, being completely torn asunder, while tin- wml-
Achiilis, and the tendons behind Imth of the malleoli, with tlw o-rn-
sponding integuments, were unitijured. This immunity of the tiwiw
behind the nmlleol! was due to the direction in which thf Sk.! w»
drawn, namely, directly backwards. Everything which tmd ^niK-rfl
a strain l*etng thoroughly severed, I did not hesitate to aitiinpt i- v
the limb without resection. The reduction wa:? accoinpli»hiil iv"
easily. The leg and foot were plac<?d in a Imx tillwl with t-nn, ami
awl water dressings were applied to the [xirtion which wa.-" .-xj-f**!
On (he 22d of November the limb was removed from ihr bran i">
pillow, the union being sulficient not to demand so much lateral xf-
OMPOUND DISLOCATIONS OF THE LONG BONES.
port. Abriut tlie first of Mnrcli he left the hospitiil, tlie wound having
closer], but the utikle rematning swollen and stiff.
I have also seen two cases in which the ibot has been nearly severed
friMM tlie leg through the ankle-joint, by means of a "reaper." In
each ca^ the patient was standing with Wis back to the machine, and
one of tlie blades cut horizontally from side to side, severing everything
except about three ini^he^ of integuments in front, and the extensor
tendons of the toes. In the first instance, having seen the patient, a
gentleman nearly sixty years of age, within three or four hours of the
time of the receipt of the injury, I found him exceedingly exhausted
by the hasniorrhage. Both malleoli were cut off smoothly, the knife
having severed the limbso exactly through the joint, as to have touched
thecartihigcat butoneor twopoiuts. Having secured the bloodvessels,
I replaced the foot, and after a few days of attendance I left him in
the charge of an excellent young surgeon, Br. Robertson, of Lancaster,
N. Y., to whose diligence and skill the patient is no doubt mainly
indebted for his recovery. After the lapse of nearly one year he was
able, by the assistance of a shoe furnished with lateral supports, to
walk very well. In the second case, which was only brouglit to my
notice some months after the accident occurred, in consequence of a
troublesome fistula near the ankle-joint, the recovery had been com-
plete except that a small fragment of one of the malleoli was necrosed
and remiired removal.
Dr. Eli Hurd, of NiogaruCo., N. Y,, was equally fortunate in a case
of compound dislocation of the shoulder-joint. This was in the person
of G. T., wt. 30, who was caught in the gearing of a threshing-machine
on the I Sih of Febrnaiy, 1 852, which, having drawn him in with great
force, dislocated the head of the left linmerus downwards through the
integuments into the axilla. Reduction was accomplished aeconling
to the method recommended by Nathan Smith, by pulling from each
wrist at right angles with the body, while the operator himself seized
the tiaket) head of the humerus with his left hand, his right resting
upon the top of the shoulder, and pushed it into place. The time
occupied in the reduction was about thirty seconds. The forearm was
then suspended in a sling, and the venous hiemorrhage, occasioned by
a rupture of the subclavian vein, was arrested by compression. The
t^umcnlary wound, between three and four inches in length, was
subsc(|uently closed by sutures, and cool water dressings were applied..
On the fourth day the wound had united by first intention, and the-
nmn was walking about his room. In less than a month he was dis-
missed cured, and in the following harvest he was able to cut his own
hay and grain, and to use his arm sis before the accident.'
Miller and Hofl'man reduces! Bucceesfully a compound dislocation of*
} knee,* and Galli has communicated a similar case to Malgaigne.'
lether either of the last three mentioned examples admit of the
me explanation as the preiiKling three, I am unable to say, but
794 COMPOUND IHSI.OCATIONS OF THE LOXQ BONES.
whether tliey do or tlo not, tiiey are too exceptional in their characM
to prejiidice the argument materially which we shall hereafter ni^
in I'avor of nsection.
Non-Reduction. — On the other hand, it will be very difficult to find
an e(]iial number of cases of componnd dislocations, unreduced, whid
have terminated favorably. The fact is, no doubt, that at the prcs
day very few sui^ons would feel themselves jnstified in Wvingi
bone out of place unless they proceeded to amputate. In the Tnun
adions nf the Neie York State Medical Soeieii/ for 1855, 1 have n
ported (Case 16 of Tibia and Fibula, p. 87) a compound dislotnlio
at the ankle-joint, which, lieing unreduced, terminated fatally on th
twenty-eighth day. This is the only example of a comptmnd dislcHi
cation of a long bone, let) unreduced, which has fallen under my c
servation; excepting, of course, those casea in which amputatioD «
immediately practiced.
The united testimony, however, of the old sut^eons, who giweral^
neither amputated nor adopted the method of resection, but who r
ommenddl and practiced non-reduction, is, that it is much more a
to leave these boue.= unreduced, than to reduce them without r«
tion^ and I see no reason to doubt the correctness of their npiniM
in this matter. But whetlier it would be more safe to leave end
limbs unreduced, or having practiced resection to restore them, i
another question, in which the advantage and comparative safely 4
the latter practice are too obvious lo require explanation or defence.
AmpuitUion. — Says Pott: "When thia accident (dialocaiion of th
ankle) is accompanied, as it sometimes is, with a wound of the ini
mentii' of the inner ankle, and that made by the protrusion of ihc h
it not unfrequently ends in a fatal gangrene, unlesi^ prevcnt«'d I
timely amputation, though I have several times seen it do ver>' w(
without." And Sir Aetlcy Coojier, speaking of coni|>ound di»]ocntioa_
of the ankle-joint, remarks: "Thirty years ago it was the pmctkvl
amputate limbs for this act^ident, and the ojH-nition was then ibouj*
absolutely necessary for the preservation of life, by some of our b
Bui^eons." Nor is it difficult to see by what renstming surgeou-id
"thirty years ago" had fallen back upon this dcsjicnitc n-nicdy, Botfe
reduction and non-reduction having proven cminenlly hnninloiu, i»
the absence of perha|>s both knonlinlge and experience in rrmvlio^
they finally adopted the alternative of amputation, as that whirh ttt/^
all must give to the patient the lK!st disnee for life; and were no <Ahtt
alternatives to be presented, this would be our choice in a hi?^ piO»
portion of cases. ■
It must not be understood, however, that amputation is an cx[MdifNl
wholly free from danger; or, indeed, that the chances of the Mlioi
are in the average very greatly increasetl by this practice. Of thirtn
amputations made for compound dislocations at tlie ankltsjomt, in ti
Royal Infirmary at Edinburgh, only two rt«ulted in the rvaavtTTi
the patients.' Alluding to which, Mr. Ferguiuwn rcmorku: "A
amount of mortality which may well incline the surgutn to sol lift
> Edinb. Med. Monthly, Aug ^^**-
COMPOUND DISLOCATIONS OF THE LONG BONES. 795
the doctrine inculcated by Sir Astley Cooper" (to attempt to save
the limb l)y reduction). But Mr. Fergusson has added a sentiment
which accords very closely with my own exi)erience and opinions.
" I fear, however, that in the attempts which have been made to save
the foot (by reduction), the results in all the cases have not met with
the same publicity — that the instances w^here amputation has l)een
afterwards necessary, or where death has been the consequence, have
not always been recorder! ; and, from what I have myself seen, I would
caution the inexperienced practitioner from being over-sanguine in
anticipating a happy result in every example."
By Tenotomy, — As a means of overcoming the resistance of the
muscles, and for the purpose especially of facilitating the re<Uiction,
tenotomy has been proposed. First by Dieffenbach in cases of ancient
unreduced luxations ; but Wm. Hey, Jr., was the first to make a prac-
tical application of this suggestion in a case of compound 'dislocation.
After cutting the tendo-Achillis, the ankle being disloi*ated, the reduc-
tion was easily effected, but a strong tendency to displacement l)ack-
wanls remained, and he was obliged afterwards to cut the tendons of
the tibialis posticus and flexor longus digitorum.*
This method, based in some degree upon a very correct notion of
the principal sources of difficulty, I regard as totally impracticable,
at least to any useful or adequate extent. In order to be efficient, all
the tendons passing the articulations must be cut, or nearly all of
them ; and I doubt whether the judgment of any discreet surgeon will
ever sanction such an extreme, I might almost say such an absurd,
measure. Nor do I think that in the point of view in which we are
now considering this subject, having reference only to the question of
danger, if the cutting of the tendons was sufficiently extensive to have
any real effect in facilitating the reduction, the practice would l)e found
to have any advantage over other methods known to Ik? eminently
dangerous.
By Bisection, — Finally, resection presents itself for our consideration
as the only remaining surgicjil expedient.
We have seen that most of the early writers understood the effects
of a constant strain upon the muscles in increasing the danger of
spasms, inflammation, and death; but in general they have suggestc»d
no remedy but non-reduction or amputation. Hip|)ocrates, however,
uses the following language, after speaking of resection of protruding
bones in accidental amputations or in fractures of the fingers: "Com-
plete resection of bones at the joints, whether the foot, the hand, the
leg, the ankle, the forearm, the wrist, ibr the most part, are not at-
tended with danger, unless one be cut off at once by deliquium animi,
or if continued fever sujwrvene on the fourth day." To which pas-
sage the translator adds the following note : " This pamgraph on resec-
tion of the bones in compound dislocations and fractures contains
almost all the information on the subject which is to be found in the
works of ancient medicine." C'elsus notices the practice of resecticm
in com|K)und dislocations very briefly, as follows : "Si nudum os emi-
* Hey, Trans, of Provinc. Med. and Surg. Assoc, vol. xii, p. 171, 1844.
796 coMPonyD dislocations of the long bones.
1
n flip
net, imjtedi men turn acmjitT futiiiiim est; ideo quml uxoeilit, nbsriu-
(ienduiii est."
Mr. Hey, of Leeds, was the first of motiern aurj^one wliu (n1l«>l
es]jeci!il attention to the value of resection in eompound dislocations.
Suljsequently, Mr. Parks, of Liveqxx*!, in an " Account of a New
Method of treating Diseases of the Joints of the Knee and Rlbovr,"
advocates the practice of resection in certain coses of diseases of these
Joints, but especially In "affection? of the joints produced hy pxtemal
violence."
Mr. Irfvfille, in France, also following, as he affirms, the guidd
of Hippocrates, has advocated a similar practice.
Velpeau, Syme, Fergiisson, Fricht^en, Miller, Listoii, Chelius, Liij
Gibson, Norri^, under certain circiinistaures, and e^iiecially where i
bones cannot otherwise he rciluccd, and where the disiiioitidnA uveal
in certain joints, and especiidly the e]l>ow and ankle joints, rectjinmeui!
resection. To which names we may add that of Sir Astley Cooper,
who has considered the subject, as applied U> ihe ankle-joint, ({nite at
length, and who mys: "I have known no case of death wheu the
extremities of the Ijone" (tibia, at the ankle) "have been sawed oiT,
altboiigh I shall have oc^easion to mention some cases which terminated
fotally when this was not done."
Why resection should diminish the danger (o life, by placing nt
rest the injured muscles, has been already sufficiently i\)ni'iilcrc<l ; bu^-
it seems not improbable that, if synovial membranes arc actually a
susceptible of violent and dangerous inflammations lliaii the i
tissues about thejoint-*, then would this source of dan^r be r
just in projmrtion as the synovial membranes themselves are rvnioval
Such, indeetl, was the argument used by Sir Astley ; and Mr. Sotitli, la
a note to Chelius, when referring to this fact, has maile the followio^
statement i
" In compound dislocations of the ankle-joint, with protrusioa of
the shin-bone through the wound, moet Kuglish surgeons saw ofl' the
joint end, not merely to render reduction more easy, but alsti, acooni^
ing to Sir Astley Cooper's opinions, to Uwseu the suppumtivc pm
by diminishing the synovial surface. This mode of practiuc i
tiiinly not commonly followed in reference to other joints, nnd I
younger Cline was always op|(osed to its being resorted to in dbluc
ankle."
Tile following cases having occurred under my own vyc, will »
in illustrale tlic value of llie principle which I have bet-n podo^'Ol
to establish:
Samuel Adamsoii, of Buffalo, tet. 24, was cAUghl by ihu
vessel, June 17th, 1855, dislocating the left tibia at its lower Midi
wanls, and bi-eaking the fibula two inches nUwe the anklr^ If
immediately calle<l, and found the tibia protruding through ihoaf
about three inches. The ])i'riuslcuni was turn up, hiuI the mrtilaitid
Hurfuce of the end of the ln>newas rouglK-nvd. His thigh v
severely bruised and laoemted, but the l>onc was not broken.
Dr. Boardmau assisting mc, we atteuipti-«l U> nilucc the bonce,!
with our hands we fouud it iuipussihlv to do su. I pmccnlol im
rcuMMQ
COMPOUND DISLOCATIONS OP THE LONG BONES. 797
diately to remove about one inch and a half of the lower end of the
tibia with the saw. The remaining portion was then brought easily
into place, and the wound dressed with sutures, adhesive straps, band-
ages, and light splints. On the same day he became an inmate of the
marine wards at the Hospital of the Sisters of Charity, and was placed
under the care of Dr. Wilcox, through whose politeness I was permitted
to see him frequently.
The wound in the leg healed kindly, with only a slight amount of
inflammation and suppuration. Violent inflammation, however, oc-
curred in the thigh, followed by extensive suppuration and sloughing.
This, in fact, proved to be by far the most serious injury, and that
which most endangered his life and delayed his recovery.
After about two months, the ankle was in such a condition as to
require little or no further attention. The fragments of the fibula had
shortened upon each other and were united, so that the tibia rested
upon the astragalus. It was nearly two months, however, before he
began to walk, owing to the condition of his thigh.
August 24, 1856, fourteen months after the accident, Adamson called
at my office. He was then employed again as a sailor on board the
schooner Sebastopol, and performed all the duties of an ordinary deck-
hand. His leg is shortened one incb and a quarter; from which, it
seems, that there has been some deposit upon the end of the bone, which
has compensated for one-quarter of an inch of that which I removed.
The ankle is perfect in its form, being neither turned to the right nor
to the left, and he treads square and firm upon the sole of his foot.
There is considerable freedom of motion, especially in flexion and ex-
tension. Occasionally it becomes a little swollen and painful.
January 1, 1875, Rosanna Wilbur, set 45, was admitted to ward 13,
Bellevue, having just been injured by a street car. She was in good
health, but very fat, weighing 185 lbs. She was found to have a com-
j)ound dislocation at the right ankle-joint — the tibia being thrust com-
pletely through the flesh — and also a fracture of the fibula. Dr. I^ewis,
the house surgeon, reduced the dislocation at once, and easily, and
then sent for me. I advised an attempt to save the limb without
resection, and by supporting the limb with the plaster of Paris dress-
ing. This dressing was applied fourteen hours after the accident by
Dr. Lewis, a window being made opposite the ankle. January 3, the
window was enlarged. January 5, gangrene and phlebitis had occurred ;
fenestra again enlarged. January 7, entire splint laid open, and hot^
water dressings applied. January 12, suspended limb. January 21,
the condition of the limb very critical ; and, in a consultation composed
of the visiting surgeons, we were equally divided between amputation
and resection. It was permitted, therefore, that I should choose my
own course. I immediately resected two inches of the lower end of
the tibia, and placed the limb again in a sling supported with com-
presses as means of lateral support, and warm-water dressings were
continued. The subsequent progress of the case was very slow, and
there were several smart attacks of erysipelas, so that her life was at
times in danger; but finally all unfavorable symptoms disappeared,
and on the 1st of May, the ankle was in perfect shapc^ admitting of
798 COMPOUND DISLOCATIONS OF THE LOSG BOS E8.
some flexion and extoiisiou, and the wounds were almost compleld
closed. It is now apparent, that a resection on the fit^t day would liaii
been the mo^t judicious practice, but tliat even at a later day it i»vi
her life.
In a case of compound dislocation of the upper end of the hutuer
occurring also under my own oljservalion, and recorded in the Tra
adiovs 0/ (Ac AW York State Medical Society for 1S55 (p. 27, Case Ifl
in which reduction was folhiwed by death, I have now much rmsoad
iaelieve that if I had pnMli(«l resetrtion Ijefore the reduction, my p
tient'a chances for recovery would liave been gr(«tly inorease«l ; pcrlii
also the case of comjMiund diBlocation at the wrist-joint reconlrdi
the same vohune (p. 68), in which, having reduced tlie bones, [ <
gubse<|uently compelled to amputate, may G<iually illustrate the hiu
to which the practice of reihiction without resection mast often espi
the patient.
The same remarks I will venture to apply to the case of eomiMol
dislocation of the hip, of which I have already sjiolten aa baviiie a
curred in the practice of Dr. Walker, of Charlestown, Mam. Had tl
head of the femur been resected before it» reduction, I cannot don
but that the unfortunate man's chance for recovery would have fa
very greatly improved. ,
Thus, if we consider the question of the life of the pHticnt o
ai^ument and the testimony seem to favor resection in a gn-st muioriH
of cases of compound dislocations occurring iu large joiul^, and ioH
considerable number of cases of similar accidents in the smaller join'
It is certainly more safe than non-reduction or reduction without r
tion, and it is probably quite as safe as amputation or tenotomy.
But tliere is another question, which is, in our estimation, scconJi
to the one now considered, hut which is oflen iu the estimation uf l]
patient himself of the firat impi>rta[ice, namely, by which method t
ne suifer the least maiming or mutilation?
This question I do not find it difficult to answer. Certainly
not by non-reductiou or by amputation; and, putting teunloiay »
it is now a question only l>etween reduction without re&ectioii, and a
duction with resection. These two methods, one of which experitt
has shown to be fraught with danger, and the other of which ei|
enw has shown to be relatively safe, are now to be compare<l in a p
of view in which their antagonisms are perhaps less i^nspicuuut^ y
sufficiently marked.
First. Iu either case the inSammation consequent upon tha inJBI
may he violent, and the recovery slow and tedious. The miav »
ments, however, which we have applied to the question of tlic (
parative danger of the two modes, must apply with nearly vqual fi
to this question of maiming ; since the amount of maiming mit^ ol
be governe<l by llie intensity and duration of the inflaiuinuiiua, i
upon this point the testimony has been shown to be in &%■««' of il
section.
It will be observed that not only is the danger of maimiug renda
more considerable by reduction without resection, liecuuse tlie tuf
mation is so much more likely to extend to th« tendons and a
COMPOUND DISLOCATIONS OF THE LONG BONES. 799
causing them to adhere to each other, and to become subsequently
atrophied, a condition from which they often never completely recover,
but also because the ligaments and capsules of the joints, with the
synovial surfaces, are in consequence encroached upon, and the free-
dom of motion is ever afterwards greatly restricted, if not completely
lost. This marked impairment of the functions of the joint does not
always happen, but it cannot be denied that it does generally. Indeed,
it is by no means uncommon for these accidents to be followed, after
ulcerations of the cartilage, by copious bony deposits in and around
the joints.
How is it, on the other hand, with these joints after resection ? I
have thus far heard of no cases in which complete anchylosis resulted ;
but in all considerable freedom of motion has returned, and in some
the restoration in this respect has been nearly or quite as complete as
before the accident.
Says Dr. Kerr, of Northampton : "Several cases of compound dis-
location of the ankle have fallen under my care, and it has been uni-
formly my practice to take off the lower extremity of the tibia, and to
lay the limb in a state of semiflexion upon splints; by this means a
grc^t degree of painful extension, and the consequent high degree of
inflammation, are avoided. The splints I used are excavated wood,
and much wider than those in common use, with thick movable pads
stuffed with wool. I keep the parts constantly wetted wuth a solution
of liquor ammonifie acetatis, without removing the bandage. In my
very early life, upwards of sixty years ago, I saw many attempts to
reduce compound dislocations without removing any part of the tibia;
but, to the Ix^st of my recollection, they all ended unfavorably, or, at
least, in amputation. By the method which I have pursued, as above
mentioned, L have generally succeeded in saving the foot, and in pre-
serving a tolerable articulation."
Sir Astley Cooper has made a valuable experiment to determine the
condition of the new joint under these circumstances; and the vast
number of cases in which resection has now been practiced in cases
of caries of the articulating surfaces, and their results, add still more
substantial proofs as to the usefulness of the joints after such opera-
tions.
" I made an incision u|x)n the lower extremity of the tibia, at the
inner ankle of a dog, and cutting the inner portion of the ligament of
the ankle-joint, I produced a compound dislocation of the bone in-
wards. I then sawed off the whole cartilaginous extremity of the
tibia, returned the bone upon the astragalus, closed the integuments by
suture, and bandaged the limb to preserve the bone in this situation.
Considerable inflammation and suppuration followed ; and in a week
the bandage was removed. When the wound had been for several
weeks perfectly healed, I dissected the limb. The ligament of the
joint was still defective at the part at which it had been cut. From
the sawn surface of the tibia there grew a ligamento-cartilaginous sub-
stance, which proceeded to the surface of the cartilage of the astragalus
to which it adhered. The cartilage of the astragalus appeared to be
absorbed only in one small part; there was no cavity between the end
800
.•OMPOUND DISLOCATIONS OF THE LONG BONCS.
of the tibia and the cartilaginous surface of the astragaliit
motion cxist«K^l between the tibia and astragalus, which was jterniittti
by the length and flexibility of the lignmentoiia subatance al>nve ('
scribed, §o as to give the advantage of n joint where no synovial artio
lation or cavity was to be found. This experiment not only showj
the manner in which the parts are ri^tored, but also the advanfaged
passive motion; for if the part !» frefiuently moved, the i
enbotance becomes entirely ligamentous; but If it l)e left jwrfectly i
rest for a length of time, ossific action proceeds from the t'Xtremiiy t
the tibia into the ligainentons substance, and thus protluoes an ossitu
ant'bylosie."
Second. Is it not probable, moreover, since the limb cati l>e retaiiM
in place so much more easily af^r resection, that it will actiiHlly, in^
majority of cases, l>e found to have been retained in pluo
fectly? Even after simple dislocations, especially in those o«;iirriB|
at the ankle-joint, great deformity and much maiming are the not u
frequeut results, and that too when all diligence and cnre have b
employed. It has been impoi^ible always to maintain a perfei^t appc
sition in the articulating surfuccs. How much greater must be tl '
difficulty in cases of compound dislocations.
Third. The only argument which remains in favor of reductioj
without resection is the necessary shortening of the limb after reseciioi
But this need seldom perhaps to esceed three-quarters of an inch, a
often not more than half an inch; an amount of sbort<>niiig which, I
I have had occasion to prove when treating of fractures, does not n
sarily produce a halt, and which indeed is often not known to exist If
the patient himself. The experience of Heine, Ijangenbcvk, Volkm
Hueter, and other German surgeons, has shown that in a ooasiHem
number of cases, when these resections have been made by the «u&m
o»tenl methods, no shortening whatever has resulted.'
Finally. It must not be inferred that the author intends to r
mend resection as a universal practice in cases of compouml dishirstioN
of the long bones. He has only sought to determine in a ff^im
manner its relative value as cora]>ured with other modes of pmaiiavd
and especially has it been his intention to iiring more prominently Jof
view the importance of rest and relaxation to the musclos '"
ment in the treatment most esiontial to succera. To din-Iare its aw
application to cases would demand a treatise more elaborate than it m
proposed to write, If, however, one were to spuak of the individol
iMtnes only, there seems sufficient authority in the facts and nrmitnoi
already presented to conclude that rcsrution is appHcnhle in e
compound dislocations of the clavicle, humerus, railius. nnd ulna, lint,
femur, tibia, fibula, and toes; in short, to a certain prop<>rtino of d
these accidents ocuurring in the long Ivmes of the cxtn-mitie».
If an attempt is made to save the limb wilbiiut r4'M.'<ai(ni,it 'u
necessary to aay that the success will deiieml, in ii gnnit t
the (»re, utt«ution, nnd skill bestowed upon the treatment. CmoI i
CONGENITAL DISLOCATIONS. 801
tepid water-dressings, according as the indications or the sensatioas of
the patient seera to demand, are among the most valuable remedial
agents. The limb must be maintained in a position of rest, combined
with moderate elevation ; and the bran-dressings, recommended in com-
pound fractures, will be found occasionally useful.
CHAPTEE XXVI.
CONGENITAL DISLOCATIONS.
i 1. General Observations and History.
We have omitted, until this moment, to speak of Congenital Dislo-
cations, because, whatever theory of causation we adopt, dissections
have shown that they are generally, in some sense, pathologic, or are
accompanied with such essential modifications of the anatomical struc-
tures as to separate them entirely from ordinary traumatic luxations,
w^hich alone constitute the proper subjects of consideration in the present
treatise. In relation to congenital dislocations, we shall find it neces-
sary to establish systems of etiology, symptomatology, prognosis, and
treatment, having very few points in common with traumatic disloca-
tions. Exceptions to this rule will occur, in examples of intra -uterine
traumatic luxations, existing at birth without either original or acci-
dental malformations of the articulations, or of the adjacent muscular,
tendinous, or ligamentous structures ; yet only in sufficient numbers to
warrant the intrusion of the subject in this place.
It is probable that congenital displacements may occur in all the ar-
ticulations of the skeleton ; and in most of them their existence has
been already established by dissections. Until within a few years,
however, the attention of surgeons has been almost entirely directed to
congenital dislocations of the shoulder and hip.
Hippocrates, in his treatise "De Articulis," speaks expressly of dis-
locations of the hip occurring in the mother's womb, comprising them
under the same order with the different varieties of club-foot.
Avic(»nna and Ambrose Par6 have each mentioned original disloca-
tions of the hip; but the first to record an example with any degree
of accuracy was Kerkring; in which case, death having occurred
during infancy, he was able to verify his opinion by an autopsy.
Chaussier has reported, in the Bulletin de la FacxilU et de la Sociifi de
Medecine, An. 1811 and 1812, the case of an infant, upon which he
discovered, at birth, two dislocations, one at the scapulo-humeral artic-
ulation, and the other at the coxo-femoral. In 1788, Palletta, of Milan,
published, under the title of Adversaria Chiruryica^ a collection of
observations, in which, among other things, he has described certaiq
congenital malformations of the hip-joint; and in 1820 he published
802 CONGENITAL DISLOCATIONS.
another work, entitled Exercitationes Pathologicce, where he enters into
a more complete exposition of the nature and causes of these deformities.
In 1826, Dupuytren read, before the Academy of Sciences, a memoir
upon the lameness produced by the original displacement of the femur ;
and in the Lefons OraleSy published in the collections of the Sydenham
Society, may be found a full record of the views and observations of
this distinguished surgeon.
The writings of Dupuytren seem, more than anything previously
written, to have directed the attention of surgeons and pathologists to
this interesting subject, and to have given a new impulse to investiga-
tion.
From this time various treatises have been written by eminent sur-
geons, many of which are characterized by profound thought, careful
investigation, and practical experiment.
Among those who have furnished us lately with elaborate treatises,
or with more precise practical information upon this subject, the fol-
lowing names deserve to be especially mentioned : Breschet,* Caillard-
Billionidre,^ Lehoux,^ Sandiforte,* Duval and Lafond, Humbert and
Jacquier, Bouvier,* S^illot,* Gerdy, Polini^re, Wrolik,^ Gu6rin,'* Pa-
rise,* Pravaz,*° Carnochan," and Robert Smith.**
i 2. Etioloiry.
Hippocrates says that the bones of the extremities may be disarticu-
lated during iiitra-uterine life by falls or blows, or by injuries of any
kind, inflicted directly upon the abdomen of the mother.
Ambrose Par^, while admitting the efficiency of the several causes
named by Hippocrates, believed also that the contractions of the
womb, and violence employed by the accoucheur, were occasionally
adequate to the production of the same results. He taught, moreover,
that the position of the foetus itself might favor the displacement ; ami
that, in some instances, an articular abscess, insufficient depth of the
socket, with a laxity of the ligaments, were competent to determine the
expulsion of the head of the femur from its natural position.
* Bresohet, Repertoire d'Anatomie et de Physiologio.
» Caillard Biilionidre, Thdse Inaugurale, 1S28.
• Leboux, Thbse Inaugurale, 1834. Paris.
* Sandiforte, Thesis, sustained before the Faculty of Med. of Leyden.
* Duval and Lafond, Humbert and Jacquier, Bouvicr. See Pravaz.
• Sedillot, Ji>urn. de Connais. Med -Chirurg., 1838.
' Gerdy, P<»linidre. Wrolik. See Pravaz.
• Gu^rin, Recherches sur les Luxations Cong^nitales ; par Jules Gu^rin. Pari*,
1841.
9 Parise, Archiv. G6n. de M6d., 1842.
^° Pravaz, Traite Th^oriaue et Pratique des Luxations Congdnitales du Femur,
suiv! d'un Appendice sur la Prophylaxio des Luxations Spontaneos ; pur Ch. G.
Pravaz, Lyons, 1847.
" Carnochan, A Treatise on the Etiology, Pathology, and Treatment of 0>n-
genital Dislocations of the Head of the Femur; by John Murray Carnucban, Nev
York, 1850.
" R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain
Accidental and Congenital Dislocations. Dublin, 1864.
ETIOLOGY. 803
S^lillot regards a softening and relaxation of the ligaments as the
most frequent cause.
PariJ^e and Malgaigne are disposed to attribute a majority of these
cases to hydrarthrosis, or water in the joints. Says Malgaigne: "For
myself, after having long meditated upon this subject, I have come to
think that inflammation of the joints enjoys a grand r6le, both in
coxo-femoral dislocations and in many others, and even also in various
congenital malformations generally ascribed to arrest of development.^'
This writer admits, however, that it will not do to generalize too much
in this matter, and that the etiology of congenital luxations is proba-
bly as complex as that of luxations aft^r birth.
Chaussier seems to have regarded muscular contraction, or the oc-
currence of an intra-uterine convulsion, as the cause of the example of
congenital dislocation of both humerus and femur seen and recorded
by him. Since whom Gu^rin has greatly extended the application of
this doctrine, having embraced in the same etiologic formula all or
nearly all congenital dislocations. Gu6rin ascribes to muscular con-
traction in one form or another, and to corresponding muscular paraly-
sis, not only dislocations of the femur and other long bones, but also
club-foot, torticollis, and various other deviations of the spine. He
affirms, moreover, that he has established incontestably the dependence
of this abnormal state of the muscular system upon the absence or
disappearance more or less complete of corresponding portions of the
central nervous systems.
Breschet and Delpech maintained similar views, especially in rela-
tion to the de|)endence of the several varieties of club-foot upon some
morbid condition of the cerebro-spinal axis. While Carnochan re-
marks as follows : " It appears most in accordance with science to
refer the muscular spasmodic retraction, upon which congenital dislo-
cations of the head of the femur from the cotyloid cavity depend, to a
perverted condition of the excito-motor apparatus of the medulla
spinalis, and more especially of that portion of it which is in direct
relation with the reflex- motor nervous fibres, distributed to the pelvi-
femoral muscles surrounding, and in connection with, the ilio-femoral
articulation."
Palletta ascribes these deformities solely to an original defect of the
germ ; and Dupuytren also declares that, in the case of a congenital
dislocation of the hip, the causes are coeval with the earliest organiza-
tion of the parts, and that the displacement is due rather to a defect
in the depth or completeness of the acetabulum, than to accident or
disease.
Breschet and Delpech, both of w^hom, as we have already stated,
refer them to some morbid condition of the cerebro-spinal axis, im-
agine that in consequence of this morbid condition of the nervous
centres, there exists an arrest of development in the bones, muscles,
ligaments, sockets, and, in short, through all the apparatus of the joint
which is the seat of the deformity.
If we proceed to analyze these various opinions, we shall find that
they are so far susceptible of classification, as that they may be ar-
ranged under the three following divisions :
804
CONGENITAL DISLOCATIONS.
First, the physioli^ieal doctrines; according to which oon^-nital
dislocations are due to an original defect in the germ, or to an arrest
of developmpnt,
Seeond, the pathologic doctrines; which refer them to some sup-
posed lesion of (he nervous centres, to contraction or paralysis of the
muscles, (o a laxity of the ligaments, to hydrarthrosis, or to soma other'
diecasetl condition of the articulating apparatus.
Third, the mechanical doctrines; which recognize no intra-uterim
dislocations except those which are strictly tmumatic. The causes
being understood to be the peculiar position of the fa>tus in nlrn^
violent contractions or the constant preaaiire of the walls of the utenii^
falls and blows upon the abdomen, and unskilful manipulation of tha
child in delivery.
Aficr a full and careful conaideratinn of this subject, we are pn-jmred
to admit the occasional agency of all the causes enumeratwl, and the
probable concurrence of two or more in many instances; nor do we see
the propriety of rejecting, as Mulgaigne has done, all that lai^ ola«
of malformations, which seem to depend upon an arrest of develojimeu^
or those which appear to be due oiainly or solely to intra-iiteriiie pa-
ralysis, of both of which many esamplos have been reported.
i 3. Congenital Dialocatioas of the Inferior Hazilla.
Malgaigne nFRrms that "we know of no congenital dish)oationof thi
jaw," and that we are " not to lake seriously the pretended liixaiioa
observed by Gu^riii upon a dfrencfiphalooe infant." The example
recorded by Robert Smith he rqects also, declaring that he does "not
comprehend how one ran see in it a luxation."
For myself, T knowof no reason why we should not take "serioaJy"
tlie case mentioned by Gn^riuj since, so &r as api>ear9 in his very brief
lort of the same, it might have been a true luxation. The spe^otnt
B before the Academy, and if Malgaigne, from a jMsrsonal examina-
tion, has become satistied that a dislocation did not exist, he ought t«
have so informed us. But since he does not si>cak of having made it'
the Biibject of especial examination, we shall feel compelled to wxfft
of it as re(>orted by Gu4rin,
As to the objection offered to Mr. Smith's case, namely, that "asiite
of the complete absence of its history, the subject did not preM'ut the
oharael eristic signs of luxation, and the dissection discovered neither
maxillary condyle nor glenoid cavity," we must reply, the diw*etioo
seems to us to have furnished surh evidence that the deformity w»
congenital as to render its history uimeccsenry ; the signs were charac-
teristic, not indeed of a traumatic luxation, but of a congenital diHlnv-
tion, such as may be supposed to have been the result of an nirreBt of
development, or of an original aberration of the germ.
The following ia a summary of the very complete account of lhia<
aisc given by Robert Smith. ■<
On the f)lh of May, 1840, Edward Lacy, wt. 38, an idiot from in-
fancy, died at the Hardwick Hospital, in consequence of gnngimi* ofj
the lunge, While making the autopsy, a singular defurniiiy 'tf the
CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 805
face was discovered. The right and left sides seemed as though they
did not l)eIong to the same individual, the left being in every respect
more fully developed. Upon removing the integuments, the muscles
of the right side were found to be much smaller than those of the left,
and especially the raasseter. These latter having been removed also,
the condition of the right temporo-maxillary articulation was carefully
studied.
When the mouth was closed, the external lateral ligament, instead
of \yeing directed backwards, was seen descending obliquely forwards,
to be attached to a very imperfectly developed condyle situated at
least one-quarter of an inch in front of its natural position. There
wa,s neither an interarticular cartilage nor cartilage of incrustation,
the joint surfaces being invested by a thick periosteum alone; nor was
there any distinct capsular ligament.
Nearly the whole of the right side of the inferior maxilla was
smaller than the left. The condyle was short and curved, being
directed nearly horizontally inwards, and resembling much more the
coracoid process than the condyle of the inferior maxilla. The coro-
noid process was very small and thin, and the sigmoid notch could
scarcely be said to exist.
The articular eminence of the temporal bone was absent, there being
in its place nearly a flat surface destitute of cartilage ; which surface
presented upon its inner side a shallow and semicircular sulcus where
the hooklike condyle of the lower jaw had played.
The malar, superior maxillary, and sphenoid bones of the right side
had also suffered corresponding changes of form and relative size.
The motions permitted in the lower jaw were more extensive than
those which it enjoys in its normal condition, that is, upon the right
side the ramus could be moved very freely forwards and backwards,
while u])on the left, the condyle underwent a species of rotation upon
its axis. During life the patient was observed to be constantly per-
forming this motion, and the right side of the face was continually
affected with s])asniodic twitches. When the mouth was closed, the
front teeth of the upper jaw projected beyond those of the lower, and
when opened the deformity was in all respects greatly increased.'
Mr. Smith takes this occasion also to express his dissent from the
views maintained by Ribes, namely, that the formation of the glenoid
cavity is consequent upon the growth of the condyle, and that, were
this process not formed, there would not exist either a glenoid cavity
or an articular eminence. It is true that neither the glenoid cavity
nor the articular eminence is found in the fcetus. Until the seventh
month of intra-uterine life there exists at this point of the temporal
bone only a plane surface, and the glenoid cavity with its correspond-
ing eminence is develope<l in proportion to the growth and develop-
ment of the condyle. But Mr. Smith justly (»bserves that although
the development of the condyle does precede that of the glenoid ciivity,
*' it by no means follows that the formation of the latter is due to the
pressure of the former.'' The cavity, or rather the transverse eminence
* Robert Smith, op. cit., p. 283.
CONOENITAt. DISLOCATIOSB.
in front of the plane surface, does not exist in fecial life, 1h«
to the peculiar form of the inferior maxilla at this period, it.-; cxisteiK
is iiot necessary. The vertical portion of the jaw (vertieiil only
adult) \e in the fcctua nearly in the game line witli the axis of the "htA
and consequently when the mouth ia of>ene<l by the action of the riu
cl&s, the condyles are pressed upwards and Itackwards instead of un
wards and forwards, as in the adnlt. A displacement forwards ntnM
therefore very well occur; and the protection of the articular eniinenoc
is not required. As age advances the angles of the jaw increase, tlj
portions upon which the condyles rest become more vertical, and finalh
a displacement forwards would occur whenever the month was WH
openetl if the articular eminences were not present to aSbrd a sufficiM'
protection in front.
Ill the case of Lacy the foetal condition of the bones upon one side
remained during life, there being neither cavity nor emiuenire, and the
condyle itself lieing only im|>erfectly developed ; but the angh- of the
jaw had assumed the form which belongs to the adult, and the a
ing ramus was vertical, consequently the condyle became sumewfai
displaced forwards.
Chronic rheumatic arthritis is occasionally found in the tempo
maxillary articulation of old persons; and it may be important to d
dnguish it from congenital luxation, with which, owin^ to the altriori
tiou of the aiticular eminence, and the consequcut displacement of t
condyle, it might possibly be confounded,
SayH Mr. Smith : " lu a majority of instances, this remarkable d
ease attacks those of advanced age, and is symmetrical ; but oecasiM
ally it occurs during the period of adult life. In the latter case
genenilly more rapid in its progress, is otrcompanied by greater [
and is more liable to implicate the neck of the condyle, and the ram
of the jaw."
When the condyle is implicated it becomes enlarged, and can W tk
beneath the »ygoma, in front of (he meatus externus. The lymphit
glands of this region are sometimes enlai^^l, and the |>rogn^*i of tf
malady is attended with a constant but not generally sevore |Niin.
The deformity of the lace varies according as one or both ttrli<iili
lions are affected. When the malady is confined to one joint, the c"
is thrown slightly forwards, but chiefly to (he opposite side, and wl
l)oth are implicated, the chin is simply advanwa so that (he le^tb )i
ject beyond those of the upper jaw.
As the disease progresses, the glenoid cavity enlarges \yy absorption
and at length a considerable {tortiun or the whole of the artictilar e«?
nenc« disap|>ears and the jaw becomes gnidually displnivd through iT
action of the external pterygoids. The di>ea.se dot's not t^xtend in tl
temporal bone beyond the articulating .surlac^ of the glenoid ia\-i^
The condyle assumes a variety of forms, somelimes lieirig greatly
laired in all its diameters, while its upiH-r surlitce may 1*"- flatfnnl, )
nmieal. The intcrarlicular tartilagc disap|>ear8; but Mr. Suiilh 1
never yet found any foreign bodies in the joint, and in only
stance nave the surfaces been polished or cburuated aa w« oflwii K«fl
CONGENITAL DISLOCATIONS OF THE SPINE. 807
examples of chronic rheumatic arthritis occurring in the hip, knee, and
other joints.
The following is an excellent summary of the diagnostic marks be-
tween congenital, accidental, and rheumatic dislocations, given by this
writer :
** 1. In the congenital luxation, the mouth can be freely opened and
closed ; in chronic rheumatism these motions can be performed, but
not without uneasiness to the patient, an uneasiness which sometimes
amounts to severe pain ; in luxations from accident, the mouth cannot
be closed.
"2. An involuntary flow of saliva accompanies the accidental luxa-
tion alone, although in some cases of chronic rheumatism there is an
increased secretion of that fluid.
**3. In congenital luxation, the teeth of the upper jaw project be-
vond those of the lower; the reverse is observer! in accidental luxation
ml '
and in chronic rheumatism.
" 4. In congenital luxation there is no fulness in the cheek, such as
the coronoid process produces in cases of accidental luxation, and the
condvle is not enlarged, as in some instances of chronic rheumatic
arthritis."^
\ 4. Congenital Dislocations of the Spine.
Says Gu6rin, of the subluxation occipito-atloidean there are two
varieties: "First. Backwards, consisting in an exaggerated flexion of
the head upon the front of the neck and chest, w^th a commencement
of sliding backwards of the occipital condyles upon the articular facets
of the atlas. Here are two examples in foetal anenc(»phalous monsters.
Second. Forwards. Those who follow my consultations can recollect
having seen last year an infant, about two or three months old, who
offered a remarkable example. The head was exactly applied against
the posterior part of the neck, and upper part of the back. There was
])robably a sliding of the condyles forwards, with elongation of the
anterior ligaments."^
The existence of the first of these varieties has since been denied
by Guerin himself;^ and it will be noticed that he only speaks of the
second as a j^f'obable subluxation forwards. Neither of them can there-
fore be regarded as established.
Guerin further remarks that he has observed subluxations in the
other regions of the spinal column many times; and he showed to the
Academy a foRtus in which the spine presented, besides the occipito-
atloidean displacement, a series of angular flexions in the antero-poste-
rior direction, with sliding of the articular surfaces.
In attempting to appreciate the value of Guerin's observations upon
this point, it must be remembered that he regards all cases of congeni-
tal torticollis, and other deviations of the spine, as examples of sublux-
ation ; and, in some sense, we think the theory of this distinguished
surgeon may be regarded as correct. The amount of articular displace-
» R. Smith, op. cit., p. 292. « Gu6rin, op. cit., 1841, p. 29.
' Ibid., op. cit., p. 32.
808 CONGENITAL DISLOCATIONS
ment between each of the adjacent verlcbree may he veiy inconsideral
in any such case, yet, however trivial, if it exceeds tlie limits of nal
ral motion, it may [iropcrly enough he reganied as the eomi
of a luxation.
i 5. Congenital DiBlocatioiis of the Petne Bonei.
BaBsius speaks of a dia^taeiH or se^mralion of the saoro-iliac svmphji
BIS, observed by him in newly horn childivn, and in inliints; but, m
cording to Malgaigne, hia nei^unt of these cases is not such as to
rant any conclusions as to the true nature of the displacements.
Congenital exstrophy of the blad<ler is aeconipanied always with
deficiency of the central and ujuwr portions of the pubic hone«, til
result manifestly of an arrest of development; lint these cases, of whii
I have seen several examples, are not projwrly examples of congcnit
dislocations, but only of diastases, the sefKir.ited portions remaining
their normal position with reference lo each other, except that they i
not prolonged sufficiently to meet in the median line.
Gu&rin declares, however, that he has seen congenital displacvmeB
or overriding of the iliac bone ayiou the sacrum, accompanie^l with vnn
femoral dislo<'ation ami curvature of the spine. The same \vrit*?r n
tions an example, in a fcDtal monster, of diastasis of the pubie Ui
and of the liacro-iliac symphysis, acrompanied with a turningout of ll
pubcs upon the external iiire of the ischium.'
i 6. Congenital Diafocations of the Sternum.
e has reported one example of luxation of the xiphoid i
tilage from the sternni
A woman in her firth month of pregnancy fell ajid dishK^ttvd 1
shoulder. Just four months after this she was brought to bed with
infant, well formed, except that, soon after it was born, the 4*nHilti
cartilage was observed to be remarkably movable, especially \rlM.-n ll
child hiccoughed, to which it was very subject. The nuiilage
separated from the strrnum by tlie breadth of tlie little Hngvr.
treatment wn^ employed ; the cartilage gradually booame restored Ui i
place, and in about one year it was tirmly united to the sterai
i 7. Congenital Ditlocations of the Clavicle.
Malgaigne says lliat a congenital diuliHation at the ntcmn-clavicull
articidntion has never been ob«;rved; hut Gu6rin deirlares that lie '
established the existence of three varieties, namely ;
1. A luxation of the sternal end of the clavicle iuwarda and I
wards ; this extremity of the clavicle lying in front of ilie sienm] fit
ohette. In ilhistmtion of which he presente«l lo the vVuidciuy a pladi
oast of a girl eight years old, in whom the displacument exivteu u]
both side».
CONGENITAL DISLOCATIONS OF THE SHOULDER. 809
2. Inwards and upwards. Observed by him in a girl eight years
old ; but which displacement took place only when the arm was moved,
and through the contraction of the sterno-cleido-mastoideus muscle.
3. Backwards. Of which he presented two examples in the corre-
sponding sides of a foetal monster.
I believe I have already referred to Fergusson'a case of dislocation
of the sternal end of the clavicle forwards, which occurred during birth.
The end rested in front of the sternum, and could be pushed into its
place with great ease ; but when left alone it immediately slipped out
again. Nothing was done, a new joint formed, and the child after-
wards possessed as much power in the one arm as in the other.^
Gu6rin says that he has seen a dislocation upwards and outwards at
the acromial end of the clavicle in a foetus of three months.
In regard to the treatment of either of the.se displacements of the
clavicle, we need only remark that a reduction ought to be attempted ;
and, if practicable, without much confinement of the little patient, it
should be maintained until the bones have become fixed in their natural
positions. It is quite probable that this can never be accomplished, at
least perfectly ; but it will nevertheless be proper always to make the
attempt.
i 8. Congenital Dislocations of the Shoulder. (Upper end of the
Humerus.)
Gu6rin aflfirms that he has established the existence of three varieties
of scapulo-humenil dislocations, namely:
1. Dislocations of the head of the humerus downwards; of which
variety he presented to the Academy a plaster cast taken from a boy
ten years old. The displacement existeil in both arms, but much more
pronounced in the right than in the left arm. It was due wholly to
paralysis of the muscles about the joint, and to elongation of the cap-
sule.
2. Downwards and inwards; complete upon one side and incom-
plete upon the other, in the same person. The head of each humerus
was applied ajijainst the ribs, and the arms maintained in an abduction
almost liorizontal, under the influence of the retraction of the deltoid
muscles. "The same case," Gu6rin remarks, " has l)een confirmed by
Koux."
3. Subluxation upwards and outwards ; seen on both sides in a
fiotal monster, which was offered to the Academy for examination ;
and in one arm of a young man fifteen years old, of which Gu6rin
presented a plaster cast. "It is characterized by a sliding of the head
of the humerus in the direction indic*ated ; this sliding being favored
bv a corresponding displacement of the coracoid and acromion pro-
cesses. ^
Malgaigne, who regards " all luxations in consequence of paralysis
as essentially posterior to birth," will not admit the first example men-
* Ferjjusson, System of Surg , 4th Amer. ed., 1853, p. 203.
* Guerin, op. cit., p. 80.
52
810 CONGENITAL DISLOCATIONS.
tioned by Gu^rin ; but, as we stated before, the objections made by
Malgaigne have failed to convince us of the propriety of rejecting all
of this class of reported examples. Of the second case, mentioned by
Gu6rin as having been confirmed by Roux, Malgaigne declares that he
has consulted Roux upon this matter, and that he affirms that "he has
never seen a congenital luxation of the shoulder."
Robert Smith has met with but two of the forms of congenital
luxation of the humerus described by Gu^rin, namely, that in which
the head of the humerus is displaced forwards, and that in which it
is displaced backwards. Of the first variety he has seen several ex-
amples.
The first was in the person of Alexander Steele, aet. 29, who pre-
sented both a dislocation of the head of the humerus under the cora-
coid process of the left scapula, and pes equinus in the foot of the left
leg. The muscles of the arm and shoulder upon that side were feeble
and greatly atroj^hied. The humerus was shortened ; its head being
of the natural size and form, but when the arm hung by the side it
dropped so far from its socket as to permit the thumb to be placed
between the head and the acromion process. By pressing the humerus
forwards, the finger could be placed in the outer part of the glenoid
cavity ; and, although the head could be moved about thus freely,
it seemed naturally to occupy only the anterior half of the glenoid
fossa.
Robert Smith's second example of subcoracoid congenital luxation
was presented in the person of Mr. H., set. 20, the condition of whose
left shoulder resembled almost precisely that of Mr. Steele, "The
deformity had existed from his birth, but became much more obvious
and striking as he increased in age and stature."
In the third example the child had attained nearly the age of one
year before the condition of the limb attracted attention, which was
then excited, not by the deformity of the shoulder, but by the atn>-
phied condition of the muscles of the arm. The child had never com-
plained of pain about the joint, nor had he ever met with any acci-
dent. No doubt this also was an example of paralysis, and it is not
improbable that it was congenital, but the evidence ui)on this point is
not very conclusive. When seen by Mr. Smith, he was nine 3'e:irs old,
the shoulder and arm presenting the same appearance as in the other
cases mentioned.
Tiie fourth was also subcoracoid and symmetrical, the same de-
formity existing in both shouldei-s. This was in the person of a
female, let. 21, who had been for many years a patient in a lunatic
asylum, and who dieil of chronic inflammation of the meninges of the
brain,
n . Mr. Smith, who himself made the autopsy, first noticed the condi-
tl" \ tion of the left shoulder. The musclc»s were atrophied ; the head of
the humerus could be felt lying under the coracoid proci^ss ; the cllxivr
/ projected from the side, but could l)e readily brought into ix)ntact with
it. The right shoulder presented the same ap|>earanc«e, but the dt^
formity was somewhat less, and the head of the humerus was not :<»
directly underneath the coracoid process.
\
CONGENITAL DISLOCATIONS OF THE SHOULDER. 811
From the external appearances presented by the two shoulders, Mr.
Smith did not doubt that these deviations from the natural state of the
parts were not the result of violence.
Proceeding to remove the soft parts upon the left side, scarcely any
trace was found of a glenoid cavity in its natural situation, but imme-
diately underneath the coracoid process, upon the costal surface of the
scapula, was formed an oblong socket completely surrounded by a
capsular ligament, which ligament included also tiiat small portion of
the original socket which remained. The head of the humerus was
changed in form, being oval, and fitted, in some measure, to both the
old and new sockets, upon which it seemed to rest alternately.
Upon the right side, although the condition of the bones was some^
wliat different, the characteristic features of the deformity were similar.
Malgaigne, who quotes Mr. Smith as saying that these dislocations
must have been congenital, and for no other reason than because they
were symmetrical, has scarcely done this author justice. Says Mr.
Smith : " The position of the glenoid cavity, the remarkable form of
the head of the humerus, the presence of a perfect glenoid ligament,
the absence of any trace of disease, and the existence of the deformity
upon each side, all indicate the original nature of the malformation."
The only example of backward luxation seen by Mr. Smith was also
symmetrical, and seems to be equally well authenticated. This was in
the person of a woman named Doyle, set. 42, a lunatic also, who died
February 8, 1839, in Dublin. She had been a patient in the lunatic
asylum fifteen years, and was subject to severe epileptic convulsions,
which ultimately proved fatal.
Mr. Smith made the autopsy on the day following her death. The
convolutions of the brain were small and atrophied, as is frequently
observed in idiots.
The two shoulders resembled each other so perfectly, both in external
appearance and in their anatomy, that Mr. Smith has only found it
necessary to describe particularly the condition of one.
The coracoid process was remarkably prominent, but the acromion
was not so prominent as in accitlental dislocations of the shoulder.
The head of the humerus could be seen and felt distinctly moving
with the shaft, upon the dorsiil surface of the scapula. On removing
the integuments, muscles, etc., no trace of a glenoid cavity was found
in its natural situation ; but upon the external surface of the neck of
the scapula was a well-formed socket, which received the head of the
humerus. This socket was covered with a cartilage of incrustation,
and surrounded by a perfect capsule. The tendon of the biceps arose
from the top and internal margin of the socket. The form of the
acromion process was changed; the capsule smaller than natural; the
head of the humerus irregularly oval, its anterior half alone being in
contact with the glenoid cavity ; the great tubercle natural, but the
lesser was elongated and curved, forming a process of an inch in
length, around the base of which the tendon of the biceps muscles
playeil.*
^ Robert Smith, op. cit.
812 CONGENITAL DISLOCATIONS.
Gaillard relates the case of a female child, upon whom the left arm
was discovered to be deformed a few days after birth, and the elbow
separated from the side. Later, the arm was found to be nearly im-
movable, and only at the end of four years was the dislocation recog-
nized ; but no attempt at reduction was then made. When sixteen
years old, she was seen by Gaillard, who found the head of the hnnie-
rus in the infra-spinous fossa. The scapula, clavicle, and arm were
pretern at u rally small ; the forearm, although well developed, could
not be completely extended nor supinated.
Despite these unfavorable circumstances, Gaillard determined to
make an attempt to accomplish the reduction. Four times in the
Space of ei^ht days he submitted the arms to extension made at right
angles with the l)ody, by means of sixteen-pound weights, the exten-
sion being contiiuied from twenty to twenty-five miiuites, and occasion-
ally his own exertions being added to the weights. On the fourth
attempt, the head of the bone was drawn gradually forwards, and by a
rotatory motion it was finally made to slip into its socket ; but it be-
came immediately displace<l. The next day Gaillard reduceil it anew,
and retained it in place one hour. Six days later it wa.s again reduced,
and, by the aid of bandages, permanently retained in place. The
slight pain and swelling which followed soon disappeared ; and by the
aid of careful exercise, at the end of two years the arm had increased
in length, and the patient could use the arm and hand so much better
than before, as to encourage a hope that the recovery would be com-
plete.^
Aristide Rixlrigue, of Hollidaysburg, Penn., in a letter to the e<litor
of the American Journal of Medical Sciences, gives the following brief
account of a case of intm-uterine dislocation of the shoulder, con)[)li-
cate<l witli a fracture of the forearm.
*' The woman, when about four months gone with child, fell on Ikt
left side, striking a lM)ard, and felt hei'self much hurt at the time: at
the full peri(Kl she was delivered of a full-grown large lK)y with the
following deformity: disloc^ation of the humerus into the axilla; irac-
ture of both bones of the forearm of left side, lower thinl. l)i>kK-ation
could not he redu(xxl ; union of the bones of the forearm by ociciitic
matter cH>niplete ; bones passing each other, and hand at an angk* of
about 40° ; the child did well otherwise; now, four yeiirs old, ?itrong
and healthy ; humerus has grown nearly apac* with the other; forearm
has not, and remains short and deformed as in birth ; the hiuid is of
the same size with that of the sound side."^
i 9. Congenital Dislocations of the Badins and Ulna B ickwards.
It is not uncommon to meet with examples of a slight subluxation
backwards of thi^se l)ones in feeble and newly-lx>rn infants; which
ciMulition is prolwbly due to a relaxation and elongation of the f:i|>suli*.
It is chamctorizeil by a preternatural mobility of the joint, an*! esjn'-
<*ially by the circumstance that the limb is capable of abnornuil exteu-
» Guillara, Mem. de lAcad. do. MW , 1841, from M«lg . p. i>i«».
■ Kodrigue, loc. cit., Jan. lSo4, p. 272.
CONGENITAL DISLOCATIONS OF HEAD OF RADIUS. 813
sion, or flexion backwards, as it is sometimes called. Gu6rin has seen
this condition more advanced, the bones of the forearm having actually
overlap[)ed somewhat upon the lower end of the humerus, so that the
articular surface of this latter presented itself in the fold of the elbow.
This was especially observed in a girl of fourteen and a boy of thirteen
years, and also in the two arms of a foetal monster.^
Chaussier relates that a young woman, at the commencement of the
ninth month of pregnancy, perceived suddenly movements of the foetus
so violent that she almost lost her consciousness. These movements
were repeated three times in the space of six minutes, after which
everything returned to its natural order, and the accouchement took
place naturally and at the usual term. The infant was pale and feeble,
and presented a complete backward luxation of the radius and ulna.*
i 10. Congenital Dislocations of the Head of the Radius.
Examples of this luxation have been reported by Dupuytren, Cru-
veilhier, Sandiforte, Adams, Dubois, Verneuil, Deville, Robert Smith,
and Gu6rin, most of which were in the direction backwards, some out-
wards, but only one of them forwards ; some were double, the same
deformity being presented in both arms, and others were single. In a
few examples the dislocations were complicated with a consolidation of
the radius to the ulna, and in others with a deficiency of the ulna or
with some deformity indicating its congenital origin.
Of the symmetrical or double dislocation backwards Dupuytren
furnishes the following example, presented to him in 1830, by M.
Loir: '*The abnormal position which the head of either radius had
assumed was at the back part of the lower extremity of the humerus,
beyond which it extended for the space of at least an inch. This dis-
position of parts was absolutely identical on the two sides, and had all
the characters of a congenital affection.''^
In January, 1860, John Fitzmorris, let. 19, was admitted to the
Bellevue Hospital, laboring under a general scrofulous cachexy, in
whose person I found a congenital dislocation of the heads of both
radii, outwards. The luxations are complete. The ulna? are in place
and of natural form, but their articulations at the wrist are loose. The
same remark applies to all the other joints in the body. The power of
pronation and supination is unimpaired, as well, also, as the power of
flexion and extension.
In the example of outward luxation, mentioned by Deville, there
was an almost complete absence of the ulna, the head of the radius
mounting upwards more than three centimetres above the level of the
articulation.^
Gu6rin, who has described the only example of a forward luxation,
says it was observed by him in a girl of seven years, and that it was
* Guerin, op. cit., p. 31.
2 ChHUPsier, from Malgaigne, op. cit., t. ii, p 268.
* Dupuytren, Injuries and Die. of Bones, p. 117.
* Deville, Bulletins de la Soc. Anat., 1S49, p. 153.
814 CONGENITAI. DISLOCATIONS.
symmetrical. The two radii lay in front of the htimtT
coronary fossettee.'
i II. Congenital Dislocation! of the Wriit.
Gn6rin thinks lie has sevn three forms of congenital luxation of tWl
wrist. First, a dislocation forwards, characteri7.cil by a sliding of tbst
wrist before the bones of the forearm, and by the projection ixjateriorlyj
of the lower ends of the radius and ulna; seen in an infant uf hs|
months, and in two adults. Second, backwards and upwnn^ls;
in a cihiid of six years, and accompanied with an incomplete pamlysirj
of all the muscles of the forearm and hand. Third, backwards an4f
outwards; in a girl of fourteen years, accompanied with incomplet
paralysis.'
Gu6riii has also seen three examples of dislocation outwards in fwlaU
monsters, and one of dislocation inwards, as the result of arrest (
development.
Robert Smith believes that the case of simple dislocation of thi
wrist or of the carpus forwards, mentioned by Cmveilhier in hnl
Anatomic Patholof/U/ac, was an example of congenital luxation ; and ham
relates two other cases equally remarkable which came under iii» own]
observation. One was in the |>enion of Deborah O'Xeil, a lunatic aw
epileptic, who died when thirty-six years old. Both upper extrcmitieil
were deformed from birth ; the right presenting an example i>f dislo
cation of the carpus forwanls, and the left of dislocation of the mqi
backwards. The dissection showed tiiat there had been an amst o
development, especially in the bones of the forearm and CHrpus. Thi
second was in the person of a young woman who died of phthitiis ifrj
the Richmond Hwpital; the right wrist presenting an cxumpie of
congenital dislocation of the carpus forwards from arn^t of ilcvclop^
^ ment also."
Marrigues describes a very singular wmgenital displacement wliid
' hs found upon a newly born infant. The radius and ulna were wideljtji
separated below, and in the interspace was lodgud the whole of the firal
range of the carpal bones ; the hand being strongly turned inwards.' 4
i 12. Congenital Diilocationi of the Finders.
Chaussier found in a f'etm the last three lingers of tlip left hno^j
dislocated at the metacarjio-phalangeal artieulatiou. The thigli^, kn«
and feet were also dislocated.*
A. Bfrard speaks of an incurvation backwards of the Insi two pluk
langes of the fingers as having been occasionally f*ecn in newly (win
children of the female sex ; and Malgaigne adds that he Iul4 hiinM^
seen a woman who had, from birth, all the phaJam/rlleB carried bacb
' Gu«rln. Of, cil.. p. 81. • Ibid., p. TIT.
' R. Smilh, op cU., pp. 3»8. 951.
< Mnrrii-ura, MHleniiine, rmm Journ. d« MM., 1TT&, I. U, p. SI.
* C'huu»ier, Mnlgalgne, op. cit., t. li, p. 761.
CONGENITAL DISLOCATIONS OF THE HIP. 815
wards to an angle of 135°, leaving the heads of the phalanges project-
ing forward under the skin.*
Robert has seen, in a girl six years old, a congenital lateral luxation
of the phalangette of the index finger, which was inclined outwards at
an obtuse angle. The external condyle of the lower extremity of the
proximal phalanx was slightly atrophied, and the internal presented a
corresponding projection. Rol>ert cut the internal lateral ligament by
a subcutaneous incision, but without any favorable result.^
i 13. Congenital Dislocations of the Hip.
Dupuytren thought that double dislocations of the hip-joint, as con-
genital accidents, were more common than single dislocations, but in
the experience of Pravaz the rule has been reversed, he having met
with but four double dislocations in a total of nineteen.
Congenital dislocations of the femur have been noticed much oftener
in females than in males. Of forty-five examples mentioned by Du-
puytren and Pravaz, only seven or eight were males.
They may be complete or incomplete. Of the complete luxations,
four varieties have been noticed.
Upwards and backwards, upon the dorsum ilii. This variety is by
far the most common.
Upwards and forwards ; the head of the femur resting upon the
eminentia ilio-poctinea.
Downwards and forwards into the foramen thyroideum ; of which
variety Chaussier alone mentions one example ; but Delpech found in
an infant, born paralytic, the head of the femur Icxlged habitually wear
the foramen thyroideum.
Dircvtly upwards ; seen by Gu6rin, Pravaz, and others ; the head
of the femur being placed immediately without the anterior inferior
spinous process of the ilium.
Gu6rin has observed, moreover, a single variety of subluxation ;
characterized by the incomplete displacement of the head of the femur
in the direction upwards and backwards, so that it rested upon the
edge of the cotyloid i^avity : " observed often in newly born children,
and with those in whom the muscular dislocations are effected spon-
taneously after birth."
Through the courtesy of Dr. Davis, of this city, I was permitted, in
March, 18f)5, to see a child, the daughter of a gentleman residing in
Victor, Monroe Co., N. Y., who was born in 1860, with dislocation of
both knees and both hip-joints. The legs at the time of birth were
doubled forward upon the thighs, the heads of the tibias resting upon
the front of the femurs, one inch above the condyles, the thighs being
at right angles with the Ixnly and the feet touching the abdomen. The
knci^s were drawn closely together. The dislocation of the heads of
the femurs was not at this time recognized. By constant pressure Dr.
J. B. Palmer had succeeded, at the end of one year, in restoring the
1 B^rardf Malg^ftigne, op. cit., p. 773.
* Robert, from Malgaigne, op. cit., p. 778.
816
CONGENITAL I>IS LOCATIONS,
leg to posilian, the tliighn remaining flexed ; but when ttra years nidi
she liegan to walk witli Iter body bent fbrwaiflii. The displatwment ofv
the hip-boiiea was then first discovered. When four years old tbej
sartorius and tensor vaginie femoris were severed, bnt wJlh very littleV
benefit. At the time of my examination she was five years old. The!
thighs were still flexe<l and adducted ; by pressure upon the k»ec» thel
femurs could be slid upwards aud backwards upon the ilium one inob^l
on rotating the femurs the trot^hantera were ol^rved to move upon ^1
very short radium, indicating the entire absence uf head and neck. Sb» J
walkeil with the gait peculiar to these conditions.
Both Delpech and Gu6rin have called attenliun to two varieties otm
what the latter terms pseudo-luxations; of which the first simulate*]
a dislocation upwards and backwai-ds, and the second a dislocatioi^l
downwaiils and forwards. In these examplei^, the extreme adductionf
or abduction of the thighs might lead to a belief that the bones v
dislocated, when in lact tlie abnormal position of the limbe i.s due oulf I
to muscular contraction, without actual articular displacement. I
In the remarks which follow we shall have special reference lo timfel
form of congenital dislooitions of the femur in which the bead of thefl
bone rests upon the dorsum ilii, as being that which will be preseiitedl
in a vast majority of cases, and' which, characterized by the sam
general phenomena, may lie regarded as typical of all the others.
Si/jnptoriuilotoffff. — Fii-st. When the dislocation is double.
In these examples the deformity is often found to be symmptrioiljfl
the opposite limbs being precisely the same length, and in the sami
relative positions; a circumstance which, wlien it exists, may rend
the diagnosis more difBcuIt, or may cause it to be for a long tin
entirely everlooked. It is in such cases esjwcially Ihat the deformity]
is not usually discovered until the child begins to walk. I
The first circumstance which would naturally arrest our at^nti'JB,'!
if the person who is the subject of this double dislocation is ftriji^MdJ
I snd 'placed erect before us, is the great apparent length of tli« anow
and of the Irody in comparison with the lower extremities. Wt- majH
next observe that the great trochanters are carried upwards and bncit'
wanls, so as to make a remarkable projection in ihiy direction;
lumbar portion of the spinal column is thrown very much fiirwardrl
and the dorsal portion liackwards. The thighs incline inwaix)!), «>■
almost to cross each other; the whole of the lower extremities nn
imperfectly developed and feeble; the toes arc generally pointed <)m
reclly forwards, or they may be notici-d to turn inwards. I
When the person stands, and his limbs arc not in motion, the bcdl
ie usually brought d<iwn fairly to the floor; but in walking, anJI
eepecially in the attempt to run, he touches only the tmlU and Iom ia
his feet. " When they are about to walk," says Pnivnz. " wc «« iheH
lifl tlicraselves upon the points of the fei't, to incline thi.' :iu|)eriur poit^
of the trunk toward the meral^er which is about to snp)iort the wi-iglrf*
of the Ixxly, and to lift the other fi-om the ground with au effort, i
order to carry it forwards. At this moment one of tbo Irochanlii
that which corrrajHinds to the column of sustentjitioii, apgivan' i
approach the iliac crest more nearly than when the patient is stauiliii)
CONGENITAL DISLOCATIONS OF THE HIP. 817
upon his two feet." In consequence of which mobility of the thigh-
bones, the patient assumes a peculiar waddling gait, which is not only
ungraceful, but exceedingly fatiguing.
The difficulty of progression is, however, very variable in different
I)ersons. Sometimes the patient requires no aid whatever, and at
other times he cannot walk without assistance. Generally it increases
with age. It is especially deserving of notice that in rapid progression
the mobility of the heads of the femurs is appreciably less than in
slow progression, which is explained by the more constant and vigor-
ous contraction of the muscles about the joint, when the motions of
the limb are rapid.
In the recumbent posture, the thighs may be drawn down easily to
almost their natural positions. The only exception to this rule, ac-
cording to Carnochan, ^* is when the head of the femur has escaped
from the natural capsule in which it was originally inclosed, and a
new socket has been formed upon the dorsum of the ilium."
Abduction is performed with difficulty ; adduction and rotation,
especially inwards, being less restricted.
Second. When the dislocation is only upon one side.
In these cases the symptoms are essentially the same as in the double
dislocation; with only such slight differences and peculiarities as would
naturally suggest themselves to the surgeon, and which will not, there-
fore, demand from us a special consideration.
Pathology. — The head of the femur is sometimes merely changed in
form and consistence, the neck also undergoing corresponding altera-
tions in its size, form, direction, etc. ; at other times the head is absent
altogether, and with it a considerable portion or the whole of the neck
has disappeared.
The pelvic bones are usually more or less deformed. The acetabu-
lum may be entirely deficient, or it may })resent itself as an irregular
bony protuberance, without cartilage, fibro-cartilage, or ligaments.
Sometimes it exists as an oval or triangular cavity, which is expanded
as its superior and posterior margin into a distinct fossa, where the
head of the femur, descending from the dorsum ilii, occasionally rests.
A new cavity is formed usually upon the side of the pelvis, which is
shallow and without an elevated n)argin,or it may be dee|)er, and more
complete in its construction, by the addition of an osseous border. In
cither case, the new socket is often lined with a true ])eriosteum and
synovial membrane; but not unfrequently it is unprotected by any
soft tissue, the surface being hard and polished like ivory.
The head of the femur, having escaped from its original capsule,
through a button-like opening, rests in this socket constantly. In still
other examples the head of the femur remains within its capsule, and
may be observed to play backwards and forwards l)etween the two
sockets ; or the head and nec^k being absorbed, and the capsule remain-
ing entire, the latter is converted into a long narrow sac, somewhat
contracted in its centre, or finally into a firm ligamentous cord, which
being attached to the stunted upper extremity of the femur, limits its
motions in the direction of the crest of the ilium. In this case no new
socket is formed.
818 CONGENITAL DISLOCATIONS.
A portion of the pelvi-feraoral muscles are contracted, in con5?oqnence
of an approximation of their points of origin and insertion, and re-
maining in a state of comparative, if not absolute, inertia, they become
atrophied, or pass into a condition of fatty degeneration, while other
muscles, in consequence of the increased labor which they have to per-
form, become hypertrophied, or degenerate into a fibrous tissue.
Treatment. — Says Dupuy tren : " Of what possible utility can it be
to practice extension of the lower extremities in these cases, even sup-
posing the limbs could be thus brought to their natural length? Is
it not evident that the head of the femur, finding no cavity fitted to
receive and hold it, would, when abandoned to itself, resume its former
abnormal position ? There is something more rational and fea*^il»le
in adopting a palliative course of treatment. When we call to mind
the natural proneness which the heads of thigh-bones have to ascend
to the external iliac fossie, and that this tendency is partly due to the
superincumbent weight of the body, and in part to muscular action, a
just conception may be formed of the indications on which the emnloy-
ment of palliative remedies should be founded. The object should be
to relieve the lower limbs of the superincumbent weight on the one
hand, and on the other to moderate the muscular action. Both of
these indications are in part fulfilled by repose; and the attitude most
conducive to this effect is the sitting posture, in which the weight of
the upper part of the body is not. transmitted to the lower extremities,
but is centred in the tuberosities of the ischia. Therefore, laboring
persons afflicted with this infirmity should l)e rec^ommended to adopt a
sedentary occupation, as a calling which requires much standing and
walking about would dangerously aggravate their deformity. Yet
one would scarcely be willing to condemn such individuals to pcT-
j>etual rci>ose; and to avoid this it is necessary to discover some means
for diminishing the inconveniences which attend the upright posture,
the act of walking and other exercises. Experience has taught rae
hitherto but two methods of obtaining this imj)ortant object: the first
consists in the daily employment of a perfectly cold bath, in which all
the body should be immersed for the space of three or four minute?^,
the head being protected by an oiled-silk cap; the water may be fresh
or salt; and the only precautions necessary to take are to avoid kith-
ing when the body is in a state of perspiration, or when the catamenial
discharge is present. These baths have a local, as well as general,
tonic effect. The second method consists in the constant use, at lea^t
during the day, of a belt, which embraces the pelvis, fitting cloe^ly
over the great trochanters, and keeping them at a constant height, >o
as to bind the parts together, and prevent that continual unsteadiness
of the body which results from the loase connections of the heads of
the thigh-bones. For the proper fulfilment of these indications, cer-
tain precautions are necessary in the construction of this cincture; in
the first place, it should occupy the narrow interval between the crest
of the ilium and great trochanters, completely filling this space, and
therefore being about three or four fingers' breadth, according to the
age and size of the patient. It should further be well padded with
wool or cotton, and covered with doeskin, so that it may not abrade
CONGENITAL DISLOCATIONS OF THE HIP. 819
the parts to which it is applied; and there should be a piece let in on
either side, so as to receive and support the trochanters without en-
tirely covering them ; it should be buckled behind, and padded straps
be carried under the thigh, and across the tuberosity of the ischium,
on either side, to prevent the zone from slipping up. I do not mean
to assert that I have ever succeeded in completely getting rid of the
inconveniences of congenital dislocations of the thigh-bones, but I
have prevented their increasing, and have rendered supportable what
I could not cure. The testimony of some patients to the value of this
treatment has been of a most unequivocal character; for being worried
by the pressure of the belt, they have laid it aside, but have speedily
restored it again, as they found that without it they had neither a sense
of firmness in the hip, nor confidence in walking.
In relation to which opinions the same excellent writer subsequently
made the following candid admission : " I at first thought that no bene-
fit would be derived in these cases from the employment of continual
traction on the lower extremities, for reasons already stated ; but the
experiments of MM. Lafond and Duval tend to throw some doubt on
the correctness of this conclusion. These distinguished practitioners
tested the influence of extension, in their orthopjedic institution, on a
child eight or nine years of age, who was the subject of double con-
genital dislocation of the hip; after the uninterrupted employment of
this treatment for some weeks, I satisfied myself that the limbs had
resumed their natural length and direction ; but I was not a little
astonished to find that, after extension had been persisted in for three
or four months continuously, the greater part of the beneficial results
remained for several weeks undiminished. It would l>e idle, it is true,
to generalize on this single case ; but as an isolated example of the
utility of extension it is interesting, and it may be the forerunner of
more important results."^
Since which time Humbert and Jacquier, who, as well as Duval
and Lafond, confined themselves to the treatment of deformities, claim
to have met with equal success in the management of these cases by
extension alone; and, still more lately, Gu6rin of Paris, and Pravaz of
Lyons, by the adoption of the same general principle more or less modi-
fied, have added new triumphs, and greatly enlarged its appli(;ation.
The means recommended and practictnl by Gu^rin, are: first, pre-
paratory extension destined to elongate the muscles as much as pos-
sible; second, subcutaneous section of the muscles which mechanical
extension has not sufficiently elongated ; third, extension of the liga-
ments, and even, if extension does not suffice, their subcutaneous sec-
tion ; fourth, mano}uvres destineil to effect reduction ; fifth, treatment
designed to consolidate the reduction, and consisting in the application
of the apparatus proper to maintain the extension and separation of the
divideil tissues, and to retain the head of the femur in its place; finally,
in the gradual execution of movements proj)er to complete the coapta-
tion of the surfaces, and to establish, little by little, the physiological
movements of the joint.
* Dupuytren, op. cit., pp. 176-178.
820 CONGENITAL DISLOCATIONS.
Other surgeons have confined their efforts to the reduction of the
dislocation, and they have, consequently, abandoned all those cases in
which, owing to the complete absence of the natural socket, or to the
want of sufficient mobilitv in the limb, the reduction was deemed im-
possible ; but Gu6rin has gone a step farther, and has sought to estab-
lish a new socket upon some point of the pelvic bones as near as po?*sible
to its natural articular fossa. "The means which I adopt," says
Gu^rin, "are based upon a recognition of the processes which nature
employs for the attainment of the same purpose, and of which mine
are but an imitation. I have shown that the essential condition of the
formation of artificial cavities is perforation of the articular capsule,
and the placing in contact of the luxated extremity with an osseous
surface, and that the condition of the maintenance of this abnormal
rapport is the intimate adherence of the borders of the rent with the
circumference of the new cavity. Now it appeared to me that art
could realize, in all points, the conditions which preside at the spon-
taneous formation of artificial joints. To this end I commence by
practicing under the skin, and at the point corresponding to that where
it is most convenient to fix the luxated extremity, scarifications of the
capsule, down to the bone to which it is attached. By this means the
disloc»ated extremity is placed in immediate contact with the bony sur-
face upon which it reposes. It makes upon this point a beginniuor of
the work of organization resulting from the adhesion and fusion of the
scarified points with the corresponding points of this surface. Then,
in order to circumscribe and imprison the luxated extremity, in this
place of election, I practice all about deep scarifications, which tend to
excite the same work of organization and to establish fibro-cellular
adhesions between the incised borders of the capsule and the contigu-
ous bony surfaces.
"Finally, when the fibro-cellular adhesions are supposed to be suf-
ficiently solid to resist the movements of the new articulation, I pro-
voke, little by little, the development of the cavity destined to embrace
the luxated extremity by the means which nature herself employs in
analogous circumstances ; that is to say, by circumscribed and fre«juent
movements of this articulation."*
The treatment ought to be commenced as early as ix>ssible, no ex-
amples of success having been recorded in persons over fifteen years of
age ; while the youngest child whose treatment is rej)orted as succi'ssful
was three years of age.
For the purposes of making the requisite extension, and of main-
taining the lx)ne in place, Pravaz (who does not, however, adopt GuiTin's
practice of establishing for the head of the Iwne a new socket, l>ut only
seeks to reduce and maintain it in its old socket) has inv^ented S4*verjl
forms of apparatus adapted to the different stages of progress in the
treatment. Heine of Caunstadt, Gu6rin, and others, have also sug-
gesteil sjKXiial contrivances for the same purpose ; but no surgeon wlio
understands fully the principle upon which tlie cure is supptiseil to be
^ Gii^rin, op. cit., pp. 81-83.
CONGENITAL DISLOCATIONS OF THE PATELLA. 821
accomplished, will be at a loss for apparatus suitable for making the
necessary extension, or for maintaining the reduction when once it has
been effected.
The length of time required for the completion of a cure, where a
cure is possible, must vary according to the age and health of the
patient, and according to the pathological condition of the joint, and
mav be found to extend from a few months to one or more years. It
is unnecessary to say that where the accomplishment of the cure de-
mands a period of several years, the treatment must be intermittent
and greatly varied, so as to suit all the changing circumstances in the
condition of the patient.
Finally, if after a fair trial we fail to accomplish a cure, or if the
condition of the child will not warrant even the attempt, we ought as
far as possible to seek to prevent an increase of the deformity by such
means as our ingenuity may suggest, or by such judicious appliances
and general management as we have seen recommended by Dupuytren.
South says that he has seen one case of double dislocation in which
the walking was at first extremely difficult, but from the fifteenth year
and onwards the patient so improved, that at the twentieth year scarcely
any trace of the peculiar gait could be discovered.^
i 14. Congenital Dislocations of the Patella.
Palletta found a dislocation of the patella in the cadaver of a young
man, which he supposed to be congenital.* Michaelis has reported
two cases ; one in a young man of seventeen years, and the other in a
girl of fourteen, each of whom affirmed that it had existed from birth.*
Both of tlk^e examples presented themselves at the hospital on account
of hydrarthrosis of the knee-joints, and Malgaigne, who had himself
seen a similar case, is disposed to regard them all as examples of path-
ological rather than congenital luxations. P6riat reports a (^ase in
which the dislocation was only produced by walking, and in relation
to the authenticity or pertinence of which Malgaigne seems also to en-
tertain a doubt.*
South says that he has seen a congenital dislocation on both legs, in
an aged man. The patellie rested entirely upon the outer faces of the
external condyles, leaving the front of the knee-joint completely un-
covered. When the limbs were extended the patellar could be easily
made to resume their natural positions, but on the patient's making
the slightest movement they were again displacinl. The knees were
very much inclined inwards, the feet outwards, and his gait was diffi-
cult and unstcadv.*
JV. Samuel G. Wolcott, of Utica, N. Y., informs me that he has under
observation a case similar to the one reporte<l by South, in a healthy
and otherwise well-formed and well-developed boy, let. 4. " When
the legs are flexeil the patellae slip outwards u|>on the external condyles
' South, Note to Chelius, op. cit, vol. ii, p. 245.
' Palletta, Exfircitationi'S Puthologiea*, p. 91.
' Michiieli!*, Kov. Med.-Chiruri^., torn, xv, p. 60.
* PoriMt, MrtlgMigne, op. cit., torn ii, p. 932.
* S«»uth, Note lo CIipHus, op. cit, vol. ii, p 247.
822 CONGENITAL DISLOCATIONS.
of the femurs, and on extending the 1^ the patellae resume their jx)si-
tions in front of the knee-joints. This occurs at every step he takes.
The knees are strongly inclined inwards, and the feet outward. His
step is very insecure, and if accidentally he hits his feet or legs against
anything in walking, he invariably falls."
The most remarkable example, however, has been reported by Dr.
E. J. Caswell, of Providence, R. I., inasmuch as no less than five
members of the same family have double congenital dislocations of
the patellae. The man who was the subject of Dr. Caswell's special
examination is 43 years old, and possessed of a good constitution.
The patellae lay upon the outer condyles, and are movable, [)erforniing
their functions nearly as well as if placed in their proper ixjsitions:.
He walks without difficulty upon level ground, or uj)on an ascending
plane, but great caution is required in descending. The right patella
is longer and less movable than the left, and the muscles of Inuli of
his lower extremities are small. "In addition to his labor as an oj^ht-
ative, he cultivates a small farm." Dr. Caswell examined his son
and found the same malposition, but less marked than in the case of
the father. The father then stated that his own father, his sister, and
the son of his half brother by the same father, had a similar de-
formity.^
i 15. Congenital Dislocations of the Knee.
The head of the tibia has been found, at birth, dislocated forwards,
backwards, inwards, outwards, inwanls and backwards, outwards and
backwards, and simply rotated inwards.
Mast of these luxations were incomplete ; and of them all, the dis-
location forwards has been observed much the mast often.
A subluxation forwards of the head of the tibia has been seen by
Gu6rin in a foetal monster, accompanied with extreme retraction of the
extensor muscles of the leg.^ Cruveilhier has dissected a foetus aflected
with a similar subluxation.'
In these examples the displacement forwards at the articular surface
was but slight, and the anterior flexion of the limb inconsiderable;
but when the dislcK'ation is complete, or nearly so, the deformity is
in all res])ects very much increased ; as the following examples will
illustrate :
Dr. D. H. Bard, of Troy, Vermont, has reported an example of
complete anterior luxation of the tibia, seen by himself, in a new-lH>rn
infant. The; leg was found drawn forwards upon the thigh at an acute
angle, so that the toes pointed toward the face of the child, and the
bottom of the foot was directed forwards. By the application of nuKl-
erate force*, the limb could be straightened and even flexed completelv.
These motions inflicted no pain. It was esj)ecially noticed that in
bringing down the leg from its j>osition of extreme anterior flexion
(extension) more force was required in the first part of the nianieuvre
than in the last; and that if, having brought the leg down, it was lot\
> Caswell. Amor. Journ. Med. Sci., July, 1865. » Guerin, op. cit., p. 33.
» Cruveilhier, Alius de I'Anat. PalholoR., 2e livr., pi. 2.
CONGENITAL DISLOCATIONS OF THE KNEE. 823
to itself, it immediately resumed the abnormal position, moving at first
slowly, but after a time much more rapidly.
The limb was confined by bandages for a short time, and it did not
afterwards show any disposition to return to its unnatural position.
The child did well, and when it began to use its legs, no dillerence
could be discovered between them.^
J. Youmans, of Portageville, X. Y., reports a similar case which
occurre<l in his own practice. A healthy woman was delivered, on the
16th of August, 1859, of a full-grown female child, whose left knee
was so completely dislocated that the toes rested upon the anterior part
of the thigh near the groin. Dr. Youmans immediately took hold of
the limb and brought it to its natural form, but as soon as he relin-
quished his hold, it flew back to its original position. Having again
straightened the leg it was retained in place easily by two pieces of
whalebone tied upon each side of the thigh and body. Some soreness
and swelling ensued, and it was some weeks before the splint could he
safely removed. At the time of the report, Octol)er 11, 1860, the child
was using the limb with as much freetlom and dexterity as other chil-
dren of her own age.
In the report particular attention is called to the disposition on the
part of the limb to resume its unnatural position with a spring, show-
ing contraction of the anterior muscles of the thigh; to the fact that
the patella of this knee was smaller than the other, and that the skin
on the front of the knee was wrinkled as it is usually back of the knee
in fat children.^
I have mentioned a case of congenital forward dislocation of both
tibise which came under my observation, in the section on congenital
dislocations of the hip, and I have recently seen a case of congenital
subluxation of both tibiie backwards, occasional by c^ontraction of the
hamstrings. Section of the muscles restored the bon(»s nearly to their
normal position.
Chatelain was consulted in relation to a similar case, in which the
restoi-ation of the limb to its natural position was also easily elVected,
and by means of three metallic splints, applied during about fifteen
days, the cure was consummateil. Chatelain directed, however, that
the leg should be kept fiexetl u[>on the thigh eight days longer."*
Klwl^erg found a child with the leg so much flex(»d forwards (ex-
tendc<l) upon the thigh that the popliteal region became the huvcst
point of the limb; in front and above the articular extremity of the
tibia could be felt, and the condyles of the fenjur made a correspond-
ing projection behind into the popliteal space. This wius plainly an
example of complete luxation ; and, contrary to what was observed in
Bard's case, flexion of the limb backwards was diflicult and fniinful.
The treatment was commenced by securing the limb in a straight
position by means of a splint and roller; subsequently, Kleeberg car-
ried the limb back to an obtuse angle, and finally, it wits kept eight
1 Bard, Amer. Journ. Med Sci., Feb. 1835, p. 6o5, from Bost. Med. nnd Surg.
Journ., Nov. 26, 1884.
* Younuins, Bost. Med. and Surg. Journ., Oct. 25, 1860, vol. Ixiii, p. 260.
' Chatelain, Bibliothdque Med , torn. Ixiv, p. 85.
824 CONGENITAL DISLOCATIONS.
days in a position of extreme flexion. A complete cure was said to
have been accomplished in about two weeks.*
Gu^rin has seen a subluxation backwards, accompanied with a slight
rotation of the head of the tibia outwards, in a girl fourteen years old;
and which, he affirms, was congenital, characterized by a |>ermanent
flexion (backwards) of the leg upon the thigh, and a slidhig of the con-
dyles of the tibia backwards.
This girl was under Guerin's treatment, but with what result is not
stated.^
Chaussier found both tibise displaced backwards in an infant other-
wise deformed.^
Robert speaks of an example of lateral subluxation in a man, which
had existed from birth. The right knee was thrown inwards, and the
left outwards.*
Gu6rin ** operated" publicly upon a child, two years old, who had a
congenital dislocation of the head of the tibia backwards and inwards,
accompanied with a slight rotation of the leg inwards.* In what man-
ner he operated, and with what result, he does not inform us.
The same writer speaks of a subluxation backwards and outwards,
with rotation in the same direction, a deformity which, he affirms, is
very frequent, and which ap}>ears especially after birth, although the
causes which produce it have given their first impulse during intra-
uterine life.
The case quoteil from Robert, by Malgaigne, as an example of dis-
location inwards, seems to have been rather a case of semi-rotation of
the articular surfaces, the inner condyle being thrown l>ack into the
popliteal space, while the outer condyle still retained its natural jRisi-
tion.
i 16. Congenital Dislocations of the Tarsal Bones.
Under this general term may be included all those varieties of sub-
luxation of the several bones which compose the tarsus, and which are
known as examples of talipes or club-loot; such as tibio-astmgaloid
luxations, astragalo-scaphoid, calcaneo-astragaloid, calaineoHHilM)id, etc.
Although these deformities may properly enough claim a place in a
chapter on congenital disUx^ations, they have so long been the subjects
of special treatises as to justify their exclusion from the present volume.
17. Congenital Dislocations of the Toes.
Observed occasionally at the metatarso-phalangeal articulations ; the
articular facets of the fii*st phalanges suffering a subluxation upwanls,
or laterally upon the corresponding metatarsal bones.
Gurrin has noticed cs|)ecially a c^ongcnital lateral subluxation of the
great toe/'
* Klecb<T|:, ^Inlj^nigno, op. cit., p. 983. * Guerin, sur les Lux. Congen.. p. S3.
' Chnu^sior, ^iMljraiijne. op. cit., p. 884. ♦ Kobort, Malg., op. cit , p *jS6.
• Guerin, sur les Lux. Congen., p. 83. • Guerin, op. cit., p. 84.
INDEX.
PART I. FRACTURES.
Abscess in fracture of the sternam, 173
Acetabulum. 359
Acromion process, 215
Amenbury's tbi^h splint, 420
AnsB.othetic?, use of, in diiignosis, 37
Anatomical neck of humerus, 223
Ann plasty in frnotures of the septum nariam,
98
Anchylosis after Colles's fracture, 295
after fracture!) of elbow, 2(^6
excision for anchylosis of knee, 459
Apparatus immobile, 54
in fractures of the leg, 489
Arytenoid cartilages, fractures of, 142
Ashhurst, fracture of astragalus, 505
Astragalus, 502
Atlas. 167
and axis, 168
Axis, 164
Ayres, compound fracture of clavicle, 191
Badly united fracture of leg. 501
Burtlett's apparatus for broken clavicle, 203
Barton's bran dressing, 63, 499
bandage for fractured jaw, 133
trephining vertebrse, 152
fracture of lower end of radius, 293
Base of acetabulum. 360
Bauer's wire splints, 498
Beach, R E., fracture of patella, 470
Beans, lower jaw, 127
Bending of bones, 74
Biceps, displacement of long head, 614
rupture of, 614
Bigelow. stellate fracture of lower end of ra-
dius, 291
rim of acetabulum, 362
Bonrdnian, fracture of ly go ma, 108
Body of the scapula, 209
Bodies of the vertebrie, 154
Bond s elbow splint, 263
radius splint, 298
Bosworth, Frank, tracheotomy in fractani of
lower jaw. 1 12
Box for leg. 499
Boyer's thigh splint, 420
Brainard, perforator, 71
Buck, lower jaw. 122
thigh splint, 427
Burge, patella, 471
Calcanenm, 503
Carpal bones, 343
Cartilages, 180
Carved splints, radius, 305
Cervical ligaments, strains of, 160
vertebrae, bodies of five lower, 158
axis, 164
atlas, 167
atlas and axis, 168
Children, fracture of femur, 453
Chronic rheumatic arthritis, 385
Clark, fracture of humerus, 250
Clark's ease of fracture of pelvis, 352
Clavicle, 182
partial fractures, 183
repair of fractures, 187
Cline, trephining vertebrae, 151
fracture of atlas, 167
Coates, fracture bed, 445
bran dressings, 63
Coccyx. 367
Colles*8 fracture, 286
Comminuted fractures, 61
Common signs of fracture, 34
Compound fractures, 61
forearm, 343
thigh. Qilbert on. 429
thigh, author's opinion, 455
patella, 466
tibia and fibula, 489
Concussion of spinal marrow, 161
Condyles of humerus, 267
internal, 272
external, 275
base, 257
base and between oondjles, 264
of femur. 455
external, 455
internal, 456
base. 458
between condyles, 458
CongeniUl. 31. 246. 473
Cooper, Sir Astley, fracture of oleerMioii prO'
CMS. 329
neok of femur within capsule, 379
patella. 468
Coraooid process, 219
Coronoid process of ulna, 315
Cotyloid cavity, 369
Counter-extension by adhedve plaster, 429
Crftdle for leg, 498
58
826
INDEX — FRACTURES.
Crnndall, eztenrion, fracture of leg, 495
Cricoid cartilage, 142, 144
Crosby, neck of femur within capsule, 389
external condyle, 455
Daniels's fracture-bed, 447
Deformities of legs.' 501
Delayed or non-union, 63
humerus. 248
tibia. 474
Dennis, F. S., fracture of inferior maxilla, 117
Dextrin. 55
Dingnosis, general, 33
Dieffenbacb. tenotomy in fracture of olecranon
proce!>s, 331
Diitlocotion of humerus, differential diagnosis,
23S
Division of fractures, general, 27
Dorsal vertebra), 158
Dorsey, fracture of patella, 467
Dugas, sign of dislocation of humerus, 238
Dupuytren's case of fracture of a dorsal ver-
tebra. 158
body of a lower cervical vertebra. 159
dressing for fracture of fibula, 480
Elbow splint, Pbysick's, 262
Kirkbdde's, 262
Rose's, 262
Welch's, 262
Bond's, 263
the author's, 264
Else, fracture of axis. 164
Emphysema in fracture of ribs, 178
Bpioondyle of humerus, external, 272
internal, 268
Epiphyseal sepn rat ions, 29
acromion, 216
humerus, upper end, 229
lower end, 257
femur, upper end. 373
lower end, 460
trochanter major, 403
Epiphyses, sternum, 170
scapula. 217
humerus, 230
radius. 310
ulna, 319
OS innominatum, 351
femur, 368
tibia, 473
fibula, 477
Epitrocblea. 268
Etiology, general. 29
Eve, non-union of ribs, 177
patella, 466
Exciting causes, general, 30
Experiments on bending. 7'>
on partial fractures. 80, 83
External epicondyle of humerus, 272
condyle of humerus, 275
femur, 455
Extension of thigh by adhesive plaster, 444
Fanning, N., humerus, 247
Fauger, Colles's fracture, 298
Felt splints, 51
Femur. 367
neck, within capsule, 369
Femur, neck, anatomy of, George K. Smitk,
383
differential diagnosis, 374
without capsule, 393
trochanter major and base of neok, 401
epiphysis of trochanter major, 403
shaft. 404
measurement of, 418
in children, 453
external condyle. 455
internal condyle. 456
between condyles, 458
base of condyles, 458
separation of lower epiphysis, 460
Fibula, 477
Fingers, 347
Fissures, 86
neck of femur, 372
Fitch, fractureof lower jaw, 131
Flngg'S thigh apparatus, 426
Floating cartilages in knee-joint, 740
Forearm. 322
Fore's case of fracture of hyoid bone, 138
Four-tailed bandage for broken jaw, 133
Fracture beds. 445
Jenks, 445
Hewson, 445
Barton, 445
Coates, 445
Daniels, 447
Burges, 432
Crosby, 448
Fracture-box, 499
Gangrene, after fracture at base of condyles
of humerus, 261
Dupuytren's cases after fracture of radios,
305
Robert Smith's cases, 307
Norris. 308
after fracture of forearm. 335
leg. from tight roller, 433
patella, 468
from tight bandages. 48, 476
leg, from tight bandages, 487
from use of " apparatus immobile," 433,
489
Gibson, bandage for fractured jaw, 132
fracture of clavicle, 192
of coracoid process, 219
Gilbert, apparatus for broken femur, 444
leg. 495
Glenoid cavity of scapula, comminuted, 214
Granger, fracture of epicondyle. 268
Greater tubercle of humerus, 227
Gunning's interdental splint, 126
Gunshot fractures, 510
treatment in, 513
Gutta-percha splints, 52
Harris, separation of upper maxillary booct,
103
Ilarrold, lumbar vertebra*, 156
Ilartshorne, Edward, clavicle. 197
Hartshorne, Joseph E., thigh apparatas. itS
Hays, radial splint. 298
Hayward, lower jaw, 123
Head of femur, 369
of radius. 282
and anatomical neck of humeros, 223
INDEX — FRACTURES.
827
Head and neck of hnmerns, longitadinal frac-
ture. 22fl
]Iew{<0D, frncture-bed, 445
Hodge, thigh splint, 430
Hodgen'9 frticture-crtidle, 515
wire, sunpeDiiion splint, 424
Hodges, head of radius. 282
Horner, thigh apparatus, 428
Humerus. 221
anatomical neok, 223
head nnd neck, 223-227
tubercles, 227
longitudinal fractare of head and neck,
227
surgical neck, 229
upper epiphysis, 229
diderenii.il diagnosis, 238
shaft, 246
lower epiphysis. 257
base of condyles, 257
with splitting of condyles, 264
condyles, 267
internal epicondyle. 268
external epicondyle, 272
internal condyle. 272
external condyle. 275
delayed union, 276
dislocation of, 238
Hutchinson, leg splint, 493
J. C, fracture of s|>ine, 152
Hyde, F. E., fractures of femur, 368
Hyoid bone, 137
Ilium, 355
Immovable apparatus, 54
le»r. 4H9
Impacted fractures, 28
head and neck of humerot, 223
tub<•rcle^ 227
neok of femur within capsule, 373
without the capsule, 395
Incomplete fractures,. 74
Interior maxilla, 1 1 1
Intfrrtitial absorption of neck of femur, 385
Internal condyle of humerus, 272
feiiitir. 4.*)rt
Interdental splints, 125
Intrauterine fracture, 31, 246, 473
friicture of tibia, 473
Ischiuin. 354
Jackfon, Hciomion process, 216
Jarvis'g adju'iter. 494
Jeiik>. tracture-brd, 445
Juhoi«on, nook of femur, 382
Key, lunihnr vertebra', 157
Kin^tjry, Iraoture of lower jaw, 131
Kirkbiiile, elbow splint, 262
Larynx, fracture of, 141
Laufdale, patella, 472
Lente. fracture of dorsal vertebra, 158
lemur. 430
non-union. 68
pel \ is. 350
Lewitt. patella, 466
Liston, thigh splint, 416
Liston, leg splint, 497
Lockwood, fractare of hameras at birth, 246
Long splints. 48
Lonsdale, extension in fracture of homeras, 249
patella, 469
Lower jaw, 111
Malar bone, 99
McDowell, remarkable displacement of head
of humerus, 224
separation of upper epiphysis, 232
Malgaigne, apparatus for fracture of leg, 600
Many-tailed bandage, 47
March, acromial separations, 217
Martin, fractare of humerus, 250
Maxilla, superior, 1U2
inferior. 111
Measurement of thigh and leg, 418
Metacarpus, 344
Metatarsus, 507
Metallic splints, 48
Monahan, fracture of astragalas, 602
Moore, CoUes's fracture, 293
fractare of claTiole, 200
Morbus coxas senilis, 385
Morland, statistics of fracture of tibia and
fibula. 483
Mott, prognosis in Colles's fracture, 296
electricity in non>anion. 68
Mussey. fructure of coracoid process, 219
Mutter's ** clamp." 126
neck of radios, 282
Neck of fern or, 369
within capsule, 369
prognosis. 378
Q. R. Smith on, 383
without capsule, 393
Neck of humerus, anatomical, 223
surgical neck. 229
Neck of lower jaw, 113
Neck of radius. 279
Neck of scapula, 214
signs of fracture, 238
Neill. maxilla superior, 106
coracoid process, 219
thigh, 425
leg, simple fracture. 494
compound fracture, 494
N(Slaton. radial splint, 298
Non union. 63
humerus, 252
lower jaw, 120
ribs, 177
Norris, delayed and non-union, 64
astragalus. 505
gangrene from bandages, 308
tibia, 476
Nose, fracture of, 91
Nott, wire splints, 48
thigh apparatus, 422
Odontoid process of axis, 164
Olecranon process, 324
tenotomy, 331
Ossa nasi, 91
Packard, J. A., clavicle, 197
{
828
INDEX — FRACTURES.
Palmer's thigh splint, 423
Partial fraotare, 78
Patella, 461
Pelvis, 350
traumatic separations, 350
Phalanges of fingers, 347
toes, 502
Pubes, 350
Radius. 279
Radius and alna, 332
Reduction of fractures: general considera*
tions, 44
Refraoture of badlj united legs, 501
Repair of fracture. 38
Resection for badly united fractures, 501
Rheumatic arthritis, chronic, 385
Rhinoplasty, 98
Ribs, 175
cartilages of 180
Rim of acetabulum, 362
Rodet, neck of femur, 371
Rogers, trephining vertebra, 152
Roller, 46
Rose, elbow splint, 262
Sacrum, 365
Sacro-iliac symphysis, 366
Salter's cradle for leg, 499
Sargent, separation of upper maxillary bones,
102
Sayre, L. A-, clavicle, 201
Scapula, 209
body. 209
neck, 214
acromion process, 215
coracoid process, 219
epiphyses of, 216
Soulteius, bandage, 47
Seineiology, general, 33
Septum narium, 96
Setting bones, 45
Seutin, dressing, 54
Shaft of humerus, 246
radius, 283
ulna. 311
femur, 404
Shoulder-joint ; differential diagnosis of acci-
dents. 238
Shrady, radius splint, 299
Side splints. 48
Sling for broken jaw, 133
Smith. E. P., radial splint. 299
Smith, Nathan R., fracture of femur, 422
Smith, Robert, head of humerus. 225
Smith. Stephen, fracture of lower jaw, 119
odontoid process of azi?, 167
Smith, George K., insertion of capsule of hip-
joint, etc., 383
Spinal mnrrow. concussion, 161
Spinous processes : vertebrsc, 146
ilium. 355
Splint«, 48
Stnrch bandage, 54
Sternum, 169
diu{4tai*i8, 170
Stone, biixe of condyles and resection, 267
Styloid process of radius, 292
Surgical neck of humerus, 229. 240, 242
Swing box for leg, 498
Symphyses of pelvis, 350
of pubes, 351
sacro-iliac, 366
Symphysis pubis, separation of, 351
Tarsus, 502
astragalus, 502
oalcaneum, 503
Tenotomy in fractures of olecranon
331
Thompson, fracture of Inmbar Teriebrv, 157
Thyroid cartilage, 141
Thyroid and cricoid cartilages, 142
Tibia, 472
Tibia and fibula, 481
Toes, 509
Transverse processes of spine, 148
Treatment of fractures, general, 44
Trephining for fracture of Tertebraa, 151
Trochanter major, 401
Trochlea of humerus, 272
Tubercles of humerus, 227, 239, 242
Ulna, resection of, 309
Ulna, 311
shaft, 311
coronoid process, 315
olecranon process, 324
Upper epiphysis, humerus, 229
femur, 373
Upper maxillary bones, 102
Vanderveer, fracture in utero, S3
Vandeventer, fracture of Tertebral arch. 149
Vanwagenen's suspension apparatus. 492
Velpeau, mode of dressing fractures with dex-
trin and rollers, 55
Vertebral arches, 149
Vertebrce, 146
spinous processes, 146
transverse processes, 148
vertebral arches, 149
bodies, 154
Inmbar, 156
dorsal, 158
cervical, 158
axis, 164
atlas, 167
atlas and axis, 168
Warren on anchylosis at elbow-joint, 278
Water-beds, 163
Watson, fracture of lower jaw, 113
lower epiphysis of humerus, 257
patella, 464
Weber, plaster of Paris bandage, 60
Wells, internal condyle of femur, 456
Whittaker, pelvis. 353
Wire- beds. 164
Wire j.plinti, 48
Wire rack for fracture of leg, 500
Wood, fracture of patella, 467
Wooden splints. 49
Wrist, 343
Zygomatic arch, 107
/
INDEX — DISLOCATIONS.
829
PART II. DISLOCATIONS.
Agnew, D. H.. rnptare of axillary vein, 599
Anse^theticip. 532
Ancient luxations, 52A
inferior maxilla, 536
Bpine, 544
clavicle, outer end, 566
humerus, 593
bend of radius forwards, 622
radius and aina backwards, 634
thumb, 661
femur, 727
Andrews, inferior maxilla, 533
Ankle-joint, 756
Anomalous dislocations of the hip, 719. See
Femur.
Anterior oblique dislocation, 721
A.strngalus, 769
Atla^ di.*ilocations of. 551
Axillary artery, rupture of, 597
vein, rupture of. 59S
Ayres, dislocation of cervical vertebra, 549
Batchelder, head of radius, 617, 622
thumb, 664
Biceps, ru()ture or displncement of, 614
Bigt*Iow, II. J., nn disloontions of hip, 677
Bluckm.in, tincient dislocations of humerns.
597
femur, reduced after six months, 727
Bloxham's dislucntion tourniquet. 691
Brainurd, reduction of ancient luxation of
elbow, 6,'M
Calcaneum, dislocation of, 778
Canton, railius and ulna forwards, 644
Carpus, 645
backwards, 648
forwardn. 651
conjrenital. 814
Carpal bone .•« among themselves, 655
Carpel mftacarpal articulation, 657
Car(iln|;f.», (if ribs from one another, 556
in kneojoiiit, 754
Ca.<'well. di-location of patella. 822
Clavicle, dislocations of, 557
}«ternal end forwards, 557
sternal end upwards, 561
sternal end l>.ickwards, 562
acnmiial end upwards, 564
acromial end downwards. 570
under coracoid process, 571
both end.s 572
congenital. 808
Clove-hitch. :>32
Compouml pulleys, 532
Com|K)und dislocations of the long bones, 785
reduction in. 791
non-reduction in, 794
amputation in, 794
Compound dislocations, tenotomy in, 795
resection in, 795
Congenital dislocations ; general observations
and history, 801
general etiology, 802
inferior maxilla. 804
spine, 807
pelvic bones, 808
sternum, 808
clavicle, 808
shoulder, 809
radius and ulna backwards, 812
bead of radius, 813
wrist, 814
fingers, 814
hip. 815
patella, 821
knee, 822
tarsus. 824
toes, 824
Cooper, Sir Astley, method of reducing dislo-
cation of hamerus, 589
Coxo- femoral dislocations, 672. See Femur.
Crosby, dislocation of thumb. 665
ancient dislocation of elbow, 636
Cuboid, disloeations of, 779
Cuneiform bones, dislocation of, 780
Daroainville, statistics of dislocations of fe-
mur, 692
Darby, sb«>ulder, 586
Davis, Q. P. .vertical dislocation of patella, 743
Direct cnuites of dislocations, 527
Disloontions, 525
Division and nomenclature of dislocations, 625
Double dislocation <if lower jaw. 533
Dupierris, femur reduced after six months, 727
Dynamometer, 692
Elbow-joint. 626
Everted dorsal dislocation of femur, 680
Exciting causes, general, 527
Extension by a twisted rope, 532, 690
Femur, dislocation of, 672
dislocation on dorsum ilii, 674
reduction by manipulation, 683
reduction by extension. 688
dislocation into great ischiatio notch, 701
below the tendon, 703
dislocation into foramen thyroidenm, 709
dislocation upon the pubes, 714
anomalous disloeations of the femur, 719
downwards and backwards upon the
body of the ischium, 723
downwards and backwards into Immf
ischiatio notch, 723
behind the tabtr isohii, 723
830
INDEX — DISLOCATIONS.
V
Femur, disloeation directly up, 719
directly down, 724
forwnrds into perineum, 725
ancient dislocations, 727
partial dislocations, 731
with frHcture, 732
in children, 526, 673
congenital, 815
voluntary, 735
Fenner, dislocation of femur on dorsum ilii,
676
Fibula, upper end forwards, 767
backwards, 768
lower end, 769
**Fiah" dislocation of femur, 723
Fingers, dislocations of first phalanx, 660, 668
second and third, 669
congenital, 814
Foot, dislocation outwards, 756. See Tibia,
Fountain, dicilocation of femur upon pubes, 7 1 7
Oazzam, rotation of patella on its inner mar-
gin, 742
General division, 525
direct or exciting causes. 527
prediHposing causes, 526
prognosis, 530
pathology, 528
treatment, 530
symptoms. 527
Gibson, ancient dislocation of humerus, 598
Gilbert. A. W.. dihlocationof lower jaw, 534
Grant, astragalus, 776
Graves, dislocation of dorsal vertebrm, 543
Gunn, dislocation of thigh on dorsum ilii, 676
Hnrt, dislocation of astragalus, 773
Harthhorne, reduction of humerus by manipu-
lation (note), 602
Head upon the atlas. 553
Haynes. S., double dislocation of clavicle, 572
Uinckerraan, cervical vertebra}, 548
Hodge, statistics of dislocations of tbe femur,
673
Horner, partial dislocation of fourth cervical
vertebra), 546
Howe, reduction of dislocation of the hip by
manipulation, 685
Humerus, dislocations of, 573
double, 603
downwards. 574
forwards, 602
fracture in reduction, 599
backwards, 609
partial, 613
ancient, 593
rupture of axillary artery and vein, 599
with fracture. 601
congenital, 809
Hnmero-scapular dislocation, 573. See Hu-
ntfi US
Hutchinson, dislocation of femur, 702
Ilio-femoral ligament, 677
Ilio-pubic (li.«location of femur, 714
Indian " puzzle," 666
Inferior maxilla. 533
double di^loc.'ltion, 5.33
single dislocation, 537
Inferior congenital disloeatioD, 804
Ingalls, reduction of dislocation of bip by
manipulation, 686
Internal derangement of knee-joint. 754
Isohio- pubic dislocation of femur. 709
Ischiatio disloeation of femur, 701
Jarvis's adjusUr, 532, 595, 691
Rirkbride, dislocation of the femur upon poe-
terior part of the body of the ischium. 723
Knee, slipping of semilunar cartilages, 754.
See Tihia.
\ Krackowitser, dislocation of head of radius in
delivery, 617
La Mothe, method of reducing dislocation of
humerus, 588
Lehman, spent ineous dislocation of shoulder,
575
Lente, fifth cervical vertebra, with fracture,
546
fifth cervical vertebra, without fracture.
546
femur directly upwards, 721
Levis, reduction of disloeation of thumb. 665
Ligamentum patellse, rupture of. 744
Lister, rupture of axillary artery, 598
Long bones, compound disloeation in. 785
Long head of biceps, displacement of, 614
Lower jaw, 533
simulating luxation of, 538
Lumbar vertebrss, 541
Markoe, on reduction of dislocation of femur,
687
head of radius backwards. 623
femur with fracture, reduced, 734
MaxKon, dislocation of cervical vertehrte*, 549
Mercer, on partial dislocations of humerus, 615
Metacarpus. 657
Metacarpophalangeal articulation, 660
Metatarsuii, 782
Midille tarsal dislocation. 779
Moore, on reduction of dislocation of femur.
676
ulna, 653
Mussey, dislocation of thumb, 664
ancient dislocation of elbow, 636
Norris, ancient dislocations of the humerus.
600, 605
dislocation of humerus mistaken for a
contu()ion, 605
compound diclocation of thumb. 6^7
North. N. C, double dislocation of c'avicle.
572
Occipito-atloidean dislocations, 553
I
Pardee. £. L , double dislocation of humemv,
603
Parker, head of humerus in sabscapular
fossa. 603
backwards, 610
head of radius backwards, 6S2
INDEX — DISLOCATIONS.
831
Purker, head of radios outwards, 624
femur into perineum, 726
Patella, outwards, 737
inwards. 740
on its axis, 740
upwards, 744
downwards, 746
congenital. 821
Pathnloi;y. general, 528
Pelvis. Cdngfnital, 808
Pettit, A., dislocation of tibia, 750
Phalanges, thumb and fingers, 660
toes, 784
Pope, dislocation of femurinto perineum. 726
Predispoi^ing causes, general, 526
Prognosis, general, 530
Pseudo-luxations of inferior maxilla, 538
Pulleys, 5:^2
Purple, dislocation of cervical Tertebre, 546
Radius, head dislocated forwardi, 617
backwards, 622
outwards, 624
congenital, 813
Radius and ulna, dislooatioo backwards, 626
congenital, 812
outwiirds. 636
inwurdii, 641
forwards. 644
Radio-carpal articulation, 645. See Carpus.
Radio-ulnar nrtioulation, inferior, 652
Rupture of quadriceps femoris, 746
Reid, reduction of dislocation of femur by
manipulation, 687
Rib^ from rertebrsB, 553
from sternum, 555
one cartilage, upon another. 556
Roche^>te^. sternal end of clavicle upwards, 561
Rudiger, dislocation of dorsal Tertebrae, 544
Sacro sciatic dislocation of femur, 701
Sanson, third cervical vertebra, 547
Scaphoid, dislocation of, 780
Sehuck, dislocation of cervical vertebra, 547
Shoulder. di.«locatioD of, 573. See Humerus.
Single di»ilocation of lower jaw, 537
"Sixth " dislocation of femur, 719
Skey, method of reducing dislocation of ho-
meruf. 591
Smith, Nathan, on reduction of dislocation of
the humerus, 587
reduction of femur by manipulation. 683 I
Smith II. il., on reduction of humerus, 592
Sponcer. dislocation of cervical vertebra, 547 .
Spine. 540. See VerUhra.. I
Squire. T. H., dislocation of radius and ulna \
inwiird!<. 042 j
Sternum, congenital dislocations, 808
Sternberg, vertical dislocation of patella, 743 :
Suhcoraeoid dislocation of humerus, 602
Suholaviculnr dislocation of humerus. 602
Suhcotyloid dislocation of femur, 724 '
Subluxation of the jaw. 538
Subglenoid dislocation of the humerus, 574
Subpubic dislocation of femur, 709
Subspinous dislocation of humerus, 609
Swan. di{<locution of dorsal vertebra, 544
Symptomatology, general, 627
Tarsus, 769
astragnlns, 769
astragalooalcaneo-soaphoid, 777
calcnneum. 778
middle tarsal dislocation, 779
08 cuboides, 779
OS scapboides, 780
cuneiform bones, 780
congenital, 824
Tendons, dislocation of, 614, 807
Thigh, 672. See Frmnr.
Thumb, first phalanx. 660
backwards. 660
forwards. 667
second phalanx. 669
Tibia, dislocation of upper end, 745
backwards, 746
forwards, 748
outwards, 750
inwards, 752
backwards and outwards, 752
congenital, 822
lower end. inwards, 756
outwards, 761
forwards, 762
backwards. 766
dislocation of lower end, 766
Tibio-tarsal luxations, 756
Toes. 784
congenital, 824
Treatment, general, 530
Tripod for vertical extension of femar, 700
Trowbridge, head of humerus backwards, 610
Twisted rope, extension, 532
Ulna, upper end backwards. 626
lower end backwards, 652
forwards, 289. 654
Unilateral luxation of lower jaw. 637
Van Buren. W. H., dislocation of bameras
bnckwards, 610
reduction of femur by manipalation, 696,
712
Varick. T. R.. radius and ulna outwards, 636
Vertebra). 540
lumbar. 541
dorsal. 542
six lower cervical. 645
atlas upon axis. 651
head upon atlas. 553
congenital dislocations, 801
Voluntary dislocations, 735
Warren, humerus with fracture, 601
AVaterman, T., reduction of elbow, 632
Watson, dislocation of patella outwards, 739
Wells, dislocation of tibia, 753
Windlass for extension, 532
Wood, dislocation of cervical vertebr». 649
humerus, with fracture, 603
Wrist, 645. See Carpus.
T ligament, 677
Youmans, J., ooogenital dislooation of knee,
822
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